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Course: Medical Surgical Nursing

Topic: Asthma

The Nurses International Community

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Module Goals

Learners will be able to:

Describe the clinical manifestation of Asthma.
Discuss the assessment and diagnostic findings of Asthma.
Discuss the complications of Asthma.
Describe the medical management of Asthma.
Discuss the nursing management of Asthma.

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Asthma

A chronic condition caused by narrowing of inflamed airways.
Harder for air to flow out of airways during exhalation.
Affects all ages, often starts during childhood.
Affects 1 in 13 Americans.

National Heart, Lung and Blood Institute, 2022

Contact info: info@nursesinternational.org

Occupational asthma:

the most common work-related lung disease in developed countries
Up to 15% of asthma cases in the United States may be job-related

Causes:

Inhaling fumes, gases, dust or other potentially harmful substances while "on the job."
Irritants in high doses include:

Hydrochloric acid,
Sulfur dioxide or ammonia, which is found in the petroleum or chemical industries

For example, workers in the washing powder industry may develop an allergy to the enzymes of the bacteria Bacillus subtilis, while bakers may develop an allergy and occupational asthma symptoms from exposure to various flours or baking enzymes.

It can also occur in workers after repeated exposure to small chemical molecules in the air, such as with paint hardeners or in the plastic and resin industries.

For example, isocyanates are chemicals that are widely used in many industries, including spray painting, insulation installation and manufacturing plastics, rubber and foam. These chemicals can cause occupational asthma in up to 10% of exposed workers.

American Academy of Allergy, Asthma and Immunology. (2020). Occupational Asthma. https://www.aaaai.org/tools-for-the-public/conditions-library/asthma/occupational-asthma

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Asthma: Triggers

Pollen
Exercise
Viral infections
Cold air
Medicine
Emotional stress

National Heart, Lung and Blood Institute, 2022

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Asthma Attack

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Asthma: Signs & Symptoms

Chest tightness
Coughing (especially at night or early morning)
Shortness of breath
Wheezing (a whistling sound on exhalation)

National Heart, Lung and Blood Institute, 2022

Contact info: info@nursesinternational.org

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Asthma: Signs & Symptoms Pattern

Triggers:

exercise
allergies
cold air
laughing or crying.

Occur or worsen with viral infections (such as a cold).
May occur over time or several times within a day.
May worsen at night or morning.

National Heart, Lung and Blood Institute, 2022

Contact info: info@nursesinternational.org

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Critical Thinking Question

Which of the following would the asthmatic client most likely report as triggers for asthma attack? (Select all that apply).

Pollen
Exercise
Viral infections
Cold air
Medicine
Emotional stress

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Asthma: Causes

Exact cause is unknown.
May be immune related.

Immune system may strongly react to a substances in the lungs

Pollen or mold
Smoke

National Heart, Lung and Blood Institute, 2022

Contact info: info@nursesinternational.org

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Asthma: Risk Factors

Allergens
Cigarette smoke
Viral infections
Family history
Obesity
Race
Sex
Occupational Hazards

National Heart, Lung and Blood Institute, 2022

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Asthma: Pathophysiology

Phases

Early Phase:

Initiated by IgE antibodies that are released by plasma cells response to certain a trigger.
IgE antibodies then bind to high-affinity mast cells and basophils.
When a pollutant is inhaled:

>Mast cells release histamine, prostaglandins, and leukotrienes
>which contract the smooth muscle of airway passages
>causing airway tightening.

Sinyor & Concepcion Perez, 2022

Contact info: info@nursesinternational.org

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Asthma: Pathophysiology (Continued)

Late Phase:

Occurs within several hours of early phase.
The eosinophils, basophils, neutrophils, and helper memory T-cells localize to the lungs.
which causes bronchoconstriction and inflammation.
As a result, there is intermittent airflow obstruction, resulting in increased work of breathing.

Sinyor & Concepcion Perez, 2022

Contact info: info@nursesinternational.org

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Critical Thinking Question

The nurse manager is providing staff education on the management of asthma. Which information is most relevant for the staff to know?

Asthma is an acute condition caused by enlargement of inflamed airways
Asthma affects 1 in 13 Americans
Risk factors include allergens, cigarette smoke, viral infections
Severe episodes only happens at night

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Asthma: Diagnosis

History (medical and family)
Spirometry
Spirometry with bronchodilator tests
Bronchoprovocation tests 
Peak expiratory flow (PEF) tests 
Fractional exhaled nitric oxide (FeNO) tests

National Heart, Lung and Blood Institute, 2022

Contact info: info@nursesinternational.org

Spirometry is a type of lung function test that measures how much air clients breathe out.

