Asthma : a nursing care

Alfrina Hany
Medical Surgical Nursing B, March 2014

Learning Objectives
General
After following this subject the students will
be able to apply the nursing care for adult
clients with Asthma

Learning Objectives
Specific
The Students will be able to :

1. Define, categorize, identify sign & symptoms of

clients with Asthma
2. Describe & analyze the pathogenesis of Asthma
correctly
3. Take the diagnostic examination for clients with
Asthma
4. Apply & manage the best nursing care to clients
with Asthma

Which color are you?

COPD IS NOT ASTHMA !

COPD IS ASTHMA !

COPD
Chronic obstructive pulmonary
disease
Chronic obstructive lung disease
(COLD)
Chronic airflow limitation (CAL)
the fourth leading cause of death in
the United States, and is expected to
move to third place by 2020.

Signs: Cough,
Sputum,
Dyspnea

COPD IS NOT ASTHMA !

Different causes

Different inflammatory cells

Different mediators

Different inflammatory consequences

Different response to treatment

Definition of Asthma

A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role

Chronic inflammation is associated with airway

hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness, and coughing

Widespread, variable, and often reversible

airflow limitation
Global Initiative for Asthma

ASTHMA IS NOT:
Contagious Usually genetic
Infectious It is a chronic disease
A Good Excuse -- to lead a
sedentary life

Epidemiology
Affects 8% of US population
25.7 million in 2010
1:11 children
1:12 adults

1)

8.9million office visits in 2009

1.9 million emergency room visits in 2009
479,00 hospitalizations in 2009
14.2 million missed work in 2008
http://www.cdc.gov/asthma/impacts_nation/AsthmaFactSheet.pdf accessed 9/112

Epidemiology
High cost
$56 billion/year
$3,300/person/year

Mortality
33388 deaths in the US in 2009

1)

http://www.cdc.gov/asthma/impacts_nation/AsthmaFactSheet.pdf accessed 9/12

Hello class
In this class room, how many of you
have asthma?
What questions will you ask your
friend with asthma?
What will you say to answer?

In a classroom of 30 children,
2 or more
children are
likely to
have asthma

Characteristics
reversible triad

Period

wheezing
cough
dyspnea
-- Sputum

diurnal
seasonal
provoking
factors

Airway obstruction
congestion
constriction
tight & narrow

Related Factors

Asthma Triggers
Indoor Air Pollutants
Outdoor Air Pollutants
Other Types of Triggers

Not all people with asthma

have the same triggers that
will cause an asthma attack

Indoor Air Pollutants

Chemicals
Biologicals

 Chemical Irritants
Cigarette smoke and wood smoke
Scented products such as hair spray,
cosmetics, and cleaning products
Strong odors from fresh paint or cooking
Automobile fumes and air pollution
Chemicals such as pesticides and lawn
treatments
Dust, mold, cockroaches

BIOLOGIC IRRITANTS
Infections in the upper airways, such as colds
(a common trigger for both children and
adults)
Exercise
Strong expressions of feelings (crying,
laughing)
Changes in weather and temperature

Outdoor Air Triggers

Ozone (O3)
Particulate matter
Sulfur dioxide (SO2)
Nitrogen dioxide - vehicle exhaust
Outdoor pollens and mold

Additional Triggers
Viral upper respiratory
infections
Exercise
Medications
Diet
Cold air

Is There A Cure For Asthma?

Asthma cannot be cured,

but it can be controlled.

Classification
Asma bronkial tipe non atopi
(intrinsik)
Asma bronkial tipe atopi (Ekstrinsik).
Asma bronkial campuran (Mixed)

Tipe non atopi (intrinsik)

Keluhan tidak ada hubungannya dengan
paparan (exposure) terhadap alergen
sifat-sifatnya adalah:
- timbul setelah dewasa
- keluarga tidak ada yang menderita asma
- penyakit infeksi
- pekerjaan atau beban fisik
- perubahan cuaca atau lingkungan peka

Tipe atopi (Ekstrinsik).

Keluhan ada hubungannya dengan paparan
terhadap alergen lingkungan yang spesifik.
Kepekaan ini biasanya dapat ditimbulkan
dengan uji kulit atau provokasi bronkial.
timbul sejak kanak-kanak, pada famili ada
yang menderita asma
Di Inggris jelas penyebabnya House Dust
Mite, di USA tepungsari bunga rumput.

Asma bronkial campuran

(Mixed)
Pada golongan ini,
keluhan diperberat baik
oleh faktor-faktor intrinsik
maupun ekstrinsik.

