Transcript Asthma Action Plan: An Individualized Guide

The Asthma Action Plan
April 21, 2009
Karen Meyerson, MSN, RN, FNP-C, AE-C
Asthma Network of West Michigan
Why is the Asthma Action Plan
Important?
Helps minimize or eliminate the need for
trips to the ED and hospitalizations.
Allows the family and other caregivers to
manage their asthma with the help of their
provider.
Many school systems now require them.
A Successful Equation
Patient Participation
+ Plan of Care
= Asthma Control
The Plan of Care
Includes:
Medical Management
Psychosocial Issues
Basic Asthma Education
Development of Skills
Asthma Action Plan
The Plan of Care
Begins at time of diagnosis
Includes other medical care
Reinforces important information
Includes skills demonstration and
return demonstration
Incorporates/reflects a sensitivity to
cultural factors
What is an
Asthma Action Plan?
Self-management plan for managing
asthma on a daily basis
Provider-directed
Written
Provides instructions for changes in
asthma status
Based either on peak flow readings or
symptoms (early warning signs)
What Does the Research Say?
“Provide all patients with a written asthma action
plan that includes two aspects: (1) daily
management and (2) how to recognize and
handle worsening asthma. Written action plans
are particularly recommended for patients who
have moderate or severe persistent asthma, a
history of severe exacerbations, or poorly
controlled asthma (Evidence B).”
EPR-3: Guidelines for the Diagnosis and Management of Asthma—2007
What do Asthma Educators
Say?
It’s an effective tool!
We love it!
What Does the Patient Say?
Thank You!
Now I know what I’m
supposed to do!
Goals of Asthma Therapy…
…are the
foundation of an
Asthma Action Plan
Goals of Asthma Therapy –
Reducing Impairment
 Prevent chronic and troublesome
symptoms (e.g., coughing or
breathlessness in the daytime, in the
night, or after exertion)
 Require infrequent use (≤2 days a week)
of inhaled SABA for quick relief of
symptoms
 Maintain (near) “normal” pulmonary
function
 Maintain normal activity levels (including
exercise and other physical activity and
attendance at work or school)
Goals of Asthma Therapy –
Reducing Risk
 Prevent recurrent exacerbations of
asthma and minimize the need for ED
visits or hospitalizations
 Prevent progressive loss of lung
function; for children, prevent reduced
lung growth
 Provide optimal pharmacotherapy with
minimal or no adverse effects
Developing the Asthma Action
Plan
Use existing medications
Use the three zones
Include the patient in the
development of the plan
Get provider’s signature and/or
adjustments
Peak Flow Monitoring
What you and your patient need to discuss:
Importance of peak flow monitoring
Benefits and limitations
When and how to monitor peak flow
Peak flow diary (focus on trends)
How to care for the device
Something to Remember...
Peak flow results should be validated by
spirometry annually:
Spirometry will be in liters per second
(6.0 l/sec)
Peak Flow meter is in liters per minute
(360 l/min)
What does the Research Say?
“When self-management is the chosen method for
maintaining asthma control, peak-flow-based
self-management is equivalent to symptom-based
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 self-adjustment of
medications.”
EPR-3: Guidelines for the Diagnosis and Management of Asthma—2007
Developing the Zones
Green, Yellow and Red!
Symptoms
vs.
Peak Flow
Zones
Green Zone: (Goal: Stay in this zone.)
– No Symptoms
– PEFR >80% of Personal Best
Yellow Zone: (Goal: Return to green zone.)
– Symptoms/early warning signs
– PEFR 50-80% of Personal Best with static
or downward trend
Zones
Red Zone: (Goal: Don’t go there!)
– Danger Signs-worse symptoms (medical
emergency)
– PEFR: Continuing to fall while in yellow
zone. Approaching 50% or less of Personal
Best
Early Warning Signs
 First sign of URI
 Cough
 Dark circles under
eyes (allergic shiners)
 Itchy neck or chin
 Change in face color
 Tight chest
 Stomach or headache
 Change in mood
 Change in activity
level
– flushed or pale
 Nose rubbing (allergic
salute)
 Throat clearing
Asthma Danger Signs
 Clipped speech
 Retractions
 Difficulty walking due to SOB
 Nasal flaring
 Cyanosis of lips or fingernails
 Agitation
 Wheezing stops (silent chest)
 Rescue medicines are not helping
 Peak flow (if used) is indicating red
zone
Choose a Plan
***KEEP IT SIMPLE!***
The RIGHT format is the one that
works!
May differ from patient to patient
May differ from clinician to clinician
Asthma Action Plan
University of Michigan electronic asthma action plan:
http://www.med.umich.edu/1info/fhp/practiceguides/asthma.html
Implementing the Plan
Get provider signature/approval
Provide several copies of plan
Establish follow-up plan for evaluation
Update as level of control or goals change
(or child grows!)
Encourage patient to use this as a
communication tool
The Plan as a
Communication Tool
Encourage and support the patient in:
Verbalizing his/her partnership in the self-
management of his/her asthma
Incorporating the action plan into daily
living—work place, day care, etc
Demonstrating asthma action skills
Evaluating the
Asthma Action Plan
Is the patient attaining the goals of asthma
management?
How is the plan working on a day to day
basis?
Reworking the Plan
(An Ongoing Process)
Before contacting the provider for
possible medication changes…ask:
– Are the meds being taken/delivered
properly?
– How can the patient make the “plan”
more workable?
– Have the patient’s goals changed?
If the “plan” is still not working,
medication may need to be changed
And the Cycle Continues...
Ongoing evaluation of the plan
Tweak the plan as necessary
Reinforce key information and skills
Asthma Action Plan – Yellow
Zone Medications Options
Bronchodilator
Yellow zone: albuterol
- 2 puffs every 4-6 hours as needed
Alternative:
- 2 to 8 puffs
- every 20 minutes times 3 (first hour)
- then every 1 to 4 hours
Asthma Action Plan – Yellow
Zone Medications Options
Inhaled Steroid - many preparations
Increase sooner rather than later
Usually double the dose
New guidelines say consider quadrupling
dose
Use higher dose for 1 to 2 weeks
Asthma Action Plan – Yellow
Zone Medications Options
 Oral Steroids
Liquid preparations (15 mg / 5 mL)
- 1-2 mg / kg per day for 3-10 days
- 0-4 year olds (max 30 mg/day)
- 5-11 years olds (may 60 mg/day)
- usually 1 mg / kg once a day for 5 days
- could use twice a day to start and taper to
once a day when better
- typical adult dose is 40 mg. X 5 days
Putting the Plan into Action:
One Example
 Green Zone
- fluticasone (44) 2 puffs BID
 Yellow Zone
- albuterol - every 20 minutes X 3
then every 4 hours
- fluticasone (44) 6 puffs BID X 1-2
weeks
- oral steroids- 1 mg/kg daily or BID
X 5 days
 Red Zone
- albuterol – 6-8 puffs
- oral steroids - 2 mg/kg dose
- call office or consider ER or call 911
The asthma educator practices
health care at its best by
Engaging the patient by
accepting him/her where
he/she is at the moment
Empowering him/her with
knowledge and skills needed
to make choices and changes
Supporting him/her as he/she
works to make positive
changes