The client must be thoroughly educated regarding the variability of the disease and changes necessary to achieve the best control possible. Asthma control requires some significant life changes that may or may not be acceptable—or even possible—for a given client. This is illustrated in the case of Tom, who is probably experiencing a reactivation of his disease from exposure to cat dander, which is a common trigger.
Effective management includes a partnership approach between the client and the healthcare team, with emphasis on the need for adequate control of symptoms using appropriate medications and elimination, or at least mitigation, of environmental factors known to cause exacerbations.
Client education at this time must also reinforce the concept that the potential exists at any level of severity—including intermittent—for a severe exacerbation that can result in serious illness, hospitalization, or even death.
The Rules of Two (below) is a simple and useful tool to support the client in increasing awareness of symptoms. If any of the criteria are met, the client can schedule an office visit to review factors that may be exacerbating the asthma and have adjustments made to the medication routine if needed.
Test Your Knowledge
The Rules of Two is:
- A simple and useful tool to support the client in increasing awareness of symptoms.
- Genetically, if one person in the family has asthma, another is likely to have it too.
- Clients who have asthma should see their physician at least twice a year.
- Those who have asthma should see their physician at least twice a month.
Answer: A
Rules of Two
- Need for SABA (rescue inhaler) such as albuterol more than 2 times a week (exclude use for intermittent asthma when used as premedication for exercise)
- Awaken at night with asthma symptoms more than 2 times a month (This includes cough, wheeze, chest tightness, or shortness of breath.)
- Refill your SABA (rescue inhaler) more than 2 times a year (Consider that children may need multiple inhalers for school or daycare, in the case of parents living apart, and so on.)
Source: Baylor Health Care System, 2001.
When any of these conditions are met, clients are assumed to have decreasing levels of control and they require evaluation, which can help determine if they are using their medications correctly, if their medications need to be changed, or if there are triggering events that can be modified, avoided, or eliminated. Members of the healthcare team can also use these questions during scheduled followup visits to determine the need for focused teaching or a change in treatment.
Clients exhibiting severe symptoms must be treated immediately to prevent respiratory arrest. Signs and symptoms are grouped according to their severity criteria, ranging from mild to imminent arrest. Some objective measures that are seen in adults are shown on the following table. Symptoms differ for children according to their age.
Some Objective Measures Seen in Adults with Asthma | ||||
|---|---|---|---|---|
| Mild | Moderate | Severe | Arrest imminent |
Symptoms |
| |||
Air hunger | While walking; | At rest; | At rest; | Extreme |
Talks in… | Sentences | Phrases | Words | May exhibit gasping |
Alertness | May be agitated | Usually agitated | Usually agitated | Drowsy, confused |
Signs |
| |||
Respiratory rate | Increased | Increased | Often >30/min | Erratic |
Wheeze | Moderate; end expiratory | Loud; throughout exhalation | Loud; inspiratory and expiratory | Absent; silent lung; no air movement |
Pulse | <100 | 100–120 | >120 | Bradycardia |
Functional criteria |
| |||
PEF | ≥70% | 40%–69% | ≤40% | <40% or unable to obtain PEF |
O2 saturation on room air | >95% | 90%–95% | <90% | ABG needed for accurate assessment |
In summary, clinical assessment and measures to correctly identify, classify, and treat asthma are available to guide the healthcare team and the client in improving overall outcomes and minimizing risk. A partnership approach reinforces a client’s ability to be an active participant in care. Correctly implemented these measures promotes the goal of therapy, which is to achieve symptom control by reducing impairment and managing risks.
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