Asthma

Description

 Asthma is a chronic inflammatory disease of the airways that

causes airway hyperresponsiveness, mucosal edema, and mucus
production.
 Inflammation ultimately leads to recurrent episodes of asthma
symptoms.
 Patients with asthma may experience symptom-free periods
alternating with acute exacerbations that last from minutes to hours
or days.
 Asthma, the most common chronic disease of childhood, can begin
at any age.
Pathophysiology

The underlying pathophysiology in asthma is reversible and diffuse airway

inflammation that leads to airway narrowing.

 Activation. When the mast cells are activated, it releases several

chemicals called mediators.
 Perpetuation.These chemicals perpetuate the inflammatory
response, causing increased blood flow, vasoconstriction,, fluid leak
from the vasculature, attraction of white blood cells to the area, and
bronchoconstriction.
 Bronchoconstriction. Acute bronchoconstriction due to allergens
results from a release of mediators from mast cells that directly
contract the airway.
  Progression. As asthma becomes more persistent, the
inflammation progresses and other factors may be involved in the
airflow limitation.

Schematic Diagram

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Statistics and Epidemiology

Asthma is considered as the most common chronic disease of childhood, and

is a disruptive disease that affects school and work attendance.

 Asthma affects more than 22 million people in the United States.

 Asthma accounts for more than 497, 000 hospitalizations annually.
 The total economic cost of asthma exceeds $27.6 billion.

Causes

Despite increased knowledge on the pathology of asthma and the

development of improved medications and management plans, the death
rate from the disease continues to rise. Here are some of the factors that
influence the development of asthma.

 Allergy. Allergy is the strongest predisposing factor for asthma.

 Chronic exposure to airway irritants. Irritants can be seasonal
(grass, tree, and weed pollens) or perennial (mold, dust, roaches,
animal dander).
 Exercise. Too much exercise can also cause asthma.
 Stress/ Emotional upset. This can trigger constriction of the
airway leading to asthma.
 Medications. Certain medications can trigger asthma.
Clinical Manifestations

The signs and symptoms of asthma can be easily identified, so once the
following symptoms are observed, a visit to the physician is necessary.

 Most common symptoms of asthma are cough (with or without

mucus production), dyspnea, and wheezing (first on expiration, then
possibly during inspiration as well).
 Cough. There are instances that cough is the only symptom.
 Dyspnea. General tightness may occur which leads to dyspnea.
 Wheezing. There may be wheezing, first on expiration, and then
possibly during inspiration as well.
 Asthma attacks frequently occur at night or in the early morning.
 An asthma exacerbation is frequently preceded by increasing
symptoms over days, but it may begin abruptly.
 Expiration requires effort and becomes prolonged.
 As exacerbation progresses, central cyanosis secondary to severe
hypoxia may occur.
 Additional symptoms, such as diaphoresis, tachycardia, and a
widened pulse pressure, may occur.
 Exercise-induced asthma: maximal symptoms during exercise,
absence of nocturnal symptoms, and sometimes only a description
of a “choking” sensation during exercise.
 A severe, continuous reaction, status asthmaticus, may occur. It is
life-threatening.
 Eczema, rashes, and temporary edema are allergic reactions that
may be noted with asthma.

Prevention

Patients with recurrent asthma should undergo tests to identify the

substances that precipitate the symptoms.
  Allergens. Allergens, either seasonal or perennial, can be
prevented through avoiding contact with them whenever possible.
 Knowledge. Knowledge is the key to quality asthma care.
 Evaluation. Evaluation of impairment and risk are key in the
control.

Complications

Complications for asthma include the following:

 Status asthmaticus. Airway obstruction in status asthmaticus

often results in hypoxemia.
 Respiratory failure. Asthma, if left untreated, progresses to
respiratory failure.
 Pneumonia. Mucus that pools in the lungs and becomes infected
can lead to the development of pneumonia.

Assessment and Diagnostic Findings

To determine the diagnosis of asthma, the clinician must determine that

episodic symptoms of airway obstruction are present.

 Positive family history. Asthma is a hereditary disease, and can

be possibly acquired by any member of the family who has asthma
within their clan.
 Environmental factors. Seasonal changes, high pollen counts,
mold, pet dander, climate changes, and air pollution are primarily
associated with asthma.
 Comorbid conditions. Comorbid conditions that may accompany
asthma may include gastroeasophageal reflux, drug-induced
asthma, and allergic broncopulmonary aspergillosis.
Medical Management

Immediate intervention may be necessary, because continuing and

progressive dyspnea leads to increased anxiety, aggravating the situation.

