Promotion for a Patient with Acute Asthma - Essay Example

? Health Promotion in the Emergency Department – Role of a Nurse Practitioner Your Introduction Asthma is a common chronic illness, affecting about 300 million people worldwide (Anandan et al., 2010). The British General Household Survey found the prevalence of self-reported asthma in adults aged 16–44 years to be 4.4% in 2004. Asthma is a prominent cause of impaired quality of life, use of primary health care, and mortality, and has economic ramifications through widespread prescription drug use and hospital admissions (Anderson et al., 2007). Risk factors for asthma in adults include female gender, poor lung function, atopy, nasal allergy, obesity, parental asthma, respiratory infections in early life, and high-risk occupations (Anto et al., 2010). The association between smoking and asthma has been extensively studied. About 30% of known asthmatics also smoke cigarettes (Althuis et al., 1999). Although cigarette smoking has not been found to be an independent risk factor for the development of asthma in adults, smoking is linked to increased severity and frequency of exacerbations in known asthmatics (Siroux et al., 2000). Furthermore, active cigarette smoking impairs the efficacy of short-term oral corticosteroid treatment in chronic asthmatics (Chaudhuri et al., 2003). Thus, the management and control of asthma must involve reducing cigarette smoking. The common symptoms of asthma include cough, shortness of breath, chest tightness, and wheezing. Acute asthma attacks are a frequent cause of presentations to emergency departments and hospital admissions. The costs due to asthma are substantial, attributed to both treatment and the use of health services. A small proportion of patients with poorly controlled asthma account for a disproportionate amount of these costs. This has made the reduction in the acute use of health services for asthma a target of health policy (Adams, 2000). Nurse practitioners occupy an increasingly significant role in healthcare. Their role is expanding particularly in the management of chronic conditions such as asthma, diabetes and heart disease, where they can substitute for doctors in many areas to reduce the burden on doctors, and are less expensive to employ (Sibbald et al., 2006). This essay will discuss the role of nurse practitioners, especially those in the emergency department, in the health evaluation, management, education and promotion of patients with asthma. Patient Consultation The focus of this case is Mr. B, a 46 year old gentleman with a history of asthma. Mr. B presented to the ED one afternoon with the complaint of difficulty in breathing and left-sided chest pain since the past six hours. He had been well until the previous day. He described the difficulty as ‘tightness in the chest’, and said that pain in the left side of his chest, under the arm, was sharp and experienced on breathing in. He denied having cough or fever. He had used Seretide inhaler with 2 puffs, but had not felt any improvement, after which he came to the ED. His past medical history included similar episodes, at least one in a year, in the past three decades, but he was not currently on regular medications for asthma. His drug history included Nicotine patches. In social history, he admitted to smoking about one pack per day since the last 25 years. He had started trying to quit six months ago. He had used over-the counter nicotine gums, and recently nicotine patches, with only minimal improvement in craving, and continued to smoke. The last itme that he had smoked a cigarette was the previous evening. He took alcohol in moderate amounts occasionally. On examination, the patient appeared to be in distress, was dyspneic, sitting up and using accessory muscles of respiration, with an audible wheeze during expiration. His blood pressure was 144/96, heart rate was 115, respiratory rate was 27, temperature was 36C, peak expiratory flow rate was 220 litres/minute (very low). Chest examination revealed decreased expansion, and auscultation revealed diffuse expiratory wheezing and diminished breath sounds bilaterally. His oxygen saturation was 89%. An Emergency Nurse Practitioner’s Role in Health Advice and Promotion for a Patient with Acute Asthma This patient was a known asthmatic with adult-onset asthma. His asthma was not well-controlled, as he had been through several exacerbations. He had been smoking since teenage, and continued to smoke despite his problematic lung condition. He presented to the ED with an acute exacerbation of asthma that was quite severe, as he was tachypneic, hypertensive and tachycardic, with wheezing and borderline hypoxia, requiring urgent medical treatment. In his case, early recognition of his symptoms to be an asthma exacerbation was required. He also represented a case where rapid treatment was needed to relieve his symptoms, and strong counseling methods were needed to ensure that future exacerbations be prevented and his symptoms stay abated. Current evidence regarding an emergency nurse practitioner’s role in cases such as these is discussed below. With the expanding numbers and roles of specialized nurses, their effectiveness in improving patient outcomes in chronic illnesses such as asthma is becoming better defined. Nurse practitioners can be given training in asthma diagnosis and management, and their contribution in the care of asthma patients can help reduce the cost of asthma management as well as the patient load for doctors. For example, nurse-run asthma clinics are recognized as effective alternatives to general practitioner visits, and can cause a significant reduction in the number of days lost from work or school for patients by offering easily available quick appointments. (Charlton et al., 1991). Emergency departments are frequently staffed with nurse practitioners trained in asthma care. In the emergency department, nurse practitioners can significantly reduce delays in the management of an arriving patient by rapidly performing an assessment and administering