Transcript Slide 1

ASTHMA ACTION PLAN
Presented by:
RuthAnn Begay Goradia,
MSN, MPH, RN, AE-C
EPR-3 Clinical Practice Guidelines
1. Use inhaled corticosteroids to control asthma.
2. Use written asthma action plans to guide
patient self-management
3. Assess asthma severity
4. Assess and monitor asthma control
5. Schedule follow-up visits
6. Control environmental exposures
Why Use Asthma Action Plans?
Asthma patients who spend as little as 30 minutes with a
health care professional to develop a personalized selfmanagement plan show improved adherence to medications
and better disease control.
Study findings were published in the April 2009 issue of
“The Journal of Allergy and Clinical Immunology.”
Co-authors of the study are Kelly Wong McGrath, BA; Jack K. Covington, BA;
Su-Chun Cheng, DSc; and Homer A. Boushey, MD
Why Use Asthma Action Plans?
• Recommended in EPR-3 as part of an
Educational Program
• Studies have found:
– Reduced urgent care visits, emergency department
visits, hospitalizations, work absences, and nocturnal
asthma
– Improved control
Goal Of Therapy
Goal of Therapy: To Control Asthma
I. Reducing impairment
II. Reducing risk
Goal Of Therapy
Reducing Impairment
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Prevent symptoms
Infrequent use of reliever(s)
(Near) normal pulmonary function
Normal activity levels
Patients’ and families’ satisfaction with care
EPR 3 p. 277
Goal Of Therapy
Reducing Risk
• Prevent recurrent exacerbations; minimize ED
visits and hospitalizations
• Prevent progressive lung function or loss of
lung growth
• Optimal pharmacotherapy with minimal or no
adverse effects
EPR 3 p. 277
Asthma Management
Four components of asthma management
Measures of
assessment
and monitoring
Education for a
partnership in
asthma care
Control of
environmental
conditions and
comorbid
conditions
Pharmacologic
therapy
Asthma Action Plans
A plan, or roadmap to
implement the goals of asthma
therapy that uses all four
components of asthma
management.
What Is An Asthma Action Plan?
A Written Plan
• Created in partnership with the
patient for guided self-management
• Addresses daily management to
maintain control
• Identifies what to do for
exacerbations by recognizing and
handling worsening asthma
EPR 3 p. 94
What Is An Asthma Action Plan?
The Purpose
• Empowers the user to manage their
asthma
• Following a daily management plan
should lead to control of asthma
• Used as an education and
communication tool between the
provider & patient, other caregivers
(e.g., schools, childcare)
What Is An Asthma Action Plan?
Meets
patient’s
goals
Consider
level of
control and
severity
Doable
Asthma
Action Plans
are patientcentered
Understand
able
Affordable
Culturally
appropriate
Created In Partnership With The Patient
What are the goals of the patient?
Play
basketball
Sleep
through the
night
Patient’s
Goals
Afford
medications
Not use
inhaler at
work
• What sports would you
play if your asthma
was in good control?
• What’s your biggest
concern about using
your inhaler?
• When do you feel the
most asthma
symptoms?
Motivational Interviewing
What’s important
to the patient?
• Soccer
• Working out
What would life look
like if your asthma
was well controlled?
• Breathe better while
exercising
• Take less medicine
Action steps to get
there.
• Pre-medicate
• Quit smoking
Created In Partnership With The Patient
Level of control and severity
What IS good control?
What does good control feel like?
Recognize yellow-zone symptoms and act
to avoid worsening of symptoms.
Understand the severity of red-zone
symptoms and seek medical attention
quickly.
Created In Partnership With The Patient
Is it understandable and culturally appropriate?
FORMAT
LANGUAGE
• Can range from simple design to more
detailed design
• Age appropriate, child/adult versions
• Increased font size for elderly
• Includes visual elements that are
• Use language that is understandable to the
patient (i.e., Advair, “flat, purple inhaler”;
Proventil, “yellow pump”)
• Use culturally appropriate imagery
Tailor the plan
to the patient
SYMPTOM-BASED VS. PFM-BASED
• Symptoms only
• Symptoms + peak flow
ACCESSIBILITY
• Consider who should have a copy, such as a
parents, caregivers, teachers, coaches, and
other childcare providers
• Available in print format, triplicate form,
web-based, or mobile-friendly
Created in Partnership with the Patient
Is it affordable?
