ASTHMA
ASTHMA
Q. Mrs. Mangelepa who married to a police officer is a well known Asthmatic patient. She was admitted to your ward in a severe asthmatic attack after spraying her garden with a chemical.
b. After a thorough assessment you discover that the patient has severe asthmatic attack. List five (5) clinical features that Mrs. Mangelepa will present with to show that she has severe asthmatic attack.
c. Describe the management of Mrs. Mangelepa from admission to the hospital up to her discharge.
d. Definitely Mrs. Mangelepa will receive a bronchial-dilator through a nebulizer, explain how you will assist the patient to use the nebulizer and state your role as a nurse.
e. State 5 (five) points you would include in your IEC to Mrs. Mangelepa.
ANSWERS
A. Definition of Asthma: Asthma is a common chronic inflammatory condition of the airways which is characterized by bronchospasms, severe dyspnoea, wheezing, chest tightness and expiratory exertion.
B. Clinical features of severe asthmatic attack
• Increasing wheezing and breathlessness
• Respiratory rate more or less than 25 breaths/minute.
• Heart rate persistently more or less than 110 beats /minute
• Cyanosis
• Bradycardia
• Exhaustion
• Confusion
• Unconsciousness
MANAGEMENT OF MRS. MANGELEPA
You should realize that this patient is in a severe asthmatic attack, therefore your aim should be:
• To improve pulmonary function
• To quickly reverse bronchial spasm
• To treat broncho edema
• To treat any co-existing infections.
This is achieved by giving drugs that have quick action and chose the appropriate route of drug administration.
I. MEDICAL MANAGEMENT
a. Investigation:
• History taking and Physical assessment
• Arterial blood gas analysis
• Pulmonary function test
• Chest x-ray
b. Treatment:
Upright position
Oxygen administration via musk or nasal prongs
Intravenous fluid administration
Drugs: Broncho dilators
• Ventolin puffs or nebulizer; or Allupent via nebulizer.
• Aminophyline IV 250mg as bolus or 750mg in normal saline to run in 8 or 12 hours.
Anti-inflammatory steroids via aerosol
• Dexamethasone
• Prednisolone
• Adrenaline subcutenous injection of 0.06mg or
• Hydrocortisone IV bolus of 200mg
Treat any infection that co-exists after culture and sensitivity results, e.g. a broad spectrum antibiotic such as Ampicilin.
An anxiolytic to alley anxiety such as Valium5-10 mg orally is also given.
NURSING CARE OF MRS. MANGELEPA (Specific nursing care)
An attack of asthma is extremely frightening. The patient will be fighting for breath and is often panic stricken, therefore as a nurse maintain a calm and reassuring manner.
ENVIRONMENT
The patient is nursed in a clean well ventilated unit. She should be in a sit up position well supported by pillows and backrest or lean forward on overhead table. The nurse should be on the alert for signs of impending respiratory failure; the patient appears restless and confused, increase in respiratory rate with labored ventilation and use of auxiliary respiratory muscles. Remove any materials suspected to be antigenic to the patient. Avoid use of pillows made up of lint or further. Avoid use of methyl rated spirit as she may react to it. Provide humidification, the air should not be dry. You can achieve this by steaming or using cool vapor but protect against chilling the patient.
Keep the patient dry if there is diaphoresis.
POSITION
Allow patient to breathe comfortably such as propping her up. Provide a cardiac table with pillows for patient to rest on so as to improve lung expansion and clear air-way.
PSYCHOLOGICAL CARE
Explain the disease process that is, how it comes, signs and symptoms. This is important to alley the patient’s anxiety, an informed person is able to cope well. Explain what is being done and what is expected of her in simple language to win her confidence and gain cooperation.
Maintain emotional atmosphere in which the patient will feel comfortable to express their fears and feelings. Questions should be answered as truthfully as possible, that which you cannot answer refer to the doctor or somebody who can answer it well.
OBSERVATIONS
Check the vital signs for baseline data, monitor any deviations from normal. Check the pulse for such features as regularity, strength or volume. Check respirations for frequency, any difficulties or shallow. Blood pressure whether high or low. Temperature should be evaluated for if it is raised, there could be an infection.
Check the color of the skin, mucous membranes for cyanosis, pallor and other abnormalities.
