Topic: Audience: Date: Time: Duration: Venue:

Caring for the patient with Asthma 3rd year BScN. Student Nurses (NCU) August 27th, 2013 10am-10:45am 45 Minutes Lecture Room

Methodology: Lecture/Discussion Number of participants: To be decided Learning Theories: Ausubel: Emphasized the use of advance organizers which he said was

different from overviews and summaries. His use of an advance organizer acted as a bridge the chasm between learning material and existing related ideas. The advanced organizer used; sought to bridge new knowledge with what was known (sometimes what is known is uncertain and not concrete). Though he specified that his theory applied only to reception learning in schools, it was utilized because it introduced the topic and aided the sequence of the information to be imparted. (Ormrod & Rice, 2003). Rogers: Dealt with the adult learner, he posited that learning is student centered and personalized and the educators role is that of a facilitator. Affective and cognitive needs are central and the goal is to develop self-actualized persons in a cooperative, supportive environment. This theory was used because all the participants were adult learners, thus they

were responsible for their learning experience and the teacher sought to guide them through this experience. (Quinn & Hughes, 2009). Bruner: Believed that learners were not blank slates but bought past experiences to a new situation, he also stated that new information was linked to prior knowledge, thus mental representations are subjective. Bruners Discovery learning is an inquiry-based, constructivist learning theory that takes place in problem solving situations where the learner draws on his or her own past experience and existing knowledge to discover facts and relationships and new truths to be learned. (Quinn et al., 2009). Students interact with the world by exploring and manipulating objects, wrestling with questions and controversies, or performing experiments. As a result, students may be more likely to remember concepts and knowledge discovered on their own (in contrast to a transmissionist model). (Quinn et al., 2009). Models that are based upon discovery learning model include: guided discovery, problem-based learning, simulation-based learning, case-based learning, incidental learning, among others. The advantages of this theory are: it encourages active engagement, promotes motivation, a tailored learning experience, and promotes autonomy, responsibility, independence, the development of creativity and problem solving skills. (Quinn et al., 2009) Bruners theory was used because it encouraged active engagement, promotes motivation, a tailored learning experience, and promotes autonomy, responsibility, independence and the development of creativity and problem solving skills for this presentation. Vygotsky: Posited that individuals learn from each other through social interaction and the teacher and the learner collaborate in a reciprocal relationship where each learns from each other through the same process of social interaction (Ormrod et al,, 2003). This theory was chosen

since it lays the overall foundation for human behaviours that of interaction, it coincides with the topic and the overall mode of delivery of the topic Aim of the activity: To educate/show students how the nursing process can be applied effectively to patient care situation. Scientific Principle: Gaseous Exchange: This refers to the movement of oxygen into the blood and carbon dioxide out of the blood. Oxygen and carbon dioxide move across the respiratory membrane (through the process of diffusion) which includes the alveolus and pulmonary capillary. In this principle oxygen moves out of the alveolus into the capillary, while carbon dioxide moves in the opposite direction - hence, the term gas exchange (Simmonds, 2013). This scientific principle was utilized since it explains how gases flow in and out of the lungs. Additionally, it was used, since clients will be expected to return to a state where oxygen and carbon dioxide can be adequately exchanged Resources: Objectives: Registered nurse, lap top computer, multimedia, white board, markers At the end of 45 minutes interactive session students should be able to 1. Define the term Asthma according to Smelter, Bare, Hinkle and Cheever, (2010)

2. Explain the Etiology/Risk factors/Pathophysiology for Asthma as stated by Smelter et al (2010) 3. Describe the manifestation of Asthma as cited by Pellico (2013) 4. State the diagnostic test/Lab test used in the diagnosis of Asthma according to Chernecky and Berger (2013) and National Heart, Lung and Blood Institute (NHLB), (2013) 5. Describe the general management for clients with Asthma as explained by Pellico and Berger (2013) 6. Discuss the nursing management for clients with Asthma utilizing the nursing process Evaluation: Formative and Summative. Questions will be asked before and after each objective.