Pharmacologic Therapy

 Short-acting beta2 –adrenergic agonists. These are the

medications of choice for relief of acute symptoms and prevention of
exercise-induced asthma.
 Anticholinergics. Anticholinergics inhibit muscarinic cholinergic
receptors and reduce intrinsic vagal tone of the airway.
 Corticosteroids. Corticosteroids are most effective in alleviating
symptoms, improving airway function, and decreasing peak flow
variability.
 Leukotriene modifiers. Anti Leukotrienes are potent
bronchoconstrictors that also dilate blood vessels and alter
permeability.
 Immunomodulators. Prevent binding of IgE to the high affinity
receptors of basophils and mast cells.

Peak Flow Monitoring

Peak Flow Meter. Image via: medlineplus.gov

 Peak flow meters. Peak flow meters measure the highest airflow
during a forced expiration.
 Daily peak flow monitoring. This is recommended for patients
who meet one or more of the following criteria: have moderate or
severe persistent asthma, have poor perception of changes in
 airflow or worsening symptoms, have unexplained response to
environmental or occupational exposures, or at the discretion of the
clinician or patient.
 Function. If peak flow monitoring is used, it helps measure asthma
severity and, when added to symptom monitoring, indicates the
current degree of asthma control.

Nursing Management

The immediate care of patients with asthma depend on the severity of the
symptoms.

Nursing Assessment

Assessment of a patient with asthma includes the following:

 Assess the patient’s respiratory status by monitoring the severity of

the symptoms.
 Assess for breath sounds.
 Assess the patient’s peak flow.
 Assess the level of oxygen saturation through the pulse oximeter.
 Monitor the patient’s vital signs.

Nursing Diagnosis

Based on the data gathered, the nursing diagnoses appropriate for the
patient with asthma include:

 Ineffective airway clearance related to increased production of

mucus and bronchospasm.
 Impaired gas exchange related to altered delivery of inspired O2.
 Anxiety related to perceived threat of death.
Nursing Care Planning & Goals

Main Article: 5 Bronchial Asthma Nursing Care Plans

To achieve success in the treatment of a patient with asthma, the following

goals should be applied:

 Maintenance of airway patency.

 Expectoration of secretions.
 Demonstration of absence/reduction of congestion with breath
sounds clear, respirations noiseless, improved oxygen exchange.
 Verbalization of understanding of causes and therapeutic
management regimen.
 Demonstration of behaviors to improve or maintain clear airway.
 Identification of potential complications and how to initiate
appropriate preventive or corrective actions.

Nursing Interventions

The nurse generally performs the following interventions:

 Assess history. Obtain a history of allergic reactions to

medications before administering medications.
 Assess respiratory status. Assess the patient’s respiratory status
by monitoring the severity of symptoms, breath sounds, peak flow,
pulse oximetry, and vital signs.
 Assess medications. Identify medications that the patient is
currently taking. Administer medications as prescribed and monitor
the patient’s responses to those medications; medications may
include an antibiotic if the patient has an underlying
respiratory infection.
 Pharmacologic therapy. Administer medications as prescribed and
monitor patient’s responses to medications.
 Fluid therapy. Administer fluids if the patient is dehydrated.
Evaluation

To determine the effectiveness of the plan of care, evaluation must be

performed. The following must be evaluated:

 Maintenance of airway patency.

 Expectoration or clearance of secretions.
 Absence /reduction of congestion with breath sound clear, noiseless
respirations, and improved oxygen exchange.
 Verbalized understanding of causes and therapeutic management
regimen.
 Demonstrated behaviors to improve or maintain clear airway.
 Identified potential complications and how to initiate appropriate
preventive or corrective actions.

Discharge and Home Care Guidelines

A major challenge is to implement basic asthma management principles at

the home and community level.

 Collaboration. The complex therapy of treating asthma at home

needs collaboration between the patient and the health care
provider to determine the desired outcomes and to formulate a plan
to achieve those outcomes.
 Health education. Patient teaching is a critical component of care
for patients with asthma. Teach patient and family about asthma
(chronic inflammatory), purpose and action of medications, triggers
to avoid and how to do so, and proper inhalation technique. Instruct
patient and family about peak-flow monitoring. Obtain current
educational materials for the patient based on the patient’s
diagnosis, causative factors, educational level, and cultural
background.
 Compliance to therapy. Nurses should emphasize adherence to
the prescribed therapy, preventive measures, and the need to keep
follow-up appointments with health care providers. Teach patient
 how to implement an action plan and how and when to seek
assistance.
 Home visits. Home visits by the nurse to assess the home
environment for allergens may be indicated for patients with
recurrent exacerbations.

Documentation Guidelines

Documentation is a necessary part of the nursing care provided, and the

following data must be documented:

 Related factors for individual client.

 Breath sounds, presence and character of secretions, and use of
accessory muscles for breathing.
 Character of cough and sputum.
 Respiratory rate, pulse oximetry/o2 saturation, and vital signs.
 Plan of care and who is involved in planning.
 Teaching plan.
 Client’s response to interventions, teaching, and actions performed.
 Use of respiratory devices/airway adjuncts.
 Response to medications administered.
 Attainment or progress towards desired outcomes.
 Modifications to the plan of care.