The purpose of this presentation is to present the life-threatening consequences of non-compliance in asthmatic adults and the importance of education even when the patient is resistant to learning. This case is an important learning opportunity on how to manage exacerbations and understanding the reasons for noncompliance. Asthma is a chronic disease that obstructs the airway but is most often reversible with treatment. Durham, Fowler, Smith, and Sterrett (2017) state “failure to address symptom control and prevent exacerbations can lead to a decline in respiratory function increasing asthma morbidity and mortality” (p. 16).
There are roughly 18 million people 18 years and older who are asthmatics. Asthma is more common in females 18 years and older (19.79%), and African American (9.1%). Adults over 18 years of age that have been admitted to the hospital due to exacerbations are roughly 13% with 30% of those admissions being African Americans. Most asthma attacks are a result of exposure to an allergen or irritant; 21% of people who have asthma smoke or have family members that smoke. The mortality rate of adults is 10%. It costs an estimated 56 billion dollars to treat asthma which is about $3,000 per person each year (Durham et al., 2017).
About 1.6 million visits are to the emergency department (ED) for treatment; many people use the ED rather than seeing a primary care physician to treat their asthma attacks and exacerbations due to their noncompliance with treatment plans of their disease or medical conditions. What most people don’t understand is the goal in the ED is for stabilizing and resuscitating patients in acute distress; the ED is not equipped to manage long-term care of disease processes or to follow up with care instructions. Patients will not receive the proper education and management of chronic diseases that they receive with a primary care team; if they continue to use the ED as their primary care, they increase the risk of having poor management of their asthma as well as excessive medical expenses (Roberts, Velsor-Friedrich, & Keough, 2018).
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There are many factors involved in noncompliance in patients such as socioeconomic, family support, misunderstood medicine administration, and age, both young and old. In order for a care plan to be successful, it is crucial that the patient play a vital role in the development of that care plan. Not only does noncompliance affect the patient, but it financially affects the health care facilities as well. According to Durham et al., (2017) 5.5% of patients admitted to the hospital are due to noncompliance of their health regimen; this is roughly 1.94 million people at a cost of $8.5 billion dollars.
It is critical that potential barriers to compliance be recognized and addressed as early as possible by the medical staff in the healthcare facility such as chronic disease, previous hospitalizations, economical constraints, the complexity of medicinal regimens, social support from family and friends, knowledge deficit of the disease itself, and younger patients not understanding or accepting the seriousness of their disease and consequences involved in not following their care plan.
Durham et al., (2017) stated that research has proven that a multidisciplinary approach increases compliance as well as simplifying the care plan and actively involving the patient and family. The multidisciplinary team includes the nurse, dietician, social worker, the physician, and the pharmacist working together before the patient is discharged. Working as a team also reduced readmissions, deaths, ED visits, and financial costs for both the patient and the health care facility; the team approach has proved to positively influence patients in their decisions and behaviors (Panozzo, 2018).
This particular patient is a 21-year-old African American female, her height is 173.74 cm (5’7′) tall with a weight of 50.80 kg (112 lbs.); she has a body mass index of 17.54 which is slightly underweight. She has a history of exacerbations and intubations and she is a current smoker. The patient has been treated many times in the ED for asthma exacerbations and is known by the staff as a ‘frequent flyer’; against medical advice, she refuses to quit smoking. It is of great concern that the patient was just released one week ago after having been intubated and admitted to the intensive care unit (ICU) for a similar exacerbation. The patient does not work and lives at home with her parents; they have withdrawn from the care of the patient as she refuses to take her medications, administer her breathing treatments, and continues to smoke, a proven trigger for asthma attacks.
She first presented to the ER in the early morning hours. She had wheezing, chest tightness, coughing, and (SOB). She was diagnosed and treated for an acute asthma attack per ED protocol. The patient seemed improved and was discharged with educational materials about the treatment of asthma and instructions to return to the ED if symptoms worsened. Several hours later the patient returned via ambulance, this time in respiratory distress; she presented with labored and rapid breathing, paleness, anxiety, tachycardic, diaphoretic and was only able to whisper that she “was going to die”. She was able to confirm that her last cigarette was about 1 hour ago. An asthmatic that smokes is at increased risk of inflammation of the small airways, increased risk of death, and increased mortality with an even greater risk due to prior intubation and ventilation.
