Asthma is a prevalent chronic respiratory condition characterized by airway inflammation and constriction, leading to symptoms like wheezing, coughing, shortness of breath, and chest tightness. Effective nursing care is crucial in managing asthma, from acute exacerbations to long-term management. This guide provides a detailed overview of asthma nursing diagnosis, assessment, interventions, and care planning, designed to enhance your expertise in caring for patients with asthma.
Nursing Process for Asthma Management
Nurses frequently encounter patients with asthma in various healthcare settings. Asthma management in nursing involves addressing both acute episodes and the ongoing chronic nature of the disease. A comprehensive nursing approach includes patient education on symptom recognition, trigger avoidance, and proper medication use.
Asthma Nursing Assessment: Gathering Crucial Data
The initial step in asthma nursing care is a thorough assessment. This involves collecting subjective and objective data to understand the patient’s condition comprehensively.
Health History Review: Subjective Data Collection
1. Identify General Asthma Symptoms: Begin by asking patients about common asthma symptoms they experience:
- Persistent coughing, especially at night or early morning
- Wheezing sounds when breathing, often audible
- Dyspnea or shortness of breath, varying in severity
- Chest tightness, a constricting sensation in the chest
2. Determine Asthma Triggers: Pinpoint factors that exacerbate the patient’s asthma. Common triggers include:
- Environmental allergens such as dust mites, pollen (grass, tree), mold
- Irritants like smoke (cigarette, wood), strong perfumes, cleaning products, gasoline fumes
- Animal dander (fur and feathers)
- Pests like cockroaches
- Weather changes, particularly cold, dry air
- Exercise (exercise-induced asthma)
- Certain medications (NSAIDs, beta-blockers, aspirin)
- Strong emotions and stress
- Respiratory infections (colds, flu)
3. Assess Co-existing Health Conditions: Identify any comorbidities that can complicate asthma management:
- Obstructive sleep apnea (OSA)
- Chronic Obstructive Pulmonary Disease (COPD)
- Food allergies
- Gastroesophageal reflux disease (GERD)
- Nasal polyps
- Pregnancy
- Respiratory infections
4. Explore Early Life Risk Factors: Inquire about factors during early life that might have contributed to asthma development:
- Low birth weight
- Premature birth
- Exposure to tobacco smoke (in utero or secondhand)
- Air pollution exposure
- History of viral respiratory infections (e.g., RSV)
5. Medication Review for Trigger Identification: Carefully review the patient’s current medications, noting any potential asthma triggers:
- Beta-blockers (non-selective)
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Aspirin
6. Family History of Asthma and Allergies: Assess for familial predisposition to asthma and allergic conditions:
- Asthma in parents or siblings significantly increases risk
- Allergic conditions like eczema, rhinitis, sinusitis
7. Allergy History and Atopic Conditions: Determine if the patient has a history of allergies, as asthma often coexists with allergic conditions:
- Eczema (atopic dermatitis)
- Allergic rhinitis
- Sinusitis
- Hives (urticaria)
- Nasal polyps (associated with allergic rhinitis)
8. Environmental Exposure Assessment: Evaluate the patient’s environment for potential asthma triggers:
- Mold and mildew in home or workplace
- Dust mites in bedding and carpets
- Air pollution levels in their living area
- Exposure to fumes or chemicals at work or home
- Wood-burning stoves or fireplaces
- Occupational exposures (e.g., chemicals, dusts)
9. Body Mass Index (BMI) Evaluation: Note the patient’s BMI, as obesity is a known risk factor for asthma and can worsen symptoms.
