Asthma - child - discharge

       
Your child has asthma, which causes the airways of the lungs to swell and narrow. Now that your
child is going home from the hospital, follow the health care provider's instructions on how to
care for your child. Use the information below as a reminder.
When You're in the Hospital
In the hospital, the provider helped your child breathe better. This likely involved giving oxygen
through a mask and medicines to open the lung airways.

What to Expect at Home

Your child will probably still have asthma symptoms after leaving the hospital. These symptoms
include:

 Wheezing and coughing that may last up to 5 days

 Sleeping and eating that may take up to a week to return to normal

You may need to take time off work to care for your child.

Take Charge of Your Child's Asthma at Home

Make sure you know the asthma symptoms to watch out for in your child.
You should know how to take your child's peak flow reading and understand what it means.
 Know your child's personal best number.

 Know your child's peak flow reading that tells you if their asthma is getting worse.

 Know your child's peak flow reading that means you need to call your child's provider.

Keep the phone number for your child's provider with you.

Triggers may make asthma symptoms worse. Know which triggers make your child's asthma
worse and what to do when this happens. Common triggers include:
 Pets

 Smells from chemicals and cleaners

 Grass and weeds

 Smoke

 Dust
 Cockroaches

 Rooms that are moldy or damp

Know how to prevent or treat asthma symptoms that arise when your child is active. These things
might also trigger your child's asthma:

 Cold or dry air.

 Smoky or polluted air.

 Grass that has just been mowed.

 Starting and stopping an activity too fast. Try to make sure your child warms up before being very
active and cools down after.

Understand your child's asthma medicines and how they should be taken. These include:

 Control medicines that your child takes every day

 Quick-relief asthma drugs when your child has symptoms
Keep Smoking Away From Your Child
No one should smoke in your house. This includes you, your visitors, your child's babysitters,
and anyone else who comes to your house.

Smokers should smoke outside and wear a coat. The coat will keep smoke particles from sticking
to clothes, so it should be left outside or away from the child.

Ask people who work at your child's day care, preschool, school, and anyone else who takes
care of your child, if they smoke. If they do, make sure they smoke away from your child.

School and Asthma

Children with asthma need a lot of support at school. They may need help from school staff to
keep their asthma under control and to be able to do school activities.
There should be an asthma action plan at school. The people who should have a copy of the
plan include:

 Your child's teacher

 The school nurse

 The school office

 Gym teachers and coaches

Your child should be able to take asthma medicines at school when needed.

School staff should know your child's asthma triggers. Your child should be able to go to another
location to get away from asthma triggers, if needed.

When to Call the Doctor

Call your child's provider if your child is having any of the following:

 Hard time breathing

 Chest muscles are pulling in with each breath

 Breathing faster than 50 to 60 breaths per minute (when not crying)
 Making a grunting noise

 Sitting with shoulders hunched over

 Skin, nails, gums, lips, or area around the eyes is bluish or grayish

 Extremely tired

 Not moving around very much

 Limp or floppy body

 Nostrils are flaring out when breathing

Also call the provider if your child:

 Loses their appetite

 Is irritable

 Has trouble sleeping

affects people in their different stages in life, yet it can be avoided and treated.
  Asthma is a chronic inflammatory disease of the airways that
causes airway hyperresponsiveness, mucosal edema, and mucus
production.
 Inflammation ultimately leads to recurrent episodes of asthma
symptoms.
 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.

Pathophysiology

The underlying pathophysiology in asthma is reversible and diffuse airway

inflammation that leads to airway narrowing.

 Activation. When the mast cells are activated, it releases several

chemicals called mediators.
 Perpetuation.These chemicals perpetuate the inflammatory response,
causing increased blood flow, vasoconstriction,, fluid leak from the
vasculature, attraction of white blood cells to the area, and
bronchoconstriction.
 Bronchoconstriction. Acute bronchoconstriction due to allergens
results from a release of mediators from mast cells that directly
contract the airway.
 Progression. As asthma becomes more persistent, the inflammation
progresses and other factors may be involved in the airflow limitation.
Schematic Diagram

[scribd id=136228783 key=key-ba99bnqc7zmpz8kbzpx mode=scroll]

Statistics and Epidemiology

Asthma is considered as the most common chronic disease of childhood, and is

a disruptive disease that affects school and work attendance.
  Asthma affects more than 22 million people in the United States.
 Asthma accounts for more than 497, 000 hospitalizations annually.
 The total economic cost of asthma exceeds $27.6 billion.

Causes

Despite increased knowledge on the pathology of asthma and the development

of improved medications and management plans, the death rate from the
disease continues to rise. Here are some of the factors that influence the
development of asthma.

 Allergy. Allergy is the strongest predisposing factor for asthma.

 Chronic exposure to airway irritants. Irritants can be seasonal
(grass, tree, and weed pollens) or perennial (mold, dust, roaches,
animal dander).
 Exercise. Too much exercise can also cause asthma.
 Stress/ Emotional upset. This can trigger constriction of the airway
leading to asthma.
 Medications. Certain medications can trigger asthma.

