Asthma Nursing Care Management and Study Guide

Asthma is reversible airway disease that can turn deadly. Inflammation makes the airways hyperresponsive, the mucosa swells, mucus pours out, and the airways narrow. Patients cycle between symptom-free stretches and acute exacerbations. At the bedside you are watching the work of breathing, listening for wheeze that may disappear as air movement drops, and ready to escalate before the patient tires into respiratory failure.

What is Asthma?

Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. That inflammation drives recurrent symptoms, with symptom-free periods alternating with acute exacerbations that last minutes, hours, or days. It is the most common chronic disease of childhood and can begin at any age.

Pathophysiology

The core problem is reversible, diffuse airway inflammation leading to airway narrowing.

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

Statistics and Epidemiology

Asthma affects more than 22 million people in the United States, accounts for more than 497,000 hospitalizations annually, and carries a total economic cost exceeding $27.6 billion.

Causes

• Allergy. The strongest predisposing factor for asthma.
• Chronic exposure to airway irritants. Seasonal (grass, tree, and weed pollens) or perennial (mold, dust, roaches, animal dander).
• Exercise. Can trigger asthma.
• Stress or emotional upset. Can trigger airway constriction.
• Medications. Certain drugs can trigger asthma.

Clinical Manifestations

The most common symptoms are cough (with or without mucus), dyspnea, and wheezing (first on expiration, then possibly on inspiration as well).

• Cough. Sometimes the only symptom.
• Dyspnea. General chest tightness leading to shortness of breath.
• Wheezing. First on expiration, then possibly on inspiration.

Attacks frequently occur at night or in the early morning. An exacerbation is often preceded by increasing symptoms over days but may begin abruptly. Expiration takes effort and becomes prolonged. As an exacerbation progresses, central cyanosis from severe hypoxia may appear, along with diaphoresis, tachycardia, and a widened pulse pressure. Exercise-induced asthma shows maximal symptoms during exercise, no nocturnal symptoms, and sometimes only a "choking" sensation during exercise. Status asthmaticus, a severe continuous reaction, is life-threatening. Eczema, rashes, and temporary edema are allergic findings that may accompany asthma.

Prevention

Patients with recurrent asthma should be tested to identify what precipitates their symptoms. Avoid known allergens, seasonal or perennial, whenever possible. Patient knowledge drives quality asthma care, and ongoing evaluation of impairment and risk is key to control.

Complications

• Status asthmaticus. Airway obstruction often produces hypoxemia.
• Respiratory failure. Untreated asthma progresses to respiratory failure.
• Pneumonia. Mucus that pools and becomes infected can lead to pneumonia.

Assessment and Diagnostic Findings

Diagnosis requires confirming episodic symptoms of airway obstruction.

• Positive family history. Asthma is hereditary.
• Environmental factors. Seasonal changes, high pollen counts, mold, pet dander, climate changes, and air pollution.
• Comorbid conditions. Gastroesophageal reflux, drug-induced asthma, and allergic bronchopulmonary aspergillosis.

Medical Management

Continuing, progressive dyspnea raises anxiety and worsens the attack, so intervene early.

Pharmacologic Therapy

• Short-acting beta2-adrenergic agonists. The drugs of choice for relief of acute symptoms and prevention of exercise-induced asthma.
• Anticholinergics. Inhibit muscarinic cholinergic receptors and reduce intrinsic vagal tone of the airway.
• Corticosteroids. Most effective for relieving symptoms, improving airway function, and decreasing peak flow variability.
• Leukotriene modifiers. Act against leukotrienes, which are potent bronchoconstrictors that also dilate vessels and alter permeability.
• Immunomodulators. Prevent binding of IgE to high-affinity receptors on basophils and mast cells.

Peak Flow Monitoring

Peak flow meters measure the highest airflow during a forced expiration. Daily monitoring is recommended for patients with moderate or severe persistent asthma, poor perception of airflow changes or worsening symptoms, unexplained response to environmental or occupational exposures, or at clinician or patient discretion. Combined with symptom monitoring, it gauges severity and the current degree of asthma control.

Nursing Management

Immediate care depends on symptom severity.

Nursing Assessment

Monitor respiratory status and symptom severity, breath sounds, peak flow, oxygen saturation by pulse oximetry, and vital signs.

Nursing Diagnosis

• Ineffective airway clearance related to increased mucus production and bronchospasm.
• Impaired gas exchange related to altered delivery of inspired O2.
• Anxiety related to perceived threat of death.

Nursing Care Planning & Goals

Goals are airway patency, expectoration of secretions, clear breath sounds with noiseless respirations and improved oxygen exchange, understanding of causes and the management regimen, behaviors that maintain a clear airway, and recognition of complications with appropriate preventive or corrective action.

Nursing Interventions

• Assess history. Get a history of medication allergies before giving any drug.
• Assess respiratory status. Track symptom severity, breath sounds, peak flow, pulse oximetry, and vital signs.
• Assess medications. Identify current medications, administer as prescribed, and monitor responses; add an antibiotic if there is an underlying respiratory infection.
• Fluid therapy. Give fluids if the patient is dehydrated.

Evaluation

Confirm airway patency, cleared secretions, clear breath sounds with improved oxygen exchange, understanding of the regimen, airway-protective behaviors, and recognition of complications.

Discharge and Home Care Guidelines

• Collaboration. Home therapy needs patient and provider working together to set outcomes and a plan to reach them.
• Health education. Teach the patient and family about asthma as a chronic inflammatory disease, the purpose and action of medications, triggers and how to avoid them, proper inhalation technique, and peak-flow monitoring. Match educational materials to the patient's diagnosis, causative factors, education level, and cultural background.
• Compliance to therapy. Stress adherence to the regimen, preventive measures, and keeping followup appointments. Teach the action plan and when to seek help.
• Home visits. A home visit to assess for allergens may be indicated for patients with recurrent exacerbations.

Documentation Guidelines

Document individual related factors, breath sounds, secretions and accessory muscle use, cough and sputum character, respiratory rate, pulse oximetry and vital signs, the plan of care and who is involved, the teaching plan, the patient's response to interventions and medications, use of respiratory devices, progress toward outcomes, and plan modifications.