Chapter 23: Asthma

Question 1

Asthma

Answer 1

• most common chronic disease in childhood
• characterized by the triad symptoms of bronchial smooth muscle spasm, inflammation and edema of the bronchial mucosa, and production and retention of thick, tenacious, pulmonary secretions leading to airway obstruction
• chronic childhood inflammatory disorder of the airways that results in intermittent and reversible airflow obstruction of the bronchioles

Question 2

Risk Factors for Asthma

Answer 2

• environmental factors: air pollutants, allergen exposure, exposure to tobacco smoke, and strong chemical odors
• low socioeconomic status
• health-care disparities
• extrinsic factors: allergens such as dust, pollen, animal hairs, chemical sprays, perfumes, baby powder, and molds
• foods: nuts, chocolates, oranges, and chicken
• changes in weather, pollution, and smoke
• Intrinsic Factors: exercise, anxiety, strong emotions such as fear and laughter, and infections
• family hx of asthma or allergies

Question 3

Status Asthmaticus

Answer 3

persistent and intractable asthma in which the child does not respond to therapy and a medical emergency ensues

Question 4

Signs + Symptoms

Answer 4

-recurrent wheezing
-SOB
-nonproductive cough
-chest tightness or pain
-exercise intolerance
-prolonged expiratory phase of respirations
-tachypnea
-retractions and nasal flaring
-history of allergies
-history of atopic dermatitis
-nasal polyps
-history of nighttime cough
-family history of atopy (asthma, allergic rhinitis, or atopic dermatitis)
ATI:
-dyspnea
-cough
-audible wheezing
-coarse lung sounds, wheezing throughout, possible cracks
-mucus production
-restlessness, irritability
-anxiety
-sweating
-use of accessory muscles
-decreased oxygen saturation
-tripod positioning
-sitting retractions
-inaudible breath sounds or crackles (severe obstruction

Question 5

Diagnosis

Answer 5

based on clinical symptoms, history, physical examination, and to a lesser extent, laboratory tests

• intermittent, mild, persistent, moderate persistent, or severe
• pulse oximeter to measure oxygen saturation
• blood gases to determine carbon dioxide retention and hypoxemia
• complete blood count
• pulmonary function test to assist in determining the degree of disease
• peak expiratory flow rate
• allergy testing
• chest radiography to evaluate hyperinflation and potential for coexisting infection

Question 6

Blood Gases

Answer 6

used to evaluate respiratory and metabolic function through determining the acid-base balance of the blood by measurement of oxygen and carbon dioxide

• obtained through arterial, venous, capillary, or cord blood
• arterial blood gases measure the amount of dissolved oxygen and carbon dioxide present in arterial blood and reveal the acid-base state and how well the oxygen is being carried to the body
• measurements: pH, PCO2, HCO3, PO2, and O2 Sat
• the amount of carbon dioxide is determined by the partial pressure of carbon dioxide (PCO2); controlled by the lungs; as the CO2 levels increase the pH decreases = acidosis
• HCO3= bicarbonate, as HCO3 levels increase, so does the pH= alkalosis
• amount of oxygen dissolved in the blood is measured by partial pressure of oxygen (PO2)
• amount of oxygen bound to hemoglobin is by oxygen saturation (O2 Sat)

Question 7

Blood Gases and Asthma

Answer 7

-airway diseases, such as asthma that causes respiratory structures to become less compliant, may lead to carbon dioxide retention and respiratory acidosis
-interference with breathing causes the CO2 rate to increase and the pH to drop
>ongoing carbon dioxide (CO2) retention can lead to chronic respiratory acidosis
-conditions that increase respiratory rates, such as hyperventilation, anxiety, pulmonary embolus, salicylate poisoning, and fever, lead to respiratory alkalosis, which is a loss of CO2 and an increased pH

Question 8

Prevention of Asthma

Answer 8

directed toward day-to-day management
-identifying environmental factors that trigger an attack
-compliance with medication
-how to use and clean inhalers, spacers, or aerosol equipment
>parents and children need to understand how to manage asthma in settings away from home, how to recognize when there is a need to seek additional assistance, and regular follow-ups

