Annotations Outpatient--Asthma education

Outpatient-Asthma education

The following information should ideally be covered while educating patients/caregivers on asthma-especially new patients. At each visit, it is important to determine how often the patient is taking rescue medications, the technique of taking current medications, and to review how to move through the zones. It is best not to ask yes or no questions in order to better determine if patient/caregiver understand the plan.

  1. Classify asthma severity: according to the NIH guidelines, patients symptoms should fit into a category which allows the provider to pick from one of the categories: mild/intermittent, mild persistent, moderate persistent, and severe persistent. IF not sure what category to classify, best to start with the most severe symptom
    • (Re) Assess frequency of day or nighttime symptoms and frequency of rescue medicine use.
    • Assess for appropriateness of medications ordered based on level of severity and review of asthma action cards.
  2. Action Plan: this will be what the patient is sent home with for self management of their asthma. It will explain how to step up/step down therapy depending on patients symptoms.
    • Locate any previously written asthma action plan by reviewing inpatient/outpatient and practitioner reports.
    • Evaluate plan according to the NIH guidelines.( i.e. step up therapy)
    • Assess for adequate step-up in medicines.Make sure the patient has a increased medication dose in the yellow zone and a red zone medication.
    • Complete asthma action cards/plan and /or school plan per written orders after reviewing patient information and history.
  3. Defining asthma: once asthma is diagnosed, it is important the patient/caregiver understand the disease process. The asthma action cards can be used here to cover this information or refer to the NIH guidelines 
    • Instruct caregiver and patient on "What is Asthma ?"-important to define what chronic and inflammation mean to this process.
    • Describe asthma severity.
    • Review the patient goals of asthma treatment.
    • Know reference sources to provide written information or for further review.
  4. Asthma triggers identified and described.
    • Review common triggers with caregiver and patient to assess for additional known irritants.
    • Instruct caregiver and patient on prevention or remediation procedures based on identified triggers or universal asthma irritants.
  5. Asthma Medications: any medications prescribed for the patient should be explained so the patient understands why and when to take.
    • Explain controller/preventive vs. quick-reliever/rescue medicines.
    • Review medicines prescribed per written order.
    • Review written AA Plan; identify controller vs. quick reliever based on patient's individual plan.
    • Instruct caregiver/patient on use of medicines including dose, frequency, and medicine specific devices.
  6. Zone treatment (green, yellow, and red): zone management best describes how to move through the zones depending on asthma symptoms. Patients may need to begin taking medications or step up their current medications in the different zones.
    • Explain system of managing asthma according to treatment zones.
    • Review symptoms associated with /identification of zones.
    • Instruct caregiver/patient on use of AAP to identify zones and medicines to use in each zone.
    • Explain the test dose to help identify whether to move to yellow or red zone.
    • Explain the theory of step-up and the importance of using the medicines from the previous zones.
    • Instruct caregiver/patient to call provider if repeatedly moving to the yellow zone.
    • Instruct caregiver/patient to notify provider if beginning the red zone medications.
    • Review use of 911 vs. ambulance vs. private transport when in red zone.
  7. Demonstration of devices: important to review every visit how to give/take asthma medications. It is essential that each patient has a thorough instruction and proper technique. What works for one patient, may not work for the rest.
    • Nebulizer: may be used to administer the quick reliever or inhaled corticosteroid. Patients under the age of 5-6 should use a face mask. When able to inhale with a mouthpiece may be switched to that route. Blow by should not be used to administer the medication.
    • Spacers/holding chamber: this device can increase the medication delivered to the lung and reduce the deposition of medicine into the throat and upper airway. Instruct patient/caregiver on use of appropriate spacer (mouthpiece vs. facemask) depending on age and ability to master technique.
      • Using placebo if available, instruct patient/caregiver to:
        • Hold spacer device properly (if age appropriate).
        • Sit in upright position or stand.
        • Shake MDI canister and place into spacer.
        • Exhale normally.
        • Put mouth on spacer and spray one puff into spacer (if using spacer with a facemask, hold the mask securely over the child's nose and mouth).
        • Inhale slowly and as deeply as possible (note flow signal - if it makes a sound, instruct patient to breathe more slowly). If using facemask, continue to breathe through the mask and spacer for 6-10 breaths (20 seconds).
        • Attempt breath hold for 10 seconds.
        • Wait 30-60 seconds and repeat puffs as prescribed.
        • Clean mouthpiece as needed; store in non-plastic container or bag.
    • Diskus/ Dry powder inhaler: DPI delivers medication to the lungs as the patient inhales through the device. The DPI does not contain propellants or any other ingredients.
      • Using placebo if available, instruct patient/caregiver to:
        • Hold the device properly-flat like a hamburger.
        • Sit in upright position or stand.
        • Exhale normally.
        • Place Diskus/DPI into mouth.
        • Inhale rapidly and as deeply as possible.
        • Attempt breath hold for 10 seconds.
        • Wait 30-60 seconds and repeat puffs as prescribed.
        • Clean mouthpiece as needed.
    • Peak flow meters (PFM): this is a tool used to monitor asthma, not make a diagnosis. The NIH guidelines encourage peak flow monitoring for all moderate-severe persistent patients with asthma. Patient technique is very important with this tool for accurate readings.
      • Define peak flow measuring.
      • Instruct patient/caregiver on appropriate use/technique:
        • Stand straight and upright.
        • Move marker to zero.
        • Take a full deep breath in.
        • Put mouthpiece in mouth with lips and teeth around the mouthpiece. (Avoid placing tongue in mouthpiece hole).
        • Blow all air out through the peak flow meter in one fast breath.
        • Look at reading, write down the number, and repeat same technique for three consecutive breaths. (If patient coughs or makes a mistake, do not write number down).
        • Record best of the three in asthma diary.
  8. Medication refills: review with patient when medication should be refilled and how many they have left. This needs to be done on each level-providers, educator, pharmacy-Many patients do not understand they have refills and may call back for more medication when they do not need to do that.

(References: CMH asthma action cards and NIH/NHLBI guidelines.)

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.

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