Classification of Asthma Severity

Days with
symptoms

Nights with
symptoms

Lung Function
FEV1 PEF %

Step 4

Severe

Continual

Step 3
Moderate

Daily

Frequent

FEV1 PEF <= 60%

>= 5 times per month

FEV1 PEF 60-80%

Step 2
Mild persistent
> 80%

3-6 times/week

Step 1
Mild intermittent
>= 80%

<= 2 times/week<= 2 times per month

3-4 times per month FEV1 PEF

FEV1 PEF

Diagnostic Tests

CXR INFILTRATES
SEVERE BLOOD EOSINOPHILIA
ORGANISM IN SPUTUM
BLOOD GAS ANALYSIS
LUNG FUNCTION TEST
reveal a decreased forced expiratory
volume, increased residual volume from air
trapping and decreased vital capacity
(max amount of air exhaled)
SKIN TEST to identify allergens
PULSE OXYMETRI

LUNG FUNCTION
the values on a pulmonary function
test must tell you the % of predicted
value
the absolute values have too much
variability
lung function tests can be modified
varies with body size, age, lung
compliance

LUNG FUNCTION
Vital capacity - air volume that can be
expelled from lungs after deep breath
FEV1 - forced expiratory volume in 1 sec
PEF - peak expiratory flow rate
Take a deep breath and blow out
it lasts about 4 - 5 seconds
you expel about 4 L Vital capacity
about 3L is expelled in first secondFEV1

Congesti
Tightness

Inflammation
Mucus produced

Constriction
Narrow

PATHOPHYSIOLOGY
How Airways Narrow

3 Components of an
Asthma Attack
1. Bronchospasm
The smooth muscles that wrap
around the windpipe (bronchi)
tighten, reducing the size of the
airway.
normal

Asthma attack

3 Components of an
Asthma Attack
2. Inflammation
The mucosal lining of the windpipe
becomes inflamed and swells,
thereby reducing the size of the
airway even further.
3. Mucus
Increased mucus production takes up
more space; now the airway is very
constricted.

Asthma Inflammation: Cells and

Mediators

Source: Peter J. Barnes, MD

Mechanisms: Asthma
Inflammation

Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and

Mediators

Source: Peter J. Barnes, MD

I am familiar with the most current

asthma treatment guidelines?
1.
2.
3.
4.
5.

Strongly Agree
Agree
Neutral
Disagree
Strongly
Disagree

Asthma Medications
Long-term Controllers

Used to control and

prevent asthma
symptoms
Must be taken daily
Corticosteroids;
Cromolyn Sodium;
Long Acting beta
agonist; Leucotriene
modifiers;
methylxantine

Quick-Relief
Provides quick relief of
an acute asthma
episode by opening up
the bronchioles
Used as needed for
symptoms and before
exercise

Short-acting beta2
agonists;anticholine
rgic; systemic
steroid

Pharmacologic Therapy
Long-term control medications
corticosteroids
inhaled form
systemic steroids used to gain prompt control
of disease when initiating inhaled tx

cromolyn sodium or nedocromil

mild-to-moderate anti-inflammatory
medications (may be used initially in children)
preventive tx. prior to exercise or unavoidable
exposure to known allergens

 Long-term control medications

Long-acting beta2-agonists
used concomitantly with anti-inflammatory
meds for long-term symptom control
especially nocturnal symptoms
prevents exercise-induced bronchospasm

Methylxanthines
sustained-release theophylline used as
adjuvant to inhaled steroids for prevention
of nocturnal symptoms

 Long-term control medications

Leukotriene modifiers
zafirlukast - leukotriene receptor antagonist
zileuton - 5-lipoxygenase inhibitor is
alternative therapy to low doses of inhaled
steroids/nedocromil/cromolyn
alternative tx to low dose inhaled
steroids/cromolyn/nedocromil
recommended for >12yrs with mild
persistent asthma. Further study needed

 Quick relief medications

Short acting beta2-agonists - relief of
acute symptoms

Anticholinergics - may provide additive

benefit to beta2 drugs in severe exacerbation.
May be alternative to beta2-agonists

Systemic steroids - moderate-to-severe

persistent asthma in acute exacerbations or to
prevent recurrence of exacerbations

Classification of Asthma Severity

Components of Severity
2007 NAEPP Guidelines, EPR-3
Section 3, pg 74.

