Nursing Diagnoses

This week I created a chart with 5 primary nursing diagnoses for a patient with asthma. Since this blog is created for a class in my nursing program, it makes sense why I am doing this. For those of you reading this who might not know, a nursing diagnosis is different than a medical diagnosis. Instead of looking at medical problems, a nursing diagnosis is a statement about actual or potential health problems or life situations. It can encompass health concerns, emotional concerns, resource concerns, and much more. For each diagnosis, read across the row to follow the flow: problem/diagnosis --> what it is related to or caused by --> outcome goals --> interventions/ways to carry out these goals. (P.S. Sorry my chart is not one solid picture. I struggle with technology.)

I received ideas from several sources, and some of them I thought of myself. My sources are listed below for further reference:

Elsevier Care Plan Index. (2012, January 1). Retrieved from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/cpindex.html

Hockenberry, & Wilson. (2011). Wong's Nursing Care of Infants and Children (9th ed., pp. 1274-1278). Elsevier/Mosby.

Nurselabs. (2/11/12). 5 Bronchial Asthma Nursing Care Plans. http://nurseslabs.com/bronchial-asthma-nursing-care-plans/

Nursing Care of Patients With Asthma

This week I have created a summary chart of the role nurses have in caring for patients with asthma. I broke it down into 2 main categories: care of patients in emergency situations ("status asthmaticus"), and care for patients when they are not. This includes situations such as when a patient is visiting for a check-up appointment or once thier asthma symptoms have been relieved and they (and/or their family) are ready to talk about their symptoms, environment, lifestyle, etc. In non-emergency situations, nurses should work to plan holistic management.

For more information on asthma management, I found an article that I am really excited about from the Global Initiative for Asthma (2014) that I wish I would have found earlier in my blogging. It is titled, "Global Strategy for Asthma Management and Prevention". While it talks about pretty much everything relating to asthma, it starts talks about emergency management from pages 63-72 and has many other sections that talk about nursing interventions for prevention, education, etc. I feel that it does a good job explaining care in a step-wise manner and relates them to nursing care priorities (airway, breathing, circulation, and so forth). You can find the link below, and I encourage you to also check out the Global Initiative for Asthma's website, as they are always posting new research with knowledge that will benefit nurses. Here is their link: http://www.ginasthma.org/

Source:
Global Initiative for Asthma (2014). "Global Strategy for Asthma Management and Prevention." Retrieved from http://www.ginasthma.org/local/uploads/files/GINA_Report_2014_Aug12.pdf

Treatment: What will help?

In this post I am going to briefly talk about treatments for managing the symptoms of asthma. Remember, asthma is not curable, but the symptoms can be significantly reduced with the appropriate medications and environmental changes. Firstly, it is important to remove allergens from environments you are around a lot. Sometimes this is not possible, but it is important to do the best you can, as this will help reduce flare-ups. For example, if you are allergic to dust, try keeping your home clean and dust-free. Or if you are allergic to cats and your best friend has one (or ten, you never know with some people), try to find other meeting places so that you don't have to be around them.

Now let's talk meds. The medications you will be put on depend on how severe your asthma is and how well-controlled it has been (or has not been). I will put up another post soon about how asthma is staged. But for now, just know that there are many different medication options available, and if something is not working for you, your doctor will work with you to find something that does.

I found an article from the NIH about how to diagnose asthma and which medications to give for different severities. The basic principal is that we will start with a medication regime that the doctor thinks will work, then we will be monitored to see if it is working. I found an article that does a thorough job of laying out how treatment decisions are made, and here is one of their charts in particular. You can look at the website for more details. (National Heart, Lung and Blood Institute; US Department of Health and Human Services. Pg 7).

(Note: SABA=short-acting beta-2 agonist. It is a bronchodilator and thus opens up tight airways. It is used for quick symptom relief. ICS means inhaled corticosteroid, and this medication prevents airway inflammation/swelling. LABA means long-acting beta-2 agonist. It also is a bronchodilator, but it works over time to open up the airways longer, and can't be used in an emergency attack since it takes awhile to work.)


This is definitely a lot to take in, but the main idea is to keep trying until something works.

         There are 2 main categories of asthma medications: Those that dilate the airways by reducing the airway constriction ("bronchodilators") and those that reduce the airway inflammation that also happens in asthma ("anti-inflammatory") :

1) Bronchodilators can be used in emergency attacks (this kind will work immediately but for a short time) or they can be used to manage airway constriction for a longer period of time (but this kind won't act right away and thus can't be used in a sudden attack).

   Bronchodilator Example:
   SABA: "Short-acting beta2 agonist"- a medication used for immediate relief of symptoms, like in a    sudden attack. A common drug of this kind is Albuterol, which is often used in a metered-dose           inhaler, such as this:

While each bronchodilator medication is a bit different, side effects can commonly include feeling jittery/shakey and having a fast heart rate. There is not too much one can do for this except to reduce the dose of the medication they are on, but it usually isn't too bothersome for people.

