Respiratory & ENT part 10-Asthma
11
March

By Adem Lewis / in , , , /


Welcome to respiratory disorders part 10 -finally the
last one! and this part of the lecture will be about asthma ,something that you
should be familiar with from your previous courses. make sure that you
watch the Khan Academy videos related to asthma already up on Blackboard
prior to listening to this lecture. so as you know, the pathophysiology of
asthma includes bronchospasm, allergy, and inflammation. So status asthmaticus
is asthma that is unrelenting no matter what kind of medical treatment is given.
when these kids come in. we need to insert an IV immediately we nebulize
bronchodilators, we will give systemic corticosteroids and for status asthmaticus these
need to be delivered intravenously. It is going to take too long for oral meds to kick in
in order to counteract the signs and symptoms of status asthmaticus. you
need to place this child on a cardio-respiratory monitor, have oxygen
available as needed as well as suction and then know where the crash cart is and have intubation equipment at the ready in case it is needed. we want to catch
these kids long before they get into this type of condition. when you do the
assessment of a child with asthma you want to find out about cough; are they short of breath? do they have audible wheezing and this can be audible with or without a stethoscope.
what does their face look like? do they have that anxious look because they’re
having such a difficult time breathing? have you ever tried to breathe more than
a minute through a straw? try it!! this is what an asthmatic has to contend with
when they have no open airways so there’ll be dyspnea; a feeling of
tightness in the chest that they can’t get a good breath, there’s going to be
some form of labored breathing and in the younger child because of the
pliable chest, this is going to be exhibited as retractions. in older
children you’re going to see retractions that are going to be suprasternal and
supraclavicular. you may also see nasal flaring Some kids only have exercise induced asthma
so they wheeze with any form of exertional activity. and then of course
our severe cases of asthma can come in with cyanosis, looking pale, and they may be
diaphoretic because of the work of breathing and do remember just because
you don’t hear wheezing doesn’t mean that their
asthma is not really the problem. they may not have anything going in and out
which is why you don’t hear any wheezing! assess their vital signs and once again
we’re paying attention to temperature because sometimes it’s some kind of an
upper respiratory infection or any other kind of infection that’s triggering this
episode of asthma. look at their heart rate; look at their respiratory rate; what
is their pulse ox doing? if we can get them to take a big breath to blow into a
peak flow meter we want to do that because this is going to be our initial
assessment and anything that we do to them in a clinic even at home as well as
in the ER indicators for admission are going to be based on pre- and
post-treatment peak flows. Is this child interested in their environment?
Are they responding appropriately and if they aren’t that is an ominous sign. listen
to their chest for adventitious breath sounds and you’ll hear wheezing and if
they have a concomitant pneumonia there also may be decreased breath sounds in
certain parts of the lung and then when they’re not moving any air, there’s
going to be a decrease in their breath sounds. depending on how
bad an asthma attack is when they come in to see you, we also want to assess
the knowledge that the parents have about asthma and what does the child know. also what treatment modalities have been used and how compliant have they been
with the treatment as well as using the peak flow meter to indicate that they’re
starting to have a bad day. indicators that we’re going to
hospitalize a hild is if their peak flow result is less than 50% of what we
expect of what you expect If you hear inspiratory and expiratory wheezing? are
they tachycardic and tachypneic? are they having dyspnea with retraction and
are they not able to maintain their o2 SATs above 91 percent despite all of the
treatment that we’ve given them thus far? so this would be a child that’s going to
be admitted the majority of these kids when they hit this level of distress
will be going to the ICU but if there is no pediatric ICU they will come to a
pediatric floor and this is another child that needs to be very close to the
nurses station. it’s important that you recognize signs and symptoms of
impending respiratory failure in a child with severe retractions and nasal
flaring that increased work of breathing that just doesn’t go away and even
respiratory effort they’ve been breathing so hard that they’re now
fatigued and they’re giving up and expiratory phase that doesn’t end until
the next breath and this kid will not be able to talk and breathe at the same
time. Severe to absent wheezing in a known asthmatic because there’s no
