In this article and video, we will be discussing diagnostic tests, medical management, and nursing management of a client with exacerbation of asthma. Review of Asthma part II is a continuation of the previous article on the review of Asthma part I. This session is part of the review series for nurses preparing for NCLEX-RN, DHA, HAAD, MOH, and Prometric exams.
Do you know Asthma is a common chronic disease worldwide and affects millions of people? Asthma is the most common chronic disease in childhood, affecting many children worldwide. Before reading this article and watching the video, you should read the part 1 article explaining about the pathophysiology of asthma which is complex and involves airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness.
Exacerbation Of Asthma – Review Part II
We are continuing with the nursing management for asthma. This is part 2 of nursing management for asthma. Let’s get started.
Diagnostic Test – Exacerbation Of Asthma
Let’s talk about the diagnostic test that is used to diagnose asthma.
1. Methacholine Test – Exacerbation Of Asthma
What is the methacholine test?
Basically, methacholine is something that is given to patients to help understand whether the person has asthma or not. For example, this is the small airway and this is the lumen of the airway. When methacholine is administered to a normal person the smooth muscles undergo constriction. That’s something which is normal.
What must be happening to somebody who already has asthma? If somebody already has asthma their lumen is already narrowed down but there is a lot of mucus and already the smooth muscles are kind of constricted. When methacholine is given to this person then there is considerable bronchoconstriction. The bronchoconstriction is so bad that it’s going to cause a lot of narrowing of the lumen and the person may find it difficult to breathe. So then it means that this person has um asthma. So that is basically what is methacholine test is to find out if somebody has asthma.
2. PFT Test – Exacerbation Of Asthma
The second type of test is PFT.
What is PFT? How is the PFT test done?
PFT is basically a pulmonary function test. Basically, we are checking the function of the lungs. How is the PFT test done? The patient is connected to the PFT machine and asked to take in air, hold it for a certain amount of time, and then ask to exhale with force. When he exhales it with force all of that air is going to go into this PFT machine. And we are going to calculate the fe v1 which is forced expiratory volume one, post expiratory volume in one second. And that is how much air is coming out from the lungs of the patient in the first second. So we need to get a ratio of fev1 to fvc which is functional vital capacity. This ratio should be more than 80 per cent and some books say that it has to be more than 75 per cent. So this has to be more than 75 to 80 per cent in normal people which means that the airway is functioning properly.
In an asthmatic patient what’s going to happen is this ratio falls down. So you can expect to find less than 80 per cent or less than 75 per cent of fe v1 in a patient who has asthma or for that matter for a patient who has any kind of obstructive disorder. This simply means that the amount of air that’s coming out is lesser than what it should normally have be.
3. Peak Flow Test – Exacerbation Of Asthma
The third kind of diagnostic test that we are going to talk about is peak flow. This peak flow is basically not to diagnose asthma but to see how well a patient’s asthma is controlled. If you have a patient who’s taking medications and you want to monitor how well that asthma is controlled, whether the patient will require medications and you do it with the help of a peak flow.
The peak flow meter has got three readings. There’s green. If the patient is blowing into a peak flow meter and it shows green, it means that the patient’s asthma is well controlled. It means that he may not need any medications. This is around 80 to 100 per cent. So well and good.
Now the second colour that we have there is yellow or orangish colour. This is anywhere between 50 to 80 per cent. So this means that the patient may need some medications.
And of course, the third one is red. So red indicates that yes, the patient definitely needs medications because the levels are less than 50 per cent. The levels are less than 50 per cent and so the patient needs medications or the patient may have to be hospitalised. So the aim is to get it here at this level. So this is why this is more of a monitoring rather than a diagnosing tool.
That’s about the diagnostic test that is done for asthma.
Medications – Exacerbation Of Asthma
Next, we go to the medications for Exacerbation Of Asthma. What are the medications? We are not really going into details of each and every medication, but this is going to be more of a general look at what medications are given for asthma and why are these medications given.
1. Short acting beta to agonist (Saba medications)
The first one that we have is short-acting beta to agonist also known as saba medications. The examples are Albuterol and Levalbuterol. What do they do? They act on the beta2 receptors. Now the beta2 receptors are present on the smaller airways and when they act on the beta2 receptors they promote bronchodilation. This is why they are also known as bronchodilators.
We also need to remember that these beta2 receptors are found in other tissues also. So sometimes your patients may have adverse drug reactions such as tachyarrhythmia or they could also be muscle tremors. The reason is that these medications act on the beta2 receptors. So these are usually given as inhalers or as nebulizers.
The second kind of medication that we have is Corticosteroids. Now we know very well that corticosteroids have anti-inflammatory action. And we already have seen in the pathophysiology that there is inflammation when we are talking about asthma. So for these anti-inflammatory properties, corticosteroids are given. Usually, inhaled corticosteroids are given in the initial stages. Examples include Fluticasone or Budesonide or Mometasone. If the condition keeps on worsening and the symptoms are too bad or out of control, then IV or oral corticosteroids may be prescribed.
One very important thing to remember with regards to corticosteroids is that since it’s anti-inflammatory if the patient has inhaled or used an inhaler to taking the corticosteroids, you must ask them to do proper mouth care or swish the mouth with water. This is because these corticosteroids can lead to candidiasis (oral candidiasis). So it’s very important that you ask patients who are taking inhalers for asthma to ensure that they take proper mouth care.