2) Anti-Inflammatory drugs are used for long-term control of asthma, or are used in higher doses during times when asthma is severe and not getting better with the regular treatment regime. There are different types of anti-inflammatory drugs, each of which works in a different way.

   Anti-inflammatory drug example: 

Glucocorticoids: These are steroid drugs and can be inhaled or taken in pill form at home. The       inhaled, low dose form works long-term to reduce inflammation. This type of steroid is NOT the   same as the steroids people sometimes abuse to increase their muscle mass and strength, so do not worry! Daily inhaled glucocoriticoids do an amazing and safe job at managing asthma and preventing sudden attacks. There are rarely any significant side effects with them. They are used for prevention and do not help with sudden attacks.

        When people are going through a period of time where their asthma medications are not working and their asthma is severe, they may go on oral corticosteroids. These are dosed much higher and are used short-term to reduce the inflammation. Side effects might include weight gain (since larger doses of glucocorticoids make you keep more water in your body), suppression of your adrenal gland (the adrenal gland naturally makes glucocorticoids in your body), and growth suppression in kids, to name a few. These symptoms are not common though if the treatment is short (such as for a week or so). We cannot avoid all of the symptoms, but the main thing the doctor will focus on is weaning someone off of the drug to see if the adrenal gland is able to still produce enough glucocorticoids on its own. Symptoms like weight gain (which can manifest as a puffy, round face or a little hump on the back) will go away after the medication is finished, but this is usually a sign not seen unless the corticosteroid is taken for long-term purposes (as is sometimes the case in patients with persistent severe asthma). A very common corticosteroid prescribed is prednisone. 

        There is a lot more information out there, and I would bore you with it all if I tried to talk about every single medication and side effect. Feel free to look at the resources I did and keep researching! You can also look at this picture below for a visualization of different "relievers" (for quick relief), "controllers" that keep airways open for a longer time than relievers do, and "preventers" that help reduce inflammation/airway swelling.

 And remember:

(Picture from Francisco Q, found on http://www.who.int/respiratory/asthma/burden/en/)

Sources:

Allergy and Asthma Network: All About Asthma Medications. http://www.aanma.org/faqs/welcome-to-precious-breathers/medicationspre/

National Heart, Lung and Blood Institute; US Department of Health and Human Services. "Asthma Care Quick Reference: Diagnosing and Managing Asthma." (2012, June 1). Retrieved from http://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf

National Heart, Lung and Blood Institute & National Asthma Education and Prevention Program. (2007, August 28). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Retrieved January 31, 2015, from http://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf

Symptoms over time

In some diseases, the symptoms people have change over time as the disease begins to do different things to the body. In asthma, the disease stays in the airways. In a previous post, I have already discussed how an asthma attack progresses, but as a refresher, when some allergen irritates your airways, they overreact by getting smaller and making more mucous. This ultimately makes it harder for air to move in and out and makes breathing difficult. In any asthmatic, this is what happens. Most people will experience the classic symptoms of asthma: Wheezing, difficulty breathing, coughing, and a feeling of tightness in the chest might also occur. A person with asthma can expect this to happen throughout their life when they have an attack, but it can be reduced significantly if controlled well with medication.

What happens to a person with asthma's lungs over time is thought to be dependent on how well they control it. As I have said before, even when someone might not feel like they are having an asthma attack, there still might be a little bit of airway flare-up happening. Over a long period of time, if this mild flare-up is not controlled, the airways can do what is called "re-modeling." This remodeling is what can cause even more problems down the road. Remember, inflammation is a natural process that is made to help heal the body after it experiences injury, but in asthma, this inflammation is not wanted because it serves no good purpose: it makes us unable to breathe and it works when we don't even notice it to slowly damage our airways over time if it is not controlled with medication. The idea is that over time, after being under even small amounts of inflammation, the cells in our airways change because they are adapting to the inflammation. They are "remodeling." In this process, the little smooth muscles that line our airways (and cause them to either constrict or open up) become thicker. The walls of the airways themselves also thicken. This makes the airway even smaller and is irreversible. The cells also begin to lose their cilia, which are like little fingers that push mucous and other things that shouldn't be in our airways up and out. These impairments will cause persistent airflow limitation and obstruction.

(In this picture, don't worry about the tricky words. You can see the changes that can happen to airways overtime in a person with asthma. The bottom left picture shows an airway that is more fibrous, meaning it has become stiffer. This makes it less easy to open and close the airways how we would like them to. The little smooth muscle layer that lines our smaller airways gets really thick, which means there is less room for what we want, which is air! Also, the cells that make mucous in our airways increase and we have more of it. This is what we want to prevent!)

