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UT Tyler College of Nursing, Nurse Educator MSN program

Evaluation in Nursing Education NURS 5328


Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

Scenario Name: Respiratory Distress,

Reactive Airway Anaphylactic Response


Target Audience: Undergraduate Nursing Students within a Bachelor of Science Program
Learner Levels: Junior I or II in a Fundamentals in Nursing Course.
I. Introduction
Actively engaging students requires immersion. To immerse students in an online
format requires active learning through encouragement by making the lessons fun and
engaging. Students may have fun if the content is presented in a way that helps them
understand, but is also creatively administered. The ENGAGE Model originally designed by

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

Hasley (2011) has a six-step model using the engage acronym while also incorporating The
Brilliance Learning System (Figure 1). The ENGAGE Model steps are as follows: 1. Energize
Learnerscapture student interest early. This might be a YouTube video creatively
demonstrating abnormal cardiac arrhythmias. 2. Navigate Contentpose interesting questions
pertaining to course objectives to spark conversation. 3. Generate Meaningallow students to
reflect on how learning has impacted their personal lives or change their work behavior. 4.
Apply to Real Worldpermit reflection and sharing of real world scenarios to engage and
stimulate memory for practice. 5. Gauge and Celebrateassess student learning and celebrate
achievements in ways that are fun and interactive. 6. Extend Learning to Actionguide
students to act on their intentions (ELT, 2015).
In recent decades the implications of constructivism for teaching have been studied
using a variety of teaching techniques. Constructivist teaching strategies in the may include: 1.
making a construct whereby the students must apply, use or process the information in some
fashion, 2. Ensure student participation and holding them accountable for their own learning, 3.
Develop higher level teaching projects to ensure the tasks require students to process the
information (Blooms taxonomy) with evaluation, synthesis, analysis etc., in mind, 4. Students
devise a method to identify learning errors and omissions through speaking to a partner,
matching cards, or other written work etc., 5. Students check for errors, their own and each
others learning errors and omissions and 6. Students are expected to correct these learning
errors and omissions (Petty, 2015).
Problem-Based Learning (PBL) is a student-centered teaching/ learning process utilized
in educational programs. This approach to teaching provides scenarios that introduce a problem
and encourages students to use methods to solve the problems. The problems may be simple or
complex depending on the level of learning in a particular program. Blooms Taxonomy (1956)
is incorporated into The Fundamentals in Nursing Course, which is a course intended and
designed for the novice learners in the areas of nursing practice and skills. The PBL provides
course content as complex and authentic problems that require student classmates to solve. The
students must develop content knowledge as well as problem-solving, clinical reasoning,
critical thinking skills, communication, social skills, negotiation, and self-assessment skills
during this learning process (Billings, 2009).
Participants are expected to understand basic nursing skills and scientific and
humanistic issues and underlying disease process assessment and treatment care delivery with

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

the use of simulator to deploy an immersion role-play exercise involving a case scenario for a
medical-surgical patient within an acute care environment. The introduction to the simulator
will enhance the overall effects of real world scenarios and provide students with an
opportunity to permit hands-on learning, critical thinking, skill demonstration, safety in patient
care delivery, and team collaboration. The simulation scenario will be played out as skit. The
sections within this simulation module include a Pre-simulation preparation, the skit, a Postsimulation debriefing and evaluations. This skit will focus on the asthma patient who develops
acute respiratory distress as a result of an anaphylactic response.
Centers for Disease control (2012) identify the incidence for Asthma occurrence in the
ER was higher during the2008-2010 period amongst multiple-race, blacks than for white
persons. Black persons also had a higher rate of ED visits and hospitalizations as well as a
higher death rate related to asthma for the period 20072009 than white persons with asthma
(Akinbami, et al., 2012).
Fundamentals Course Objectives and Student Learning Outcomes:
A. Simulation Course Objectives
1. Focus on interdisciplinary communication, collaboration, assessments and patient
centered care
2. Learners will complete a respiratory assessment, will provide reassurance to the patient,
establish need for input from collaborative disciplines (Respiratory Therapy, X-Ray or
Laboratory Technician, Medical Provider) and prepare for an assessment and treatment
plan for acute respiratory insufficiency, anaphylaxis scenario.
3. Demonstrate effective teamwork
B. NCLEX Focus areas
1. Patient-Centered Care/Human Flourishing
o
Symmetric Chest Expansion
o
Additional History for Infants, Children, or Aging Adult
o
Culture and Genetics
o
Assessment of Common Respiratory Conditions
2. Teamwork and Collaboration/Professional Identity
o
Anterior Thoracic Landmarks
o
The Acutely Ill Person
o
Measurements for Pulmonary/ Respiratory status

