2. Learning objectives
• Describe the disease Asthma
• Explain the pathophysiology of Asthma
• Explain the risk factors and triggers of asthma
attacks.
• Explain the nursing assessment of a client with
asthma attack
• Discuss the nursing interventions given to a
patient in asthmatic attack
• Explain the health education given to a client with
asthma
3. Description and pathophysiology
• An inflammatory disease of the airways
characterized by airway hyper responsiveness
to a variety of stimuli
• This inflammation is characterized by mast cell
activation , inflammatory cell infiltration,
edema, and disruption of the bronchial
epithelium, collagen deposition beneath the
basement membrane and smooth muscle
thickening
4. • This results in airflow limitation , pathological
damage and associated respiratory
symptoms(wheezing, shortness of breath and
chest tightness)
• Factors contributing to airflow
limitation(airways are narrowed) in asthma
include acute bronchocostriction, airway
mucosal edema and formation of mucus
plugs.
5. In summary
• The inhaled irritants such as pollens , stimulate
irritants receptors in the walls of larynx and
bronchi which initiate a reflex arc that travels
to CNS and back to vagus nerve
• This cause the release of chemical mediator
from mast cell such as histamine,
Prostaglandins , leukotrienes, and kinins
• These initiate inflammatory process which
results into damage to epithelial cells leads to
leakage of fluids. There is also goblet cell
6. Patho cont,
• Intermittent episodes of airway obstruction
caused by bronchospasm, excessive bronchial
secretion, or edema of bronchial mucosa;
resultant airway resistance, especially during
expiration, produces symptoms of wheezing,
dyspnea, and chest tightness
7. Allergens Genetic Obesity Exercise
Stimulate irritants receptors in the walls of larynx and
bronchi
Mast cell release histamine, Prostaglandins
, leukotriene, and kinins
Globlet cell
hyperpleasia
Thickening and
contraction of smooth
muscle
Bro
Chronic mucous
plug & airway
remodelling
wheezing, dyspnea, and chest tightness
8. STATUS ASTHMATICUS
• An acute emergency that requires prompt
intervention to avoid acute and fatal respiratory
failure.
• The asthmatic attacks are unresponsive to
medical therapy(refractory asthma) with severe
bronchospasms creating decreased oxygen and
perfusion.
• Patient present with a dramatic picture of acute
anxiety, marked labored breathing, diaphoresis.
9. Risk factors/Triggers
• Allergen exposure- antigen antibody reaction
• Non compliance with medication regimen
• Vigorous Exercise- airway obstruction may
occur due to changes secondary to
hyperventilation
• Acid reflux- into lungs causing vagal
stimulation and bronchoconstriction
10. Risk factors/Triggers cont,
• Air pollutants/environmental-tobacco smoke,
elevated ozone levels, sulfur and nitrogen
dioxide.
• Factors such as hot, cold, dusty areas,
Perfumes, sprays . These irritants cause
changes in responsiveness of airways.
11. Risk factors/Triggers cont,
• Food addictives, drugs- Sensitivity to i.e. ASA,
brufen, some foods, beverages and
flavourings.Wheezing can develop within 2
hours.
• Psychological factors-Extremes of crying,
laughing, anger, and fear can lead to
hyperventilation and hypocapnia causing
narrowing of bronchioles.