Question 9

Nursing Care

Answer 9

assisting with relief of symptoms and providing health education to parents and family

• asthma attacks are frightening and stressful for both patient and family; nurse has a calm approach
• administering quick-relief medications without delay
• provides education about use of a peak flow meter

Question 10

Essential Nursing Interventions

Answer 10

• giving medications on time
• liquefying secretions through adequate hydration
• positioning child properly; head of bed elevated 30 degrees to provide comfort and lung expansion; side-lying and semi-prone positions
• report and record respiratory assessment and response to medications
• ensure respiratory treatments happen in a timely manner and that ordering prn treatment may be necessary

Question 11

Medical Care

Answer 11

depends on the level of severity of the disease
>quick-relief or rescue medications
>long-term control medications
-daily anti-inflammatory agents to control the levels of persistent asthma, with increasing doses of medication as necessary
-With mild, persistent asthma: use of low-dose medications such as inhaled steroids, cromolyn sodium (Intal), nedocromil (Tilade), or an anti-leukotriene (Montelukast sodium) tablet
-For moderate and Severe persistent asthma: a higher dose of steroids with the addition of long-acting beta antagonists
-For quick relief of bronchospasm and with asthma: short-acting inhaled beta antagonists

Question 12

Treatment Consists of?

Answer 12

early relief of symptoms through drug therapy and prevention of further attacks through allergen control, environmental manipulation, health education, and attainment of self-management skills
>goal is to enable the child to have as regular a life as possible by keeping the lung function within normal limits

Question 13

Asthma Action Plan

Answer 13

educational communication tool used between the health-care provider and the patient, along with their family and caregivers, to properly manage asthma and respond to asthma episodes
-completed by child’s primary care provider
-includes the symptoms and management for each color zone including peak flow measurements appropriate for each color zone
-peak flow meter is an essential companion for the Asthma Action Plan for children older than 6
>to determine the child’s zone for children younger than 6, symptoms are used alone

Question 14

Peak Flow Meter

Answer 14

-essential for Asthma Action Plan (for children over 6)
-a portable, handheld device that is used to measure the ability to push air out of the lungs
>the “personal best” peak flow is determined when the child is symptom free
-peak flow meter package usually contains a form where peak flow readings are recorded regularly

Question 15

Education/ Discharge

Answer 15

nurse can offer health education to families that emphasizes correctly adhering to the treatment regimen, preventing infection, and avoiding asthma triggers

Question 16

Spacers

Answer 16

-recommended for children less than 5 years of age
-attached to the meter dose inhaler
-may deliver the medication to the child’s lungs better than an inhaler alone and may be easier to use
-child-sized masks are available that fit the valved holding chamber (VHC)
-there is more medication deposited in the lungs and less systemic side effects
>after VHC use, the nurse can have the child follow with mouth washing and spitting to decrease swallowing medication and side effects (incase of inhaled corticosteroids, prevention of oral candidiasis)

Question 17

What to do in cases of an acute asthma attack

Answer 17

can occur anytime and anywhere

• nurses can give information on environmental control and creating an allergen-free environment
• nurse can emphasize that when a child exhibits difficulty breathing, wheezing, and coughing, it is important to be calm and reassure the child
• find out if the child’s medicine is available; if not call 911

Question 18

Why does the Obstruction Occur?

Answer 18

the mast cells release histamines and leukotrienes which causes inflammation or airway hyper-responsiveness

Question 19

What would a CBC show?

