Asthma is a chronic respiratory condition characterized by the constriction of muscles around the airways and inflammation with mucus accumulation, leading to breathing difficulties. Asthma attacks, if untreated, can be life-threatening, highlighting the importance of effective management and care. While there is no definitive cure, numerous treatments are available to control and manage asthma effectively.
It is particularly prevalent in children, making it the most common chronic condition in this demographic. Children’s airways, being smaller, are more susceptible to swelling and mucus, exacerbating asthma symptoms. Although approximately half of childhood asthma cases resolve by adolescence, the condition can recur in adulthood.
In this article, we will delve into the essential aspects of asthma management from a nursing perspective, focusing on creating and implementing an effective Asthma Diagnosis Care Plan.
Nursing Approach to Asthma Management
Nurses frequently encounter patients with asthma, both in acute exacerbations requiring immediate intervention and as a chronic condition requiring ongoing management. A crucial role of nurses is to empower patients through education, equipping them with knowledge about their symptoms, triggers, and medications to effectively manage their asthma. This comprehensive approach forms the cornerstone of an asthma diagnosis care plan.
Comprehensive Asthma Nursing Assessment
The initial step in providing optimal nursing care is a thorough nursing assessment. This involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic – to understand the patient’s condition fully. This section will outline both subjective and objective data points crucial in assessing asthma for an effective asthma diagnosis care plan.
Detailed Review of Health History
1. Identify General Asthma Symptoms. Recognize and document common asthma indicators:
- Persistent coughing, particularly at night or early morning
- Wheezing sounds during breathing, audible to the ear
- Shortness of breath (dyspnea)
- Chest tightness, a constricting sensation in the chest
2. Pinpoint Asthma Triggers. Determine factors that worsen symptoms. Note seasonal variations or triggers associated with infections like colds. Common asthma triggers include:
- House dust mites
- Tobacco smoke
- Pollen from grass and trees
- Animal dander (fur and feathers)
- Cockroaches
- Strong fragrances from soaps and perfumes
- Fumes from gasoline or strong chemicals
- Physical exercise
- Certain medications (see below)
- Intense emotions
- Exposure to cold, dry air
3. Evaluate Co-existing Health Conditions. Identify comorbidities that can complicate asthma management. These include:
- Obstructive sleep apnea
- COPD (Chronic Obstructive Pulmonary Disease)
- Food allergies
- Gastroesophageal reflux disease (GERD)
- Nasal polyps
- Pregnancy
- Respiratory infections
4. Determine Early Life Risk Factors. Explore events during early development that may predispose individuals to asthma:
- Low birth weight
- Premature birth
- Exposure to tobacco smoke (secondhand smoke)
- Air pollution exposure
- Viral respiratory infections (e.g., RSV)
5. Medication Review for Asthma Triggers. Scrutinize the patient’s current medication list for drugs known to potentially exacerbate asthma:
- Beta-blockers (often for heart conditions or blood pressure)
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Aspirin
6. Family Asthma History. Inquire about family history of asthma, as genetics play a significant role. The risk increases substantially if parents or siblings have asthma.
7. Allergy Assessment. Recognize the strong link between allergies and asthma. Allergic conditions often coincide and trigger asthma symptoms, termed allergic asthma. Note presence of:
- Eczema (atopic dermatitis)
- Rhinitis (allergic rhinitis, hay fever)
- Sinusitis
- Hives (urticaria)
- Nasal polyps
8. Environmental Factor Assessment. Consider environmental exposures, particularly in urban settings where asthma prevalence is higher due to:
- Mold
- Dust mites
- Air pollution (outdoor and indoor)
- Chemical fumes
- General dust
- Wood smoke from fires
- Occupational exposures to irritants
9. Body Mass Index (BMI) Assessment. Assess BMI, as obesity is a risk factor for asthma development and can worsen symptom control.
