By Adem Lewis / in , , /

– [Instructor] The next topic
that we’re gonna focus on regarding respiratory illnesses is asthma. Again, please pay
attention to the objectives as you are studying for quizzes and exams and just learning about
the disease process. Please focus on the objectives so that you know where
to put your attention. This is the definition
that your book provides. Asthma is a condition in which a person’s
airway becomes inflamed. The airway narrows, and it swells, and it produces extra mucous. That makes it difficult to breathe and actually kills roughly
nine people every single day. So what they mean by
heterogeneous is that asthma is not a single disease
but rather a series of complex, overlapping,
individual diseases, each defined by its unique interaction between genetic and environmental factors. So some of the risk factors
and triggers that you can see in asthmatic patients
are related to genetics. Researchers have studied
more than 33,000 different possible mutations in
more than 11,000 people. And what they have found, you know, after they combed through
their DNA and searched for any kinda mutations that people had in common with one another, they actually did discover three genes that were markers for asthma, but these were rare mutations found in less than 5% of the population, which really only means that
there’s only a small portion of people who are technically at risk for inheriting asthma from
their mom or their dad. Again, if you look at
page 539 on your book, it lists all the different kinds of triggers for asthma attacks. So it will list allergens,
so various animal dander, cockroaches, house dust
mite, molds, pollens. It also lists air pollutants. So if there’s any aerosol
sprays, cigarette smoke, exhaust from cars, perfumes. When people even walk
by with large amounts of perfume or cologne on, it can cause people to
trigger that asthma attack. There can be food additives in beer, wine, dried fruit,
shrimp, processed potatoes. Also there can be candles, people getting triggered
by the scent of candles that are lit around them. There are also, if somebody gets a bacterial
or a viral infection, so somebody who gets sinusitis
or allergic rhinitis, maybe an upper respiratory tract can trigger an asthma attack. Other factors, exercise,
or cold air, dry air. People with GERD tend to get asthma
attacks more frequently. The reflux may trigger
that bronchoconstriction. There are even some drugs that can cause or
trigger an asthma attack, and those, again, are listed on that table
28 one on page 539. They call it the asthma triad. When somebody has nasal polyps, asthma, and a sensitivity to aspirin and NSAIDS, it can cause them to
trigger an asthma attack and develop wheezing within two hours. Other meds like beta adrenergic
blockers can trigger asthma, because they cause bronchiospasm. Bronchiospasm is the
spasm of bronchial tubes. It narrows it, which is what asthma is
doing in the first place. So it narrows those bronchial tubes and makes it more difficult to breathe. So for further triggers, please
see your book on page 539. That talks about them until 540. So the videos that I listed on Blackboard should provide a good
pathophys for you to review about what is happening
during the asthmatic process. So I’m gonna leave these
here for your notes, but I will not discuss
the pathophys in depth. Clinical manifestations of individuals suffering from asthma, and I think the majority
of you are going to know just from the general nature of asthma, lots of people know about
asthma, but coughing. Sometimes there’s instances
that cough is the only symptom of somebody having an asthma attack. So you won’t always hear the wheezing, or see someone clutching
their chest like this picture, and not always have the obvious dyspnea, but those are other things. So wheezing, sometimes people
will get chest tightness, and then there’s gonna be
variable airflow obstruction depending on the person and
the extent of their disease and possibly what
medications they’ve taken by the time that they see you. A lotta times, the expiration requires
effort and becomes prolonged. And asthma exacerbation, which you will learn
about more next semester, is when it really triggers
something intense in them, and it can produce symptoms that actually increase over days. So by the time they come to see you, this might have already
been going on for some time. There is the exercise induced asthma, so these are when the symptoms become very severe during exercise, and it almost feels like a choking sensation during exercise. The exacerbations, when people have more
difficulty with this, it can sometimes be very
unpredictable and variable. Not everybody has specific triggers that trigger their asthma. Some do, some don’t, but sometimes they can have
these recurrent episodes of wheezing, and breathlessness,
and cough, and tight chest. Sometimes it can be abrupt, and
sometimes it can be gradual. Sometimes it can last minutes, and sometimes it can last hours. So it’s all just gonna
depend on the patient. Getting a full history
and understanding exactly what happens to them during
their asthma attacks is going to be super important in order
to know how to treat them. So again, these are things that you’re
going to see next semester, severe and life-threatening exacerbations and life-threatening asthma. So these are the types
of patients that come in, and they cannot speak at all, and they are really tight and wheezing, and we are at risk for
losing their airway. So we would probably take ’em back and most likely intubate them right away. But again, we’ll get
to this next semester. So diagnostic studies
that are going to happen for somebody that has asthma, obviously a detailed
history and physical exam is going to be done for
every disease process. As we talked about with COPD, they are going to do spirometry to see what the lung