Answer 19

-increased WBC, eosinophils

Question 20

Pulmonary Function Tests

Answer 20

• most accurate tests for diagnosing asthma and its severity
• baseline test at diagnosis
• repeat testing after treatment is initiated and child is stabilized
• test every 1 to 2 years

Question 21

Peak Expiratory Flow Rate (PEFR)

Answer 21

• uses a flow meter to measure the amount of air that can be forcefully exhaled in 1 second
• each child needs to establish personal best

Question 22

What Does a Chest x-ray show

Answer 22

hyper-expansion and infiltrates

Question 23

ATI: Nursing Care for Asthma

Answer 23

• assess airway patency, respiratory rate, symmetry, effort, and use of accessory muscles
• assess breath sounds in all lung fields
• monitor for SOB, dyspnea, and audible wheezing; an absence of wheezing can indicate severe constriction of the alveoli
• monitor vital signs and oxygen saturation
• check CBC and x-ray results, possible ABGs
• position the child to maximize ventilation
• administer oxygen therapy as prescribed; keep endotracheal intubation equipment nearby
• initiate and maintain IV access as prescribed
• maintain a calm and reassuring demeanor
• encourage appropriate vaccinations and prompt medical attention for infections
• administer medications
• educate about rescue vs maintenance medications

Question 24

ATI Medications: Short-acting beta 2 agonists

Answer 24

-Albuterol
-levalbuterol
-terbutaline
>used for acute exacerbations
>prevention of exercised induced asthma

Question 25

ATI Medications: Long-acting beta 2 agonists

Answer 25

-formoterol -salmeterol >used to prevent exacerbations, especially at night, and reduce use of short-acting beta agonists >must be used along with anti-inflammatory therapy >cannot be used to treat acute exacerbations

Question 26

ATI Medications: Corticosteroids

Answer 26

decrease airway inflammation (anti-inflammatory agent) -methylprednisolone (parenterally) -prednisone (orally) -fluticasone (inhalation) >oral systemic steroids (prednisone) can be given for a short period (3 or 10 days); prednisone is used short-term for exacerbations >inhaled (fluticasone) are administered daily as a preventative measure >monitor child's growth >observe oral mucosa for infection secondary to use of inhaled medication >assess weight, blood pressure, electrolytes, glucose, and growth with oral corticosteroid use

Question 27

ATI Medication: Theophylline

Answer 27

anti-inflammatory agent - decreases airway inflammation - used in the pediatric intensive care unit (PICU) when the child is not responding to therapy b/c of increased risk for toxicity and frequent monitoring of blood levels

Question 28

ATI: How to use a peak flow meter

Answer 28

- use at same time each day - ensure the marker is zeroed - stand up straight - remove gum or food from mouth - close lips tightly around the mouth piece (ensure tongue not occluding) - blow out as hard and as quickly as possible - read number on meter - repeat these steps for 2 more times, total of three - record highest number

Question 29

Analysis of peak flow rates according to colored zones

Answer 29

>Green: 80 to 100% -Good control. Follow routine plan >Yellow: 50 to 79% -Caution. This zone warns of an acute attack. Use maintenance medications. Notify provider if the peak flow rate stays in this zone. >Red: Less than 50% -Emergent action needed. Use a short-acting bronchodilator. Notify Provider if the peak flow rate does not improve

Question 30

ATI: Status Asthamticus

Answer 30

a life-threatening episode of airway obstruction that is often unresponsive to common treatment. Prolonged severe asthma attack

Question 31

ATI: Status Asthmaticus Manifestations

Answer 31

- wheezing - labored breathing - nasal flaring - lack of air movement in lungs - use of accessory muscles - distended neck veins - tachycardia - tachypnea - hypoxia - diaphoresis - risk for cardiac and respiratory arrest

Question 32

ATI: Status Asthmaticus Nursing Actions

Answer 32

- monitor oxygen saturations continuously - place on continuous cardiorespiratory monitor - position the child sitting upright, standing, or leaning slightly forward - administer humidified oxygen - administer three nebulizer treatments of a beta 2 agonists, 20 to 30 minutes apart or continuously; Ipratropium bromide can be added to the nebulizer to increase bronchodilation - obtain IV access - monitor ABGs and blood electrolytes - administer corticosteroid - prepare for emergency intubation - Magnesium sulfate IV decreases inflammation and improves pulmonary function and peak flow rate among children who have moderate to severe asthma when treated in the ED or pediatric ICU