10. Social History Relevance. Social determinants can significantly impact asthma. Evaluate:
- Living conditions (housing quality, overcrowding)
- Smoking habits (active and passive)
- Workplace or school environments (exposure to triggers)
- Employment type and setting
- Social support systems
- Substance use
- Financial constraints affecting medication access
- Medication adherence history
11. Exacerbation History. Detailed history of asthma attacks is vital. Note:
- Common early warning signs of attacks
- Speed of onset (sudden or gradual)
- Precipitating factors or triggers for past attacks
- Frequency of exacerbations in the past year
- History of emergency room visits, hospitalizations, or intubation
- Impact of asthma on daily living and activity levels
- Missed work or school days due to asthma
12. Asthma Knowledge Assessment. Evaluate the patient’s and/or caregiver’s understanding of asthma management:
- Knowledge of personal asthma triggers
- Proper medication usage (inhaler technique, timing)
- Effective coping strategies during attacks
- Availability of family support
- Access to financial resources for healthcare
Physical Examination for Asthma
1. Vital Signs Monitoring. Assess for signs of asthma exacerbation severity through vital signs:
Mild Exacerbation:
- Increased respiratory rate
- Heart rate below 100 bpm
- Absence of pulsus paradoxus (drop in systolic blood pressure during inhalation)
- SpO2 (oxygen saturation) greater than 95%
Moderate Exacerbation:
- Increased respiratory rate
- Heart rate between 100-120 bpm
- Presence of pulsus paradoxus
- SpO2 between 91-95%
Severe Exacerbation:
- Respiratory rate exceeding 30 breaths per minute
- Heart rate greater than 120 bpm
- SpO2 less than 90%
2. Physical Assessment Findings. Observe physical signs indicating exacerbation level:
Mild Exacerbation:
- Breathlessness only after physical activity
- Ability to speak in full sentences and lie down comfortably
Moderate Exacerbation:
- Breathlessness while talking
- Use of accessory muscles for breathing
- Retractions, nasal flaring, and abdominal breathing (in children)
- Poor feeding in infants, weaker cry
Severe Exacerbation:
- Breathlessness at rest
- Tripod positioning (leaning forward to breathe)
- Marked accessory muscle use and chest retractions
- Agitation or decreased alertness
- Speaking only in single words or short phrases
3. Recognize Respiratory Failure Signs. Be vigilant for signs of impending respiratory failure, including:
- Drowsiness or confusion (especially in children)
- Absent wheezing (silent chest), indicating severe airway constriction
- Severe hypoxemia with bradycardia (slow heart rate)
- Diaphoresis (sweating), bradypnea (slow breathing), agitation
- Patient stating “I can’t breathe” and pulling at oxygen devices due to fatigue
4. Lung Auscultation. Listen for characteristic breath sounds:
- Expiratory wheezing, typically bilateral
- Inspiratory and expiratory wheezing in severe exacerbations
- Diminished or absent breath sounds in life-threatening asthma due to severely restricted airflow
5. Cough Pattern Observation. Note cough characteristics:
- Nocturnal cough is a key indicator of asthma, often occurring in early morning hours when bronchoconstriction is maximal.
6. Exercise-Induced Symptom Monitoring. Evaluate symptoms during or after exercise:
- Typical asthma symptoms (cough, wheeze, shortness of breath)
- Sore throat or gastrointestinal upset may also be reported
Diagnostic Procedures for Asthma
1. Peak Flow Meter Use. Utilize peak flow meters for objective assessment of airflow:
- Portable, easy-to-use devices to measure peak expiratory flow rate (PEFR)
- Compares current PEFR to patient’s personal best or predicted values
- Aids in assessing asthma severity and response to treatment
2. Arterial Blood Gas (ABG) Analysis. Obtain ABGs in acute settings:
- Measures blood oxygen and carbon dioxide levels, and pH
- May reveal respiratory alkalosis and hypoxemia in asthma exacerbations
3. Electrocardiogram (ECG). Perform ECG in severe asthma:
- Necessary for patients with severe symptoms to assess cardiac function, especially if beta-agonists are used.
4. Chest X-ray. Assist with chest X-ray:
- Useful to rule out other pulmonary conditions, especially in acute asthma.
- Chest CT scan may be indicated for persistent symptoms unresponsive to treatment.
5. Spirometry Testing. Facilitate spirometry:
- Preferred diagnostic test for asthma, measures lung function.
- Demonstrates obstructive pattern, reversible with bronchodilator (e.g., salbutamol).
- Essential to assess disease severity before initiating long-term treatment.
6. Allergy Testing Discussion. Discuss allergy testing options:
- Skin prick tests or blood tests (RAST) to identify common allergic triggers (dust mites, pet dander, pollen).
- Helps in tailoring environmental control and potential immunotherapy.
Nursing Interventions for Asthma Management
Effective nursing interventions are crucial for patient recovery and long-term asthma control. The following section details key interventions within an asthma diagnosis care plan.