volume is in the patient. They will also do a peak flow rate. And a lotta times, this
is done by the nurses, not only by respiratory therapy, but also done by the nurses. And patients even learn
how to do this themselves. I know in the ER that
we always got these out and actually taught
patients how to use them so that they can use it
when they’re feeling well to know what their
maximum capacity could be and then be able to do it
when they are not feeling good so that they know if
their asthma is acting up. So the, to measure your peak flow, you take a really deep breath. So we’re looking at this picture that’s in the upper right hand corner, that white instrument, and
you take a deep breath, and you blow as fast as you can into that small hand-held plastic tube called a peak flow meter. The measurement taken is
called your peak flow. To get the best from your peak flow meter, you need to take your readings
every day, twice a day, and keep a diary of your symptoms. That way, like I said, you understand if it is getting
better or worse and how, what your levels are when
you’re feeling really good. So another thing that they
will do is a chest X-ray. That’s just to rule out anything acute and possibly infectious. They will do the pulse oximetry, so down in the bottom right hand corner. I know you guys all know about pulse ox, and they will measure
how much oxygen you have running through your system. They may end up doing allergy testing, and that is, they can do allergy testing in a couple of different ways. They can either draw your blood, or they can do the scratch test method. And the scratch test method
is where they take things that are possible triggers for you
that you might be allergic to, and they will take a
little bit of the allergen, whatever it is, and they
will scratch it on your back. And they actually keep track
of what they’re scratching and where so that they can see if you react to it in any way, and then they know that you
are possibly allergic to that, and that could be a possible
trigger for your asthma. Remind me, and I’ll show you a picture of what that looks like. I had to take my son
in for allergy testing after I found out he was allergic to eggs. And it’s quite simple, and
it’s relatively painless. It can be quite itchy
though if you react to a lot of the things that they are
scratching on your back. Another test that they might do is checking the blood
levels of your eosinophils. So unlike other kinds of asthma, eosinophilic asthma involves
abnormally high levels of a particular type of white
blood cell called eosinophils, which I’m sure you are all familiar with. So (stutters) eosinophils are
part of the immune system, and they help the body
fight off infection. However, high levels can cause
inflammation of the airways, affecting the person’s
or the patient’s sinuses, and their nasal passages, as
well as their lower airways. So in general, as the level
of eosinophils increase, inflammation and other symptoms of asthma can become more severe. This type of asthma is typically found in people between ages 25 to 35. People with eosinophilic asthma usually do not suffer from allergies. The condition can be difficult to treat, and they may have detrimental effects on the individual’s quality of life. Oral corticosteroids,
corticosteroids, I’m sorry, were the standard treatment
for eosinophilic asthma, but new treatments, called
biological therapies, are now used to treat the condition. Medications that we’re gonna
talk about called leukotriene and antagonists may also be
used to reduce the inflammation, and we can find this on
page 547 of your book. So I want you to take a look
at page 542 table 28 two. It’s the classification
of asthma severity. So if you look at the different parameters that will show you how
severe somebody’s asthma is will depend on the type of treatment that they are going to get. So it really depends on
the symptoms that they have and how frequent those symptoms are, how many times they’re
waking up during the night. SABA, or the S-A-B-A, stands
for short acting beta agonists, and those are your rescue
reliever medications, and how many times they’re
using those per week, how much interference do they
have with normal activity, and what is their lung function. So once the RT, and doctors, and nurses figure out how severe the
asthma is for the patient, that will help guide
their treatment better. While looking at this slide, I encourage you to look at page 545. It tells you basically when
someone has intermittent asthma, and the daily medication
that they should use, the various steps that they should take prior to moving on to the next medication. So I won’t go through all of the steps, but in step one, it just says
preferred SABA if needed. So if they need to use that short-term rescue inhaler medication, that would be the first line of treatment to help their asthma if
they’re having difficulty with asthma while they are at home. And then the steps go up and up. So if you are seeing somebody in clinic or on a chronic basis, if you are doing a home health visit, you should assess the
patient’s respiratory status by monitoring the severity
of their symptoms. Again, going back to
the table on page 544, the components of asthma control, and finding out what kinda
symptoms they’re experiencing, and take a look at those
so that you get good at asking questions about what’s going on with their asthma symptoms. Obviously, you’re gonna
listen to breath sounds, you are going to assess that peak flow, you may assess the level
of oxygen saturation through a pulse oximeter, and then, of course, looking
at their vital signs. If they have been using their
inhaler more than they should, you may tend to see that they
are going to be tachycardic and might not necessarily,