It also measures how fast a client can blow air out

video: https://www.youtube.com/watch?v=6dNPNEfstl0

Spirometry with bronchodilator tests

These tests measure how much and how fast air moves in and out both before and after a client breathes in a medicine to relax the muscles in the airway.

Bronchoprovocation tests

These tests measure how airways react when clients breathe in specific substances in the air.
During this test, a client breathes in allergens or medicines that may tighten the muscles in the airways. How fast the air moves when clients breathe in and out is measured before and after the test.

Video:https://www.youtube.com/watch?v=BioFHEu7N6U

Peak expiratory flow (PEF) tests: 

PEF tests measure how fast a client can blow air out using maximum effort
This test can be done during spirometry or with a small handheld device.

video: https://www.youtube.com/watch?v=jdA8KU_D9JU

Fractional exhaled nitric oxide (FeNO) tests:

Fractional exhaled nitric oxide (FeNO) tests measure how much nitric oxide is in the breath
High levels of nitric oxide may mean that the airways in the lungs are inflamed, which can make it hard to breathe.
For this test, a client will breathe out into a tube that is connected to the portable device
It requires steady but not heavy breathing and has few or no risks
It is done in adults and children age 5 and older.

Video: https://www.youtube.com/watch?v=NHcJ88NVM_U

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Asthma: Complications

Fatigue or exhaustion,
Poor sleep
Inability to exercise
Impairs physical activity
Poor mental health

stress
anxiety
depression

Health Direct; NHS

Pulmonary infections (Pneumonia)
Delay in growth or puberty in children
Status Asthmaticus
Atelectasis
Respiratory failure leading to death

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Asthma: Treatment (Quick Relief Medicines)

Inhaled short-acting beta2-agonists (SABAs): Dilates airways.

Oral corticosteroids: Reduces swelling/edema.

Short-acting anticholinergics: Opens airways quickly.

National Heart, Lung and Blood Institute, 2022

Contact info: info@nursesinternational.org

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Asthma: Long Term Control Medicines

Corticosteroids
Biologic medicines (benralizumab).
Leukotriene modifiers reduce swelling and keeps airways open.
Inhaled mast cell stabilizers (cromolyn) prevents swelling.
Inhaled long-acting bronchodilators, such as long-acting beta2-agonists (LABAs).
Allergy shots: Called subcutaneous Immunotherapy (SCIT), reduces the body’s response to allergens.

National Heart, Lung and Blood Institute, 2022

Contact info: info@nursesinternational.org

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Treatment: Bronchial Thermoplasty:

for Severe Persistent Asthma

A bronchoscope is inserted into the airway through the mouth or nose.
Heat is applied to shrink the smooth muscles in the lungs that makes thinner and helps prevent them from narrowing.
Bronchial Thermoplasty video:

https://youtu.be/cgDLjG0Wqug

National Heart, Lung and Blood Institute, 2022

Contact info: info@nursesinternational.org

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Critical Thinking Question

Indicate whether the following statements about Bronchial Thermoplasty are true (T) or false (F):

It is a invasive procedure
The bronchoscope is inserted into the airway through the mouth or nose
The expandable wire electrode delivers controlled radiofrequency energy for about 10 sec
A total of three procedures are needed to complete the treatment

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Asthma: Home Management

Avoid having pets with fur.
Remove dust and mold from home.
Limit time outdoors when allergen levels are high.
Keep windows closed and avoid strenuous outdoor activity when air quality is low.
Schedule the flu vaccine each year.
Assure that cooking and heating devices are well-ventilated.
Avoid smoking and second-hand smoke.

