What are the nursing interventions needed when treating someone having an exacerbation of asthma?

Medical & Surgical Nursing (Notes)

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• Asthma is a chronic inflammatory disease of the airways characterized by hyper-responsiveness, mucosal edema, and mucus production.
• This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea.
• 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.

The main triggers for asthma are allergies, viral infections, autonomic nervous system imbalances that can cause an increase in parasympathetic stimulation, medications, psychological factors, and exercise. Of asthmatic conditions in patients under 30 years old, 70% are caused by allergies. Three major indoor allergens are dust mites, cockroaches, and cats. In older patients,the cause is almost always nonallergic types of irritants such as smog. Heredity plays a part in about one-third of the cases.

Pathophysiology

1. An asthma attack may occur spontaneously or in response to a trigger. Either way, the attack progresses in the following manner:

• There is an initial release of inflammatory mediators from bronchial mast cells, epithelial cells, and macrophages, followed by activation of other inflammatory cells
• Alteration of autonomic neural control of airway tone and epithelial integrity occur and the increased responsiveness in airways smooth muscle results in clinical manifestations (e.g. wheezing and dyspnea)

2. Three events contribute to clinical manifestations

• Bronchial spasm
• Inflammation and edema of the mucosa
• Production of thick mucus, which results in increased airway resistance, premature closure of airways, hyperinflation, increased work of breathing, and impaired gas exchange

3. If not treated promptly, status asthmaticus – an acute, severe, prolonged asthma attack that is unresponsive to the usual treatment – may occur, requiring hospitalization.

Classification

1. Extrinsic Asthma – called Atopic/allergic asthma. An “allergen” or an “antigen” is a foreign particle which enters the body. Our immune system over-reacts to these often harmless items, forming “antibodies” which are normally used to attack viruses or bacteria. Mast cells release these antibodies as well as other chemicals to defend the body.

Common irritants:

• Cockroach particles
• Cat hair and saliva
• Dog hair and saliva
• House dust mites
• Mold or yeast spores
• Metabisulfite, used as a preservative in many beverages and some foods
• Pollen

2. Intrinsic asthma – called non-allergic asthma, is not allergy-related, in fact it is caused by anything except an allergy. It may be caused by inhalation of chemicals such as cigarette smoke or cleaning agents, taking aspirin, a chest infection, stress, laughter, exercise, cold air, food preservatives or a myriad of other factors.

• Smoke
• Exercise
• Gas, wood, coal, and kerosene heating units
• Natural gas, propane, or kerosene used as cooking fuel
• Fumes
• Smog
• Viral respiratory infections
• Wood smoke
• Weather changes

 Clinical Manifestations

• Most common symptoms of asthma are cough (with or without mucus production), dyspnea, and wheezing (first on expiration, 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.
• Chest tightness and dyspnea occur.
• 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.

Primary Nursing Diagnosis

Ineffective airway clearance related to obstruction from narrowed lumen and thick mucus

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level
INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning;Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning;Respiratory monitoring

Assessment and Diagnostic Methods

• Family, environment, and occupational history is essential.
• During acute episodes, sputum and blood test, pulse oximetry, ABGs, hypocapnia and respiratory alkalosis, and pulmonary function (forced expiratory volume [FEV] and forced vital capacity [FVC] decreased) tests are performed.
• Spirometry will detect:
  1. Decreased for expiratory volume (FEV)
  2. Decreased peak expiratory flow rate (PEFR)
  3. Diminished forced vital capacity (FVC)
  4. Diminished inspiratory capacity (IC)

Steps of Clinical and Diagnostic as per National Asthma Education and Prevention Program

Mild Intermittent Asthma

• Symptoms ? 2 times per week
• Brief exacerbations
• Nighttime symptoms ? 2 times a month
• Asymptomatic and normal PEF (peak expiratory flow) between exacerbations
• PEF or FEV, (forced expiratory volume in 1 second) ? 80% of predicted value
• PEF variability < 20%