their O2 sats might be okay, but they might be really tachycardic and feeling kinda jittery from using their medications too much. So when you are doing that assessment, make sure that you are
paying very close attention and asking the appropriate questions to get a full picture of
what’s going on with them. So then when we get to drug therapy, some of these are gonna
look familiar to you. We’ve already talked
about corticosteroids, and this is very commonly
given to people with asthma. Not usually, prednisone
is usually something that is given on an intermittent basis. People are usually not, are
not on long-term prednisone, but they may be on a medication
called leukotriene modifiers like Singulair, like you
see in the picture here. Those help fight against inflammation by blocking the release of substances that cause inflammation in the lungs. It’s usually not used in an acute reaction like prednisone may be, but they do use it prophylactically or for maintenance therapy. So that kinda medication
is usually best taken on an empty stomach, and some of the common side
effects that you’ll see with the leukotriene
modifiers like Singulair are a headache, nausea,
vomiting, insomnia, and irritability. Another one that they will
sometimes choose to give people, depending on what has worked
and what has not worked for the patient is by giving
them monoclonal antibody to IgE. So one way the immune system
attacks foreign substances in the body is by making a
large number of antibodies. An antibody, if you remember,
is a protein that sticks to a specific protein called an antigen. So are antibodies circulate
throughout the body until they find and attach to the antigen. So immunoglobulin IgE are antibodies produced by the immune system. And if you have an allergy, your immune system
overreacts to an allergen by producing antibodies
called immunoglobulin IgE. These antibodies travel to the cells that release the chemicals
causing an allergic reaction. In the case of asthma, they cause symptoms that
we’ve already discussed. By giving a patient a monoclonal antibody, it prevents that IgE from
attaching to the mast cell and releasing all those chemical mediators which cause the reaction. This is also used to treat some cancers, so we’ll actually be coming back to this later on in the semester. But common side effects that you can get with monoclonal antibodies
are flu-like symptoms, so nausea and vomiting, diarrhea. Sometimes people get a skin rash, sometimes low blood pressure. Sometimes they even actually
have allergic reactions to the infusion and can
get some hives and itching. Then we have medications like, I’m gonna say this wrong,
I’m sorry, methyl (laughs), the next one, (laughs). A common medication for the methylxyine, I can’t even say it, I’m sorry
you guys, is theophylline. So this is a medication that
helps relax the air passages. It is sustained release usually, and is not commonly used in patients until they’ve failed
the first line of drugs. So a drug like theophylline
is actually one that can be measured in
the blood to make sure that patients are at a therapeutic level. So levels in a normal
patient taking theophylline will be five to 10
micrograms per milliliter. Anything greater than
20 is considered toxic, and you should hold the medication. So again, patients can
become toxic to this drug, so levels should be checked
and should be therapeutic. The other downside to this methylxyine is that it can be really
expensive for patients. 60 tablets cost anywhere from $43 to 135, and it also interferes
with a lot of other drugs. So we just have to be
careful with that one. Again, that one’s not commonly used unless the first line
of treatment has failed. And then, we’ve already
discussed anticholinergics, but these are the
long-acting bronchodilators. They are, it’s given, we talked about it with chronic bronchitis and emphysema. You wanna look for
angioedema, rash, and itching. Again, it can be detrimental to people with closed angle glaucoma, because it increases
the intraocular pressure and causes some blurred
vision and dry eyes. It can exacerbate urinary
retention in patients with prostate issues or any preexisting bladder obstructions. And it can cause tachycardia. It’s also excreted in the kidneys, so just knowing those
kidney labs are important. And yep, you should already
have a drug card on that. Alright, let’s talk a little bit about how to teach your patient to
take a metered dose inhaler. I know we discussed this
a little bit in class, but if you pause this video
and actually go to the video where I show you a lady that
is actually taking it wrong, and pause this, watch that, and let me know what
factors she is doing wrong. Okay, so hopefully you had
a chance to watch that, and some of the things that
she did wrong in that video was she takes multiple puffs in a row, her combination of
pressing that medication and taking a deep breath
in was all over the place, and she didn’t even know the medication. So she didn’t know if
that was a corticosteroid, or if that was a rescue inhaler, or if it was one of her
longer acting inhalers. So patient education on
the correct medication and when to take it is super important. Even if they are taking it correctly, sometimes patients are
only getting 45 to 50% of that medication, and that will drop dramatically as they are doing two puffs in a row. So we wanna make sure they’re
getting the full benefit of their medicine, or what’s gonna happen? Their symptoms are not gonna be relieved, and they’re gonna end up
coming into the hospital. So part of the dangers of self-treatment is over the counter medications. So the comment here of avoidance of nonprescription combination drugs, over the counter medications
containing ephedrine can have severe reactions with patients who have a lotta comorbidities, and they can cause the heart