10. Social History and Socioeconomic Factors: Explore social determinants of health that can impact asthma management:
- Living conditions (housing quality, overcrowding)
- Smoking habits (patient and household members)
- Workplace or school environment (exposure to triggers)
- Employment type and potential occupational hazards
- Social support system
- Substance use (including illegal drugs)
- Financial constraints (affecting medication access, healthcare)
- Medication adherence challenges
11. Asthma Exacerbation History: Gather details about past asthma attacks to understand their severity and frequency:
- Common early warning signs and symptoms
- Sudden or gradual onset of exacerbations
- Triggers for previous attacks
- Frequency of exacerbations in the past year
- Need for emergency room visits, hospitalizations, or intubation
- Impact of exacerbations on daily life and activities
- Absences from work or school due to asthma
12. Asthma Knowledge Assessment: Evaluate the patient’s understanding of their condition and management:
- Knowledge of asthma triggers and avoidance strategies
- Proper use of asthma medications (inhalers, spacers, nebulizers)
- Coping mechanisms and self-management techniques
- Availability of family and social support
- Financial resources for healthcare and medications
Physical Assessment: Objective Data Collection
1. Vital Signs Monitoring: Assess vital signs to determine the severity of asthma exacerbation:
- Mild Exacerbation:
- Elevated respiratory rate
- Heart rate < 100 bpm
- No pulsus paradoxus
- SpO2 > 95%
- Moderate Exacerbation:
- Increased respiratory rate
- Heart rate 100-120 bpm
- Pulsus paradoxus may be present
- SpO2 91-95%
- Severe Exacerbation:
- Respiratory rate > 30 breaths per minute
- Heart rate > 120 bpm
- SpO2 < 90%
2. Physical Examination Findings: Observe for physical signs of respiratory distress:
- Mild Exacerbation:
- Breathlessness with activity
- Able to speak in full sentences and lie down comfortably
- Moderate Exacerbation:
- Breathlessness while talking
- Use of accessory muscles to breathe
- Retractions, nasal flaring, and abdominal breathing in children
- Infants may have poor feeding and a weak cry
- Severe Exacerbation:
- Breathless at rest
- Tripod positioning (leaning forward, hands on knees)
- Marked accessory muscle use and chest retractions
- Agitation or decreased level of consciousness
- Unable to speak in full sentences, only words
3. Recognize Signs of Respiratory Failure: Be alert for signs indicating impending respiratory failure:
- Drowsiness or confusion, especially in children
- Absence of wheezing (silent chest) due to severe airway constriction
- Severe hypoxemia with bradycardia
- Diaphoresis (sweating)
- Bradypnea (slow breathing) or gasping breaths
- Agitation followed by decreased level of consciousness
- Patient may pull at oxygen mask/cannula, stating “I can’t breathe”
4. Lung Auscultation: Listen to lung sounds to assess airflow:
- Wheezing, typically bilateral and expiratory, may become inspiratory in severe cases
- In very severe exacerbations, breath sounds may be diminished or absent due to poor air movement (“silent chest”)
5. Cough Pattern Observation: Note the characteristics of the patient’s cough:
- Cough is a primary symptom, especially in nocturnal asthma
- Nighttime cough, often in early morning, is common due to increased bronchoconstriction
6. Exercise-Induced Symptoms: If relevant, assess symptoms related to exercise:
- Symptoms similar to asthma exacerbation (wheezing, cough, shortness of breath)
- Some patients may also report sore throat or gastrointestinal upset with exercise-induced asthma.
Diagnostic Procedures for Asthma
1. Peak Flow Meter Use: Utilize peak flow meters to assess lung function:
- Portable, easy-to-use devices to measure peak expiratory flow rate (PEFR)
- Compares patient’s PEFR to their baseline or predicted values
- Helps assess asthma severity and response to treatment
- Expressed as a percentage of personal best or predicted PEFR
2. Arterial Blood Gas (ABG) Analysis: Obtain ABGs in acute exacerbations, particularly if severe:
- Measures oxygen and carbon dioxide levels in arterial blood
- Assesses blood pH balance
- May reveal hypoxemia (low PaO2) and respiratory alkalosis (early) or acidosis (late) in asthma exacerbations
3. Electrocardiogram (ECG): Perform ECG in patients with severe asthma symptoms:
- Monitors heart rhythm and detects any cardiac abnormalities
- Important in severe exacerbations as hypoxemia can affect the heart
4. Chest X-ray: Consider chest X-ray, especially in acute asthma:
- Primarily used to rule out other pulmonary conditions (pneumonia, pneumothorax)
- Not routinely diagnostic for asthma itself, but helpful in differential diagnosis
- Chest CT scan may be used for persistent symptoms unresponsive to treatment to rule out structural abnormalities.