References: Ackley, B. J & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier Chernecky, C & Berger, B. (2013). Diagnostic test and laboratory procedures. Saint Louis Missouri: Elsevier Saunders Gulanick, M & Myers, J. (2013). Nursing care plans: Diagnoses, Interventions, outcomes (8th ed.) Philadelphia: Elsevier Mosby National Heart, Lung and Blood Institute (2013). How is asthma diagnosed? Retrieved on August 14th, 2013 from http://www.nhlbi.nih.gov/health/health-topics/topics/asthma/diagnosis.html

Ormrod, J & Rice, F. (2003). Lifespan development and learning. Boston MA: Pearson Publishing. Pellico, L. (2013). Focus on adult health medical nursing. Philadelphia: Wolters Klower Health/Lippincott Williams & Williams Quinn, F & Hughes, S. (2009). Quinns principles and practice of nurse education (5th ed.) Cheltenham: Nelson Thornes Smelter, C., Bare, B., Hinkle, J & Cheever, K. (2010). Brunner & Suddarths textbook of medical surgical nursing. (12th ed.)Philadelphia: Wolters Klower Health/Lippincott Williams & Williams

Objectives Icebreaker

Contents

Teachers Obj Teacher will ask student to look at picture and identify the topic to be discussed

Learners Obj Learner will look at the picture and attempt to identify the topic to be discussed

Evaluation

Define the term Asthma according to Pellico (2013)

Defined as a common, complex disease of the airways characterized by recurring and variable symptom, airflow obstruction and bronchial hyper-responsiveness (Pellico, 2013)

Teacher will randomly ask students to define the terms Asthma in their own words. Teacher will define asthma nursing process PowerPoint according to the content Teacher will ask one student to define the term Asthma according to the content

Students will attempt to define the Asthma process in their own words. Students will sit and listen attentively as the term Asthma defined Student will define the term nursing process according to the content using at least two key words such as: Students will correctly define

Students will correctly define the terms the nursing process utilizing at least two key words according to the content such as: A common, complex disease of the airway characterized by recurring and variable symptom, airflow obstruction and bronchial hyperresponsiveness

Explain the Etiology/ Risk factors or Pathophysiology for Asthma as stated by Smelter et al (2010) and Pellico (2013)

Pathophysiology Asthmas pathophysiology is characterized by a reversible and diffusive airway limitation. Acute inflammation leads to airflow limitation and changes in the airways. Bronchoconstriction, which is constriction of smooth muscles of the airway, occurs in response to a variety of allergens and irritants. The airways become hyper-responsive (respond to stimuli in an exaggerated way). Airway edema (swelling of the membranes that line the airway) becomes more progressive as severity increases. Mucus hyper-secretion and plug occurs. In some cases remodeling can occur (permanent narrowing (changes) in the airway structure) causing fibrosis and scarring (resulting in irreversible CAL). Cellular elements such as mast cells, neutrophils, eosinophils, and lymphocytes are implicated. They release chemical mediators such as histamine, bradykinnin, prostaglandin and leucotrienes. These mediators perpetuate the inflammatory response and cause increased blood flow, vasoconstriction,

the terms the nursing process utilizing at least two key words according to the context such as: A common, complex disease of the airway characterized by recurring and variable symptom, airflow obstruction Teacher will ask two Two students at students at the front the front of the and three in the class and three middle of the class to in the middle explain the will attempt to etiology/risk explain the factors/pathophysiol etiology/risk ogy for asthma factors/pathophy siology for asthma

Teacher will explain the etiology/risk factors/pathophysiol ogy for asthma utilizing the white board, markers

Students will sit and listen attentively ask questions as necessary as the etiology/risk

Students will be able to explain the etiology/Risk Factors or pathophysiology of Asthma, by using words such as: A reversible and diffusive airway limitation; An Acute inflammation leads to airflow limitation and changes in the airways. Atopy

fluid leak into the airway, attraction of white blood cell resulting in broncho-constriction (Smelter et al., 2010) Risk Factors Atopy the genetic predisposition for the development of IgE-mediated response to allergens, is the most common identifiable risk factor. Allergens can be seasonal (grass, tree and flower pollen) or perennial (mold, dust, animal feaces). Asthma has as a genetic component, which is not clear. Exposure to environmental factors such as airborne allergens, viral respiratory infections are associated with increased incidents. Exposure to smoke, air pollution and diet (cheese, chocolate). Exercise, stress, emotions, menses, pregnancies and thyroid disease could also trigger attacks (Pellico, 2013)

the genetic predisposition for the development of IgE-mediated response to Teacher will ask Three students at allergens is the three students to the the back, one in most common back, one in the the middle and identifiable risk middle and one at the one at the front factor. front to explain the will explain the etiology/risk etiology/risk factors/pathophysiol factors/pathophy ogy for asthma siology for according to the asthma content according to the content and PowerPoint presentation. factors/pathophy siology for asthma is explained

Describe the manifestation of Asthma as cited by Smelter et al (2010).

