Topic: Caring for the patient with AsthmaAudience: 3rd year BScN. Student Nurses (NCU)Date: August 27th, 2013 Time: 10am-10:45amDuration: 45 MinutesVenue: Lecture Room Methodology: Lecture/DiscussionNumber of participants: To be decidedLearning 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 topicAim 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 exchangedResources: Registered nurse, lap top computer, multimedia, white board, markersObjectives: At the end of 45 minutes interactive session students should be able to1. 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 SaundersGulanick, M & Myers, J. (2013). Nursing care plans: Diagnoses, Interventions, outcomes (8th ed.) Philadelphia: Elsevier MosbyNational 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.htmlOrmrod, 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 & WilliamsQuinn, 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

ObjectivesContentsTeachers ObjLearners ObjEvaluation

IcebreakerTeacher will ask student to look at picture and identify the topic to be discussedLearner will look at the picture and attempt to identify the topic to be discussed

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 contentStudents 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 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 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 hyper-responsiveness

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

PathophysiologyAsthmas pathophysiology is characterized by a reversible and diffusive airway limitation. Acute inflammation leads to airflow limitation and changes in the airways. Broncho-constriction, 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, fluid leak into the airway, attraction of white blood cell resulting in broncho-constriction (Smelter et al., 2010)Risk FactorsAtopy 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)Teacher will ask two students at the front and three in the middle of the class to explain the etiology/risk factors/pathophysiology for asthma

Teacher will explain the etiology/risk factors/pathophysiology for asthma utilizing the white board, markers and PowerPoint presentation.

Teacher will ask three students to the back, one in the middle and one at the front to explain the etiology/risk factors/pathophysiology for asthma according to the contentTwo students at the front of the class and three in the middle will attempt to explain the etiology/risk factors/pathophysiology for asthma

Students will sit and listen attentively ask questions as necessary as the etiology/risk factors/pathophysiology for asthma is explained

Three students at the back, one in the middle and one at the front will explain the etiology/risk factors/pathophysiology for asthma according to the content

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 the genetic predisposition for the development of IgE-mediated response to allergens is the most common identifiable risk factor.

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 themTeacher will describe the manifestations of asthma with the help of PowerPoint presentationFour 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 themStudent will sit, listen and ask questions where necessary as the manifestations of asthma are describedStudents will be able to describe the manifestation of asthma by using key words such as: Cough, dyspnea and wheezing due to circadian variation; diaphoresis, tachycardia and widened pulse pressure may occur with hypoxemia and central cyanosis

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 TESTSLung 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.If the test results are lower than normal and improve with the medication, and if the medical history shows a pattern of asthma symptoms, the doctor will likely diagnose the client with asthma (Chernecky et al., 2013 & NHLB, 2013)Other Tests: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)

Teacher will write five characteristics of diagnostic test on the board and ask five students to match them with their respective names these will be given to them by teacher on strips of paper

Teacher will state the characteristics of the nursing process utilizing the PowerPoint presentation.

Teacher will ask two students to the back and three at the front to state one each, the five characteristics of the nursing processFive students will attempt to match the five characteristic of diagnostic test with their respective names these will be given to them by teacher on strips of paper

Students will sit and listen attentively as the characteristics of the nursing process are stated.

Two students at the back and three at the front will state one each, the five characteristics of the nursing process according to the content

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 x-rays

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

The goals of management are to prevent chronic and troublesome symptoms, maintain near or normal pulmonary function, maintain normal activity, prevent recurrent exacerbations, and to meet patients and families expectation of care (Pellico, 2013).PHARMACOLOGICAL MANAGEMENTShort-Acting B2 Agonists Albuterol interacts with B2 receptors in bronchial smooth muscles resulting in relaxation of bronchial smooth muscles thus reducing bronchospasm and airway resistanceLong Acting B2 Agonist Salmeterol acts similar to Albuterol, has slower onset and longer durationAnticholinergic Atrovent used for maintenanceMethylxanthines Theophilline, Aminiphilline prevention and treatment of asthma (McKenry et al., 2006)Teacher will ask five students randomly to describe the general management of clients with asthma

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

Five students chosen randomly will attempt to describe the general management of clients with asthma

Students will sit, listen, follow PowerPoint and ask questions as is necessary

Two students will describe the general management for clients with asthma according to the contentStudents will be able to describe 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

Teacher will ask students to form themselves into three groups, one group will note the assessment details, the other the nursing diagnoses and the patients outcome and the third group at least five priority interventions

Teacher will provide clarity and feedback on the scenario and answer question asked with the aid of marker and white boardStudents will form themselves into three groups, one will look at the nursing assessment, the other the possible diagnoses and the third group at least five priority interventions

Students will ask questions and listen to the feedback given by teacher

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

EVALUATIONQuestions1. Define the term Asthma2. Explain one risk factor for asthma3. Describe three (3) manifestations of Asthma4. Name three (3) classes of medications used to manage Asthma5. Give two diagnosis and two interventions with rationalesAnswers1. 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

AssessmentDiagnosisPatient Objective/GoalIntervention and RationalesEval

Client has SOB, Dyspnea, Use of accessory muscles, thick viscous secretions.

Assessment revealedV/S P100Bpm, R32Bpm,

Diagnosis of Acute Asthmatic attackIneffective Breathing Pattern related to trachea-bronchial 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 musclesWithin hour of nursing and other interventions client will demonstrate an improvement in respiratory rate as evidence by respiratory rate of 16-24bpm

Client will demonstrate signs of patent airway and adequate oxygen exchange within the 8hr shift following nursing and other interventions1. 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 reaction2. Assess then monitor V/S Initially for baseline and then for comparison3. Administer Humidified Oxygen 2-5l as required to improve tissue oxygenation and prevent drying of the nares4. 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 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.5. 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.6. Encourage and assist abdominal and pursed lip breathing exercises - Provides some means to cope with or control dyspnea and reduce air trapping. 7. Increase fluid intake to 2500- 3000ml within cardiac tolerance - Hydration helps thin secretions, facilitating expectoration and using warm liquids may decrease bronchospasm.8. 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)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

-Had frightened look on face

-Inability to breathe

-V/S P100bpm, R32bpmAnxiety 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 (16-22)

- 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.-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)

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