9 Asthma Nursing Care Plans

Ineffective Breathing Pattern

The main related factor identified in the literature for ineffective breathing patterns was bronchial secretions followed by hyperventilation. The airway diameter is reduced, which leads to the narrowing of the lumen due to mucosal edema, exacerbated secretion, and infiltration of inflammatory cells, leading to different degrees of obstruction. The presence of obstructed airways leads to excessive levels of carbon dioxide and hydrogen ions in the blood, causing hyperventilation, which is a breathing pattern deeper, faster, and longer than normal, aimed at eliminating excess carbon dioxide (de Prado et al., 2019).

Nursing Diagnosis

• Ineffective Breathing Pattern

May be related to

• Swelling and spasm of the bronchial tubes in response to inhaled irritants, infection, drugs, allergies, or infection
• Bronchial secretions
• Inability to mobilize and spontaneously expel secretions

Possibly evidenced by

• Cough
• Cyanosis
• Dyspnea
• Loss of consciousness
• Nasal flaring
• Prolonged expiration
• Respiratory depth changes
• Tachypnea
• Use of accessory muscles

Desired Outcomes

• The client will maintain an optimal breathing pattern, as evidenced by relaxed breathing, normal respiratory rate or pattern, and absence of dyspnea.
• The client will display normal arterial blood gas results.
• The client will be free of cyanosis and other signs and symptoms of hypoxia.
• The client will experience no signs of respiratory compromise or complications.

Nursing Assessment and Rationales 

1. Assess the client’s vital signs as needed.
Increased respirations, tachycardia, and hypotension may result from the effects of hypoxia. Hypoxia results from vasoconstriction which is an adaptive response to ventilation/perfusion mismatch.

2. Assess the respiratory rate, depth, and rhythm.
Changes in the respiratory rate and rhythm may indicate an early sign of impending respiratory distress. Chronic inflammation of the airways is associated with increased bronchial hyperresponsiveness, which leads to bronchospasm and typical symptoms of wheezing, shortness of breath, and coughing after exposure to allergens environmental irritants, viruses, cold air, or exercise (Morris & Mosenifar, 2022).

3. Monitor the client’s weight and BMI.
In adults, obesity is defined as a BMI of 30 kg/m² or greater. Adults diagnosed with obesity tend to have more severe asthma than lean adults, with a 4- to 6-fold higher risk of being hospitalized compared with lean adults diagnosed with asthma. Obesity is both a major risk factor and a disease modifier of asthma in children and adults (Peters et al., 2018).

4. Assess the client’s level of anxiety.
The emergency situation and an unfamiliar environment can aggravate the symptoms of the disease, especially if this is the client’s first experience with the condition. If the client is a child and the parent is anxious, the child’s level of anxiety increases, and the attack may worsen (Sommers, 2018). The client and family members are often frightened and anxious because of dyspnea, therefore, a calm approach is an important aspect of care.

5. Assess breath sounds and adventitious sounds such as wheezes and stridor.
Adventitious sounds may indicate a worsening condition or additional developing complications such as pneumonia. Wheezing, a musical, high-pitched, whistling sound produced by airflow turbulence, is one of the most common symptoms. As severity increases, the wheeze lasts throughout expiration. During a most severe episode, wheezing may be absent because of the severe limitation of airflow associated with airway narrowing and respiratory muscle fatigue (Morris & Mosenifar, 2022).

6. Assess the relationship of inspiration to expiration.
Reactive airways allow air to move into the lungs more easily than out of the lungs. If the client is gasping for air, instruction for effective breathing is needed. In the mildest form, wheezing is only end-expiratory. In a moderately severe episode, loud expiratory wheezing can be heard. In a severe episode, loud biphasic (expiratory and inspiratory) wheezing can be heard (Morris & Mosenifar, 2022).

7. Assess for signs of dyspnea (flaring of nostrils, chest retractions, and use of accessory muscle).
Dyspnea may indicate respiratory distress. Once the movement of air into and out of the lungs becomes challenging, the breathing pattern changes. Airway hyperreactivity causes bronchospasm which narrows the diameter of the airways. The degree of airway hyperresponsiveness generally correlates with the clinical severity of asthma. Airway obstruction increases resistance to airflow and makes exhalation difficult (Farrell, 2017).

8. Assess for conversational dyspnea.
Dyspnea during a normal conversation is a sign of respiratory distress. This clinical feature of asthma includes breathlessness which may impact the client’s ability to speak related to airflow limitation and the development of hypoxemia and/or hypercapnia; both of which will result in respiratory failure (Farrell, 2017).

