Transcript F-clinical_TAM_2005 - Allies Against Asthma: Promoting

Teach Asthma Management
(TAM)
Provided by:
Generously supported by the Robert Wood Johnson Foundation
Some slides adapted from Physician Asthma Care Education, developed by
Noreen Clark, University of Michigan, School of Public Health
Part II of II
Hand-Held Nebulizer
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Mask <5yrs., Mouthpiece >5yrs.
Assemble equipment
Sit child upright
Put mouthpiece in mouth between lips and teeth (if using mask, cover
nose & mouth)
Turn machine on
Instruct to take slow deep breaths (mist should disappear on inspiration)
Done when medicine is gone, may need to tap
Rinse and air dry, Disinfect once per week
Change filter when dirty
MDI Technique (Break-out)
Use with spacer/holding chamber
 Dry powder inhaler; close mouth tightly around the
mouthpiece of the inhaler and inhale rapidly
 If don’t have spacer/holding chamber
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Open mouth technique with inhaler 1-2” away
In mouth (not for use with corticosteroids)
MDI with Spacer Technique (Break-out)
Remove cap, attach MDI to a spacer & shake
 Breathe out & put spacer between lips
 Press canister one time
 Take deep breath in slowly & hold for 10 sec
 Breathe out
 Take one more deep breath without pressing canister
 Wait 60 seconds before taking next puff
 Rinse Mouth if using inhaled corticosteroid
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MDI with Spacer and Mask (Break-out)
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Remove cap, attach MDI to spacer & shake
Place mask tightly on child’s face (cover nose and mouth)
Press canister one time
Hold mask tightly on face for 6-10 breaths
Assure valve is opening with each breath
Take mask off & wait 60 seconds before giving next puff
Wash face & rinse Mouth if using inhaled corticosteroid
Maxair™ Autohaler™ (Break-out)
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Remove cover & shake
Prime if needed (1st use and if not used for 48 hrs.)
Load Dose
Lips tight around mouthpiece
Take deep steady breath in and hold for 10 seconds
Remove from mouth & exhale
Lower lever and repeat if needed
Turbuhaler® (Break-out)
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Prime if this is a new Turbuhaler (twist & click X2)
Load a dose (twist & click)
Turn head away & exhale
Place in mouth tightly, take deep, quick breath
Hold breath for 10 seconds
Repeat as needed
Diskus® (Break-out)
mouthpiece
grip
lever
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Push grip to open Diskus®
Push lever away until hear & feel click
Turn head away & exhale
Place in mouth tightly, take deep, quick
breath
Hold breath for 10 seconds
Foradil® Aerolizer™ (Break-out)
Remove cover and open Aerolizer™ Inhaler
 Remove capsule from foil, place in capsule-chamber
 Twist mouthpiece to close position
 With mouthpiece upright, press buttons ONCE (hear click), this will break
the capsule
 Turn head away & exhale
 Place in mouth tightly, take deep, quick breath (if no whirling sound, may
be stuck)
 Hold breath for 10 seconds
 Check Aerolizer™ for left over medicine, if some left close and breathe
rest of medicine
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Asthma Triggers
Laurie Smrz,RN, BSN
Medical College of Wisconsin
Asthma Triggers
Objective: Teach caregivers to control asthma
triggers
Role of Allergy in Asthma:
Clinical Evidence
• Allergy is common in children
(80%–90% of school-aged children with asthma)
• Presence of allergy is associated with more severe and persistent
asthma
• Allergen exposure is associated with
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Increased risk of developing asthma
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Increased asthma morbidity
• Allergen avoidance can reduce airway hyperreactivity (AHR) and
asthma morbidity
Identifying Asthma Triggers
Avoiding triggers can:
Prevent asthma symptoms and exacerbations
Reduce need for medication
Identifying Asthma Triggers
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Hypersensitivity of the immune response to allergens
initiates an allergic cascade:
Sensitization: Initial exposure to allergen
production of
allergen specific IgE antibody
Early phase reaction: Subsequent exposure of IgE antibody to
specific allergen
release of histamine, tryptase,
leukotrienes, cytokines
inflammation &
bronchoconstriction
Late phase reaction: mediators
continued inflammatory
reactions
Stimulation of immune cells produces inflammatory response
Identifying Asthma Triggers
"Atopy“ - The genetic tendency to develop the "classical" allergic
diseases: Allergic rhinitis, asthma and atopic dermatitis.