to race, irregular heart beats, insomnia, increasing blood pressure. So this is especially
dangerous with patients with heart problems or
underlying heart problems that they don’t know about yet, on top of all of their asthma medication, which also can increase their heart rate. So really understanding, when I ask patients about medications, I always ask about nonprescription and over the counter medications
that they may be taking. Before you leave this slide, I would like you to pause it again, and please go back to the
video of the right way to take a metered dose inhaler. You also can find a backup
on page 550 of your book where it talks about the
correct way to use that inhaler. So remember when you are taking a health history of a patient, you want to make sure that
you are taking objective, so that’s what you
observe, and subjective, what the patient tells
you, information down. So I always tell my students, half of my information
that I get from patients is hands on, and listening, and observing, but I would say sometimes
50 to even 75% is really asking them questions to get a good idea about what’s going on. So understanding ABGs are
gonna help you determine what’s going on with your patient and how to treat them
during acute exacerbations. But again, you’re getting
that next semester, so we’re not going to focus on ABGs, except for knowing that that
is part of the treatment plan when someone gets admitted with an acute exacerbation of asthma. Lung function tests should
be done on a regular basis, done with checkups to establish a baseline so that when people are
starting to have symptoms that they can compare those to and know how badly their asthma
is acting up at the time. That will help guide them in cases of do they need to go on a steroid, do they need a long-term
inhaler steroid medication to help keep their asthma under control, especially during specific
times of the year. Again, we’ve talked a
little bit about this with our chronic bronchitis
and our emphysema patients, but a physical examination, you wanna look for accessory muscle use. So looking to see if they have those intercostal retractions, see if they are using those neck muscles. What does their skin feel like? Sometimes you actually need to touch it in order to feel if
it’s diaphoretic or not. Sometimes you can’t visibly see when someone’s that diaphoretic, or you touch their shirt and realize that their shirt is saturated with sweat. Look for cyanosis. I have listed on here the
central cyanosis that you can see in patients that have blue lips or a bluish tinge to their mouth. Also listen to lung sounds, right? That’s obviously a pretty common one. These are just some nursing diagnoses that I wanted you to be aware of. I’m not gonna go through
each one of these. I think they’re pretty self-explanatory. And the goals that we of course have for our asthmatic patients. Obviously, it’s important
for patient teaching to let them know when they
should actually go and be seen. When they are taking
their inhaler, you know, inhalers are meant to be taken
two puffs every four hours as needed usually for
those rescue inhalers. So if they find that they are taking it, and 15 minutes later, they
are not getting any relief, that’s gonna be time that they need to probably go into the doctor. So they wanna seek, they
should seek medical attention for bronchiospasm or when they’re having really severe side effects. There are, it says on here to take fluids, two to three liters every day. Of course, this is going to depend upon their other comorbidities. If we have patients on a fluid restriction or they have kidney
issues or heart issues, we don’t want to overload them, but fluid intake does help, not only keep the airways hydrated and mucous membranes moist, it’s also good to help clear out that mucous out of their lungs. So making sure that people
are taking in adequate fluids, but making sure you’re also
checking their comorbidities to make sure that that is safe. Good nutrition, it’s shown
in the research that people who are obese have a tendency
to have more severe asthma. So people who ingest more
foods with higher antioxidants have lower rates of asthma. So really encouraging
those foods with that, that we hopefully will
learn about next week. Exercise within limits of tolerance, so patients may need to
pre-medicate before working out or bring their inhaler with them. They may need to take that rescue inhaler to open up their airway
so that they don’t get that exercise induced asthma. Again, it all depends on
the patient, and if you are, when you are talking to
them about their symptoms, ask them about activity
and how their asthma, how they handle their
asthma with activity. Uninterrupted sleep is important. It tells you a lot about
whether their asthma is controlled or not. So if they are not getting adequate rest, and they’re waking up multiple
times during the night, that is going to be an issue of concern. And then always make sure that you involve the
patient caregiver or family. They can always help
reiterate this information and help patients remember
when, or call them out on it, when they’re not compliant. One of the important things is if your patient is
having an asthma attack, it’s very scary, and it
causes them to usually panic, their anxiety level is up. So it’s important that you stay with them. Do not get anxious yourself. Make sure that they are
positioned correctly, help them sit up, maybe
in the triad position, and try to talk them down. Usually I find if I can
ask patients questions and get them focused on something other than their breathing, they will help to calm down a little bit. These are some of the things
that we’ve already reiterated, so I don’t think I need
to go over them again, but we’ll leave this in
