Professional Documents
Culture Documents
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 :
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
Different causes
Different mediators
Definition of 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)
Epidemiology
High cost
$56 billion/year
$3,300/person/year
Mortality
33388 deaths in the US in 2009
1)
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
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
Additional Triggers
Viral upper respiratory
infections
Exercise
Medications
Diet
Cold air
Classification
Asma bronkial tipe non atopi
(intrinsik)
Asma bronkial tipe atopi (Ekstrinsik).
Asma bronkial campuran (Mixed)
Nights with
symptoms
Lung Function
FEV1 PEF %
Step 4
Severe
Continual
Step 3
Moderate
Daily
Frequent
Step 2
Mild persistent
> 80%
3-6 times/week
Step 1
Mild intermittent
>= 80%
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.
Mechanisms: Asthma
Inflammation
Strongly Agree
Agree
Neutral
Disagree
Strongly
Disagree
Asthma Medications
Long-term Controllers
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
Methylxanthines
sustained-release theophylline used as
adjuvant to inhaled steroids for prevention
of nocturnal symptoms
Components of Severity
2007 NAEPP Guidelines, EPR-3
Section 3, pg 74.
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/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
Step 5
Step 4
Step 3
Preferred:
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)
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
Assess
control
Step
down if
possible
(and asthma
is well
controlled at
least 3
months)
Components of Control
Well-Controlled
Not WellControlled
Very Poorly
Controlled
Symptoms
2 days/week
>2 days/week
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
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)
MDI technique
Plaza et al. Resp 1998;65:195-198
9% of patients, 15% of nurses, and
28% of physicians showed correct
MDI-technique.
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
Patient education:
Recognition need for additional 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
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.
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
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:
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
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?