3. Long-acting beta 2 agonists (LABA Medications)
The next group of medications that we have is Long-acting beta 2 agonists also known as Laba medications. An example is Salmeterol. These are again given not for acute exacerbations, for acute exacerbation we will always go with short-acting beta 2 agonists. These are given when the other medications are failing and you need to give a long-acting beta 2 agonist. One another thing to be remembered with regards to laba medications is that you have to always give them in combination with corticosteroids.
4. Mast Cell Stabilizers
Next, we come to a group of medications known as Mast Cell Stabilizers. Recollecting from what we had seen happen in the pathophysiology we know that we had these mast cells which had histamines. And these mast cells break open and all of these histamines are spilled out which leads to an allergic reaction.
So what do Mast Cell Stabilizers do? It does not allow the mast cell to burst open and throw out all of that histamines, it stabilizes it. An example is Cromolyn Sodium.
5. Leukotriene Receptor Antagonists
Another class of medications is leukotriene receptor antagonists. An example is Montelukast. Again we remember that there are leukotrienes that are spilled out when there is an asthmatic attack. So these medications prevent leukotrienes from being spilled out and hence reduces allergic reactions or inflammatory reactions.
Another kind of drug that’s used these days is Omalyzumab also known as monoclonal antibodies. These are Anti IgE drugs. We had seen that immunoglobulin E comes when an allergen enters and then it forms a complex and then this complex goes and attaches to the Mast cells and destabilizes. Mast cells release out histamines, leukotrienes and then starts a whole cascade of events that leads to bronchoconstriction and inflammation and so on. So these Anti-IgE drugs stop the IgE from doing all of these things and hence reducing or preventing the symptoms associated with asthma.
These are all the very commonly used medications that are given to asthmatic patients.
Nursing Interventions – Exacerbation Of Asthma
Next, we go on to the nursing interventions. In nursing interventions since we have seen all of these things that are happening with asthma, we need to remember that asthma is a condition in which there are exacerbations. So it’s not that you give medication and it’s gone all of a sudden. There can be exacerbations and the most important thing is to monitor them. To monitor for the vital signs, monitor the pulse oximetry readings, monitor the peak flow, monitor for lung sounds before the treatment, during the treatment and after the treatment so that you get to know if the treatment is working properly or not.
The interventions during the attack specifically would include provide a high fowler’s position or sitting position to aid in respiration, to aid in breathing, provide oxygen as prescribed, provide bronchodilators. So we have already seen what are the bronchodilators that are given and we have also discussed in short about what are the common adverse drug reactions of these bronchodilators. So you must be very careful and you must monitor the patient when the patient is taking a bronchodilator.
Provide corticosteroids as prescribed. Remember that corticosteroids are anti-inflammatory agents and they have kind of immunosuppressive actions as well. So if the patient is taking it in an inhaler, important thing is to ensure that you give them mouth care. If they’re taking IV or oral corticosteroids, tell them to avoid public places, tell them to avoid crowded places, hospitals. Not to get in contact with somebody who is already sick to prevent getting infections from others.
Although magnesium sulfate may be provided as prescribed to the client. Magnesium sulfate is basically a bronchodilator. So it dilates the bronchial smooth muscles and opens the airways so that the patient is able to breathe away.
So that’s it about the nursing interventions.
Exacerbation Of Asthma – Question For Nurses
Let’s take a look at a question pertaining to what we have learned.
A client has asthma. The nurse is aware of the options:
a) A written asthma plan and peak expiratory flow measurements foster self-care
b) As my education (information) improves health outcomes in adults
c) Regular ongoing reviews of client education are not necessary or beneficial
d) Clients with asthma have the same incidence of hospital admissions, unscheduled physician visits, and missed days of work as clients without asthma.
I give you a couple of seconds to just go through these options and try to figure out the answer.
Option a) Written asthma plan and peak expiratory flow measurements foster self-care.
If you look at the question here the question clearly states that we have a client who has asthma and the nurse is aware, or the nurse knows that option a) has basically two parts to it. 1) is a written asthma plan and 2) is peak expiratory flow measurements. So both of these are important. One is giving them a plan of what to do when to do it, how to do it, plus monitoring if that plan is working or no, can foster self-care now. We have already seen how they can monitor with the help of a peak flow that is why this is the right answer.
Option b) says asthma education improves health outcomes in adults.
Definitely, as my education can improve health outcomes, but with only my education you can not expect to see improving health outcomes. There has to be proper asthma information plus there has to be some kind of self-monitoring happening. So that is why this option is not the right one.
Option c) says regular ongoing reviews of client education are not necessary or beneficial.
Are not necessary? They are necessary and they are beneficial. You need to regularly talk to the client, keep educating the client because asthma is a long-term condition, it’s a chronic condition and they’re going to be exacerbations up at some point in time. So you will have to regularly review the client’s level of knowledge and provide proper education.
Option d) States clients with asthma have the same incidence of hospital admissions, unscheduled physician visits, and missed days of work as clients without asthma.
No, clients with asthma usually have more hospital admissions and physician visits and may miss work for more days because of the nature of the condition and because there can be exacerbations that occur frequently due to asthma. So that is why option d) is also wrong.
And that’s why option a) is the most appropriate for this question.
I’m pretty sure that you must have understood the concepts of asthma, nursing management, and medical management of asthma. And you will be able to deal with questions related to asthma if it comes to your exams.
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