If a person has asthma that is not well-controlled by medication (I am not talking about fast-acting inhalers here, but am instead talking about medications that are made to provide asthma control for long periods of time), this remodeling will happen, and the extent to which it happens varies depending on the person. As you can see, we don't want this and should take our controlling medications to prevent it, because it is not reversible.

Source:

National Heart, Lung and Blood Institute (2014). What Are the Signs and Symptoms of Asthma? Retrieved February 7, 2015, from http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/signs

Shifren, A., Witt, C., Christie, C., & Castro, M. (2012). Mechanisms of Remodeling in Asthmatic Airways. Hindwai Journal of Allergy, 12-12. Retrieved on 2/7/15 from http://www.hindawi.com/journals/ja/2012/316049/.

How do I know I have asthma and what can happen over time?

Diagnosis:

In order to determine if you have asthma, a visit to a healthcare provider (such as a doctor or a nurse practitioner) is the best way. While the internet is a wealth of information, one should never diagnose themselves based on things that haven't been confirmed by a healthcare professional. There are several ways a health care provider can diagnose asthma:

1) Health History

They will ask about your concerns, such as when you noticed you have trouble breathing, what it feels like, when your breathing becomes worse or better, and how long your symptoms have been going on, in addition to other important questions. A hallmark of asthma is when someone wheezes during exercise, when they are sick, are around animals with hair or fur, when the weather changes, or when they inhale dust or pollen, to name a few.

2) Physical Exam

Your diagnosis is also based on an assessment of your lungs, chest, nose, throat, and skin. An x-ray might be done, too. This helps the doctor rule out the possibility of other diseases. Wheezing during regular breathing is a sign of asthma.

                                          

3) Breathing tests

You will most likely be asked to do a few breathing tests. These are nothing to worry about. For example, the doctor might give you something called a "spirometer" (a hand-held device that measures how much air you can breathe in), and ask you to take as deep of a breath as you can. They also might test you with a "peak flow meter," which is a small device that you hold and blow into. When you blow out the air, a little line moves and tells you how well your lungs are working. The higher the number, the better (keep in mind that different ages will have different target numbers). You will do this then take medicine that is made to expand the airways. Then you will do the peak flow meter test again. If you are able to blow the line further, [specifically, if the volume of air you can blow out in 1 second increases by 10 or more (National Heart, Lung and Blood Institute & National Asthma Education and Prevention Program; p 65-66)] this means that the medication worked, and could mean you have asthma.

Left: Spirometer; RIght: Peak Flow Meter

4) There might also be allergy testing. Since asthma and allergies are closely related, the doctor might do this to see what could cause flare-ups.

Overall, what a healthcare provider will do is see if a) your symptoms match those of asthma b) your airway constriction is reversible with medications meant to help and c) rule out other causes (like COPD).

Disease Progression:

Diagnosis is important because then asthma control can be planned. Even when a person with asthma does not feel like they are struggling to breathe, there still might be airway inflammation. Over time, this damages the lungs. It can reduce lung function by permanently narrowing the airways and cause airway scarring over time. This is termed "airway remodeling," and occurs over time in an asthmatic, especially if their asthma is not controlled with medication. 

Sources:

I found   all of my information from the the sources listed below. The U.S. Department of Health and Human Services article is very long, in depth, and research-oriented, but if you like reading things like this is has a ton of information on what asthma is, how exactly it is diagnosed, and how it can be managed.

Asthma and Allergy Foundation of America. (2011) Asthma Overview: Diagnosis. Retrieved January 31, 2015, from http://www.aafa.org/display.cfm?id=8&cont=7

National Heart, Lung and Blood Institute & National Asthma Education and Prevention Program. (2007, August 28). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Retrieved January 31, 2015, from http://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf

The Asthma Center: Remodeling of the Airways. Retrieved January 31, 2015, from http://www.theasthmacenter.org/index.php/disease_information/asthma/what_is_asthma/definition_of_asthma/remodeling_of_the_airways_/

Who gets asthma?: It's complicated

In my second post, I explained an asthma attack/episode (the so-called "pathophysiology"), so to refresh your memory on this please take another glance! I also found another video that I think explains an asthma attack very well, and it goes into more detail than the last one I posted:

This week I am going to touch on what researchers believe puts a person at risk for developing asthma, although this process is not fully understood.

While genetics are thought to play a role, there are many other theories of why a person might get asthma. I found an article published in NCBI, titled "Asthma: epidemiology, etiology and risk factors" (2009), discussing that having a parent with asthma might increase a person's risk of developing it; however, it is not necessary. A person's risk is affected more by the environmental and lifestyle exposures they have experienced. The idea is that certain things from outside of our bodies can mess with certain bits of our genetic material inside our bodies, making them more defective.