5. Spirometry: Perform spirometry for asthma diagnosis and severity assessment:
- Gold standard for asthma diagnosis
- Measures lung volumes and airflow rates (FEV1, FVC, FEV1/FVC ratio)
- Demonstrates obstructive pattern (reduced FEV1/FVC ratio)
- Bronchodilator reversibility testing: spirometry repeated after bronchodilator administration to assess improvement (significant improvement supports asthma diagnosis)
- Spirometry helps determine baseline lung function and asthma severity.
6. Allergy Testing: Consider allergy testing to identify triggers:
- Skin prick tests or blood tests (radioallergosorbent test – RAST)
- Identifies common allergens (dust mites, pet dander, pollen, mold) that may trigger asthma symptoms
- Helps guide allergen avoidance strategies and targeted therapies (allergy immunotherapy).
Alt Text: A nurse demonstrates the use of a peak flow meter to a young patient, emphasizing proper technique for accurate asthma monitoring.
Nursing Interventions for Asthma Management
Nursing interventions for asthma are aimed at managing acute symptoms and preventing future exacerbations.
Managing Acute Asthma Symptoms
1. Albuterol Administration: Administer short-acting beta2-agonists (SABAs) like albuterol for acute exacerbations:
- Inhaled albuterol provides rapid bronchodilation
- Administer immediately at the onset of acute symptoms
- Repeat doses can be given every 20 minutes for up to 3 doses, then every 1-4 hours as needed, depending on severity and response.
2. Oxygen Therapy: Administer supplemental oxygen as needed:
- Based on SpO2 levels and severity of respiratory distress
- Nasal cannula or face mask for oxygen delivery to maintain SpO2 > 90-92%
- High-flow oxygen or non-invasive ventilation may be needed in severe cases.
3. Corticosteroid Administration: Administer corticosteroids to reduce airway inflammation:
- Oral corticosteroids (prednisone, prednisolone) are often as effective as IV steroids for acute exacerbations
- Reduce airway inflammation and prevent late-phase asthma response
- Typically given for a short course (3-10 days) to control exacerbations.
4. Hospitalization Preparedness: Prepare for potential hospitalization based on assessment findings:
- Assess severity and duration of symptoms, response to initial treatment
- Consider history of severe exacerbations, comorbidities, and home support system
- Ability to adhere to medication regimen at home is crucial for discharge planning.
- ICU Admission Criteria:
- Worsening condition despite aggressive treatment
- Changes in mental status (confusion, lethargy)
- Respiratory arrest or impending respiratory failure
- Need for intubation and mechanical ventilation
5. Alternative and Adjunct Therapies: Consider other therapies in specific cases:
- Allergen Immunotherapy (Allergy Shots): For patients with identified allergic triggers where avoidance and medications are insufficient. Gradually desensitizes the patient to specific allergens.
- Monoclonal Antibody Treatments: For severe allergic asthma. Medications like omalizumab reduce IgE levels and histamine release, reducing allergic response.
- Bronchial Thermoplasty: A bronchoscopic procedure for severe asthma. Applies thermal energy to airway walls to reduce airway smooth muscle mass and constriction. Reserved for select patients with severe asthma uncontrolled by other treatments.
Preventing Future Asthma Exacerbations
1. Medication Adherence Education: Educate patients on proper medication use and adherence:
- Long-term Control Medications (Preventers): Taken daily to prevent inflammation and exacerbations.