(Youths 12 years of age and adults)

Persistent
Intermittent
Mild

Symptoms
Impairment
Normal
FEV1/FVC:
8-19yr
20-39yr
40-59yr
60-80yr

85%
80%
75%
70%

Nighttime
awakenings
Short-acting 2agonist use for
symptom control
(not EIB prevention)
Interference with
normal activity

Lung function

Moderate

Severe

>2 days/week
but not daily

Daily

Throughout
the day

2x/month

3-4x/month

>1x/week but
not nightly

Often 7x/week

2 days/week

>2 days/week
but not >1x/day

Daily

Several times
per day

Some limitation

Extremely
limited

FEV1 80%
predicted

FEV1 >60% but

< 80%
predicted

FEV1 < 60%

predicted

FEV1/FVC
normal

FEV1/FVC
reduced 5%

FEV1/FVC
reduced >5%

2 days/week

None
Normal FEV1
between
exacerbations
FEV1 >80%
predicted

Minor limitation

FEV1/FVC normal
0-1/year
Risk

Exacerbations
requiring oral

2/year

Consider severity and interval since last exacerbation. Frequency and

STEP-WISE APPROACH TO THERAPY

Intermittent
Asthma

Persistent Asthma: Daily Medication

Consult asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.

Step 5
Step 4
Step 3
Preferred:

Low dose ICS

Low-dose ICS +
LABA
OR Medium
dose ICS

Alternative:
Cromolyn,
LTRA,
Nedocromil or
Theophylline

Alternative:
Low-dose ICS +
either LTRA,
Theophylline, or
Zileuton

Step 2
Step 1
Preferred:
SABA PRN

Preferred:

Preferred:
Medium Dose
ICS + LABA
Alternative:
Medium-dose
ICS + either
LTRA,
Theophylline,
or Zileuton

Preferred:
High
Dose ICS +

Step 6

Step up if
needed

Preferred:

(first, check
adherence,
environmental
control &
comorbid
conditions)

High dose ICS

+ LABA + oral
corticosteroid

LABA

AND

AND

Consider
Omalizumab
for patients
who have
allergies

Consider
Omalizumab
for patients
who have
allergies

Each Step: Patient Education and Environmental Control and management of comorbidities
Steps 2 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma

2007 NAEPP Guidelines, EPR-3 Section 4, pg 343.

Assess
control
Step
down if
possible
(and asthma
is well
controlled at
least 3
months)

Classification of Asthma Control

Components of Control

(Youths 12 years of age and adults)

2007 NAEPP Guidelines, EPR-3

Section 3, pg 77.

Well-Controlled

Not WellControlled

Very Poorly
Controlled

Symptoms

2 days/week

>2 days/week

Throughout the day

Nighttime
awakening

2x/month

1-3x/week

4x/week

None

Some limitation

Extremely limited

>80%
predicted/persona
l best

60-80%
predicted/personal
best

<60%
predicted/personal
best

0
0.75*
20

1-2
1.5
16-19

3-4
N/A
15

Interference with
normal activity
Impairment

FEV1 or peak
flow
Validated
Questionnaires
ATAQ
ACQ
ACT

0-1/year
Exacerbations

Risk

Progressive loss of
lung function

2/year

Consider severity and interval since last exacerbation

Evaluation requires long-term follow-up care
Medication side effects can vary in intensity from none to very

Stepping UP (EPR 3, 2007)

Asthma NOT WELL CONTROLLED
Review adherence, inhaler technique,
environmental control, co morbid conditions
Step up 1 step and reevaluate in 2-6 weeks

Asthma VERY POORLY CONTROLLED

Review adherence, inhaler technique,
environmental control, co morbid conditions
Consider short course of oral steroid
Step up 1 or 2 steps and reevaluate in 2
weeks

Stepping DOWN (GINA, 2011)

(asthma is controlled >3months)
If pt on Medium-High dose
Reduce dose 50% at 3 month intervals (Evidence B)

If control achieved on low dose

Switch to once daily (Evidence A)

If pt taking ICS + LABA

Reduce ICS dose 50% + LABA (Evidence B)
Once control achieved on low dose + LABA (Evidence D)
Attempt to d/c LABA

If pt taking ICS + other controller

Reduce ICS dose 50% + other controller (Evidence D)
Once control achieved on low dose + other controller
(Evidence D)
Attempt to d/c other controller

If pt on lowest dose of controller and no symptoms

for 1 year
Attempt to d/c controller

http://hamptonroads.com/files/images/6161.jpg. accessed 3/08

I can instruct a patient on how

to properly use an MDI?
1. Yes
2. No

MDI-technique Is
significant
Lindgren et al. Eur J Resp Dis
1987;70:93-98.
56% of patients made errors in MDItechnique which resulted in a 30%
decrease in bronchodilation versus control
(p<0.01)

Giraud et al. Eur Resp J 2002;19:246251

71% of patients misused MDIs
47% due to poor coordination

Asthma less stable in misusers (p<0.001)

Among misusers, asthma less stable in
poor coordinators (p<0.001)

MDI technique
Plaza et al. Resp 1998;65:195-198
9% of patients, 15% of nurses, and
28% of physicians showed correct
MDI-technique.