12. Risk factors/Triggers cont,
• Genetics- atopic genetic predisposition to
develop an allergic response to common
allergens
• Obesity
• Respiratory infection-cause increase in
hyperresponsiveness of bronchial system
13. Nursing Assessment
History and physical examination
• Dyspnoea associated with wheezing especially
during the late night or early morning hours
• Pronounced fatigue because of continuous
efforts of breathing
• Chest tightness after exposure to a trigger
• Cough(cough variant asthma)
14. Nursing Assessment cont,
• A feeling of suffocation because of difficulty
with air movement in and out of lungs
• Therefore pt sits upright or bends forward
using accessory muscles to try get enough air
15. Nursing Assessment cont,
• Examination reveals hypoxemia-restlessness,
increased anxiety, inappropriate behaviour,
increase pulse and BP
• In worse situations- difficult to speaking or
complete sentences
• Increases respirations greater than 30 with
accessory muscle use
16. Nursing Assessment cont,
• easily become dehydrated due to hyperpnoea
• Percussion of lungs –hyperresonance
• Auscultation- inspiratory and exp Wheezes
• As episode resolves coughing produces thick
stringy mucus
17. Nursing Assessment cont,
Inspection
for evidence of atopic dermatitis or eczema
mouth breathing, dark discoloration beneath
the lower eyelids,(allergic shiners), edematous
or pale nasal mucosa, clear nasal discharge
Check
Vital signs, height/ weight vs. age,
18. • A detailed history to determine previous
attacks of similar nature, precipitating factors
Symptoms and symptom patterns: pt may
complain of shortness of breath especially
during night with sleep disruption
Current treatment
Effect of symptoms on activities of living
19. • A detailed history may indicate previous
attacks often precipitated by a known cause
• Seasonal attacks may indicate pollen triggers
• Attacks that occur at night may be caused by
sleeping with a cat, sleep apnea, or mattress
dust
• Asthma history
• Relieving factors
20. Diagnostic studies
• Laboratory-CBC and sputum specimens show
elevated WBC, positive sputum cultures. Allergen
test to ascertain precipitating allergens.
• CXR -to observe infiltrates or hyperinflation to
the lungs and to rule out other causes
• ABGs- to identify problem with oxygenation and
acid base balance. Initially PaCo2 may be low
normal with an elevated PH and decreased Pao2;
with severe asthmatic attacks a progression to
normal or increased PaCo2 may indicate
impending respiratory failure
21. Medical Treatment
• Oxygen- to provide supplemental available O2
• Bronchodilators- are used to relax bronchial
smooth muscle to dilate the bronchial tree to
facilitate air exchange, depending on severity
22. • Corticosteroids- are used to decrease the
inflammatory response and edema; most act by
suppression of the immune response by
stabilization of the leukocytic lysosomal
membranes.
• Note: Antimicrobials are only used when
infective process is documented-Amoxcillin
500mg orally 8 hourly for 5 days and its
corresponding analgesia, Paracetamol I gm orally,
8 hourly for 3 days
23. Nursing diagnoses
1). Ineffective airway clearance related to airway
obstruction , edema of bronchioles, inability to
cough effectively , excessive mucus production
as evidenced by edventitious breath sounds,
dyspnoea, shallow respirations
24. Nursing diagnoses cont,
• Impaired gas exchange related to
bronchospasm , inflammation to bronchi ,
hypoxemia, fatigue, secretions as evidenced
by dyspnoea, tachypnoea, hypoxia,
hypoxemia, restlessness, anxiety , decreased
oxygen saturation
26. Acute Nursing interventions
• Place patient in upright
• Remove tight clothing
• SEVERE= Prednisolone 40 mg PO stat if able to
swallow OR hydrocortisone 100mg IV as anti
inflammatory FOLLOWED by
• Salbutamol 1ml(5mg) in 4 mls of saline given by
nebulizer back to back (meaning running 5 mg
ampoules through the nebulizer one after the other up
to three treatments every 15-20 minutes) during the
first hour.
• Reassess after each treatment, by third time dose
patients should be stable.
27. Acute Nursing interventions cont,
• If no improvement, administer Aminophyline
5mg/kg(average 250mg) iv push slowly over
10- 20 minutes.
• Reassess and after 1-2 hours
• If there is no improvement Magnesium
Sulphate 2 gm in 500mls of normal saline is
commenced to run over 15 to 20 minutes.
• Re assess the presenting clinical
manifestations
28. • If still no improvement, Adrenaline 1mg diluted in
5mls of normal saline given by nebulization over
15 minutes.
• Usually by this time patient might be required to
be transferred to ICU for ventilatory support as
patient may get tired
• Monitor cardiopulmonary system: resp, O2
saturation, pulse rate, blood pressure every 15-30
minutes until patient settles.
• Side effects: tachycardia, arrhythmias and
systemic hypertension
29. Acute Nursing interventions
• Where nebulization is not available,
Salbutamol can be administered using a
Metered Dose Inhaler (MDI) via a spacer for
effective delivery of the drug
• Salbutamol inhaler 2 puffs(200 micrograms or
0.2 mg ) repeated whenever necessary.
• Reassess as above
• Explain effect: stimulate B2 receptors
producing bronchodilation
30. NOTE
• Observe patients for 6-24 hours then
discharge to home.
