DESIGN SERVICES OF

CONNECTIONS: NURSING PRACTICE APPLICATION

Patients Receiving Pharmacotherapy for Asthma and Chronic Obstructive Pulmonary Disease
Assessment Potential N ursing Di agnoses
Baseline assessment prior to administration:
Understand the reason the drug has been prescribed in order to assess for
therapeutic e ffects.
Obtain a complete health history including previous history of symptoms
and association with seasons, foods, or environmental exposures, existing
cardiovascular, respiratory, hepatic, renal, or neurologic disease, glaucoma,
prostatic hypertrophy, difficulty with urination, presence of fever or active
infections, pregnancy or breast-feeding, alcohol use, or smoking. Obtain
a drug history, noting the type of adverse reaction experienced to any
medications.
If asthma symptoms are of new onset, particularly in infants and young children,
assess for any recent changes in diet, soaps including laundry detergent, laundry
softener, cosmetics, lotions, and environmental factors (e.g., pets, travel, or recent
carpet-cleaning) that may correlate with the onset of symptoms.
Obtain baseline vital signs, noting respiratory rate and depth.
Assess pulmonary function with pulse oximeter, peak expiratory flow meter, and/
or arterial blood gases to establish baseline levels.
Evaluate appropriate laboratory findings (e.g., CBC, hepatic, and renal tests).
Assess symptom-related effects on eating, sleep, and activity level.
Assess the patients ability to receive and understand instructions. Include the
family and caregivers as needed.
Impaired Gas Exchange
Anxiety
Disturbed Sleep Pattern , related to adverse drug effects
Activity Intolerance , related to disease processes or ineffective drug therapy
Deficient Knowledge (Drug Therapy)
Risk for Ineffective Cardiac Tissue Perfusion