- Inhaled corticosteroids (ICS) – e.g., fluticasone, budesonide
- Leukotriene modifiers – e.g., montelukast
- Combination inhalers (ICS + LABA) – e.g., budesonide/formoterol, fluticasone/salmeterol
- Theophylline (less common, for severe asthma)
- Short-term Relief Medications (Rescuers): Used for quick relief of acute symptoms.
- Short-acting beta-agonists (SABAs) – albuterol
- Anticholinergics – ipratropium bromide (often in combination with SABA for acute exacerbations)
- Oral corticosteroids – for exacerbation management, not routine long-term use
- Provide detailed instructions on inhaler technique, spacer use, nebulizer operation, and medication schedules.
2. Environmental Control Strategies: Educate on and implement strategies to minimize allergen and irritant exposure:
- Regular home cleaning and dusting (damp dusting)
- Use face mask during vacuuming and cleaning
- Cockroach control measures
- Smoke avoidance (tobacco, wood smoke)
- Allergen-proof mattress and pillow covers
- Wash bedding in hot water weekly
- Store clothing in closets and drawers
- Reduce indoor humidity (dehumidifier)
- Stay indoors during high pollen counts
- Wear mask when mowing lawn or gardening
- Pet management (groom regularly, keep out of bedrooms, consider HEPA filters).
3. Lifestyle and Occupational Modifications: Counsel patients on lifestyle changes to improve asthma control:
- Self-monitoring of symptoms and peak flow
- Weight management if overweight or obese
- Smoking cessation (very crucial)
- Limiting exposure to air pollution and occupational irritants
- Stress management techniques
4. Long-Term Monitoring and Action Plans: Develop and educate patients on asthma action plans:
- Provide a written asthma action plan outlining daily management, medication adjustments, and steps to take during worsening symptoms.
- Teach patients how to use a peak flow meter for home monitoring and when to adjust medications based on peak flow readings or symptom changes.
- Ensure referral to a pulmonologist or asthma specialist for ongoing management, especially for moderate to severe asthma.
- Schedule regular follow-up spirometry and asthma control assessments.
5. Vaccination Recommendations: Emphasize the importance of vaccinations:
- Annual influenza vaccine
- Pneumococcal vaccine (especially for adults with asthma)
- Other recommended vaccines (pertussis, COVID-19)
- Respiratory infections are common asthma triggers; vaccination can reduce the risk of exacerbations.
NANDA International Nursing Diagnoses for Asthma
Identifying appropriate NANDA-I nursing diagnoses is essential for creating effective care plans. Here are common NANDA asthma nursing diagnoses:
Activity Intolerance
Nursing Diagnosis: Activity Intolerance
Related to:
- Airway constriction and bronchospasm
- Imbalance between oxygen supply and demand
As evidenced by:
- Dyspnea on exertion
- Chest tightness
- Fatigue and weakness
- Reports inability to perform activities of daily living (ADLs) or participate in usual activities (play in children)
- Sleep disturbances due to respiratory distress or coughing
Expected Outcomes:
- Patient will demonstrate improved tolerance to activity, able to perform ADLs without significant dyspnea or wheezing.
- Child will participate in play and age-appropriate activities without shortness of breath or excessive coughing.
Nursing Assessments:
- Assess Activity Triggers: Identify activities that trigger symptoms, such as exercise, specific chores, or recreational pursuits.
- Determine Level of Limitation: Observe and document the patient’s ability to perform activities, noting the degree of dyspnea, fatigue, and limitations compared to their baseline.
- Monitor Emotional Factors: Assess for anxiety or fear related to activity, which may exacerbate activity intolerance.
Nursing Interventions:
- Encourage Progressive Activity: Recommend and support gradual increases in activity levels, starting with low-intensity exercises like walking or yoga, as tolerated.
- Educate on Trigger Avoidance During Activity: Advise patients to avoid outdoor activities during high pollen or pollution days, and to be mindful of temperature extremes.