Clinical Manifestations

The signs and symptoms of asthma can be easily identified, so once the
following symptoms are observed, a visit to the physician is necessary.

 Most common symptoms of asthma are cough (with or without mucus

production), dyspnea, and wheezing (first on expiration, then possibly
during inspiration as well).
 Cough. There are instances that cough is the only symptom.
 Dyspnea. General tightness may occur which leads to dyspnea.
 Wheezing. There may be wheezing, first on expiration, and 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.
 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.

Prevention

Patients with recurrent asthma should undergo tests to identify the substances
that precipitate the symptoms.

 Allergens. Allergens, either seasonal or perennial, can be prevented

through avoiding contact with them whenever possible.
 Knowledge. Knowledge is the key to quality asthma care.
 Evaluation. Evaluation of impairment and risk are key in the control.

Complications

Complications for asthma include the following:

 Status asthmaticus. Airway obstruction in status asthmaticus often

results in hypoxemia.
 Respiratory failure. Asthma, if left untreated, progresses to
respiratory failure.
  Pneumonia. Mucus that pools in the lungs and becomes infected can
lead to the development of pneumonia.

Assessment and Diagnostic Findings

To determine the diagnosis of asthma, the clinician must determine that

episodic symptoms of airway obstruction are present.

 Positive family history. Asthma is a hereditary disease, and can be

possibly acquired by any member of the family who has asthma within
their clan.
 Environmental factors. Seasonal changes, high pollen counts, mold,
pet dander, climate changes, and air pollution are primarily associated
with asthma.
 Comorbid conditions. Comorbid conditions that may accompany
asthma may include gastroeasophageal reflux, drug-induced asthma,
and allergic broncopulmonary aspergillosis.

Medical Management

Immediate intervention may be necessary, because continuing and progressive

dyspnea leads to increased anxiety, aggravating the situation.

Pharmacologic Therapy

 Short-acting beta2 –adrenergic agonists. These are the medications

of choice for relief of acute symptoms and prevention of exercise-
induced asthma.
 Anticholinergics. Anticholinergics inhibit muscarinic cholinergic
receptors and reduce intrinsic vagal tone of the airway.
 Corticosteroids. Corticosteroids are most effective in alleviating
symptoms, improving airway function, and decreasing peak flow
variability.
 Leukotriene modifiers. Anti Leukotrienes are potent
bronchoconstrictors that also dilate blood vessels and alter
permeability.
  Immunomodulators. Prevent binding of IgE to the high affinity
receptors of basophils and mast cells.

Peak Flow Monitoring

Peak Flow Meter. Image via: medlineplus.gov

 Peak flow meters. Peak flow meters measure the highest airflow

during a forced expiration.
 Daily peak flow monitoring. This is recommended for patients who
meet one or more of the following criteria: have moderate or severe
persistent asthma, have poor perception of changes in airflow or
worsening symptoms, have unexplained response to environmental or
occupational exposures, or at the discretion of the clinician or patient.
 Function. If peak flow monitoring is used, it helps measure asthma
severity and, when added to symptom monitoring, indicates the
current degree of asthma control.

Nursing Management

The immediate care of patients with asthma depend on the severity of the
symptoms.

Nursing Assessment
Assessment of a patient with asthma includes the following:

 Assess the patient’s respiratory status by monitoring the severity of the

symptoms.
 Assess for breath sounds.
 Assess the patient’s peak flow.
 Assess the level of oxygen saturation through the pulse oximeter.
  Monitor the patient’s vital signs.

Nursing Diagnosis
Based on the data gathered, the nursing diagnoses appropriate for the patient
with asthma include:

 Ineffective airway clearance related to increased production of

mucus and bronchospasm.
 Impaired gas exchange related to altered delivery of inspired O2.
 Anxiety related to perceived threat of death.

Nursing Care Planning & Goals

Main Article:  5 Bronchial Asthma Nursing Care Plans

To achieve success in the treatment of a patient with asthma, the following goals
should be applied:

 Maintenance of airway patency.

 Expectoration of secretions.
 Demonstration of absence/reduction of congestion with breath sounds
clear, respirations noiseless, improved oxygen exchange.
 Verbalization of understanding of causes and therapeutic management
regimen.
 Demonstration of behaviors to improve or maintain clear airway.
 Identification of potential complications and how to initiate appropriate
preventive or corrective actions.

Nursing Interventions
The nurse generally performs the following interventions:

 Assess history. Obtain a history of allergic reactions to medications

before administering medications.
 Assess respiratory status. Assess the patient’s respiratory status by
monitoring the severity of symptoms, breath sounds, peak flow, pulse
oximetry, and vital signs.
  Assess medications. Identify medications that 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.
 Pharmacologic therapy. Administer medications as prescribed and
monitor patient’s responses to medications.
 Fluid therapy. Administer fluids if the patient is dehydrated.