The most common symptoms are: cough, dyspnea, and wheezing. Generally occurs at nights or early morning due to circadian variation that influence airway receptor thresholds. Usually begins abrupt, with cough with or without mucus production (when present it is thick and viscous and cannot be coughed up). This is followed by wheezing on expiration and possibly inspiration. Chest tightness and dyspnea then occurs. Expiration requires effort and become prolonged. As this progress diaphoresis, tachycardia and widened pulse pressure may occur with hypoxemia and central cyanosis (late sign of poor oxygenation)

Teacher will distribute 4 pieces of cards to 4 student with the manifestations of asthma written on them, they will be ask to explain them or call out the name of one of their classmate who can assist them

Four students will receive cards and will attempt to describe the manifestations of asthma as written on card, if not, they will call the name of a class mate who can assist them

Students will be able to describe the manifestation of asthma by using key words such as: Cough, dyspnea and wheezing due to circadian variation; diaphoresis,

Teacher will describe the manifestations of asthma with the help of PowerPoint presentation

State the diagnostic test/Lab test used in the diagnosis of Asthma according to Chernecky et al (2013) and NHLB, (2013)

Family and Medical History: The doctor/nurse may ask about family history of asthma allergies, triggers, symptoms and when and how often they occur (NHLB, 2013). Physical Exam: The doctor will listen to the clients breathing and look for signs of asthma or allergies. These signs include wheezing, a runny nose or swollen nasal passages, and allergic skin conditions (such as eczema) (NHLB, 2013) DIAGNOSTIC TESTS Lung Function Test: Spirometry - used to check how your lungs are working. This test measures how much air you can breathe in and out. It also measures how fast you can blow air out. If the result is poor, the client may be given medication and then retest to see whether the results have improved.

Student will sit, listen and ask questions where necessary as the manifestations of asthma are described Teacher will write Five students five characteristics of will attempt to diagnostic test on the match the five board and ask five characteristic of students to match diagnostic test them with their with their respective names respective names these will be given to these will be them by teacher on given to them by strips of paper teacher on strips of paper Teacher will state the characteristics of the nursing process utilizing the PowerPoint presentation. Students will sit and listen attentively as the characteristics of the nursing process are stated.

tachycardia and widened pulse pressure may occur with hypoxemia and central cyanosis Students will state the diagnostic tests used for asthma by recalling key words such as: Family and medical history; Physical examinations; Lab function test; Chest xrays

Teacher will ask two students to the back and three at the front to state one each, the If the test results are lower than normal and improve with the medication, and if the medical history shows a pattern of five characteristics of

Two students at the back and three at the front will state one each, the five

asthma symptoms, the doctor will likely diagnose the client with asthma (Chernecky et al., 2013 & NHLB, 2013)
Other Tests:

the nursing process

characteristics of the nursing process according to the content

The doctor may recommend other tests if he or she needs more information to make a diagnosis. Other tests may include:

Allergy testing to find out which allergens affect the client, if any. A test to measure how sensitive the airways are. This is called a broncho-provocation test. Using Spirometry, this test repeatedly measures lung function during physical activity or after you receive increasing doses of cold air or a special chemical to breathe in (Chernecky, 2013). A test to show whether the clients have another condition with symptoms similar to asthma, such as reflux disease, vocal cord dysfunction, or sleep apnea (NHLB, 2013). A Chest x ray or an EKG (electrocardiogram). These tests will help find out whether a foreign object in the airways or another disease might be causing the clients symptoms (Chernecky, 2013)

Describe the general

The goals of management are to prevent chronic and troublesome symptoms, maintain near or normal pulmonary