A diagnosis of status asthmaticus was made due to the patients repeated exacerbations and the presenting symptoms of severe bronchospasm, severe airway inflammation, and increased mucus production. Bronchospasms affect the lungs by contracting the smooth muscles of the bronchioles and increases mucus production and inflammation. The immune response of the body is hyperactivated causing mast cells to ‘release excess amounts of histamine, leukotrienes, interleukins, and prostaglandins” (Keep, Reiffer, Bahl, 2016, p. 127). These combined actions reduce the diameter of the bronchioles which in turn obstructs airflow in and out of the lungs. Common presentations of this process include wheezing, coughing, chest tightness, and difficulty speaking.
Her vital signs were: temperature: 98.2; SaO2: 78%, respirations: 35; heart rate: 140; blood pressure 180/90. Her lung sounds were absent (silent chest) and retractions were noted; she was on 2L of oxygen when brought in by ambulance. The patient was continued on 2L of oxygen, put on a venturi mask, and was administered continuous albuterol/ipratropium (5mg/3mL-0.5mg/2.5mL) with budesonide (0.5mg/2mL) via nebulizer with orders to repeat if needed after one hour. The patient was also administered magnesium sulfate (2g over 20 minutes) and methylprednisolone (125mg IVP) to relax the muscles of the airway in an attempt to improve ventilation. It is very important to not over-oxygenate the patient as this will impair CO2 clearance; according to the Haldane effect, hemoglobin has an attraction to CO2. Hyperoxic atmospheres reduce the carrying capacity of hemoglobin thus decreasing the alveolus exchange of CO2.
After 45 minutes with no marked improvement, the patient was transferred to the medical-surgical floor. It was decided in the ED that because the patient had just been intubated one week prior, it was not safe to intubate her because the concern was that she may not be able to be weaned from another intubation and ventilation so soon. It was determined that efforts would be continued to clear the airway and improve gas exchange on the medical-surgical floor by the staff there.
According to (Doenges, Moorhouse, & Murr, 2014), there are two main pathologic problems that occur: a decrease in bronchial diameter and a ventilation-perfusion abnormality. Therefore, the most important aspects of nursing care for asthma focuses on averting hypersensitivity reactions due to allergens or irritants, maintaining airway patency and gas exchange, and preventing complications. The following nursing diagnosis needs to be addressed:
- Ineffective airway clearance: the nurse will continue to monitor respiratory quality, rate, pattern, nostril flaring, and depth, adventitious lung sounds, assess any skin or mucosal color change, assess and encourage coughing to release secretions that may be blocking the airway, and monitor lab results especially potassium and ABGs. It was necessary to suction secretions to aid the patient in clearing the airway. The patient was also instructed to assume the tripod position to help reduce the work of breathing by forcing the diaphragm down and forward, which she did. Use of beta-adrenergic agents often shifts potassium into the cells, causing hypovolemia; ABGs monitor the carbon dioxide that is retained when a patient is working hard to breathe. A patient must have a clear, unobstructed airway from secretions or obstruction in order for oxygenation to occur.
- Impaired gas exchange: the nurse will assess respiratory quality, rate, and depth of respirations, assess lungs sounds for decreased ventilation, auscultate for adventitious breath sounds, and monitor mental status for restlessness, agitation, anxiety, confusion, and lethargy. It is also important to monitor for any signs and symptoms of atelectasis, such as crackles, bronchial breath sounds, and shift of the trachea to the affected side. If this occurs, the alveoli collapse which increases shunting (perfusion without ventilation) with resulting hypoxemia.