Assessment throughout administration:
Assess for desired therapeutic effects (e.g., increased ease of breathing, improvement
in pulmonary function studies, improved signs of peripheral oxygenation and
increased activity levels, maintenance of normal eating and sleep periods).
Continue periodic monitoring of pulmonary function with pulse oximeter, peak
expiratory flow meter, and/or arterial blood gases as appropriate.
Assess vital signs, especially respiratory rate and depth. Assess breath sounds,
noting the presence of adventitious sounds, and any mucus production.
Assess for adverse effects: dizziness, tachycardia, palpitations, blurred vision,
or headache. Immediately report fever, confusion, tachycardia, palpitations,
hypotension, syncope, dyspnea, or increasing pulmonary congestion.
Planning: Patient Goals and Expected Outcomes
The patient will:
Experience therapeutic effects dependent on the reason the drug is being given (e.g., increased ease of breathing, improvement in pulmonary function studies, able to
experience normal sleep and eating periods, and able to carry out activities of daily living (ADLs) to a level appropriate for the condition).
Be free from or experience minimal adverse effects.
Verbalize an understanding of the drugs use, adverse effects, and required precautions.
Demonstrate proper self-administration of the medication (e.g., dose, timing, and when to notify the provider).
Implementation
Interventions and (Rationales) Patient-Centered Care
Ensuring therapeutic effects:
Continue assessments as above for therapeutic effects. (Increased ease
of breathing, lessened adventitious breath sounds, improved signs of tissue
oxygenation, and normal appetite and eating and sleeping patterns should
occur.)
Teach the patient to supplement drug therapy with nonpharmacologic measures
such as increased fluid intake to liquefy and mobilize mucus, and to reduce
exposure to allergens where possible.
Advise the patient to carry a wallet identification card or wear medical
identification jewelry indicating the presence of asthma or a respiratory condition,
any significant allergies or anaphylaxis, and use of inhaler therapy.
Monitor pulmonary function periodically with pulse oximeter, peak expiratory
flow meter, and/or arterial blood gases. (Periodic monitoring is necessary to assess
drug e ffectiveness.)
Teach the patient how to use the peak expiratory flow meter or other equipment
ordered to monitor pulmonary function.
Instruct the patient to immediately report symptoms of deteriorating respiratory
status such as increased dyspnea, breathlessness with speech, increased anxiety,
or orthopnea.
(continued)
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DESIGN SERVICES OF
For treatment of acute asthmatic attacks, inhaler therapy should be started at
first sign of respiratory difficulty to abort the attack. For preventive therapy,
long-term bronchodilation by inhaler or orally will be used to maintain
bronchodilation. LABAs and long-acting bronchodilators are not to be used to
abort an acute attack. (Acute asthmatic attacks are managed with quick-acting
bronchodilation such as beta
2
agonists. For maintaining bronchodilation
and preventing attacks, LABAs, anticholinergics, mast cell stabilizers, and
glucocorticoid or methylxanthine therapy may be used. It is crucial to know and
recognize the difference between quick-acting and long-acting inhalers.)
Provide explicit instructions on the use of quick-acting versus long-acting
inhalers. Teach the patient to use quick-acting inhalers at the earliest possible
appearance of symptoms. Long-acting inhalers or oral therapy may be used to
maintain bronchodilation but do not discard quick-acting inhalers if on long-term
maintenance therapy . They may still be needed for periodic acute attacks.
Minimizing adverse effects:
Continue to monitor respirations, rate, depth, breath sounds, mucus production,
and for increasing dyspnea, adventitious breath sounds, and signs of tissue
hypoxia (e.g., cyanosis), anxiety, confusion, or decreasing pulmonary function
(e.g., pulse oximeter, peak expiratory flow). Immediately notify the provider if
symptoms continue to increase, especially if respiratory involvement worsens
or fever is present. (Increasing dyspnea, adventitious breath sounds, diminished
oxygenation, or increasing anxiety or confusion may indicate inadequate drug
therapy, worsening disease process, or respiratory infection and should be
reported i mmediately.)
Instruct the patient to report immediately symptoms of deteriorating respiratory
status such as increased dyspnea, breathlessness with speech, increased anxiety,
or orthopnea.
Provide explicit instruction on the use of quick-acting and long-acting inhalers.
Ensure that the patient is able to identify the appropriate inhaler for the treatment
of acute asthmatic attacks or for preventive therapy. (Acute asthmatic attacks
are managed with quick-acting bronchodilation such as beta
2
agonists and the
patient must be able to identify the appropriate inhaler to use. Provide written
instructions, including drug name and when to use if both quick-acting and long-
acting inhalers are ordered.)
Teach the patient to use the quick-acting inhaler at the earliest possible
appearance of symptoms. Long-acting inhalers or oral therapy may be used to
maintain bronchodilation but do not discard quick-acting inhalers if on long-term
maintenance therapy . They may still be needed for periodic acute attacks.
Teach the patient not to rely on the color of the inhaler to indicate quick-acting
versus long-acting inhalers. Depending on the manufacturer and trade versus
generic drugs, the color may change. If the patient desires to color-code, suggest
individual color stickers or tape be used per patient preference. Instruct the patient
not to obscure the drug name with the sticker.
Monitor eating and sleep patterns and ability to maintain functional ADLs. Provide
for calorie-rich, nutrient-dense foods, frequent rest periods between eating or
activity, and a cool room for sleeping. (Respiratory difficulty and fatigue associated
with hypoxia and the work of breathing may affect appetite, ability to eat during
dyspnea, and maintenance of required ADLs. Adequate nutrition, fluids, rest, and
sleep are essential to support optimal health.)
Teach the patient to supplement drug therapy with nonpharmacologic measures
including:
Increased fluid intake to liquefy and assist in mobilizing mucus
Small, frequent meals of calorie-rich, nutrient-dense foods to prevent fatigue
and maintain normal nutrition
Adequate rest periods between eating and activities
Decreased room temperature for ease of breathing during sleep
Reduced exposure to allergens where possible.
Instruct the patient to immediately report any significant change in appetite,
inability to maintain normal intake, inadequate sleep periods, or inability to carry
out required ADLs.
Eliminate smoking, limit exposure to secondhand smoke, and limit caffeine intake,
especially if methylxanthines are prescribed. (Cigarette smoke irritates respiratory
mucous membranes, increasing the risk of adverse effects and increasing
bronchoconstriction. Caffeine may increase the risk of tachycardia in addition to
the drugs adverse effects, and both smoking and caffeine affect the metabolism
of me thylxanthines.)
Teach the patient about smoking cessation programs, to avoid environments
with secondhand smoke, and to limit or abstain from caffeine intake while taking
bronchodilator therapy.
Maintain consistent dosing of long-acting bronchodilators. LABAs,
anticholinergics, mast cell stabilizers, and corticosteroids are used to prevent
or limit acute bronchoconstrictive attacks. Regular, consistent dosing must be
maintained for best results.)
Teach the patient the importance of continuing regular and consistent
administration of all bronchodilation therapy to prevent acute attacks. Irregular
use may increase the risk or severity of bronchoconstrictive events.
Utilize the appropriate spacer between the inhaler and mouth and rinse mouth
after using the inhaler, especially after corticosteroids. (Spacers between metered-
dose inhalers may be ordered to assist in coordination and timing of inhalation
and to prevent medication being delivered to the back of the pharynx. Rinsing the
mouth after the use of inhalers prevents systemic absorption or localized reactions
to the drug such as ulceration.)
Instruct the patient in the proper use of spacers if ordered, followed by return
demonstration.
Teach the patient to rinse the mouth after each use of the inhaler and not to
swallow after rinsing.
CONNECTIONS: NURSING PRACTICE APPLICATION (continued)
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Patient understanding of drug therapy:
Use opportunities during administration of medications and during assessments
to discuss the rationale for drug therapy, desired therapeutic outcomes, commonly
observed adverse effects, parameters for when to call the health care provider,
and any necessary monitoring or precautions. (Using time during nursing care
helps to optimize and reinforce key teaching areas.)
The patient should be able to state the reason for drug, appropriate dose and
scheduling, what adverse effects to observe for, and when to report them.
Patient self-administration of drug therapy:
When administering the medication, instruct the patient, family, or caregiver in
proper self-administration of the drug, e.g., take the drug at the first appearance
of symptoms before they are severe. (Utilizing time during nurse-administration
of these drugs helps to reinforce teaching.)
The patient, family, or caregiver is able to discuss appropriate dosing and
administration needs.
The patient recognizes the difference between quick-acting and long-acting
inhalers, and knows when each is to be used.
Instruct the patient in proper administration techniques for inhalers, followed
by return demonstration, including:
Use a spacer if instructed between the metered-dose inhaler and the mouth.
Shake the inhaler or load it with a tablet or powder as instructed.
If using a bronchodilator and corticosteroid inhalers, use the bronchodilator first,
wait 5 min, then use the corticosteroid to ensure the drug reaches deeply into
the bronchial area.
Rinse mouth after using any inhaler.
Clean the inhaler at least weekly by running warm water through the plastic
mouthpiece after removing the drug canister, shaking out excess water, and
allowing to air dry.
Evaluation o f Outcome C riteria
Evaluate the effectiveness of drug therapy by confirming that patient goals and expected outcomes have been met (see Planning).
CONNECTIONS: NURSING PRACTICE APPLICATION (continued)
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