Interiano et al. Arch Intern Med

1993;153:81-85
65% of patients, 39% of housestaff,
82% of nurses were categorized as
having poor MDI-technique.

Asthma Management Plan

Goals of therapy
Prevent symptoms
Maintain (near) normal PF
Maintain normal activity
Prevent exacerbations & minimize ER
visits/hospitalizations
Optimal drug tx, minimal problems
Patient/family satisfaction

 Recommended
monitoring
S&S
PFT
Quality of
life/functional status
Exacerbations
Drugs
Patient/provider
communication &
satisfaction

Monitor using
clinician
assessment/pt.
self-assessment
Spirometry tests
Initial assessment
Post tx after
patients symptoms
and PF stabilize
Minimally Q 1-2 yrs

 Written action plan based on:

Signs & symptoms &/or PEF

Patient education:
Recognition need for additional therapy

Asthma Action Plan

Peak Flow Measurements

Asthma Symptoms,
Asthma Medications,
Relaxation exercise
Emergency Numbers

Crisis Plan for Asthma

Begin this plan when I have:
These Symptoms: Taking these medications:
_______________ _____________________
_______________ _____________________
Call my doctor:
Name: _______________ Phone number: _________________
If I cannot reach my doctor immediately:
Take ______________________________________________________
If I have severe symptoms or I am getting worse very quickly:
Go to the emergency room if within ten minutes distance:
Location of emergency room ________________________
Contact and emergency transport
system____________________________________________
Phone number _____________________________
Name of system ________________________
Planning for Travel
____________________________________________________________________

Key Elements of Asthma Therapy

NURSING CARE
ASSESSMENT
Sesak
RR > 20x/menit
Otot bantu
Wheezing
Rhonki
Saturasi oksigen
BGA
PEV

DIAGNOSIS
1. Impaired gas exchange
2. Ineffective airway
clearance
3. Ineffective breathing
pattern
4. Impaired spontaneous
ventilation
5. Ineffective tissue
perfusion

Journal Corner
Common Cold,
Pregnancy, Asthma
GINA, Issued Feb 3,
2014
Germany
513 pregnant mother
526 children
Monitored frequently
Result

Implications:
Trigger
Percentage
assessment

DIAGNOSIS
6. Latex allergy response
7. Contamination
8. Readiness for
enhanced coping
9. Readiness for
enhanced family
coping
10. Electrolyte
imbalance
11. anxiety

12. Readiness for

enhanced self health
management
13. Insomnia
14. Ineffective protection
15. Relocation stress
syndrome
16. Impaired skin
integrity
17. Risk for suffocation

ineffective Airway Clearance may be related

to increased production and retained
pulmonary secretions, bronchospasm,
decreased energy, fatigue,

possibly evidenced by
wheezing,difficulty breathing,
changes in depth and rate of
respirations, use of accessory
muscles, and persistent ineffective
cough with or without sputum
production.

impaired Gas Exchange may be related

to altered delivery of inspired oxygen,
air trapping

possibly evidenced by dyspnea,

restlessness, reduced tolerance for
activity, cyanosis, and
changes in arterial blood gases and
vital signs.

Anxiety [specify level] may be related

to perceived threat of death,

possibly evidenced by apprehension,

fearful expression, and extraneous
movements

Nursing Diagnosis
Activity Intolerance may be related to
imbalance between oxygen supply and
demand, possibly evidenced by fatigue
and exertional dyspnea.
risk for Infection: risk factors may
include presence of atmospheric
pollutants, environmental contaminants
in the home (e.g., smoking or
secondhand tobacco smoke).

NURSING OUTCOMES/EVALUATION
CRITERIA

Respiratory Status: Airway Patency: Open, clear tracheobronchial

passages for air exchange
Aspiration Control: Personal actions to prevent the passage of fluid
and solid particles into the lung
Cognition: Ability to execute complex mental processes

Client Will (Include Specific Time Frame)

Maintain airway patency.
Expectorate or clear secretions readily.
Demonstrate absence or reduction of congestion with breath sounds clear,
respirations noiseless,
improved oxygen exchange (e.g., absence of
cyanosis, arterial blood gas [ABG] results within client norms).
Verbalize understanding of cause(s) and therapeutic management regimen.
Demonstrate behaviors to improve or maintain clear airway.
Identify potential complications and how to initiate appropriate preventive
or corrective actions.