So what are these factors that increase our risk besides possible family inheritance? While not fully understood, here are a few: Having a mother who smoked or was stressed during pregnancy, being exposed to cigarette smoke or animals early in life, exposure to mold (such as at home or in school), and exposure to chemicals in the air (such as pollution) or certain chemicals in one's workplace. Researchers have also found that people who have a lower socioeconomic status have a greater change of getting asthma. I once read that one possible explanation for this is that people who are unable to afford newer, safer housing are more likely to live in homes that cost less but as a result may not be as safe for a person's health (for example, housing that is located near a freeway where families will be exposed to fumes or mold-infested homes). 

Something else many people are curious about is why some people get asthma in childhood and later seem to outgrow it, and why some don't have it until adulthood. The NCBI article suggests that children are most affected by factors in pregnancy and early life, whereas adult-onset asthma is commonly related to repeated exposures at work. Below is a video about the myth of "outgrowing" asthma:

And on one final note, I am going to mention that the contributing factors to asthma deaths are also complex. After reviewing the actual disease process, discussed in my second post, it is easier to understand how the narrowing of the airways can cause death, but even with the same disease process, sadly, some people are more likely to die from asthma than others. This may be related to a number of factors, such as a person's desire to not take preventative medication, a person's inability to afford medication, and disparities in health care access among minority populations, to name a few. For more information, I encourage you to view this article:

https://www.aafa.org/pdfs/Disparities.PDF

Sources:

Subbaro, P., Mandhane, P.J., Sears, M.R. (2009). Asthma: epidemiology, etiology and risk factors. CMAJ: Canadian Medical Association Journal, 181(9), E181-E190. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2764772/

The Asthma and Allergy Foundation of America, The National Pharmaceutical Council. (2005). Ethnic Disparities in the Burden and Treatment of Asthma . https://www.aafa.org/pdfs/Disparities.PDF

Who's Most Affected? Asthma in the US

This week I will be giving a little bit of information on who is more at risk for asthma, based on recent trends. While searching for data from the past 5 years, I found that the overwhelming amount of the most recent nation-wide research is from 2007-2011 or 2012. I assume that more recent data is still being processed and put into documents by organizations such as the WHO and CDC. Once I find more recent data I will update this post. For now, here is what I've found:

• Approximately 1 in 12 people in the United States have asthma, and this trend has been and will likely continue to rise over time.

• More children than adults (9.5% vs 7.7%) and more females than males (9.2 vs. 7.0%) have asthma.
• People who identified as being of multiple races had the highest prevalence of asthma (14.1%), followed by African Americans (11.2%), Alaska Natives (9.4%), Whites (7.7%), Hispanic/Latino (6.5%), and Asians (5.2%). [I dislike when statistics clump many different ethnicities in such broad categories, but nonetheless it is often what happens in statistical analysis. If you choose to click on the link from where I found this information, the data table (figure 2) includes just a few more categories that have been broken down.]
• People of lower income are more affected , especially in households with an annual income below $15,000. Overall , the less income a family makes below the poverty line , the more cases of asthma we see. 
• According to the World Health Organization, asthma causes an estimated 25.6 million missed school/work days each year. 
• Asthma deaths, while rare, still do occur. According to 2010 data , asthma deaths have been decreasing, but they are most common among the elderly (over age 65), African Americans, and females. It is estimated that 9 people per day in the US die from asthma. 

Below I have added a nice picture from the CDC that includes their most updated nation-wide information on some of what I have mentioned and more:

Here is a map from the national Behavioral Risk Factor Surveillance System of people who reported having asthma in 2010. This map should give an idea of how asthma is distributed in the US, but use it with caution. Because this data is self-reported, there is a possibility of bias, as the population surveyed may not be an accurate representation of the total US prevalence. (For instance, there could be many more people unaccounted for in this survey, either because not everyone with asthma was questioned or did not have telephones to answer the survey, or there were people who did not wish to answer the survey, etc. The list goes on). What I personally take from viewing this map is simply the fact that asthma is distributed throughout the US.

Sources:

         Akinbami LJ, Moorman JE, Bailey C, et al. Trends in asthma prevalence, health care use, and mortality in the United States, 2001–2010. NCHS data brief, no 94. Hyattsville, MD: National Center for Health Statistics. 2012.http://www.cdc.gov/nchs/data/databriefs/db94.htm

       Asthma Facts: CDC's National Asthma Control Program Grantees. (2013, July 1). Retrieved January 16, 2015, from http://www.cdc.gov/asthma/pdfs/asthma_facts_program_grantees.pdf

         Asthma: Scope of the Problem in the USA. (n.d.). Retrieved January 18, 2015, from http://www.who.int/gard/news_events/21_casale_aaaai.pdf?ua=1

2010 Adult Asthma Data: Prevalence Tables and Maps. (2012, August 27). Retrieved January 18, 2015, from http://www.cdc.gov/asthma/brfss/2010/current/mapC1.htm