- Suggest Alternative Activities: Recommend activities that are less likely to trigger asthma, such as swimming (indoor pool, if chlorine is not a trigger), walking, or low-impact sports like golf.
- Plan for Exercise-Induced Asthma: Educate on pre-medication with SABA before exercise, proper warm-up routines, and monitoring respiratory status during and after exercise.
Impaired Gas Exchange
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Bronchospasm and airway constriction
- Airway obstruction due to mucus and inflammation
- Respiratory muscle fatigue
As evidenced by:
- Dyspnea and shortness of breath
- Changes in mental status (confusion, restlessness, lethargy)
- Abnormal arterial blood gases (hypoxemia, hypercapnia)
- Cyanosis (late sign)
- Abnormal vital signs (tachypnea, tachycardia)
- Agitation
Expected Outcomes:
- Patient will demonstrate improved gas exchange, as evidenced by ABGs within normal limits for the patient.
- Patient will be free from signs of respiratory distress (cyanosis, severe dyspnea, altered mental status).
- Patient will verbalize understanding of symptoms requiring prompt medical attention.
Nursing Assessments:
- Assess Respiratory Status: Continuously monitor respiratory rate, depth, SpO2, breath sounds, and effort of breathing (accessory muscle use, retractions).
- Assess Mental Status: Monitor for changes in alertness, orientation, confusion, restlessness, or drowsiness, which can indicate hypoxemia or hypercapnia.
- Monitor Heart Rate and Rhythm: Assess for tachycardia, which may be a compensatory response to hypoxemia.
Nursing Interventions:
- Administer Oxygen Therapy: Apply supplemental oxygen to maintain adequate SpO2 levels as prescribed.
- Monitor Arterial Blood Gases (ABGs): Obtain and monitor ABGs in patients with moderate to severe exacerbations to guide oxygen therapy and other interventions.
- Administer Medications: Administer bronchodilators (SABAs, anticholinergics) and corticosteroids as prescribed to reverse bronchospasm and reduce inflammation.
- Prepare for Intubation and Mechanical Ventilation: Be prepared to assist with intubation and mechanical ventilation if the patient develops respiratory failure, indicated by worsening ABGs, mental status changes, or respiratory muscle fatigue.
Ineffective Airway Clearance
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Airway edema and inflammation
- Increased mucus production
- Bronchoconstriction
- Respiratory infections
- Exposure to asthma triggers
As evidenced by:
- Abnormal respiratory rate and rhythm (tachypnea, dyspnea)
- Adventitious breath sounds (wheezing, rhonchi, crackles)
- Excessive coughing, productive or non-productive
- Restlessness and anxiety
- Difficulty expectorating secretions
Expected Outcomes:
- Patient will maintain a patent airway.
- Patient will effectively expectorate or clear airway secretions.
- Patient will exhibit clear or improved breath sounds.
Nursing Assessments:
- Monitor Respiratory Status: Assess breathing patterns, respiratory rate and depth, use of accessory muscles, and cough effectiveness.
- Auscultate Lung Fields: Assess for adventitious breath sounds indicating mucus or airway obstruction.
- Assess for Signs of Infection: Monitor for fever, changes in sputum color or consistency, or other signs of respiratory infection that can worsen airway clearance.
Nursing Interventions:
- Elevate Head of Bed: Position patient in a semi-Fowler’s or high-Fowler’s position to promote lung expansion and secretion drainage.
- Administer Anticholinergics: Administer anticholinergic medications (e.g., ipratropium bromide) as prescribed to reduce mucus production and promote bronchodilation.
- Reduce Allergen Exposure: Implement measures to reduce exposure to known allergens and irritants in the patient’s environment.
- Educate and Assist with Inhaler/Nebulizer Use: Provide thorough education and ensure correct technique for using metered-dose inhalers (MDIs), dry powder inhalers (DPIs), and nebulizers to optimize medication delivery and airway clearance.