Teacher will ask five students randomly

Five students Students will be chosen randomly able to describe

management for clients with Asthma as explained by Pellico (2013) and McKenry et al (2006)

function, maintain normal activity, prevent recurrent exacerbations, and to meet patients and families expectation of care (Pellico, 2013).
PHARMACOLOGICAL MANAGEMENT Short-Acting B2 Agonists Albuterol interacts with B2 receptors in bronchial smooth muscles resulting in relaxation of bronchial smooth muscles thus reducing bronchospasm and airway resistance Long Acting B2 Agonist Salmeterol acts similar to Albuterol, has slower onset and longer duration Anticholinergic Atrovent used for maintenance Methylxanthines Theophilline, Aminiphilline prevention and treatment of asthma (McKenry et al., 2006)

to describe the general management of clients with asthma

will attempt to describe the general management of clients with asthma Students will sit, listen, follow PowerPoint and ask questions as is necessary

Teacher will describe the general management for clients with asthma with the aid of PowerPoint presentations Teacher will ask two students to describe the general management of clients with asthma according to the content

the management for clients with asthma by using key terms such as: symptoms prevention, maintenance of pulmonary function and normal activity, prevent exacerbations, meeting clients and significant others

Discuss the nursing management for clients with Asthma utilizing the nursing process

Mrs. Jones is brought to the UHWIs Emergency room with SOB, Dyspnea, and use of accessory muscles, thick viscous secretions crackling cough and frightened look on her face. She complained of being unable to sleep due. Her vital signs revealed: T 37. 2 C; P100bpm; R32bpm; B/P100/65..She is diagnosed with an acute asthmatic attack. You are asked to outline the Nursing Management for her under the following needs: -Oxygenation -Psychosocial

Two students will describe the general management for clients with asthma according to the content Teacher will ask Students will students to form form themselves themselves into three into three groups, one group groups, one will will note the look at the assessment details, nursing the other the nursing assessment, the diagnoses and the other the patients outcome possible and the third group at diagnoses and

Students will be able to discuss the nursing management of asthma by correctly relating the needs approach and appropriate interventions

least five priority interventions

the third group at least five priority interventions Students will ask questions and listen to the feedback given by teacher

(nursing process)

Teacher will provide clarity and feedback on the scenario and answer question asked with the aid of marker and white board

EVALUATION Questions 1. 2. 3. 4. 5. Define the term Asthma Explain one risk factor for asthma Describe three (3) manifestations of Asthma Name three (3) classes of medications used to manage Asthma Give two diagnosis and two interventions with rationales

Answers 1. Defined as a common, complex disease of the airways characterized by recurring and variable symptom, airflow obstruction and bronchial hyper-responsiveness 2. Atopy the genetic predisposition for the development of IgE-mediated response to allergens, is the most common identifiable risk factor. Allergens can be seasonal (grass, tree and flower pollen) or perennial (mold, dust, animal feaces). Asthma has as a genetic component, which is not clear. Exposure to environmental factors such as airborne allergens, viral respiratory infections are associated with increased incidents. Exposure to smoke, air pollution and diet (cheese, chocolate). Exercise, stress, emotions, menses, pregnancies and thyroid disease could also trigger attacks (Pellico, 2013) 3. cough, dyspnea, and wheezing, cough with or without mucus production (when present it is thick and viscous and cannot be coughed up). Chest tightness and dyspnea then occurs, diaphoresis, tachycardia and widened pulse pressure may occur with hypoxemia and central cyanosis (late sign of poor oxygenation)

4. Short-Acting B2 Agonists, Long Acting B2 Agonist, Anticholinergic, Methylxanthines 5. Ineffective Breathing Pattern/Ineffective Airway Clearance (See Care Plan)

CARE PLAN

Assessment Client has SOB, Dyspnea, Use of accessory muscles, thick viscous secretions. Assessment revealed V/S P100Bpm, R32Bpm, Diagnosis of Acute Asthmatic attack

Diagnosis Ineffective Breathing Pattern related to tracheabronchial obstruction/inflammatory process as evidence by SOB, use of accessory muscles, V/S P100bpm, R32bpm Ineffective Airway Clearance related to inflammatory process/excess mucous production as evidence by thick viscous secretions, Dyspnea, use of accessory muscles

Patient Objective/Goal Within hour of nursing and other interventions client will demonstrate an improvement in respiratory rate as evidence by respiratory rate of 16-24bpm

