Warning! Is your asthma patient normal?

A mother rushes into your ED and states that her child is having an asthma attack, but the child seems to be breathing normally. It's a mistake to make your triage decision on the basis that your patient looks fine with stable vital signs, says William Downum, RN, an ED nurse at St John's Mercy Medical Center in St. Louis, MO.

In fact, children with an acute asthma exacerbation often present with normal or near normal vital signs, says Downum.

"They may have received treatments just before arrival to the ED, which gives them temporary relief of their symptoms," he explains. "Also, some patients have a tendency to compensate well for a certain period of time."

Downum recommends the following clinical practices:

• Always auscultate the patient's breath sounds for any signs of wheezing or extremely diminished breath sounds.

"Perform a rapid assessment in conjunction with the vital signs to assess the true status of the patient's condition," says Downum. (See related story, right, on determining the actual status of an asthma patient, and clinical tip, p. 47, on allergic reactions.)

• Assess the patient's chest area for signs of sternal retractions, intercostal retractions, and use of accessory muscles.

"Some patients may present with a frequent dry cough that is unrelieved with over-the-counter medications," notes Downum.

• Initiate treatment for acute exacerbations shortly after arrival, even if vital signs are stable.

"These patients should be treated as soon as possible, to prevent their condition from deteriorating," says Downum. Your goal is to administer treatments and medications that will open the patient's airways as soon as possible, he explains.

• Provide the patient with a calm environment.

"Anxiety interferes with the breathing process," says Downum.

• Identify other disease processes or conditions that might be affecting the patient's ability to breathe.

To determine if your asthma patient has a secondary diagnosis of pneumonia, Downum says to take these steps:

— After initial care is provided to improve breathing, assess the patient for a productive cough.

— Recheck the patient's temperature, and check for depressed oxygen saturation after breathing treatment is given, especially if wheezing has improved.

— Assess for the presence of extremely diminished lung sounds over a specific area of the chest. "Alert the physician if these conditions exist, so that a chest X-ray or additional labs may be obtained," says Downum.

• If you encounter a pediatric patient with wheezing and respiratory difficulty and no previous history of asthma, obtain an accurate history.

"Many times younger pediatric patients are evaluated for asthma, but not given a formal diagnosis of asthma until it is proven if the asthma will continue past childhood," says Downum. "These patients need to be treated as asthma patients."

Sources

For more information on improving care of asthma patients in the ED, contact:

  • William Downum, RN, Emergency Department, St John's Mercy Medical Center in St. Louis, MO. E-mail: William.Downum@Mercy.Net.
  • Rebecca A. Steinmann, APN, CEN, CPEN, CCRN, CCNS, FAEN, Clinical Nurse Specialist, Emergency Department, Northwest Community Hospital, Arlington Heights, IL. Phone: (847) 618-3935. E-mail: rasteinman@nch.org.

Learn actual status of asthma patient

ED nurses shouldn't be misled

Temperature, pulse, respiratory rate, and blood pressure, and even oxygen saturation are only a small component of the assessment of an asthma patient, according to Rebecca A. Steinmann, APN, CEN, CPEN, CCRN, CCNS, FAEN, a clinical nurse specialist in the ED at Northwest Community Hospital in Arlington Heights, IL.

"These can all be relatively 'normal,' and your patient may still be in imminent danger," Steinmann says.

The distinction between respiratory distress and respiratory failure is "a fine line," she adds. "When a patient presents in respiratory distress, you see the evidence of the patient's attempts to compensate," says Steinmann. "They are working hard to breathe. Their heart rate is elevated, and the respiratory rate may be elevated, although expiration is prolonged."

As respiratory distress progresses into respiratory failure, the work of breathing often decreases, because the patient has insufficient energy left to work so hard, says Steinmann. "The heart rate and respiratory rate normalize, until both rates become depressed," she says.

Steinmann says to use these other assessment parameters:

  • Level of consciousness.
  • Pattern of speech. "Is the patient able to speak in full sentences, or are they barely able to speak short phrases?" asks Steinmann.
  • Posture. Steinmann says to note whether the patient is sitting upright or hunched forward in an attempt to maximize their airway and allow full lung expansion.
  • Breath sounds. "Wheezing is what we equate with an asthma attack, but the patient who is not wheezing and barely exchanging any air because of such severe bronchoconstriction is the graver concern," says Steinmann.

Obtain this info

Steinmann gives these tips to determine a patient's status:

• Use objective measures.

"Obtain a peak flow measurement on every patient presenting with an exacerbation of asthma," Steinmann says. "Typically, children can cooperate with this measurement by 5 years of age."

Determine how this reading compares with the patient's predicted measurement and their baseline, she says. "By measuring exhaled carbon dioxide, you can determine the effectiveness of the patient's ventilation and can monitor their response to interventions," Steinmann adds.

• Use the patient's history to learn valuable clues.

Steinmann recommends asking these questions:

— What medications are you using? Are you taking steroids? How often are you using "rescuer" inhalers?

— Have you ever been intubated?

— Have you had an ED visit for asthma in the past three months?

— Have you had an overnight hospitalization for asthma in the past three months?

"These questions provide information regarding the severity of this chronic illness and the degree of control the patient has in managing the disease," says Steinmann.

• Be familiar with how equipment needs to be maintained, zeroed, and/or calibrated, to make sure readings are accurate.

"Some devices require warm-up time, and some have to be calibrated. Others perform their own self-test and don't require calibration. Every brand is different," says Steinmann.

She notes that the American Heart Association's 2010 guidelines cite use of continuous capnography as a Level I recommendation for every intubated patient.1 In light of this guideline, says Steinmann, "ED nurses will have to become familiar with this technology."

Otherwise, you might not recognize early warning signs that your patient is in trouble, she says. "Nurses should understand reasons why the readings would be low or high, and know how to interpret the waveform," Steinmann says. "Asthmatic patients have a characteristic 'shark-fin' appearance to their waveform which normalizes as bronchoconstriction resolves."

Reference

  1. Field JM, Hazinski MF, Sayre MR, et al. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation 2010;122:S640-S656.

Clinical Tips

'Asthma' may be allergic reaction

Is your patient wheezing? Don't assume that asthma is the acute problem, says William Downum, RN, an ED nurse at St John's Mercy Medical Center in St. Louis, MO.

"Always assess the patient for allergies, and note skin for signs of an allergic reaction," he says. "An allergic reaction may cause the patient to wheeze, but requires a different drug regimen for treatment."