Observe for any cough, if there’s phlegm check for color, viscosity, blood stain and report.
Observe the emotional state of their condition.
NUTRITION AND FLUIDS
Maintain hydration to help liquefy secretions for easy expectoration. Replace volume deficit and electrolytes loss to maintain homeostasis. Increase fluid intake to prevent constipation. Serve small nutritious meals frequently to prevent respiratory embarrassment. Document all fluids being given. Provide appropriate car if there’s any need for fluids.
Maintain fluid intake and output balance chart, and document.
HYGIENE
During acute attacks bed baths are avoided so as not to disturb the patient, later when the patient has stabilized assisted baths are given to promote self-esteem. When patient has stabilized hair care is also done to promote self-esteem, look presentable according to her preference.
REST AND ACTIVITY
Minimize patient’s exertion and fatigue by anticipating patient’s needs and plan or care in such a way that they are not disturbed when they are resting. Provide assistance in eating and drinking so as to conserve her energy.
Two visitors only should be allowed to visit at a time during visiting time.
ELIMINATION
Ensure that the patient is not constipated especially in an acute stage. Straining may worsen the dyspnoea. Note the frequency, color, and amount of urine. Note the bowel movement.
MEDICATION
Administer medication as prescribed to relieve the attack. Oxygen to aid in breathing is usually administered and it should be humidified. Monitor the side effects of the drugs.
INFORMATION, EDUCATION AND COMMUNICATION
Give the patient the following information:
• Avoid overcrowding places and people with respiratory infections.
• Obtain influenza and pneumococcal vaccination
• Teach the patient and relatives how to perform postural drainage and percussion to help patient expectorate.
• Teach patient about coughing and deep breathing techniques to promote good ventilation and removal of secretions.
• Teach about the importance of drug compliance, dosage, side effects.
• Teach her how to use the inhalers.
• She should report any reactions of the drugs
• Discourage to smoke
• She should avoid inhaled irritants to prevent triggering the attacks
• Avoid strong perfumes or aerosol sprays
• Avoid areas where there is industrial pollution
• Exposure to coldness may precipitate an attack.
HOW TO ASSIST PATIENT WITH THE USE OF NEBULIZER AND THE ROLE OF THE NURSE
• A nebulizer is attached to the flow of Oxygen or air converts a liquid into an aerosol mist. The medication is prescribed by the doctor along with 2-3ml of normal saline.
• Medication is checked and drawn up into a syringe and diluted with the prescribed 2-3mls of normal saline, if two medications are prescribed they should not be mixed together. Separate nebulizers should be used and the bronchodilator drug given first.
• The equipment and purpose of the medication is explained to the patient. The medication is put into the nebulizer, which is assembled and attached to the oxygen or air supply. If oxygen is used, a ‘No smoking’ sign is put up and the reason explained. Air is used instead of oxygen if the patient has COAD, because of the danger of disrupting his hypoxic drive.
• Peak flow is measured if required and the best of three attempts is charted
• The patient sits up in a comfortable position.
• Oxygen flow meter is adjusted to 51 to ensure vaporization of the medication.
• The nurse observes to ensure that there is a fine vapor coming from the nebulizer and encourages the patient to breathe it in through the mouthpiece if possible. If this is too difficult for him he may use an oxygen mask instead. The patient is instructed to breathe normally, taking an occasional deep breath. If the patient is on a respirator a nebulizer can be introduced into the ventilator circuit.
• The nurse should stay with the patient until all the medication is nebulized and observe his respirations. She should ask him how he feels and encourage him to cough and expectorate if he has mucus in his lungs. A clean sputum container should be ready for use.
• Half an hour after the treatment peak flow readings are taken again and the best of three is charted.
• The procedure is documented and the equipment washed and dried and stored in the patient’s locker until needed again.
FIVE POINTS TO INCLUDE IN IEC
• Give information about their disease and its treatment and importance about drug compliance.
• Teach how to use an aerosol at home and demonstrate
• They should keep themselves warm especially in cold weather.
• Recognize and keep away from allergens such as food stuffs, pollen etc.
• They should avoid over the counter medication that can complicate the condition.
• Teach about importance of early treatment of any respiratory infection
• Teach about avoiding the use of pillows made of lint or furthers.
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