Asthma Action Plan: An Individualized Guide
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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