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

3. Safety/Nursing Judgment
o
Objective Patient Data
o
Breath Sounds
o
Utilization of Oxygen Delivery Devices
o
Administration of Medication, 5 Rights
4. Informatics/Nursing Judgment
o
Documentation
o
Critical Thinking Decision-making processes
o
SBAR communication
C. Student Learning Outcomes
Following this simulation vignette, the students will be able to:
1. Collect and organize appropriate clinical data (history, physical exam, laboratory
assessments including technology advancements in diagnostic such as PFT).
2. Adequately apply principles of evidence-based medicine to determine clinical diagnoses,
and formulate and implement acceptable treatment modalities.
II.

Vignette Scenario
A.

Clinical Case Information

HPI:

Mr. S is a 28 year old mixed race (African American/White) male, who presents

to the ER accompanied by his spouse, with complaints of difficulty breathing with


facial swelling and itching involving lips and tongue. Past medical history of Asthma
and prior anaphylaxis events for peanut derivatives. But no prior Asthma exacerbations
in recent 6 months. Wife reports that while at a work potluck lunch, he ate food
containing peanut oil unknowingly and started to immediately have an allergic reaction
and began to swell. The ingestion of food containing the highly allergic substance took
place approximately 8 minutes ago. Patient did not have his EpiPen as the most recent
pen was expired, and with recent financial constraints, he has not filled his Rx for
Symbicort or the EpiPen, thus he presents to the ER today.
B.

Vignette Staging, Simulator Moulage

Young Adult, African American/White male


Dressed in Business Casual clothing attire

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

C.

Assignment of Roles (Please indicate below roles to be assigned):


Nurse (#1)
Respiratory Therapist
Observer (s)

Nurse (#2)
Spouse
CRNA (on stand-by)
Provider [NP/Physician]: available via phone

Important Information Related to Roles:

Secondary role is supportive and to assist with problem solving,


collaboration and to accept delegated responsibilities.
Observers are responsible for noting specific behaviors on a checklist.
Provider [NP/Physician]: Receives report and gives new orders.
Respiratory Therapist: Receives report, acts on RT orders.
Spouse: scripted verbiage. Acting in a concerned, supportive role
Patient: (SIM-lab Wizard tech)-Speaks as though tongue/lips swollen

D.

Skit Fidelity
Please see Fidelity table included Appendix A.

E.

Skit for Scenario


Scenario framework description is noted in the above discussion with the
included supportive data as follows:

Triage VS: T = 98.7 F P = 94 RR = 24 BP=118/60 O2 sat = 93%

Ht: 6'1" Wt: 190 lbs

PMH: Asthma, diagnosed at age six. Anaphylaxis, severe for peanuts and peanut derivatives.
Previous symptoms reported as controlled with scheduled medications.
Social History: Non-smoker. Married, good family support. No children. Works full-time as
office manager in manufacturing. No religious affiliations.
FmHx: non-contributing
Allergies: PCN [Hives], Peanuts [Anaphylaxis]
Home Medications:
1. EpiPen-- last dose has not administered yet today as current EpiPen was expired and Rx had
not been filled due to expense constraints.
2. Singulair 10mg PO once daily-last dose 0730 today.
3. Albuterol Sulfate MDI rescue inhaler 2 puffs every 4-6 hours as needed for SOB, wheezinglast dose approximately 2 weeks ago per patient report.
4. Symbicort 160/4.5mg 2 puffs BID, however patient has not used this agent in a couple of
weeks due to financial constraints. He has not obtained new prescription due to Rx cost.
Current Orders: available at the start of scene and include Medication Administration Profile
Medication profile is available from Pharmacy [see MAR attachment in Appendix B]

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

EpiPen 0.3mg IM injection to lateral thigh x1 dose STAT, repeat x1 after 5 min. prn.
Diphenhydramine (Benadryl) 50mg IV x1 Now
Ranitidine (Zantac) 10mg IV x1 dose Now, administered with Diphenhydramine dose
O2 @ 2L per nasal cannula prn SOB or to keep O2 Saturations > or = to 92%
O2 delivery via 100% non-rebreather for saturations <92%
Cimetidine (Tagamet) 300mg po x1 now (Administer po when able to swallow later)
Racemic Epinephrine 0.5ml per 2.25% NEB per RT every 10 min. prn Bronchospasm
DuoNeb unit dose 3ml (0.5mg/ 2.5mg) via neb per RT every 4 hours prn wheezes