- Ineffective self-health management: although this patient has had asthma for some time and has had many admissions to the ICU as well as many intubations on ventilation, this patient continues to ignore the daily regimen of her disease to maintain her health. According to Panozzo (2018) “up to 50% of patients do not take medications as prescribed” (p. 35). Contributing factors include but are not limited to the patient’s age, the lack of motivation, socioeconomic issues, and family support. This particular patient did not seem concerned with the upkeep of her asthma; she only considers her asthma when she is having exacerbations. Even though the patient has been taught the proper techniques and has access to the prescribed medications, she does not seem motivated to improve her current situation. Despite warnings by a healthcare professional’s instructions for smoking cessation, the patient continues to smoke on a regular basis. The nurse will need to assess the patient’s ability to learn, evaluate the patient’s desire to perform the required regimen to maintain her health, and assess and address any barriers to her learning ability.
The goals for this patient are to reverse the severe airway obstruction by using medications such as albuterol/ipratropium with budesonide via a nebulizer to relax bronchial airways, correct hypoxemia via oxygen therapy, prevent pneumothorax and respiratory arrest, and educate the patient to be more compliant in caring for her asthma. As the nursing student, I auscultated her lungs, assisted in relaxation techniques, assisted her into the tripod position, stayed by the bedside, and assured the patient that she was being taken care of, in order to help relieve the patient’s anxiety and fear of dying.
I also helped take the patient to the medical-surgical floor into her room. She was still in severe respiratory distress and seemed very frightened to be leaving the emergency room. The nurse accepting the patient but did not like the condition of the patient; she did a quick focused assessment of the patient. Since breath sounds were so inaudible, the nurse contacted the physician on duty; the physician and the nurse determined that in order to prevent the patient from going into respiratory failure, she needed to be transferred to the ICU as soon as possible. She was taken to ICU by the medical-surgical staff where she was intubated and placed on ventilation.
Asthma is a complex disease that is a lifetime commitment to medication administration, lifestyle changes, and adherence to a carefully planned course of action by the provider. If the disease is not managed properly, exacerbations can occur; the more a patient is treated for exacerbations, the worse the patient’s health becomes. This can lead to multiple intubations and more seriously, death.
Often, patients do not adhere to these plans either out of denial of the seriousness of their condition, because it is too time-consuming, or due to a lack of understanding about their disease process. That is why it is important for healthcare professionals to gather information and address the obstacles to keep patients from constant exacerbations and readmissions to the hospital for their disease. Early education, a patient involvement of self-care, understanding of medicines, and knowledge of the consequences involved if regimens are not strictly adhered to, are vital in keeping patients from complications or death.
It is in the best interest of both patients and health care providers to work together to decrease ED visits and health care costs when it comes to the proper maintenance and management of their diagnoses. Although frustrating as a nurse to constantly watch a patient come in due to poor management or simply not caring for themselves, nurses must remember that patients have the right to refuse medications and the right to refuse medical treatment; despite this, nurses must continue proper treatment of that patient even if it feels futile to do so. After all, it is the oath that nurses take to uphold the standard of nursing and to do no harm.
References
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. Philadelphia, PA: F.A. Davis Company.
- Durham, C. O., Fowler, T., Smith, W., & Sterrett, J. (2017). Adult asthma: Diagnosis and treatment. The Nurse Practitioner, 42(11), 16-24. doi:-10.1097/01.NPR.0000525716.32405.eb
- Keep, S. M., Reiffer, A., & Bahl, T. E. (2016, March). Supporting Self-management of Asthma Care. Home Healthcare Now, 34(3), 126-134. doi:10.1097/NHH.0000000000000366
- Panozzo, G. (2018, January/February). An Intervention to Reduce Medication Noncompliance and Hospitalizations. Home Healthcare Now, 36(1), 34-42. doi:10.1097/NHH.0000000000000628
- Roberts, E., Velsor-Friedrich, B., & Keough, V. (2018). Implementation of an Asthma Self-Management Education Guideline in the Emergency Department: A Feasibility Study. Advanced Emergency Nursing Journal, 40(1), 45-58. doi:10.1097/TME.0000000000000177