Associated with the capacity to have an IgE response to
common, generally inhaled, allergens
"Allergen" - Substances that can induce IgE antibody responses
"Allergy" - IgE antibody responses to allergens
“Irritant" - Cold air, laughing, crying, yelling, weather change, air
pollution
Irritants
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“Irritate already inflammed sensitive airways”
Air pollutants: ETS, wood smoke, ozone, chemicals in
the air
Strong odors/sprays: perfumes, household cleaners,
paints, and varnishes
Airborne particles: chalk dust, talcum powder
Changing weather conditions
Viral infections
Exercise
Strong emotional response: crying/laughing
Allergens
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“Any substance that triggers an allergy”
Pollen
Molds
Animal Dander
House dust mites
Cockroaches
Identifying Asthma Triggers
Allergens Confirm:
RAST Blood Test
(Radioallergosorbent
Test)
Skin prick (most accurate)
 Irritants Observation:
Ask child or caregiver:
What do you think makes
your asthma worse?
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Most Common Triggers
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Tobacco Smoke
Avoid it!
Ask smoker to “Take it outside”
Even odor of smoke residue is a trigger
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Colds and Infections (most common childhood trigger)
Wash hands before meals and bedtime
Encourage yearly flu shot
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Exercise
Plan warm up activities
Allow time for pre-medication
Indoor Triggers
Dust Mites (Der p, Der f)
Eight legged arachnids (related to spiders, chiggers
and ticks)
 Thrive in warm moist micro-environments (inside
pillows, cushions, mattresses)
 Feed on human and animal dander (dead skin
flakes)
 Focus on the bedroom
Pillow and mattress covers
Wash bedding in hot water
Damp dust
Cost effective tips
The weight of a paper clip
(cheese cloth)
1gram of dust = 100-19,000 dust mites
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Cockroaches (Bla g1, Bla g2)
• American and German cockroach
• Integrated Pest Management (IPM)
• Minimal use of pesticides
• Eliminate food, water & entry points
• Use baits: keep away from children
©Children's Health Education Center 1997
Animal Allergy - Why So Important
• 5%–10% of general population
• 20%–70% of people with allergies/asthma
• >50% of US homes have at least one cat or dog
• Homes and public buildings without pets may have
significant allergen levels
• Other furred animals also are commonly encountered
Furry and Feathered Friends (Can d1, Fel d1, Mus m)
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Dander: proteins in dead skin, urine and saliva
Cats (most common)
Dogs
Birds
Rodents
Cat Dander (Fel d I)
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Unlike dust mite allergen, stays airborne
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Unlike dust mite allergen, it is sticky
Bind to walls and other surfaces in buildings
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Detected in homes and buildings without cats
Munir AK, et al. JACI 1993:91:1067-74
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May take months for all allergen to decompose
Animal Control Measures
The ideal solution:
Remove pets from house
 If not possible:
Keep pet out of bedroom
Use HEPA air filtering system
Remove carpet and other reservoirs for allergens in the
bedroom
Encasing on mattress, box springs, and pillow
Wash pet weekly
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Outdoor Triggers
• Pollens: particles released from trees, weeds
and grasses
• Highest levels at midday (10-2pm)
• Use air conditioning, not fans
• Visit an air-conditioned mall or movie theater
• Not many options (avoidance)
Mold and Air Pollution
• Molds (indoors and out)
• Damp soil and leaves
• Outdoor plastic toys and equipment
• Poor kitchen/bathroom ventilation
• Leaky faucets
• Clean mold with a mild bleach solution
• Air Pollution
• Small particulate matter: ozone, diesel exhaust
• and coal combustion byproduct
• Stay indoors on Ozone Action Days
©Children's Health Education Center 1997
Non-Specific Triggers - Irritants
Strong Odors
• Self-care products
• Cleaning products
• Scented candles & aerosol spray room
• deodorizers
• Purchase scent-free products
• Weather
• Sudden changes in temperature
• Cold weather
• Cover nose and mouth
©Children's Health Education Center 1997
Help families focus on their specific triggers
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Keep it simple
Focus on the patient’s triggers
Encourage caregiver to select 1 intervention to begin
Teach simple intervention for a specific trigger
Key Messages
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Triggers CAN be avoided or controlled
Use quick-relief medicine before exercise or an
unavoidable exposure
Establish a daily – weekly - monthly cleaning
routine: break it down into simple steps!