Evaluation
To determine the effectiveness of the plan of care, evaluation must be
performed. The following must be evaluated:

 Maintenance of airway patency.

 Expectoration or clearance of secretions.
 Absence /reduction of congestion with breath sound clear, noiseless
respirations, and improved oxygen exchange.
 Verbalized understanding of causes and therapeutic management
regimen.
 Demonstrated behaviors to improve or maintain clear airway.
 Identified potential complications and how to initiate appropriate
preventive or corrective actions.

Discharge and Home Care Guidelines

A major challenge is to implement basic asthma management principles at the
home and community level.

 Collaboration. The complex therapy of treating asthma at home needs

collaboration between the patient and the health care provider to
determine the desired outcomes and to formulate a plan to achieve
those outcomes.
 Health education. Patient teaching is a critical component of care for
patients with asthma. 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. Obtain current
 educational materials for the patient based on the patient’s diagnosis,
causative factors, educational level, and cultural background.
 Compliance to therapy. Nurses should emphasize adherence to the
prescribed therapy, preventive measures, and the need to keep follow-
up appointments with health care providers. Teach patient how to
implement an action plan and how and when to seek assistance.
 Home visits. Home visits by the nurse to assess the home
environment for allergens may be indicated for patients with recurrent
exacerbations.

Documentation Guidelines
Documentation is a necessary part of the nursing care provided, and the
following data must be documented:

 Related factors for individual client.

 Breath sounds, presence and character of secretions, and use of
accessory muscles for breathing.
 Character of cough and sputum.
 Respiratory rate, pulse oximetry/o2 saturation, and vital signs.
 Plan of care and who is involved in planning.
 Teaching plan.
 Client’s response to interventions, teaching, and actions performed.
 Use of respiratory devices/airway adjuncts.
 Response to medications administered.
 Attainment or progress towards desired outcomes.
 Modifications to the plan of care.
Health education. Patient teaching is a critical component of care for patients with asthma.
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.
 An asthma flare-up is a worsening of asthma symptoms and lung function compared
to what you would usually experience day to day. An asthma flare-up can come on
slowly (over hours, days or even weeks) or very quickly (over minutes).

A sudden or severe asthma flare-up is sometimes called an asthma attack. An

asthma attack can quickly become an asthma emergency, but if you take quick
action, you can reduce the risk of an asthma emergency.

If you or a family member have asthma, make sure you have an updated Asthma
Action Plan from your doctor and know the four steps of asthma first aid. 

Your doctor will:

 prescribe the correct medication 

 help you to develop a plan to manage your asthma 
 provide you with an action plan to manage your asthma and provide
instructions in case of an asthma flare-up.

Follow your Asthma Action Plan if the symptoms of an asthma attack appear.

Signs that you need to use asthma first aid 

If you are experiencing any of the following signs, start asthma first aid. Do not wait
until asthma is severe. 

Mild to moderate asthma signs (commence asthma first aid):

 minor difficulty breathing

 able to talk in full sentences
 able to walk or move around
 may have a cough or wheeze.

Severe asthma signs (call triple zero (000) for an ambulance and commence
asthma first aid):

 obvious difficulty breathing

 cannot speak a full sentence in one breath
 tugging of the skin between ribs or at base of neck
 may have cough or wheeze
 reliever medication not lasting as long as usual.

Life-threatening asthma signs (call triple zero (000) for an ambulance and
commence asthma first aid):

 finds it very difficult to breathe (gasping for air)

 unable to speak one to two words per breath
 confused or exhausted
 lips are turning blue
 has symptoms that get worse very quickly
 collapsing
 is getting little or no relief from their reliever inhaler
 may no longer have wheeze or cough.

In asthma emergencies, follow your Asthma Action Plan.

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Know the four steps of asthma first aid

It’s important for everyone in the community to know the four steps of asthma first
aid.

To use asthma first aid:

1. Sit the person upright.

2. Give four puffs of blue reliever puffer. Make sure you shake the puffer, put
one puff into a spacer at a time and get the person to take four breaths of each puff
through the spacer. 
Remember: shake, one puff, four breaths. 
If you don’t have a spacer, simply give the person four puffs of their reliever directly
in to their mouth. Repeat this until the person has taken four puffs. 
3. Wait four minutes. If there is no improvement, give four more separate puffs
as in step 2. 
Remember: shake, one puff, four breaths.
4. If there is still no improvement, call triple zero (000) for an ambulance. Tell the
operator that someone is having an asthma emergency. Keep giving the person four
separate puffs of reliever medication, taking four breaths for each puff, every four
minutes until the ambulance arrives.

If you are not sure if someone is having an asthma attack, you can still use blue
reliever medication because it is unlikely to cause harm.

Call triple zero (000) immediately if:

 the person is not breathing

 their asthma suddenly becomes worse
 the person is having an asthma attack and there’s no blue reliever medication
available.