Scenario Scenes for Skit


Scene 1:
[5 minutes]
VS: T = 98.7 Pulse = 94 RR = 24 BP = 118/60 O2 sat = 97%
RN1 (student): Lead RN for scenario. Assigned as Primary nurse for the patient, Mr. S. Patient has been
assigned to ER room 1 from triage. RN performs hand hygiene and enters room. RN introduces self and
colleague RX and then acknowledges the patient and asks for 2-patient identifiers [name and date of
birth] and then proceeds to perform the initial respiratory assessment (obtains RR and breath sounds/
lung sounds).
Patient in a hoarse, stuttering voice: I cant take a deep breath and my Lips are really starting to swell
RN2 (student): Assists RN1 and Takes direction to perform follow-up VS and to attach patient to
telemetry monitoring equipment. RN2 performs VS: BP, Pulse, O2 sat via and pulse oximetry.
Spouse (student): Stands close to bedside, nervous/anxious. Asks patient/ spouse questions in regards to
medications, Why havent you been taking your Symbicort? Dont you keep your EpiPen with
you?
Scene 2:
[5 minutes]
VS taken earlier by RN2: Pulse = 108

BP 100/60 02 Sat = 90%

Patient in ER room 1. Noticeably swollen lips and face. Sitting up in bed. Wife at bedside. Nasal
cannula on, but not connected at O2 flow meter.
RN1 enters room, introduces self. Patient noticeably struggling to report "my lips are swelling and I
cant breathe".

-if Oxygen delivery and flow go unnoticed, patient continues to complain of SOB,
dizziness, and O2 Sat decreases to 88%, with RR rate now 32 breaths per minute.

Spouse becomes anxious, "Why can't he breathe? What's going on?"

-if orders not checked/administered within 5 minutes, patient with noticeable difficulty
breathing, increased work of breathing, audible +stridor, tachypnea and diaphoresis.

Patient: Unable to speak.


Spouse: "Please do something!"

Expected action: RN1 Check new orders. Verify IV access. Administers EpiPen 0.3 mg IM
injection STAT per order and verify using the 6 Rights technique. RN1 will also check to be
sure IV access is available. Documentation performed on the MAR.

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

Expected Action: RN1 will also administer Diphenhydramine (Benadryl) 50mg IV and
Ranitidine 50mg IV and follow the verification using the 6 Rights technique.
Documentation on MAR performed.
Expected Action: RN2 reviews VS and changes the O2 delivery to non-rebreather (NRB)
and sets flow meter delivery to 100% with NRB delivery.
Expected Action: RN2 also then is expected to Call RT for RT Rx treatment.
Expected Action: RN2 performs SBAR and updates RT of situation

Scene 3:
[5 minutes]
Respiratory Therapist: Verifies order and administers the nebulizer treatments (Racemic Epinephrine
NEB versus Duoneb nebulizer).

If Diphenhydramine (Benadryl) neglected to be administered IV for lack of access and


unable to swallow p.o. or the Ranitidine was neglected to be administered, the patient will
continue to develop progressive swelling of the lips, face and tongue, urticarial s/s and rash.
Expected action: RT will then administer Racemic Epi NEB.

RN2 will follow-up on patient respiratory assessment and response to Rx administered.

Expected action: RN2 will readdress need for follow-up if s/s persists and RT will be
requested to repeat the Racemic Epi NEB every 5 min if s/s have not remarkably improved.
-If RT treatment delivery performed and O2 delivery appropriate the RR = 20, and O2 sat
will improve to 93%.
-If EpiPen administered, respiratory assessment may continue to reveal no significant
improvement in swelling or airway. +Stidor or work of breathing versus wheezes to
bilateral upper lobes on expiration with improved airway.

RN1 will follow-up on patient respiratory assessment and response to Rx administered.


VS as follows: RR = 36 Pulse 120 BP 95/55 O2 sat = 92%

Expected Action: RN1 will assess airway, breath sounds, check 02 Sat, RR, and Pulse
-If action incomplete patient will continue to deteriorate with notable facial swelling,
limited airway movement, and progressive anxiety.
Expected action: RN1 will repeat the EpiPen 0.3mg IM to thigh if swelling, respiratory
distress s/s persists. Medication administration verified using 6 Rights. Documentation on
MAR.
-If action incomplete patient will continue to deteriorate with diaphoresis, Nausea with
abdominal cramps and restlessness. VS: Pulse=120 BP= 90/60 RR=36 O2 sat 90%
Expected action: RN2 will identify no significant improvement and administer
methylprednisolone (Solu-Medrol) 125mg IV Now, verify using 6 Rights technique and
Document on MAR.
Expected action: RN2 will readdress need for follow-up for persistent s/s and RT will be
update status for doses of Racemic Epi NEB required if s/s have not remarkably improved.
-If RT treatment delivery performed and O2 delivery appropriate the RR = 20, and O2 sat
will improve to 96%.
-If EpiPen administered, respiratory assessment reveals Wheezes to bilateral upper lobes on
expiration with improved airway.