Mild Persistent Asthma

• Symptoms > 2 times/week, but less than once a day
• Exacerbations may affect activity
• Nighttimes symptoms > 2 times a month
• PEF/FEV ? 80% of predicted value
• PEF variability 20%-30%

Moderate Persistent Asthma

• Daily Symptoms
• Daily use of inhaled short-acting ?2 – agonists
• Exacerbations affect activity
• Exacerbations ? 2 times a week
• Exacerbations may last  days
• Nighttime symptoms > once a week
• PEF/FEV > 60%-<80% of predicted value
• PEF variability > 30%

Severe Persistent Asthma

• Continual symptoms
• Frequent exacerbations
• Frequent nighttime symptoms
• Limited physical activity
• PEF or FEV ? 60% of predicted value
• PEF variability > 30 %

Medical Management

Pharmacologic Therapy

There are two classes of medications—long-acting control and quick-relief medications—as well as combination products.

• Short-acting beta2-adrenergic agonists
• Anticholinergics
• Corticosteroids: metered-dose inhaler (MDI)
• Leukotriene modifiers inhibitors/antileukotrienes
• Methylxanthines

Nursing Management

The immediate nursing care of patients with asthma depends on the severity of symptoms. The patient and family are often frightened and anxious because of the patient’s dyspnea. Therefore, a calm approach is an important aspect of care.

• Assess the patient’s respiratory status by monitoring the severity of symptoms, breath sounds, peak flow, pulse oximetry, and vital signs.
• Obtain a history of allergic reactions to medications before administering medications.
• Identify medications 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.
• Administer fluids if the patient is dehydrated.
• Assist with intubation procedure, if required.

Teaching Points

• 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.
• Teach patient how to implement an action plan and how and when to seek assistance.
• Obtain current educational materials for the patient based on the patient’s diagnosis, causative factors, educational level, and cultural background.

Continuing Care

• Emphasize adherence to prescribed therapy, preventive measures, and need for followup appointments.
• Refer for home health nurse as indicated.
• Home visit to assess for allergens may be indicated (with recurrent exacerbations).
• Refer patient to community support groups.
• Remind patients and families about the importance of health promotion strategies and recommended health screening.

Documentation Guidelines

• Respiratory status: Patency of airway, auscultation of the lungs, presence or absence of adventitious breath sounds, respiratory rate and depth
• Response to medications, oxygen therapy, hydration, bedrest
• Presence of complications: Respiratory failure, ruptured bleb that may result in a pneumothorax

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Ineffective Airway Clearance

Assessment

Patient may manifest

• Difficulty breathing
• Changes in depth and rate of respiration
• Use of respiratory accessory muscles
• Persistent ineffective cough with or without sputum production
• Wheezing upon inspiration and expiration
• Dyspnea
• Coughing
• Tachypnea, prolonged expiration
• Tachycardia
• Chest tightness
• Suprasternal retraction
• Restlessness
• Anxiety
• Cyanosis
• Loss of consciousness

Nursing Diagnosis

• Ineffective airway clearance RT bronchoconstriction, increased mucus production, and respiratory infection AEB wheezing, dyspnea,  and cough

May be related to

• Increased production or retainment of pulmonary secretions
• Bronchospasms
• Decreased energy
• Fatigue

Planning

• Patient will maintain/improve airway clearance AEB absence of signs of respiratory distress
• Patient will verbalize understanding that allergens like dust, fumes, animal dander, pollen, and extremes of temperature and humidity are irritants or factors that can contribute to ineffective airway clearance and should be avoided.
• Patient will demonstrate behaviors that would prevent the recurrence of the problem.