appropriate medications (Qazi et al., 2010). It is essential that emergency nurses be trained in suspecting an acute exacerbation when a patient with a history of asthma presents to the ED with respiratory symptoms (Asthma UK, 2011). Triage nurses can assess a patient with a presentation like Mr. B, using the Pulmonary Index Score to assess asthma severity based on respiratory rate, degree of wheezing, accessory muscle use, and oxygen saturation. Patients assessed to have moderate to severe exacerbations of asthma are then taken by the nurse to the resuscitation room, and the urgent attention of the emergency physician is sought. Patients with mild exacerbations can be taken to the asthma care room for a more relaxed evaluation by the emergency physician. In this way, the emergency nurse practitioner can play a crucial role in delivering care rapidly to those asthma patients in greatest need. The emergency nurse practitioner may also be given the authority to administer the first dose of salbutamol nebulization after assessing a patient to have a moderate to severe exacerbation. This is already a practice at some centers around the world (Qazi et al., 2010), and helps to reduce the average ‘door-to-first-nebulization-time’ for acute asthma patients presenting to the emergency department. Health promotion necessitates that the patient be facilitated with identifying and learning how to avoid triggers of asthma, and what to do when symptoms occur. Asthma patients and their families are most receptive to health education following an acute attack (Asthma UK, 2011). Nurses play a central role in patient education regarding triggers and essentials of self-management. Asthma specialist nurses can educate patients with acute asthma at the time of discharge from the hospital, and can educate general practitioners and practice nurses in outreach areas on asthma (Griffiths et al., 2004). Nurse-led discharge planning that includes a structured patient education programme has been found to be an effective tool in reducing future asthma exacerbations and re-admissions to the hospital in children (Wesseldine et al., 1999). Before a patient with asthma is discharged from the hospital, the nurse must review all discharge medications with the patient and ensure that the patient can correctly use the administration technique, whether nebulizer or inhaler. As occupational factors account for one in six cases of asthma in adults, a detailed occupational history to determine possible asthmagens needs to be undertaken by the nurse, and patients need to be informed of the likely symptoms related to exposure, how to address avoiding exposures, and what to do when symptoms develop (Fishwick et a., 2010). A follow-up review appointment in 2 days is also to be set up. The nurse should develop a written individualized asthma management plan with the patient before discharge. The action plan informs the patient about when and how to modify medications taken at home, for how long to continue home medications, and how to access the medical system in response to worsening asthma. For example, one effective component is to instruct the patient to check the peak expiratory flow (PEF) when symptoms arise, and to initiate treatment if the PEF is lower than the personal best reading. For symptoms worsening over time, increasing the frequency of home medication – inhaled beta agonist, is advised. If symptoms do not respond to this approach, adding both inhaled and oral corticosteroids can be helpful. Personalized action plans such as these optimize the treatment of asthma and help reduce hospital visits and admissions (Gibson and Howell, 2004). The patient also needs understand when to seek medical care when and if the next exacerbation arises (Taylor, 2011). The role of an emergency nurse practitioner for the patient in the given case also includes delivering information about cigarette smoking and its association with asthma severity. The patient should be informed that cigarette smoking can make asthma exacerbations more frequent and severe in patients with established asthma, and also reduce the effectiveness of asthma medications. Thus, the patient should be advised to consider quitting smoking. Nurse counseling has been found to positively influence smoking cessation (Reeve et al., 2000). The emergency nurse can suggest easily accessible resources that help with quitting, such as the National Health Foundation SmokeFree website (http://smokefree.nhs.uk/) that offers advice, information and quit kits. The British Health Foundation also offers online and electronic resources to help with quitting (http://www.bhf.org.uk/heart-health/prevention/smoking.aspx). Conclusions In conclusion, asthma is a common chronic illness affecting adults. Patients with asthma exacerbations frequently visit the emergency department, and nurse practitioners can play an important role in assessing asthma severity, and facilitating early treatment for patients such as Mr B with moderate to severe exacerbations. Nurses also provide the crucial service of counseling and advising the patient after the acute attack is resolved, regarding how to manage their illness at home –preferably with a written action plan - , when to come to the hospital, and to identify and avoid triggers of acute attacks. In Mr. B’s case in particular, smoking cessation is to be advised to reduce the frequency and severity of future exacerbations. References Adams RJ, Smith BJ, Ruffin RE. 2000. Factors associated with hospital admissions and repeat emergency department visits for adults with asthma. Thorax, 55(7):566-73. Althuis MD, Sexton M, Prybylski D. 1999. Cigarette smoking and asthma symptom severity among adult asthmatics. J Asthma, 36(3):257-64. Anandan C, Nurmatov U, van Schayck OC, Sheikh A. 2010. Is the prevalence of asthma declining? Systematic review of epidemiological studies. Allergy, 65(2):152-67. Anderson H R, Gupta R, Strachan D P, Limb E S. 2007. 50 years of asthma: UK trends from 1955 to 2004. 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