Patient with a slightly Breathy/ labored voice "I am starting to breathe a little better now"

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer
Spouse asks questions, "Is he going to be okay?"

Expected action: Education on carrying EpiPen on person at all times. Nurse responds to
questions appropriately and calms anxiety in patient and wife.

Scene 4:
[5 minutes]
Patient demonstrates intense itching to face, throat, and hands.

Expected action: RN1 performs skin assessment. Notes progressive hives to neck and central
chest with progression to bilateral palms and redness noted around mouth. SBAR call to
NP/Physician provider.
Expected action: RN2 obtained orders from SBAR call and Orders reviewed for Cimetidine
(Tagamet) 300mg po x1 now and Diphenhydramine (Benadryl) 25mg po every 6 hours prn
itching or hives. Prednisone 20 mg po Documentation of New Order performed.
Expected action: RN2 administers Cimetidine (Tagamet) 300mg po x1 now and will
determines need for Benadryl 25mg po for every 6 hour PRN for urticarial/ hives and utilizes
the 6 Rights technique and documents Rx on the MAR.

Spouse applies cool compress to patients head and neck area.

-If Rx administered as ordered patient will improve with the following status change upon RN
reassessment
Expected actions: RN1 performs respiratory assessment and reassesses VS: Pulse 96 RR 28
O2 sat 94% Less work of breathing, less anxious, no longer diaphoretic

Patient is requesting the mask be removed and is increasingly less anxious, breathing continues to
improve, RR=19, O2 sat is 96%.

Expected action: RN2 exchanges the NRB 02 delivery for 02 @2 L/nasal cannula.
Expected action: Anticipate additional Rx for oral steroids.

Patient condition stabilizes.


Skit Scenario Ends

III.

Learning Exercises, Skills and Activities


A. The nursing fundamentals skills (Taylor, 2008) utilized in this scenario will include:
Please see Appendix C for the Checklist.

Obtaining Vital Signs (T, BP, HR/ Pulse, RR and O2 saturation)


Hand Hygiene
Health Assessment
o Obtaining Health History
o Physical exam/ assessment of the patient
o Documenting data
Medication administration
o The five (5) rights
o Principles of pharmacology
Oxygenation

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

o Anatomy and physiology of the respiration


o Factors affecting respiratory function
o Nursing process for oxygenation
B. Incorporation of Blooms Taxonomy

IV.

Foundational Knowledge
Using model questions for the following areas:
o Knowledge
o Comprehension
Application
Using Model questions for the following areas:
o Analyze
o Apply
o Evaluate
Integration
o Interaction
Model questions
Case scenario
o Relationships
Interdisciplinary
Connecting to people
o Synthesis
Immersion experience
Adaptation to real world scenario
A. Predict and Manage Tool, Questions
1. What are you on alert for today with this patient?
2. What are the important assessments to make?
3. What complications may occur? What could go wrong?
4. What interventions will prevent complications?
5. How will you prioritize implementation of nursing interventions? Explain
6. What actions will you take for potential complications?
Clinical Evaluation Tool is completed using the grading Rubric.
The Clinical Evaluation Tool for Grading Rubric is available in Appendix D
B. What will be discussed in debrief:

Was the SBAR complete?


Did the learners demonstrate effective teamwork?
Was the respiratory assessment completed properly and were findings shared?

C. Debriefing process:
1. Student reviews notes taken, including nurse actions and events.

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

2. Discuss overall feel for performance.


3. Discuss areas of opportunity and successes during the sim.
4. Review objectives, reflect and answer questions.
5. Complete the survey
o Did learner progress through the scenario efficiently? Did
communication unnecessarily delay treatment of patient?
o Was there evidence of collaboration?
o Did professional communication occur between disciplines AND include
the patient?
o Did both disciplines fulfill their professional responsibilities, or did they
defer to the other discipline?
V.

Conclusion
The anaphylactic reaction has a multiple level progression for novice to advanced

training and may be a complex and very involved scenario. The need to understand emergency
airway and handling of stressful scenario algorithms in the acute care environment are
important aspects of care delivery. The clinicians knowledge, understanding, comprehension
of disease specific conditions, medication administration and team collaboration as well as
communication and caring aspects for patients and families is necessary to performance.
The depth of the scenario is completely dependent on the levels of the student. For
example, hypotensive patients will require additional IV hydration or IV epinephrine infusion
as a potential deterioration into acute respiratory failure scenario requiring intubation for
airway protection and to prevent hypoxemia. For the purposes of this scenario the anaphylactic
scenario was abbreviated and not indicative of the scenario for the advanced level student.
Additional evaluation criterion and outcomes may be seen within the Clinical Evaluation Tool
located in the Appendix.
Check Lists
A. Instructor

1.
2.
3.
4.
5.