Work with the patient’s health
insurance plan
• Health insurance plan may change over time
• Consider options to lower costs
• Refer to formularies; may need to find the
best medications at the lowest price/co-pay
• 90-day mail order
• Prescription assistance programs
Created In Partnership With The Patient
Is it doable/convenient/manageable?
Standard
Question
• Taking medications twice a day is
doable, right?
Better
Question
• What are your work hours?
• Where are you at 7 am and 7 pm?
• What are you doing at 7 am and 7 pm?
Link To Understanding Asthma
Maintain
Good Control
Understand
the nature of
asthma
Inflammatory
Connect
symptoms
with variability
Chronic
Associate
symptoms
with triggers
Recognize
symptoms and
follow the plan
Asthma Action Plans
www.lung.org/asthma
• Available in English & Spanish
• Large or regular font
Asthma Action Plans
•NHLBI Asthma Action Plan:
•http://www.nhlbi.nih.gov/heal
th/prof/lung/asthma/naci/disc
over/action-plans.htm
Asthma Action Plans
Asthma Action Plans
Other Asthma Action Plans:
• CDC:
•
http://www.cdc.gov/asthma/tools_for_control.htm
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Print and Fill forms
Electronic forms
Computer-based, interactive plan
• New Mexico Asthma Action Plan for Schools
•
http://nmhealth.org/eheb/asthma_schoolhealth.shtml
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Name, important contacts
Healthcare provider signature
Severity classification
Triggers
Premedication and exercise instructions
Asthma Zone – green means go!
• Signs you are doing well
• No symptoms
• Peak flow meter reading of more than 80% of
personal best or number
• Control medications – name, dosage, when to
take, descriptions
• May include allergy medications
Asthma Zone Yellow: Caution!
• Worsening symptoms
• Peak Flow Meter reading between
50% - 80% of personal best, or number range
• Quick-relief medications – name, dosage, when to
take
Asthma Zone Yellow: Caution!
• What to do when symptoms and
peak flow meter reading improves
• What to do if symptoms and peak flow meter
reading to do not improve
Asthma Zone Red: STOP!
• Worsening symptoms
• Peak Flow Meter less than 50% of personal best,
or number range
• Quick-relief medications – name, dosage, when to
take
Asthma Zone Red: STOP!
• What to do if symptoms and peak flow meter
reading does not improve in 15 minutes after using
rescue medications
• When to call an ambulance immediately
Include Treatment for Comorbid Conditions
If patients has other conditions, it’s also
important to include. . .
• Meds, relaxation, breathing techniques for
COPD
• Antihistamines, nasal steroids, hypertonic saline
irrigation for rhinosinusitis
• Meds, dietary changes, elevation of bed for
GERD
• Speech path, relaxation techniques for VCD
Practical Tips for Medications: A
Emphasize difference between
controllers and relievers at each
encounter.
Success means control,
especially of inflammation.
Relief also must be adequate.
Practical Tips for Medications: B
Repeat
demonstration/counterdemonstration of
inhaler and peak flow
technique at each visit.
Keep regimen simple,
affordable, doable.
Coordinate All the Players on the Team
• Patient and family
• All caregivers – at school, after school, coaches
• All professional caregivers – healthcare provider,
school nurse, etc.
• Copies of Asthma Action Plan for all
Revising Asthma Action Plans
Assess
FollowUp
Revise
Reassess
• Control – adjust until
optimal
• Ongoing assessment,
communication
• Trial and error, always
subject to revision
• Frequency based on
severity and acuity,
how new
Follow-Up
Type of follow-up
Phone
Face-to-face
Document in patient record
Paper
Electronic charting
Frequency of follow-up
Initial, intermittent, final
Daily Self-Management Activities
Asthma diary
Symptom monitoring
To peak flow or not to peak flow?
Environmental control
What Is an Asthma Diary?
A log to help a patient monitor their asthma
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Use of controllers
Use of relievers
Daily symptoms
Peak flows
Nocturnal episodes
Triggers
Effects on activities
From: Seattle Children’s Hospital,
http://www.seattlechildrens.org/kidshealth/page.aspx?id=62128
Self-Monitoring: Asthma Diary
Available in print, web-based, or mobile-friendly
Controllers:
AM
PM
Activities limited?
Yes
No
Nocturnal symptoms?
Yes
No
Puffs Albuterol last 24 hours:
Triggers:
Peak flows:
Zone:
Notes:
Green
Yellow
Red
Peak Expiratory Flow Monitoring (PEF)
Peak Flow Monitoring
• PEF provides a simple, quantitative and
reproducible measure of the existence and
severity of airflow obstruction.