Nursing Interventions
Criteria
Airway Management: Facilitation of
patency of air passages
Respiratory Monitoring: Collection and
analysis of patient data to ensure airway
patency and adequate gas exchange
Cough Enhancement: Promotion of deep
inhalation by the patient with subsequent
generation of high intrathoracic pressures
and compression of underlying lung
parenchyma for the forceful expulsion of air

Priority 1:

To maintain adequate, patent

airway

Evaluate respiratory rate/depth and breath sounds. Tachypnea is usually

present to some degree and may be pronounced during respiratory stress.
Some degree of bronchospasm is present with obstruction in airways and
may/may not be manifested in adventitious breath sounds, such as scattered
moist crackles (bronchitis), faint sounds with expiratory wheezes
(emphysema), or absent breath sounds (severe asthma)
Evaluate amount and type of secretions being produced. Excessive &/or
sticky mucus can make it difficult to maintain effective airways, especially if
client has impaired cough function,is very young/elderly,is developmentally
delayed, has restrictive/obstructive lung disease, is mechanically ventilated.
Note ability to, and effectiveness of, cough. Cough function may be weak
or ineffective in diseases and conditions such as extremes in age (e.g.,
premature infant or elderly), cerebral palsy, muscular dystrophy, spinal cord
injury (SCI), brain injury, postsurgery and/or mechanical ventilation due to
mechanisms affecting muscles of throat, chest, and lungs.
Suction (nasal, tracheal, oral), when indicated, using correct-size catheter
and suction timing for child or adult to clear airway when secretions are
blocking airways

Priority 2 :To mobilize secretions

Elevate head of the bed or change position, as needed. Elevation or

upright position facilitates respiratory function by use of gravity;
however, the client in severe distress will seek position of comfort
Position appropriately (e.g., head of bed elevated, side-to-side) and
discourage use of oilbased products around nose to prevent
vomiting with aspiration into lungs.
Encourage and instruct in deep-breathing and directed-coughing
exercises; teach (presurgically)& reinforce (postsurgically)
breathing&coughing while splinting incision to maximize cough
effort, lung expansion, and drainage, and to reduce pain
impairment.
Mobilize client as soon as possible. Reduces risk or effects of
atelectasis, enhancing lung expansion and drainage of different
lung segments.

Conclusions
Asthma is a chronic disease when improperly
treated can lead to poor outcomes
Successful asthma therapy requires regular
assessments of symptom control and medication
adherence
Proper inhaler technique is critical to successful
asthma therapy
Asthma education requires continuous
reinforcement
Nursing care should include asthma
management/guidelines

Resources

Smeltzer et al. 2010. Brunner & Suddarths Textbook of

Medical Surgical Nursing, 12th edition. Lippincott William
Wilkins
Doengoes, Moorhouse, Murr. 2013. Nursing Diagnosis Manual.
4th Edition. USA:FA Davis Company
William,Hopper.2007. Understanding Medical Surgical Nursing
NANDA 2012-2014
Nursing Outcome Criteria (NOC)
Nursing Intervention Criteria (NIC)
Asthma Guidelines http://www.ginasthma.com
Common Colds during Pregnancy may lead to Childhood
Asthma.http://www.acaai.org/allergist/news/New/Pages/Comm
onColdsduringPregnancymayleadtoChildhoodAsthma.aspx
National Asthma Education and Prevention Program -http://www.nhlbi.nih.gov

Scenario
Tn. Roim, 24 th, dibawa keluarga ke RS dengan keluhan utama
sesak napas, batuk berdahak warna putih agak kental dan sulit
dikeluarkan. Klien mengatakan sesak sejak 2 hari lalu dan
bertambah berat pada malam hari atau hawa dingin. Klien juga
mengatakan cemas akan kondisinya karena tidak pernah muncul
keluhan seperti ini. PF: tampak sesak dan cemas, CM, TD 120/80
mmHg, N 120x/mnt, RR 30x/mnt, napas cuping hidung, wheezing
seluruh lapang paru. Klien tampak bingung dan tidak tahu
bagaimana cara menangani keluhan atau menggunakan MDI.
YOU ARE NURSE IN CHARGE, WHAT WILL YOU DO?