Pre-Scenario Check List

Equipment is staged as requested.


The learner has been oriented to the simulator.
The learner understands the guidelines/expectations for the scenario.
Learner(s)s understand their assigned roles.
The time frame Expectations for simulation met: 0 Yes 0 No.

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

6.
7.
8.

The time frame Expectations for debrief met: 0 Yes 0 No.


Audio/Visual Consent signed and turned into CHESC sheet.
Attendance sheet completed and given to CHESC staff.

Post Scenario

If you could change anything next time, what would it be?


Comments:___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
B. Student Learner(s)

1.
2.
3.
4.
5.

Pre-Scenario Check List

I have been oriented to the simulator.


I understand the guidelines/expectations for the scenario.
I understand the assigned role.
My questions about the simulation have been answered.
I have all necessary equipment for the simulation.

Post Scenario

If you could change anything next time, what would it be?


Comments:___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Learner(s) Signature ____________________________________ Date __________________
VI.

References

Akinbami, L.J., Moorman, J.E., Bailey, C., Zahran, H.S., King, M., Johnson, c. A. (2012).
Trends in asthma prevalence, health care use, and mortality in the United States, 2001
2010. Center for Disease Control. National Center for Health Statistics. Retrieved from
website http://www.cdc.gov/nchs/data/databriefs/db94.htm
Asthma Initiative of Michigan (2015). Get asthma help. Guidelines for the diagnosis and
treatment of asthma. Asthma Initiative of Michigan, for healthy lungs. Retrieved from
websites http://getasthmahelp.org/asthma-guidelines.aspx,
http://getasthmahelp.org/site-map.aspx,
http://getasthmahelp.org/asthma-health-professional-main.aspx
Billings, D., Halstead, J. (2009). Teaching in nursing: A guide for faculty. St. Louis: Saunders,
Elsevier. ISBN: 978-1-4160-4084-2

UT Tyler College of Nursing, Nurse Educator MSN program


Evaluation in Nursing Education NURS 5328
Program Simulation Module

Presented by Lynlee Gayle, Bethany Rudolph, William Sandberg, and Tanya


Schlemmer

DeWit, S. C. (2005). Fundamental concepts and skills for nursing, 2nd Ed. Philadelphia:
Elsevier.
ELT (2015). Best learning platforms, Bestlearningplatforms.com. Retrieved from website:
http://info.shiftelearning.com/blog/bid/254770/eLearning-Strategy-The-Ultimate-WayTo-Engage-Your-Learners
Halsey, V. (2011). Brilliance by design: Creating learning experiences that connect, inspire,
and engage. San Francisco: Berrett-Koehler Publishers, Inc.
Jarvis, C. (2016). Physical examination & health assessment, 7th Ed. Retrieved from website
http://online.vitalsource.com
Luckman, J., & Sorensen, K. (1974). MedicalSurgical nursing a psychophysical approach.
Philadelphia: W.B. Saunders Company
Ma, O.J., Cline, D.M., Tintinalli, J.E., Kelen, G.D., Stapczynski, J.s. (2004). Emergency
medicine manual, 6th Ed. American College of Emergency Physicians, New York:
McGraw-Hill, Medical Publishing Division.
Oermann, M.H. (2013). Teaching in nursing and the role of the educator: The complete guide
to best practice in teaching, evaluation, and curriculum development. New York:
Springer Publishing Company. ISBN: 9780826195531
Petty, G. (2015). An introduction to constructivist teaching. Par model and constructivism.
Retrieved from website http://www.geoffpetty.com/activelearning.html
Petty, G. (2004). Constructivist teaching. Retrieved from website
http://www.geoffpetty.com/activelearning.html
Taylor, C., Lillis, C., LeMone, P., Lynn, P. (2008). Fundamentals of nursing: The art and
science of nursing, 6th Ed., Philadelphia: Wolters, Kluwer/ Lippincott, Williams &
Wilkins. ISBN: 978-0-7817-8157-2.
National Institutes of Health (2012). Expert panel report (EPR) 3: Guidelines for the diagnosis
and management of asthma. National Heart, Lung, and Blood Institute, U.S.
Department of Health & Human Services Retrieved from website
http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/fullreport