• PEF can be measured with inexpensive,
portable peak-flow meters.
• PEF is effort- and technique-dependent; patients
need frequent instruction, demonstration and
review of technique.
When To Use Peak-Flow Monitoring
Discretion of
patient and
provider
Evaluate
responses to
treatment
Occupational or
environmental
exposures
Poor perceivers
EPR 3 p. 59
NAEPP-3 on Peak-Flow Monitoring
“When self-management is the chosen method
for maintaining asthma control, peak-flow-based
self-management is equivalent to symptombased self-management as long as either
method also includes a written asthma action
plan with instructions on how to recognize and
handle worsening asthma, including selfadjustment of medications.”
EPR 3 p. 60-61
Peak Flow vs. Signs & Symptoms
Peak Flow vs. Signs & Symptoms
Questions and Answers
Clicker Time!!!
Which of the following statements BEST describes
the concept of an “active partnership in asthma
care” between the health care provider and the
person with asthma and/or the family?
A. The person with asthma and/or the family is fully
compliant, carrying out all aspects of the plan of care
on a regular basis.
B. All asthma management decisions must be approved
by both the health care provider and the person with
asthma and/or the family.
C. The health care provider designs an asthma care plan
that is acceptable to and realistic for the person with
asthma and/or the family
Best Answer:
C. The health care provider designs an asthma
care plan that is acceptable to and realistic for
the person with asthma and/or the family
True or False: An Asthma Action Plan should be
written according to the judgment and experience
of the provider and then carefully explained to the
patient.
A. True
B. False
Best Answer:
B. False
John’s peak flow reading in the office is between
50-80% of his personal best. This reading
indicates:
A. An expected level for individuals with asthma.
B. A need for observation but no increase in the level of
medication.
C. A need for observation and an increase in the level of
medication.
D. A severe asthma episode.
Best Answer:
C. A need for observation and an increase in the
level of medication.
Which of the following signs/symptoms indicates a
deteriorating or worsening asthma status that
requires immediate medical intervention?
A. No improvement in asthma symptoms within 5 minutes
of use of a quick relief inhaler.
B. Difficulty walking and talking due to shortness of breath.
C. Inspiratory wheezing and persistent cough.
D. A and B.
E. B and C.
Best Answer:
D. A and B.
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–
A. No improvement in asthma symptoms within 5
minutes of use of a quick relief inhaler.
B. Difficulty walking and talking due to shortness of
breath.
Peak flow monitoring can be used for all of the
following EXCEPT:
A.
B.
C.
D.
Short term monitoring.
Managing exacerbations.
Daily long-term monitoring.
Diagnosing asthma.
Best Answer:
D. Diagnosing asthma.
Asthma Action Plans should be revised:
A. Whenever therapy is stepped up or down on a longterm basis.
B. When a patient who has adhered well to the plan has
an exacerbation requiring oral steroids.
C. When a patient’s PEF/Personal Best is re-established.
D. When a patient has not needed to use a short-acting
beta agonist reliever for 2 consecutive months.
E. Both A and C.
Best Answer:
E. Both A and C.
–
–
A. Whenever therapy is stepped up or down on a
long-term basis.
C. When a patient’s PEF/Personal Best is reestablished.
A person with asthma has a predicted peak flow
reading of 400L/min. Today the peak flow reading
is 450L/min. Based on the predicted reading, what
is the BEST interpretation of today’s peak flow?
A.
B.
C.
D.
Red zone.
Yellow zone.
Green zone.
Personal best zone.
Best Answer:
C. Green zone
Case Study
Case Study: Pedro, 23 y.o. male
1. Break into groups and discuss Pedro case
study
2. Think about the Asthma Action Plan for Pedro,
and discuss:
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Controllers
Relievers
Environmental changes
Monitoring
Other
Acknowledgements
• RuthAnn Goradia, MSN, MPH, RN, AE-C
APS Chronic Health Needs Resource Nurse
• Expert Panel Report 3 (EPR3): Guidelines for
the Diagnosis and Management of Asthma
– Pages 115-121
– Pages 124-125
– Pages 277-288
We will breathe easier when the air in every
American community is clean and healthy.
We will breathe easier when people are free from the addictive
grip of cigarettes and the debilitating effects of lung disease.
We will breathe easier when the air in our public spaces and
workplaces is clear of secondhand smoke.
We will breathe easier when children no longer
battle airborne poisons or fear an asthma attack.
Until then, we are fighting for air.