Advise smoking treatment if smokers in the home
Provide family with resources to reduce triggers
Where to Get Allergy Products
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Local Department Stores
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National Allergy Supply Company
1-800-522-1448
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Allergy Supply Company
1-800-323-6744
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American Allergy Supply
1-800-321-1096
Tobacco Interventions
Mary Balistreri (Cywinski), MS
UW Center for Tobacco Research and Intervention
Education & Outreach
(414) 219-4014
[email protected]
Objectives:
Know what works best to help adults quit
 Learn about available resources
 Know why you should be an anti-smoking advocate
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Risks to Children
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Asthma
Respiratory infections
- bronchitis, pneumonia
Otitis media (ear infections)
Low birth weight
Poorer school achievement
Sudden Infant Death (SIDS)
Half of parents likely to die prematurely
Treating Tobacco Dependence
• Quitting smoking is one of the best things parents can do for
themselves and their children.
• Intervention from health care providers is
clinically effective and cost effective.
• Nicotine is addictive, relapse is prevalent.
AAAAI Guide
A Systematic Approach
to Every Patient at Every Visit
is Most Effective
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Ask smoking status and readiness to quit
Advise to quit
Assess willingness to quit
Assist plans to quit
Arrange follow-up
What Works Best to Help Smokers:
Counseling and Medications
• Practical counseling, even brief, along with FDA approved
medications can triple success.
• Counseling messages should be clear, strong, and personal.
• Medicaid covers cessation treatments.
Wisconsin Tobacco Quit Line
1-877-270-STOP toll free
Counseling by trained professionals
 Individualized for each patient
 Highly effective
 7 days/week, 7am to 11pm
 Connection to clinicians and local program
To order Quit Line materials:
Email: [email protected] or
Fax: 608-265-3102
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First-line pharmacotherapies
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Bupropion SR
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Nicotine gum
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Nicotine inhaler
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Nicotine nasal spray
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Nicotine patch
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Nicotine lozenge
Resources
UW Center for Tobacco Research & Intervention
www.ctri.wisc.edu
- Resources for health care providers, smokers, family members
US PHS Clinical Practice Guideline:
Treating Tobacco Use and Dependence
- Current research and support materials
www.surgeongeneral.gov/tobacco/
Asthma Care Plans
Erin Lee, FAM Allies Coordinator
Children’s Health Education Center
Objective
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Teach caregivers to recognize symptoms,
adjust medications, and seek help
according to the written action plan
What are the Symptoms of Asthma?
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Cough
Shortness of breath
Wheezing
Tightness in the chest
Coughing at night or after physical activity; cough that lasts
more than a week
Waking at night with asthma symptoms (a key marker of
uncontrolled asthma)
Asthma Diary
A record that helps patients track:
 Asthma symptoms
 Medication use
 Peak flow numbers
 Trigger contact
Diaries can help
 Improve communication with healthcare team
 Doctors evaluate and establish asthma control
Asthma Care Plan
Problem solving tool, tailored to
individual patients
 Based on information from both
parent and provider
 Mutually developed between parent,
patient, and provider
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Care Plan Checklist
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Patient name
Provider name and phone number
Medications, dosages, and frequency of use for Green,
Yellow, and Red zones
List symptoms for each zone
Peak flow zones (when appropriate)
List who to call with questions or in an emergency
Communication Tips for the Asthma Care Plan
Color Code the Symptoms and peak flow numbers
 Give parent confidence to read child’s symptoms
 Explain how to use the plan to adjust medications
 Reassure that help can be reached
Provide a clinic contact for questions
Emphasize who must be called if in red zone.
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Practice Using the Plan
Make sure parent understands how to “read” child’s breathing
in each zone
Encourage parent to talk often to child about their breathing
Go over what to do if breathing changes
 Ask parent to identify when/how meds will be given
In a daily routine
Preventatively, if child gets a cold or flu
If yellow zone treatment isn’t working
 Make sure parent knows when they should contact the clinic
and who to talk to
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Update Asthma Care Plans
If there is a change in the following:
 Medication
 Peak flow zones
 Provider
 Symptoms persist or worsen
 Triggers
Encourage parents to take care plan to all visits so plan
can be reviewed and modified as needed by MD
A mother brings her 3 year old son to clinic because he has a
bothersome daytime cough. For the past 2 weeks, he has
coughed 3 days per week, but has no nighttime symptoms. For
the past year, he has been coughing and wheezing every time
he gets a cold.