Intervention and Rationales 1. Assess respiratory status lung sounds, respiratory rate and depth, presence and severity of wheezing, breathing pattern, use of accessory muscles Some degree in bronchospasm is present with obstruction in airway and may be manifested with wheezing or absent breath sounds in severe asthma. Tachypnea is usually present to some degree and respiratory dysfunction is variable depending on underlying process such as allergic reaction 2. Assess then monitor V/S Initially for baseline and then for comparison 3. Administer Humidified Oxygen 2-5l as required to improve tissue oxygenation and prevent drying of the nares 4. Assist patient to assume to comfortable position, i.e. elevate head of bed, (fowlers position) have client lean on over bed table or sit on the

Eval What is hoped to be achieved) Outcome Criteria: Client will verbalize reduction or absence in difficulty in breathing and feeling of chest constriction, respiration and cardiac rate within normal range, absence or reduction of inspiratory and expiratory wheezing following nursing and other interventions

Client will demonstrate signs of patent airway and adequate oxygen exchange within the 8hr shift following nursing and other interventions

5.

6.

7.

8.

edge of bed - Elevation of head of the bed facilitates respiratory function by use of gravity, however client in distress may seek position that most eases work load of breathing. Keep environmental pollution to a minimum according to individual situation Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. Encourage and assist abdominal and pursed lip breathing exercises - Provides some means to cope with or control dyspnea and reduce air trapping. Increase fluid intake to 25003000ml within cardiac tolerance - Hydration helps thin secretions, facilitating expectoration and using warm liquids may decrease bronchospasm. Provide warm liquids and recommend intake of fluids between meals, instead of during meals - Fluids during meals can increase gastric distension and pressure on the

diaphragm. 9. Administer medications as indicated. (Atrovent) Anticholinergic medications are the first line drugs for clients with this condition. 10. Monitor side effects of bronchodilator (Salbutamol) Bronchodilators are known to cause (tremors/ tachycardia, bronchospasm). 11. Provide supplemental humidification, e.g., nebulizer in respiratory treatments Humidity helps reduce viscosity of secretions, facilitating/stimulate expectoration, and reduce bronchospasm 12. Monitor ABGs, pulse oximetry, chest x- ray, capillary refill indicates acid-base balance, oxygen saturation levels, level of obstruction and Establishes baseline for monitoring progression/ regression of disease process (Ackley & Ladwig, 2011)

-Had frightened look on face -Inability to breathe -V/S P100bpm, R32bpm

Anxiety related to fear (of death related to inability to breath/ the unknown/change in health status (secondary to asthmatic attack) evidenced by frightened look on face

Throughout hospitalization patient will exhibit a reduction in levels of anxiety/ increase in coping mechanism, evidenced by a relaxed expression and normal vital signs (1622)

- Acknowledge awareness of patient's anxiety - Acknowledgment of the patient's feelings validates the feelings and communicates acceptance of those feelings. - Reassure patient that he or she is safe. Stay with patient if this appears necessary - The presence of a trusted person may be helpful during an anxiety attack. -Maintain a calm manner while interacting with patient - The health care provider can transmit his or her own anxiety to the hypersensitive patient. The patient's feeling of stability increases in a calm and nonthreatening atmosphere. -Establish a working relationship with the patient through continuity of care establishes a basis for comfort in communicating anxious feelings. -Orient patient to the environment and new experiences or people as needed promotes comfort and may decrease anxiety. -Use simple language and brief statements when instructing patient about self-care measures, or diagnostic and surgical procedures - When experiencing moderate to severe anxiety, patients may be unable to comprehend anything more than simple, clear, and brief instructions.

Goal Met Patient demonstrated positive coping mechanisms and described a reduction in levels of anxiety evidenced by RR of 18bpm following nursing interventions

-Reduce sensory stimuli by maintaining a quiet environment; keep "threatening" equipment out of sight Anxiety may escalate with excessive conversation, noise, and equipment around the patient. This may be evident in both hospital and home environment. -As patient's anxiety subsides, encourage to explore specific events preceding both the onset and reduction of the anxious feelings - Recognition and exploration of factors leading to or reducing anxious feelings are important steps in developing alternative responses. Patient may be unaware of the relationship between emotional concerns and anxiety. -Assist the patient in developing anxiety-reducing skills (relaxation, deep breathing, positive visualization, reassuring self-statements, and others Using anxiety-reduction strategies enhances patient's sense of personal mastery and confidence. -Instruct the patient in the appropriate use of anti-anxiety medications To promote compliance and reduce anxiety. (Gulanick & Myers 2013)