Nursing Interventions

• Keep the patient adequately hydrated.
  • Rationale: Systemic hydration keeps secretion moist and easier to expectorate.
• Teach and encourage the use of diaphragmatic breathing and coughing exercises.
  • Rationale: These techniques help to improve ventilation and mobilize secretions without causing breathlessness and fatigue.
• Instruct patient to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperature, and fumes.
  • Rationale: Bronchial irritants cause bronchoconstriction and increased mucus production, which then interfere with airway clearance.
• Teach early signs of infection that are to be reported to the clinician immediately.
  • Rationale: Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of an asthmatic person. Early recognition is crucial.
• Assist and prepare patient for postural drainage.
  • Rationale: Uses gravity to help raise secretions so they can be more easily expectorated.
• Administer nebulization as ordered.
  • Rationale: This ensures adequate delivery of medications to the airways.
• Administer medications as ordered.
  • Rationale: Antibiotics may be prescribed to treat the infection.

Ineffective Breathing Pattern

Assessment

Patient may manifest: 

• wheezing upon inspiration and expiration
• dyspnea
• coughing
• tachypnea
• tachycardia
• chest tightness
• suprasternal retraction
• restlessness
• anxiety
• cyanosis
• loss of consciousness

Nursing Diagnosis

• Ineffective breathing pattern r/t presence of secretions AEB productive cough and dyspnea

Planning

• Patient will demonstrate pursed-lip breathing and diaphragmatic breathing.
• Patient will manifest signs of decreased respiratory effort AEB absence of dyspnea
• Patient will verbalize understanding of causative factors and demonstrate behaviors that would improve breathing pattern

Nursing Interventions

• Assess patient’s respiratory rate, depth, and rhythm. Obtain pulse oximetry.
  • Rationale: To obtain baseline data
• Monitor and record vital signs.
  • Rationale:Increase in respiratory rate could mean worsening condition.
• Auscultate breath sounds and assess airway pattern
  • Rationale: to check for the presence of adventitious breath sounds
• Elevate head of the bed and change position of the pt. every 2 hours.
  • Rationale: To  minimize difficulty in breathing
• Encourage deep breathing and coughing exercises.
  • Rationale: To maximize effort for expectoration.
• Demonstrate diaphragmatic and pursed-lip breathing.
  • Rationale: To decrease air trapping and for efficient breathing.
• Encourage increase in fluid intake
  • Rationale: To prevent fatigue.
• Encourage opportunities for rest and limit physical activities.
  • Rationale: To prevent situations that will aggravate the condition
• Reinforce low salt, low fat diet as ordered.
  • Rationale: To mobilize secretions.

Impaired Gas Exchange

Assessment

Patient may manifest: 

• wheezing upon inspiration and expiration
• dyspnea
• coughing, sputum is yellow and sticky
• tachypnea, prolonged expiration
• tachycardia
• chest tightness
• suprasternal retraction
• restlessness
• anxiety
• cyanosis
• Altered loc
• Changes in ABGs

Nursing Diagnosis

• Impaired gas exchange RT ventilation perfusion imbalance AEB dyspnea, tachypnea, and tachycardia

May be related to

• altered delivery of inspired O2 or air trapping

Planning

• Patient will improve gas exchange AEB absence of respiratory distress
• Patient will demonstrate improved ventilation and adequate oxygenation of tissues by ABG’s within client’s normal limits and absence of symptoms of respiratory distress.
• Patient will verbalize understand of causative factors and appropriate interventions (deep breathing, cough exercises, etc)

Nursing Interventions

• Assess vital signs, noting respiratory rate, depth, and rhythm.
  • Rationale: To obtain baseline data
• VS monitor and record
  • Rationale: Serve to track important changes
• Auscultate breath sounds and assess airway pattern
  • Rationale: to check for the presence of adventitious breath sounds
• Elevate head of the bed and change position of the pt. every 2 hours.
  • Rationale: To minimize difficulty in breathing and promote maximum lung expansion.
• Encourage deep breathing and coughing exercises.
  • Rationale: To maximize effort for expectoration.
• Demonstrate diaphragmatic and pursed-lip breathing.
  • Rationale: To decrease air trapping and for efficient breathing.
• Encourage increase in fluid intake
  • Rationale: To prevent fatigue.
• Encourage opportunities for rest and limit physical activities.
  • Rationale: To prevent situations that will aggravate the condition
• Reinforce low salt, low fat diet as ordered.
  • Rationale: To mobilize secretions.