He was diagnosed with mild persistent asthma. The physician
ordered Flovent 44mcg 2 puffs BID, (increase to 4 puffs BID in
yellow zones X2 weeks), and albuterol 2-4 puffs as needed for
asthma symptoms and prior to exercise.
Improving Clinician-Patient/Family Communication
Linda Gehring, PhD
Alverno College
Objectives
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Clinician can utilize communication skills to:
Identify family concerns,
Improve teaching effectiveness,
Promote patient self-confidence
Improving clinician-patient/family
communication
Good communication between patient and staff helps:
Identify patients concerns that may block their ability to follow
a care plan.
Make patient teaching more effective
Promote patient’s self-confidence to follow the self-care plan.
Identify traditional folk health practices being used.
AAAAI Guide
Barriers To Effective Communications
Studies show that patients often:
• Feel they are wasting the
clinician’s valuable time
• Don’t understand medical
terms
• Omit details they deem
unimportant
• Believe the clinician has
not really listened and
therefore doesn’t have the
information needed to give
proper treatment
• Are embarrassed to
mention things they think
will make them look bad
Strategies for open Communication
with patients/families
Interactive conversation is based on:
Being attentive
Addressing immediate concerns
Giving reassurance
Discussing mutual goals in tailoring their plan
 Finding out underlying worries and concerns
 Giving verbal and non-verbal praise
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Purnell Model for Cultural Competence
Heritage
Communication
Family roles and
organization
Work force issues
High-risk behaviors
Nutrition
Spirituality
Health care practices
Health care practitioners
Disparity Considerations
Work with each family to develop an action plan that
takes into consideration:
 The families cultural, ethnic, and socioeconomic
background
 The asthma regimen needed
 The families ability to implement the plan, physically,
socially and economically
 The families high-risk behaviors that may sabotage
the plan
Interventions
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Provide explanations for all Rx and OTC
products at level appropriate to client/family
Involve family in teaching
Provide written instructions in client’s preferred
language
Explaining Asthma
Provider wants to:
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Explain what happens during
an asthma attack
Inflammation: Airway lining
swells and produces too
much mucus
Bronchospasm: Airway
muscles squeeze too
much
Asthma episodes are
reversible
Parent want:
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An explanation that takes away
the mystery about asthma, so can
“see” what is going on in the lungs
Reassurance that asthma is
manageable and can be controlled
Communication Tips for Explaining
Asthma
Make it simple and use pictures of airways
 Use the “fist” example, asking parent/patient to do it
with you.
 Convey the dynamic
 of open/shut airways
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Teachable Moments
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Office visits
Checking in
Rooming
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Phone calls
Grocery Store
Health fairs
Mentoring
Parents can ask…
Does my child need a "quick-relief inhaler" more than TWO
TIMES A WEEK?
 Does my child wake up at night with asthma more than TWO
TIMES A MONTH?
 Do we refill the "quick-relief inhaler" more than TWO TIMES
A YEAR?
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Rules of TwoTM is a registered trademark of the Baylor Health Care System.
If yes, the asthma may not be in control.
Contact the physician.
Implementing Change in the Primary Care
Setting
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How can all this information be
implemented into your office setting?
What has worked in your setting?
Wrap-Up
Erin Lee
Fight Asthma Milwaukee Allies
FAM Allies works together with children and families
connecting them to caring people, reducing hospital stays, and
supporting healthy lives
Clinical Quality Improvement
 Family and Community Education
 Care Coordination and Case Management
 Parent and Neighborhood Organizing
 Public Communication
 Surveillance and Evaluation
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For more info, contact Erin Lee,
414-390-2179, [email protected]
Wisconsin Asthma Coalition
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Clinical Care
Enhanced Covered Services
Education
Health Disparities
Public Policy
Environment
Work-Related
Surveillance
For more info, contact Kristen Grimes,
414-390-2189, [email protected]
Evaluation
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General evaluation needs to be completed by
all participants
 In addition, nurses will need to complete the
program objective evaluation for CEU credits
THANK YOU!