• For non responsive severe cases, Nebulization
back to back may be continued in between
other treatments if patient has underlying
conditions
– these are referred for investigation and further
management to the wards/ICU
31. Acute Nursing interventions cont,
• If ASTHMA not severe, Prednisolone 40mg PO stat
then once daily PO to continue at home for 5 days.
– Salbultamol inhaler and Beclomethasone inhaler to be
taken 2 puffs each at home PRN during an attack.
• Prednisolone and Beclomethasone decrease
inflammation via suppression of the migration of
polymorphonuclear leukocytes and reversing increased
capillary permeability.
• Explain effect: antiinflammatory and
immunosuppressive which decrease edema in
branchial airways, decrease mucus secretion
32. Acute Nursing interventions cont,
• Humidified Oxygen by mask or prongs.
Humidified O2 helps to keep secretions
thinned to allow for easy expectoration.
• IV fluids to replace loss through
hyperventilation since insensible loss is
increased
• If necessary antibiotic to prevent or combat
infection
33. Acute Nursing interventions cont,
• Monitor oxygen saturation by oximetry and
notify Dr if <90%. O2 saturation levels <90%
compromises perfusion and oxygenation of
tissues
34. Acute Nursing interventions cont,
• Observe respiratory status, work of breathing,
nasal flaring, prolonged respiratory phase as
presence of these symptoms may indicate
impending respiratory failure
• Auscultate lung fields 1 to 4 hrly and notify Dr
for significant changes as expiratory wheezing
may be heard as secretions and air move
through the narrowed airways.
35. Acute Nursing interventions cont,
• Have emergency equipment at hand including
tracheostomy tray as severe bronchospasm
can result in cardiopulmonary compromise
and arrest requiring emergency treatment
• Monitor for side effects such as tachycardia,
tremors, nausea, vomiting which may occur as
adverse reaction from medication .May
require change in specific drug used.
36. Nursing diagnosis 3,
Anxiety related to dyspnoea, percieved loss of
control and fear of suffocation as evidenced
by restlessness, muscle tension, helplessness,
sense of impending doom
37. Nursing interventions cont,
• Use calm reassuring approach to provide
reassurance
• Stay with patient to promote safety and
reduce fear
• Encourage verbalizing feelings, fears to
identify problem areas for proper planning
• Instruct in use of relaxation techniques to
relieve tension and promote ease of
respirations
38. Group 1 Assignment
Taibu is now stable , but has
demonstrated lack of knowledge of
the disease and you come up with
the nursing diagnosis: Knowledge
deficit related to lack of information
and education about asthma and its
treatment as evidenced by frequent
questioning.
39. Taibu
Task:
• Develop an education plan following the
guide and sample in the practice module
• Using the guide Demonstrate in class how you
will give health education in the local
language to promote understanding of the
disease and compliance to treatment regimen
when discharged.
40. Education
• Determine patient/family understanding of
disease and management to identify learning
needs
• Teach pathophysiology
• Identify possible precipitating factors/
allergens and void them: ie fumes, pollen, cold
air, house dust; cigarette and wood smoke,
emotional stressors which induce an attack
41. • How to take the puffs (observe this please)
• How to use a spacer and emphasise compliance
• Instruct on anti-inflammatory and bronchodilator
medications and appropriate use Salbutamol and
Beclamethasone inhaler when in an attack
• Instruct to avoid medication changes without Dr’s
knowledge as noncompliance or changes in
schedules of medication can result in asthma
exacerbations
42. • Assist in recognition of signs/symptoms of
impending asthmatic reaction and
implementation of appropriate response
measures to prevent escalation.
• Instruct in dietary limitations as some foods
and food preservatives are known allergens
and can provoke asthma attacks.
43. • Encourage to maintain fluid intake and good
nutrition and adequate rest to stay healthy
and prevent respiratory tract infections
• Advice when to seek medical help
– Breathlessness not controlled by inhalers
– Sudden increase in need for relievers
• Follow up /report to nearest health facility
when condition worsens
44. NOTE
• If problem occurs at night-Salbutamol inhaler
before bedtime-2 puffs
• If Asthma is caused by exercise- 2 puffs inhaler
few minutes before taking the sport/game