Fatigue

Assessment

Patient may manifest: 

• Generalized weakness
• Verbalization of overwhelming lack of energy
• Inability to maintain usual routines
• Tired
• Lethargic
• Compromised concentration
• Decreased performance

Nursing Diagnosis

• Fatigue r/t physical exertion to maintain adequate ventilation AEB use of accessory muscles to breathe

Planning

• Patient will verbalize understand on health teachings given and report improved sense of energy.
• Patient will perform ADL’s within client’s ability and participates in desired activities.
• Patient will be able to identify basis of fatigue and be able to cope up with the problem.

Nursing Interventions

• Establish rapport
  • Rationale: To gain patient’s trust
• Monitor and record vital signs.
  • Rationale: For baseline data.
• Provide environment conducive to relief of fatigue.
  • Rationale: Temperature and level of humidity are known to affect exhaustion.
• Assist client to identify appropriate coping behaviors.
  • Rationale: Promotes sense of control and improves self-esteem.
• Encourage patient to restrict activity and rest in bed as much as possible.
  • Rationale: Helps counteract effects of increased metabolism.
• Avoid topics that irritate or upset patient. Discuss ways to respond to these feelings.
  • Rationale: Increased irritability of the CNS may cause patient to be easily excited, agitated and prone to emotional outbursts.
• Discuss with the patient the need for activity. Plan schedule with patient and identify activities that lead to fatigue.
  • Rationale: Education may provide motivation to increase activity level even though patient may feel too weak initially.
• Alternate activity with rest periods.
  • Rationale: Prevents excessive fatigue.
• Monitor VS before and after activity.
  • Rationale: Indicates physiological levels of tolerance.
• Increase patient participation in ADL’s as tolerated.
  • Rationale: Increases confidence level and/or self-esteem and tolerance level

Risk for Activity Intolerance

Assessment

• Not applicable. Presence of signs and symptoms will establish an actual nursing diagnosis. 

Nursing Diagnosis

• Risk for Activity Intolerance r/t decrease oxygenation

Planning

• Patient will participate willingly in necessary/ desired activities such as deep breathing exercises.
• Patient will perform ADL’s within client’s ability and participates in desired activities.
• Patient will be able to increase activity tolerance AEB attendance of self-care needs.
• Patient will be able to gradually increase activity within level of ability

Nursing Interventions

• Monitor VS.
  • Rationale: For baseline data.
• Assess motor function.
  • Rationale: To identify causative factors.
• Note contributing factors to fatigue.
  • Rationale: To identify precipitating factors.
• Evaluate degree of deficit.
  • Rationale: To identify severity.
• Ascertain ability to stand and move about.
  • Rationale: To identify necessity of assistive devices.
• Assess emotional or psychological factors
  • Rationale: Stress and/or depression may increase the effects of illness.
• Plan care with rest periods between activities
  • Rationale: To reduce fatigue
• Increase activity/exercise gradually such as assisting the patient in doing PROM to active or full range of motions.
  • Rationale: Minimizes muscle atrophy, promotes circulation, helps to prevent contractures
• Provide adequate rest periods.
  • Rationale: To replenish energy.
• Assist client in doing self care needs
  • Rationale: To promote independence and increase activity tolerance
• Elevate arm and hand
  • Rationale: Promotes venous
• Place knees and hips in extended position
  • Rationale: Maintains functional

Other Possible Nursing Care Plans

• Anxiety—may be related to perceived threat of death, possibly evidenced by apprehension, fearful expression, and extraneous movements.
• Risk for contamination—risk factors may include presence of atmospheric pollutants, environmental contaminants in the home.

Sample NCP

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