9. Assess for fatigue and stress.
Fatigue may indicate distress, leading to respiratory failure. Inequities in social determinants of health influence asthma risk and morbidity through multiple mechanisms and contribute to long-term stress and fatigue. Long-term stress is proposed to have direct effects on asthma through long-term hypothalamic-pituitary-adrenocortical activation, which leads to a decrease in B2 adrenergic and glucocorticoid receptors and therefore, a decreased responsiveness to asthma medication and an increase in asthma symptoms (Grant et al., 2021).

10. Assess the presence of a paradoxical pulse of 12 mm Hg or greater.
A paradoxical pulse is an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mm Hg. A paradoxical pulse of 12 mm Hg or greater indicates a severe airflow obstruction. Pulsus paradoxus is not present in a mild episode of asthma; however, in moderately severe and severe episodes, pulsus paradoxus may reach up to 40 mm Hg. Pulsus paradoxus noted earlier may be absent in imminent respiratory arrest; this suggests respiratory muscle fatigue (Morris & Mosenifar, 2022).

11. Monitor oxygen saturation.
Oxygen saturation is a term referring to the fraction of oxygen-saturated hemoglobin relative to the total hemoglobin in the blood. Normal oxygen saturation levels are considered 95-100%. In a mild episode, oxygen saturation with room air is greater than 95%; in a moderately severe episode, it can be 91 to 95%; and,d in severe episodes it can be less than 91% (Morris & Mosenifar, 2022).

12. Monitor peaked expiratory flow rates and forced expiratory volume as taken by the respiratory therapist.
The severity of the exacerbation can be measured objectively by monitoring these values. The peak expiratory flow rate is the maximum flow rate that can be generated during a forced expiratory maneuver with fully inflated lungs. It is measured in liters per second and requires maximal effort. When done with good effort, it correlates well with forced expiratory volume in 1 second (FEV₁) measured by spirometry and provides a simple, reproducible measure of airway obstruction. During an exacerbation, the FEV₁ and forced vital capacity (FVC) are markedly decreased but improved with bronchodilator administration (Farrell, 2017).

13. Monitor arterial blood gasses (ABG).
With worsening obstruction and increasing ventilation-perfusion mismatch, carbon dioxide retention occurs. Respiratory alkalosis results from hyperventilation. Later the increased effort of breathing, increased cardiac output, and increased oxygen consumption results in metabolic acidosis (Morris & Mosenifar, 2022). An ominous finding is respiratory acidosis, which usually indicates that respiratory failure is pending and that mechanical ventilation may be necessary.

Nursing Interventions and Rationales

1. Plan for periods of rest between activities.
Fatigue is common with the increased work of breathing from the ineffective breathing pattern. Activity increases metabolic rate and oxygen requirements and is generally limited by the client’s ability to exercise and their response to medications. Many clients have fewer problems when exercising indoors or in a warm, humid environment than they do outdoors or in a cold, dry environment (Morris & Mosenifar, 2022).

2. Maintain the head of the bed elevated and position the client depending on respiratory effort.
Head elevation and left lateral Sims position to prevent aspiration of secretions or vomitus, enhance ventilation to lower lobes, and relieve pressure on the diaphragm. Clients with mild acute asthma are able to lie flat. In more severe cases, the client may assume a sitting position. As the severity increases, the client increasingly assumes a hunched-over position with the hands supporting the torso, referred to as the tripod position (Morris & Mosenifar, 2022).

3. Encourage the client to use breathing exercises.
In people diagnosed with asthma, the presence of dysfunctional breathing independently of hyperventilation can contribute to dyspnea. Breathing exercises are a commonly used approach for correcting dysfunctional breathing. The protocol for breathing training usually pays attention to tidal and minute volume and encourages relaxation, exercise at home, the modification of breathing patterns, nasal breathing, holding of breath, and lower rib cage and abdominal breathing (Santino et al., 2020).

4. Promote weight reduction for the client experiencing obesity.
Obesity is now considered a major risk factor for asthma; several longitudinal epidemiologic studies show that obesity or increased adiposity often precedes incident asthma. Clients diagnosed with obesity also have worse asthma control and lower quality of life. In adults, it appears that weight loss of at least 5% is required to produce a significant improvement in asthma control. Interventions may vary from liquid diet replacement to a more graduated dietary education approach (Peters et al., 2018).

5. Encourage a proper diet that benefits both weight and allergen avoidance.
Beverages containing high sugar levels are a risk factor for asthma, as is a diet with poor vegetables and grains but rich in sweets and dairy products. Omega-3 has been associated with a lower incidence of asthma, whereas omega-6 fatty acids are associated with a higher risk of asthma in pediatric subjects (Peters et al., 2018).