air exchange whatsoever. If they have the hyperinflated lungs that ‘s obvious so
they look like they actually have a barrel chest. when the child starts
becoming combative, inconsolable, and then goes to– moves on to
lethargy or somnolence, this is a bad sign. when we treat the child with everything
that we have available to us and there still isn’t good response that child is
ready to have a respiratory arrest and then we have our pH and our CO2/O2 parameters
and when they’refglipped from normal this child is getting ready to go and of
course cyanois. So when we look at the plan and the nursing interventions. first
of all does this doctor want to admit this kid or not? we need to get respiratory
therapy involved and they will be in to do the nebulizers but if they’re real
busy that’s going to be your job and you need to know how to set up a nebulizer. If
you don’t know how to do that go to the Skills Lab and practice. Know how to use
the peak flow meter and to be able to read it so we want to get that peak flow
before treatment and after treatment and record the results .the medications we
use for rescue are going to be your short-acting bronchodilators primarily
albuterol and this can be given as a metered dose inhaler or it can be
nebulized and its preferred to be nebulized with a nebulizer. we can also
give oxygen; we can give steroids IV as well as oral and like I already said the
IV is going to kick in much sooner than the oral– the oral form
is solumedrol you need to also consider the side effects of steroids and I’m
talking about the short-term especially when we give it orally. it causes GI upset
and for this reason you will see some type of the PPI on the MAR and you wonder why do they need a PPI? well some of them actually end up having GERD as a
separate problem. but most of these kids that are on steroids are going to have gastritis
develop so that’s why we give it. For long-term control we’re going to use
inhaled steroids so pulmocort or flovent is an example. we can use long
acting bronchodilators in the form of Serevent and the leukotriene modifiers
are now indicated for young children down to the age of two.
they’re quite safe but keep in mind these particular medications for
long-term control are never used to rescue! When they have an acute flare-up
of asthma they need to use that short-acting bronchodilator and if that
isn’t working they need to be seen. so as I told some of you during Skills
Lab asthmatics should not die and I think that we have done a very poor job of
teaching of our patients when an asthmatic person does die; and this is a
child or an adult. you need to assess and reassess your patient while they’re in
front of you ,administer oxygen, give them IV fluids if they can’t tolerate oral.
If they can try tolerate oral and they’re getting more comfortable with breathing
we want to push the fluids. your patient and parent education is huge every time they are in front of use this is
one of those illnesses that similar to diabetes you need to assess and
reassesstheir knowledge and their compliance. every time they are in front of
you review the medications what are the short-term? what are the long-term? what
do they do as rescue medications? teach them how to use that peak flow meter
what is normal? what is their green zone? their
yellow zone and their red zone? what do they need to do with the results. the yellow zone, the still need to contact their pediatrician or pulmonologist. But
usually these kids have a medication list- this is what I take every day ;this is
what I take one my peak flow gets into the yellow zone and when I’m in the red
zone I’m not only take my rescue meds but I also need to make sure
I either go to the emergency room or I go to my to the doctor’s office so I can be
seen. These kids need to take their peak flow meters with them to school and the
school nurse needs to be notified that the child is asthmatic. if we know what
the triggers are that cause the flaring up asthma, we need to help them modify their environment to reduce these
triggers. but kids can have an asthma attack just from the winds blowing, when
it starts to rain, those type of things! notify others that are caring for this
child of their asthma this would include the teachers, coaches, babysitters as well
as relatives. this slide has a variety of YouTube videos that you can watch in
regards to peak flow meter readings It tells you how to actually use it other medications that can be used
actually there’s no YouTube video for that but the way that they can be
administered is so we have the arrow chamber spacer if you’re not familiar
with it as well as the nebulizers. we do have asthma camps, asthma support groups,
and internet-based support groups available for these children because asthma can be crippling and it does affect their activities of daily living. This
ends the lecture videos about respiratory and ENT disorders


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