Ineffective Breathing Pattern
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Inflammation and swelling of airways
- Airway spasm and bronchoconstriction
- Increased mucus production
As evidenced by:
- Dyspnea and shortness of breath
- Coughing
- Cyanosis
- Nasal flaring
- Use of accessory muscles of respiration
- Wheezing
- Tachypnea or bradypnea
Expected Outcomes:
- Patient will demonstrate an effective breathing pattern, evidenced by a respiratory rate and rhythm within normal limits, and reduced wheezing and coughing.
- Patient will verbalize understanding of potential triggers for ineffective breathing patterns.
- Patient will demonstrate proper use of a peak flow meter to monitor breathing effectiveness.
Nursing Assessments:
- Auscultate Lung Fields: Assess for wheezing and other adventitious sounds, noting their location and characteristics.
- Monitor Respiratory Status Closely: Track respiratory rate, rhythm, depth, SpO2, and signs of respiratory distress.
- Monitor Arterial Blood Gases (ABGs): Assess ABGs for signs of respiratory alkalosis (early) or respiratory acidosis (late) related to ineffective breathing.
Nursing Interventions:
- Administer Bronchodilators and Corticosteroids: Administer prescribed bronchodilators (SABAs, LABAs) to relax airway muscles and corticosteroids to reduce inflammation. Administer bronchodilators before corticosteroids for optimal effect.
- Instruct on Peak Flow Meter Use: Educate the patient and family on the purpose and correct use of a peak flow meter for daily monitoring and early detection of worsening breathing patterns.
- Help Identify and Avoid Triggers: Assist the patient in identifying personal asthma triggers (allergens, irritants, stress) and develop strategies for avoidance.
- Promote Calm, Relaxed Breathing: Provide reassurance during exacerbations, position the patient upright, and guide them in slow, deep, diaphragmatic breathing techniques to improve ventilation and reduce anxiety.
Readiness for Enhanced Therapeutic Regimen Management
Nursing Diagnosis: Readiness for Enhanced Therapeutic Regimen Management
Related to:
- Expressed desire to improve asthma management
- Interest in learning more about asthma and self-care
As evidenced by:
- Expressed desire to learn about asthma and its management
- Active questioning about medications and devices
- Demonstrates adherence to current medication regimen
- Verbalizes accurate information about asthma and treatment
Expected Outcomes:
- Child (or adult patient) will correctly state symptoms of an asthma attack and appropriate actions, including when to seek help.
- Child (or adult patient) will correctly demonstrate the use of inhalers and other devices at prescribed intervals.
- Child (or adult patient) will maintain optimal asthma control and remain free from frequent exacerbations.
Nursing Assessments:
- Assess Readiness to Learn and Decide: Evaluate the patient’s (or child’s) interest in learning about asthma, asking questions, and participating in self-management.
- Assess Support System: Determine the availability of family, caregiver, and community support to assist with asthma management.
- Assess Understanding of Asthma: Evaluate the patient’s (or child’s) current knowledge about asthma, triggers, medications, and action plans.
Nursing Interventions:
- Provide Educational Resources: Utilize games, videos, age-appropriate materials, and interactive tools to enhance learning about asthma, triggers, medications, and action plans.
- Make Symptom Tracking Engaging: Encourage symptom diaries, charts, or apps to track symptoms and medication use in a fun and engaging way (especially for children), using stickers or rewards.
- Observe and Teach Proper Device Use: Provide hands-on teaching and observe the patient’s (or child’s) technique for using inhalers, spacers, nebulizers, and peak flow meters. Correct any errors and reinforce proper technique.
- Develop Collaborative Action Plan: Work with the patient, family, healthcare providers, and school nurses (if applicable) to create a comprehensive and individualized asthma action plan. Ensure the patient (and child) has a copy and understands how to use it in different settings.
Alt Text: A nurse reviews an asthma action plan with a young patient and his mother, highlighting key steps for managing asthma symptoms at home and school.