Managing Acute Asthma Symptoms
1. Albuterol Administration. Provide immediate bronchodilation:
- Administer inhaled beta2-agonist like albuterol for acute exacerbations.
- Repeat doses as needed, typically up to three times initially, then every 1-4 hours.
2. Oxygen Therapy. Administer supplemental oxygen as prescribed:
- Based on severity of exacerbation and SpO2 levels.
- Via nasal cannula or face mask to treat hypoxia.
3. Steroid Administration. Use corticosteroids to reduce airway inflammation:
- Oral steroids are often as effective as IV steroids in acute exacerbations.
- Alleviate airway obstruction and prevent late-phase inflammatory responses.
4. Hospitalization Preparation. Determine need for hospital admission:
- Based on symptom severity and duration, past exacerbation history.
- Ability to adhere to medication at home and adequacy of support system.
ICU Admission Criteria:
- Worsening condition despite initial treatment.
- Altered mental status.
- Respiratory arrest.
- Need for intubation.
5. Alternative Therapy Consideration. Discuss options beyond standard medications:
- Allergen immunotherapy (allergy shots) for specific allergen triggers when medications are insufficient.
- Monoclonal antibody treatments for moderate to severe allergic asthma (reduces IgE levels).
- Bronchial thermoplasty: a bronchoscopic procedure to reduce airway constriction in severe cases.
Preventing Future Asthma Exacerbations
1. Medication Adherence Education. Emphasize proper medication use and schedules:
- Differentiate between long-term control (daily) and short-term rescue (as needed) medications.
- Provide thorough instruction on inhaler technique, spacers, and nebulizer use.
Long-term Control Medications:
- Inhaled corticosteroids (ICS)
- Leukotriene modifiers
- Combination inhalers (ICS/LABA)
- Theophylline
Short-term (Rescue) Medications:
- Short-acting beta agonists (SABA) – e.g., albuterol
- Anticholinergics (e.g., ipratropium)
- Oral and intravenous corticosteroids (for exacerbations)
2. Environmental Control Promotion. Advise on strategies to minimize allergen exposure at home:
- Regular cleaning and dusting, damp dusting preferred.
- Use face mask during vacuuming.
- Cockroach eradication.
- Smoke avoidance (primary and secondary).
- Allergen-proof mattress and pillow covers for dust mites.
- Hot water washing of bedding.
- Storing clothes in closets and drawers.
- Dehumidification to reduce humidity.
- Staying indoors during high pollen counts.
- Wearing mask while mowing lawn.
- Regular pet grooming and keeping pets out of bedrooms.
3. Lifestyle and Occupational Modifications. Encourage healthy habits:
- Self-monitoring of symptoms and peak flow.
- Weight management if overweight or obese.
- Smoking cessation.
- Limiting exposure to air pollution and occupational irritants.
4. Long-Term Monitoring Education. Develop and review asthma action plan:
- Provide written asthma action plan, personalized to the patient.
- Educate on when to contact provider or seek emergency care.
- Demonstrate peak flow meter use and interpretation.
- Ensure referral to pulmonologist and schedule follow-up spirometry.
5. Vaccination Promotion. Emphasize importance of vaccinations:
- Recommend and schedule influenza, pneumococcal, and other vaccines.
- Respiratory infections are common asthma triggers and can worsen outcomes.
Asthma Nursing Care Plans: Examples
Once nursing diagnoses are identified, specific nursing care plans guide interventions and prioritize care, setting both short-term and long-term goals. Examples of asthma nursing care plans include addressing:
Activity Intolerance
Asthma symptoms, particularly dyspnea and fatigue, can significantly limit activity levels.
Nursing Diagnosis: Activity Intolerance
Related to:
- Airway constriction
- Oxygen supply and demand imbalance
As evidenced by:
- Dyspnea on exertion
- Chest tightness
- Fatigue
- Inability to perform age-appropriate activities
- Sleep disturbance due to respiratory symptoms
Expected Outcomes:
- Patient will perform ADLs without significant dyspnea or wheezing.
- Child will engage in play without activity-induced shortness of breath or coughing.
Assessments:
- Identify activity triggers, especially exercise-induced asthma.
- Assess current activity limitations compared to baseline.
- Evaluate emotional factors (fear of attacks) impacting activity.
Interventions:
- Encourage gradual increase in activity, like walking or yoga.
- Educate on trigger avoidance before outdoor activities.