National Heart, Lung and Blood Institute, 2022

Contact info: info@nursesinternational.org

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Asthma: Home Management (Continued)

Healthy lifestyle changes:

Aim for a healthy weight
Choose heart-healthy foods
Regular physical activity
Manage stress
Stop smoking and avoid secondhand smoke
Strive for-quality sleep

National Heart, Lung and Blood Institute, 2022

Contact info: info@nursesinternational.org

Aim for a healthy weight:

Being overweight and having obesity can make asthma harder to manage
Even a 5% to 10% weight loss can help symptoms

Choose heart-healthy foods:

Eating more fruits and vegetables can provide important health benefits

Get regular physical activity:

Even though exercise is an asthma trigger for some people, you should not avoid it. Physical activity is an important part of a healthy lifestyle

Manage stress:

Learn breathing and relaxation techniques, which can help symptoms
Meet with a mental health professional if you have anxiety, depression, or panic attacks

Smoking tobacco and inhaling smoke from secondhand smoke make asthma harder to treat. Heating tobacco, inhaling (vaping) electronic cigarettes (e-cigarettes) and being exposed to secondhand vapor may also be linked to asthma symptoms
Develop healthy sleep habits by going to sleep and getting up at regular times, following a calming bedtime routine, and keeping the bedroom cool and dark

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Asthma: Nurses’ Role

History.
Assessment:

Respiratory status, severity of the symptoms
Breath sounds.
Client’s peak flow
Check oxygen status
Vital signs.

Position client upright.
Administer medications as prescribed.

Hashmi et al., 2022

Belleza, 2021

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Asthma: Nurses’ Role (Continued)

Health Education:

About asthma and asthma attack
Use of medications
Triggers and how to avoid them
Technique to monitor air flow with peak flow meter
Inhalation technique
Preventive measures
Facilitate support groups.

Belleza, 2021

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Critical Thinking Question

A client newly diagnosed with asthma is being discharge. Which lifestyle modification should the nurse encourage in this client?

Avoid breathing exercises
Eat a low-sodium diet
Encourage medication compliance
Stop smoking and avoid secondhand smoke

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Red Flags

Shortness of breath
Wheezing
lack of sleep
Low Oxygen saturation

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Applying Purnell’s Model for Cultural Competence

A nurse is caring for a patient from a Middle Eastern background who has been diagnosed with asthma. The patient expresses concerns about using inhalers and prefers alternative therapies for managing respiratory symptoms. The nurse understands the importance of cultural competence in providing effective care. Which action by the nurse best demonstrates cultural sensitivity as per the Purnell Model for Cultural Competence?

Educate the patient about the benefits of inhaler therapy and encourage compliance with prescribed medications.
Immediately refer the patient to a cultural expert for guidance about the patient's concerns about inhalers.
Respect the patient's cultural beliefs and solely rely on alternative therapies for managing asthma symptoms.
Engage in open communication with the patient to understand their beliefs and preferences and collaborate on an asthma management plan that incorporates alternative therapies, if appropriate.

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Answer:

D. Engage in open communication with the patient to understand their beliefs and preferences and collaborate on an asthma management plan that incorporates alternative therapies, if appropriate.

Rationale:

According to the Purnell Model for Cultural Competence, the nurse should respect the patient's cultural beliefs and preferences while incorporating evidence-based medical interventions. By collaboratively developing a care plan that integrates both the patient's cultural preferences and effective medical treatments, the nurse promotes cultural sensitivity and enhances asthma management. This understanding allows for the development of an individualized plan that incorporates the patient's alternative therapies, if appropriate, while also addressing the importance of evidence-based interventions such as inhaler therapy. Dismissing the patient's concerns or solely relying on alternative therapies may compromise the effectiveness of asthma management and disregard the patient's cultural background. Educating the patient about the benefits of inhaler therapy and encouraging compliance with prescribed medications can be an essential component of the collaborative plan, provided it is presented in a culturally sensitive manner that considers the patient's beliefs and preferences.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Race or ethnicity: African Americans and Puerto Ricans are at higher risk of asthma than people of other races or ethnicities are. African American and Hispanic children are more likely than non-Hispanic white Americans to die from asthma-related causes.

AHRQ, 2020

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References

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Belleza, M. (2021). Asthma. Nurseslabs. https://nurseslabs.com/asthma/

Hashmi, M.F, Tariq, M., & Cataletto, M.E, et al. (2022). Asthma (Nursing). Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568760/

Health Direct. (2020). Asthma. https://www.healthdirect.gov.au/asthma

Contact info: info@nursesinternational.org

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References

MedlinePlus. (2022). How to use your peak flow meter. https://medlineplus.gov/ency/patientinstructions/000043.htm

National Heart Lung and Blood Institute. (2022). What is Asthma. https://www.nhlbi.nih.gov/health/asthma

NHS. (2021). Asthma. https://www.nhs.uk/conditions/asthma/

Sinyor, B., & Concepcion Perez, L. (2022). Pathophysiology Of Asthma. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551579/

Contact info: info@nursesinternational.org

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