here just for your review. Again, as we’re always considering the gerontologic population, it’s important to understand
that they are gonna have a lot more complicated health issues than obviously a younger patient. These medications are costly, and usually older adults
are on a fixed budget. So making sure that they can actually afford their medications, and if they can’t, they
actually do have some programs at places like Wal-Mart and Target where they have $4 medications. So while it might not be the first line of treatment that physicians order, checking with them and saying, hey, can we switch over to this one so they can afford their medicines, because taking a second line of treatment is better than them not
taking their medicine at all because they can’t afford it. So really asking patients if they are getting their medications. Sometimes if it’s in a
clinic or a wellness visit, we’ll have them bring their
medication bottles along so that we can actually see them. And as I’ve talked about before, a lot of elderly people will not adhere to their medical regimen, because either they find it too expensive, or they find it annoying, or they just think they don’t need it, and then they wind up in the
hospital with exacerbations. So making sure that
they’re actually following and doing what they’re supposed to. Some of it can be due to
forgetfulness as well. So figuring out a schedule
for them and writing that down or finding ways to set
alarms or timers for them to take their medication may be something that you need to
incorporate into their care. And then there’s also the possibility of having difficulty accessing
the healthcare system, meaning if they don’t have insurance, can they get into a doctor,
can they get regular followup, and really assisting them in that process if they’re having difficulty with that. So part of your job as a nurse is to know what your resources are so
that you can direct patients that maybe have trouble with this. Maybe it’s trouble getting a ride there, because they can no longer drive. So finding transportation and other ways for them to get there. May be important to help
them navigate those issues. A lotta times patients
won’t say something to you unless you bring it up to them. So again, it has to be
one of those questions that you ask patients. So I want you to take a look
at this telemetry strip. So this is something that may happen after you take albuterol. So I think you can tell, even if you can’t see the
notches in the six second strip, that there are quite a
few QRSs in this strip, meaning that the patient is having a sinus tachycardic rhythm. I need to stop putting in what
these actually are in there so I can have you guys work harder to know what these strips are. So anyways, if you look closely, you can see the peak of the
P wave prior to the QRS, and we can tell that
our QRSs probably fall in less than that .1 second, but our heart rate is elevated. So if we have a P wave for every QRS, and we have a decent size
PR interval and a QRS, we know that our underlying
rhythm is normal sinus, but it’s beating too fast,
so sinus tachycardia. So in a rhythm like this, if you have a patient that
is being treated for asthma and received inhalers or
a nebulizer treatment, this is a perfectly normal
heart rate that we would see. We would not do any intervention for this in an asthmatic patient
that is having a heart rate like this after an albuterol treatment. So sinus tachycardia, remember, is a rate that is greater than a hundred beats per
minutes in an average adult. If people start having
signs of shortness of breath or light-headed, if their
pulse goes above 150, if they’re having heart palpitations, which you can have with albuterol, so you have to take that with a sense of what’s going on with your patient, but we may need to investigate
further if that’s the case. And then I just wanna leave you with how to serve Christ in the world. When we put the name of Jesus on those for whom we are praying, we invoke God’s blessing on them. Few of us realize how much we
uplift people in their spirits when we simply praise God for them. So one of the things
that I like to do in all of my clinicals and in
all of my days of nursing, as I was on my way home or
even before I got there, you know, I just asked God
to help give me the guidance to provide the right kinda
care to these people. And after I went home, sometimes things weighed
heavily on my heart, things that I had seen or
people that I had talked to, and even times when it
didn’t, even when, you know, I was working in the cancer center, and I would just pray to God and ask God to watch over the people that
I took care of and to maybe, you know, give them some
type of peace in their life, or pray that they got better
test results the next time, or you know, whatever I could
do to uplift these people just in my own private world
on my way home from places is something that’s very
easy to incorporate. And sometimes in your life, and sometimes that helps
relieve some of the tension that you felt during the day is just asking God to watch over them. So I encourage you all to
pray for your patients, and pray for their families,
pray for your classmates, pray for your coworkers in
that God may just help see them through some of the tough
times that we experience. So again, I look forward
to seeing you all on Friday to go over our case study and for the student
presentation and for our quiz. Again, our quiz will be on Blackboard, it will be 10 questions, it
will be mostly about COPD, and you might see a rhythm strip on there. You will see one question at a time. You have about a minute and
a half for each question, and you are allowed to go back. So I hope that helps
relieve some of the pressure in the first quiz that we have. If you have any questions,
please let me know. Thank you.

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