- Suggest alternative, less strenuous activities (crafts, golf).
- Plan for exercise: pre-medication, warm-up, monitoring, and knowing when to stop.
Impaired Gas Exchange
Airway narrowing and mucus lead to impaired gas exchange, a critical concern in asthma.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Bronchospasm
- Airway obstruction
- Respiratory muscle fatigue
- Inflammation
As evidenced by:
- Dyspnea
- Mental status changes (confusion, agitation)
- Abnormal vital signs (tachycardia, tachypnea)
- Hypoxia (low SpO2)
- Hypercapnia (elevated CO2)
- Cyanosis
- Restlessness
Expected Outcomes:
- Improved ventilation and oxygenation, evidenced by ABGs within normal limits.
- Absence of respiratory distress signs.
- Patient will verbalize symptoms requiring prompt medical attention.
Assessments:
- Monitor respiratory status: rate, SpO2, breathlessness, accessory muscle use.
- Assess for mental status changes indicating worsening gas exchange.
- Monitor heart rate and rhythm for tachycardia due to hypoxemia.
Interventions:
- Administer supplemental oxygen.
- Monitor ABGs in severe cases to guide treatment.
- Administer bronchodilators and corticosteroids as prescribed.
- Prepare for possible intubation if respiratory failure is impending.
Ineffective Airway Clearance
Excess mucus and bronchoconstriction contribute to ineffective airway clearance.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Airway edema
- Mucus hypersecretion
- Bronchoconstriction
- Respiratory infections
- Trigger exposures
As evidenced by:
- Abnormal respiratory rate and rhythm
- Adventitious breath sounds (wheezing, rhonchi, crackles)
- Dyspnea
- Cough (productive or non-productive)
- Restlessness
Expected Outcomes:
- Maintain a patent airway.
- Effectively expectorate secretions.
- Clear breath sounds on auscultation.
Assessments:
- Monitor respiratory status: breathing patterns, accessory muscle use, cough.
- Auscultate lungs for abnormal breath sounds indicating secretions.
- Assess for infection signs (fever, change in sputum).
Interventions:
- Elevate head of bed to facilitate breathing and secretion drainage.
- Administer anticholinergics (e.g., ipratropium) to reduce mucus.
- Minimize allergen exposure.
- Educate and assist with proper use of nebulizer or metered-dose inhaler (MDI).
Ineffective Breathing Pattern
Airway narrowing leads to ineffective breathing patterns and inadequate ventilation.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Lung inflammation and swelling
- Airway spasm
- Increased mucus production
As evidenced by:
- Dyspnea
- Coughing
- Cyanosis
- Nasal flaring
- Accessory muscle use
- Wheezing
- Tachypnea
Expected Outcomes:
- Effective breathing pattern with normal respiratory rate and rhythm, without wheezing or coughing.
- Patient will identify personal asthma triggers.
- Patient will demonstrate correct peak flow meter use.
Assessments:
- Auscultate lungs for wheezing and other abnormal sounds.
- Continuously monitor respiratory status for changes.
- Monitor ABGs for respiratory alkalosis or acidosis.
Interventions:
- Administer bronchodilators (albuterol) and corticosteroids.
- Instruct on daily peak flow meter monitoring.
- Assist patient in identifying and avoiding their triggers.
- Promote calm, controlled breathing techniques during exacerbations.
Readiness for Enhanced Therapeutic Regimen Management
Empowering children to participate in their asthma care promotes better self-management.
Nursing Diagnosis: Readiness for Enhanced Therapeutic Regimen Management
Related to:
- (To be developed – reflects patient’s positive disposition, not a deficit)
As evidenced by:
- Expressed interest in learning about asthma.
- Curiosity about inhalers and medical devices.
- Demonstrated medication adherence.
- Accurate verbalization of asthma knowledge.
Expected Outcomes:
- Child correctly states asthma attack symptoms and knows when to seek help.
- Child uses inhalers correctly at prescribed times.
- Child experiences fewer asthma attacks.
Assessments:
- Assess child’s readiness and interest in learning and self-management.
- Evaluate support system from family, caregivers, and school.
- Assess child’s current understanding of asthma and medications.
Interventions:
- Use games and videos to educate children about asthma in an engaging way.
- Make symptom tracking fun with planners and stickers.
- Observe and correct inhaler and device technique.
- Develop a collaborative asthma action plan involving child, parents, school, and healthcare providers.