6. Educate about environmental control and allergen avoidance.
Environmental exposures and irritants can play a strong role in symptom exacerbations. Once the offending allergens are identified, counsel the client on avoidance of these exposures. Efforts should focus on the home, where, 30 to 60% of the time is spent. Clients should clean and dust their homes regularly. If a client cannot avoid vacuuming, they should use a face mask or a double-bagged vacuum with a high-efficiency particulate air filter. Measures to avoid dust mites include using impervious covers, washing other bedding in hot water, removing rugs from the bedroom, limiting upholstered furniture, reducing the number of window blinds, and putting clothes away in closets and drawers (Morris & Mosenifar, 2022).

7. Limit the number of indoor pets that can cause allergies.
Because of the small size of dander, saliva, urine, or serum proteins of cats and other animals, these allergens are predominantly airborne indoor allergens. Avoidance involves removing animals from the home (or at least from the bedroom), using dense filtering material over heating and cooling duct vents, and washing cats and dogs as often as twice weekly (Morris & Mosenifar, 2022).

8. Avoid smoking and secondhand smoke.
Education to avoid tobacco smoke (both firsthand and secondhand exposure) is important for clients diagnosed with asthma. Active smoking and exposure to passive smoke must be avoided, especially within the home (Morris & Mosenifar, 2022).

9. Educate regarding allergen immunotherapy.
The National Asthma Education and Prevention Program Expert Panel Report recommends that immunotherapy be considered if a relationship is clear between symptoms and exposure to an unavoidable allergen to which the client is sensitive; symptoms occur all year or during a major portion of the year, and if symptoms are difficult to control with pharmacologic management because the medication is ineffective. Clients receiving subcutaneous immunotherapy demonstrated improved medical outcomes and cost savings in one study designed to evaluate the cost-effectiveness of the therapy (Morris & Mosenifar, 2022).

10. Administer medications for asthma as ordered:

• 10.1. Short-acting beta-2 adrenergic agonist agents
  Beta-2 agonists relieve bronchospasm by relaxing the smooth muscles of the bronchi. These agents act as bronchodilators and are used to treat bronchospasm in acute asthmatic episodes and to prevent bronchospasm associated with exercise-induced or nocturnal asthma. This class of drugs includes albuterol sulfate and levalbuterol (Morris & Mosenifar, 2022).
• 10.2. Anticholinergic agents
  Anticholinergics are drugs that block and inhibit the activity of the neurotransmitter acetylcholine at both the central and peripheral nervous system synapses, therefore inhibiting the action of the parasympathetic nervous system which includes involuntary actions of the smooth muscle located in the lungs (Ghossein et al., 2022). Ipratropium is an anticholinergic agent which is chemically related to atropine. It has antisecretory properties and, when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa (Morris & Mosenifar, 2022).
• 10.3. Oral corticosteroids
  Oral steroids are used for short courses to gain prompt control of inadequately controlled acute asthmatic episodes. They are also used for long-term prevention of symptoms in severe persistent asthma as well as suppression, control, and reversal of inflammation. Frequent and repetitive use of beta-2 agonists has been associated with beta-2 receptor subsensitivity and down-regulation; these processes are reversed with corticosteroids. This includes prednisone, methylprednisolone, and prednisolone (Morris & Mosenifar, 2022).
• 10.4. Inhaled corticosteroids
  Inhalant corticosteroids are the most potent anti-inflammatory agents. Inhaled forms are topically active, poorly, absorbed, and least likely to cause adverse effects. Beclomethasone inhibits bronchoconstriction mechanisms, causes direct smooth muscle relaxation, and may decrease the number and activity of inflammatory cells, which decreases airway hyperresponsiveness. Fluticasone and budesonide have extremely potent vasoconstrictive and anti-inflammatory activity and are available as metered-dose inhalers (Morris & Mosenifar, 2022). 

11. Anticipate the need for alternative treatment if life-threatening bronchospasm continues.
General anesthesia is used when there is both dynamic hyperinflation and profound hypercapnia that cannot be corrected by increasing minute ventilation. Magnesium sulfate has bronchodilating and anti-inflammatory effects that are sometimes used in the treatment of moderate to severe asthma in children. The use of helium (a less dense gas than nitrogen) causes decreased airway resistance thus lessening the work of breathing.

12. Assist in intubation as indicated.
Despite best efforts, some clients may require endotracheal intubation. Approximately 5 to 10% of all hospital admissions for asthma are to an intensive care unit- for further care of already intubated clients or for close supervision of clients at very high risk of intubation (Morris & Mosenifar, 2022).