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Patient summary
The patient is illustrative. Maya, 8, is admitted with an asthma exacerbation after a cold. She is sitting upright, speaking in short phrases, with a respiratory rate of 34, heart rate 132 and SpO₂ 91% on room air. She has expiratory wheezes throughout and subcostal retractions. She has persistent asthma and is prescribed a daily inhaled corticosteroid, but her mother says they "only use it when she's sick." This is her second admission this year.
Nursing diagnoses
- Ineffective airway clearance related to bronchospasm, airway inflammation and mucus, as evidenced by wheezing, retractions and tachypnea.
- Anxiety (child and parent) related to difficulty breathing and the hospital environment.
- Deficient knowledge (family) related to daily controller use and an asthma action plan.
(Herdman et al., 2024)
Goals
- Maya will maintain SpO₂ of at least 92% with decreasing work of breathing within 24 hours.
- Before discharge, Maya and her mother will demonstrate correct inhaler technique and explain her asthma action plan.
Interventions and rationales
| Intervention | Rationale |
|---|---|
| Assess respiratory rate, work of breathing, breath sounds and SpO₂ before and after each treatment | Shows whether bronchodilators are working and catches deterioration early |
| Give inhaled short-acting bronchodilators and systemic corticosteroids as ordered | Bronchodilators relax airway smooth muscle; corticosteroids reduce inflammation |
| Give oxygen as ordered to keep SpO₂ at the ordered target | Corrects hypoxemia from ventilation–perfusion mismatch |
| Position upright; group care to allow rest; let her mother stay | Eases breathing and reduces anxiety, which worsens tachypnea |
| Watch for warning signs: silent chest, exhaustion, falling SpO₂ or drowsiness | These signal impending respiratory failure and need immediate escalation |
| Teach inhaler and spacer technique with teach-back | Poor technique is a common reason controllers don't work |
| Review the discharge regimen and asthma action plan with the family | Prevents readmission by making daily management clear |
Discharge regimen and teaching
The 2020 focused updates to the US asthma guidelines recommend, for people aged 4 and older with moderate to severe persistent asthma, a single inhaler containing an inhaled corticosteroid and formoterol used both as a daily controller and as the reliever (single maintenance and reliever therapy, or SMART) at treatment steps 3 and 4 (Cloutier et al., 2020). If Maya's provider prescribes this approach, teaching must explain that the same inhaler is used every day and for symptoms, which differs from what the family is used to. The updates also recommend allergen mitigation only as part of a multicomponent intervention for people with relevant allergen sensitization and exposure.
Teaching for the family includes:
- why the controller must be used every day, even when Maya feels well;
- her triggers, including colds and smoke exposure;
- the green, yellow and red zones of her written action plan, and when to seek emergency care;
- a copy of the action plan for her school nurse.
Evaluation
By day 2, Maya's SpO₂ is 95% on room air, her wheezing is mild and she is speaking in full sentences. At discharge, she shows correct inhaler technique and her mother explains the action plan in her own words. A follow-up visit with her primary care provider is booked within a week.
References
Cloutier, M. M., Baptist, A. P., Blake, K. V., Brooks, E. G., Bryant-Stephens, T., DiMango, E., Dixon, A. E., Elward, K. S., Hartert, T., Krishnan, J. A., Lemanske, R. F., Jr., Ouellette, D. R., Pace, W. D., Schatz, M., Skolnik, N. S., Stout, J. W., Teach, S. J., Umscheid, C. A., & Walsh, C. G. (2020). 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. Journal of Allergy and Clinical Immunology, 146(6), 1217–1270. https://doi.org/10.1016/j.jaci.2020.10.003
Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2024). NANDA International nursing diagnoses: Definitions and classification, 2024–2026 (13th ed.). Thieme.
