Table of Contents
The Disease Process of Asthma
Asthma ensues as a consequence of the inflation of the lung. The inflammatory process takes place along the airway, all the way from lungs to nose. Upon engorgement of the inflammation and swelling of the airway, the tube becomes narrower, and as a result, less air gets through tissues of the lung (McCance & Huether, 2014). The resultant effects include the observable symptoms including chest tightness, wheezing, coughing and breathing problems. During the attack, the airways’ muscle tightens up and in so doing, worsening the symptoms. Precisely, asthma is chronic disease or disorder that affects the airways and complexly defined by variation as well as recurring symptoms, obstruction of airflow and hyperresponsiveness of bronchus (McCance & Huether, 2014). However, the disease results in variable airflow obstruction but always reversible (Horak et al., 2016). Nonetheless, the disease is commonly ascribed to children as it is a common disease among children but affects individuals of all ages.
The central defining element of asthma is that it is a disease of pulmonary obstruction, hence, characterized as obstructive pulmonary disease (Horak et al., 2016). The disease or condition is defined by the obstruction of the airway and becomes worse during expiration. The obstruction means that more force, especially within the accessory muscles is needed for expiration, or even the time required for the expiration of a specific air volume and lung; emptying of the lungs becomes slow and compromised (Horak et al., 2016). Accordingly, asthma falls under the obstructive pulmonary disease of which the unifying symptom or manifestation is dyspnea, characterized by wheezing. Therefore, under such an attack, a person will experience increased breathing, mismatching of the ventilation perfusion and overall, a decrease in the forced expiration volume per second (FEV1) (McCance & Huether, 2014).
As of currently, asthma is being defined and regarded as a hereditary illness because over 100 genes have been determined to play part in its pathogenesis and susceptibility, especially those producing eosinophils, IgE, nitric oxide along with the transmembrane proteins situated at the endoplasmic reticulum (McCance & Huether, 2014). For the disease, the specific expression of genes may impart the responsible phenotypes, including inflammation, sensitivity to allergens in addition to airway fibroblasts. Various risk factors have been associated to trigger the disease process of asthma including urban residence, exposure to allergens, tobacco smoke, air pollution, persistent viral infections within the respiratory tract among others (Horak et al., 2016). The factors are attributed to epigenetic changes that impact the functioning of the genes susceptible to asthma. Nonetheless, the exposure to specific allergens at higher concentration during childhood years has been attributed to reduced immune or defense against asthmatic attacks (Rote & McCance, 2018). Moreover, it has been found that the decrease in the exposure to specific infectious organisms leads to the immunologic imbalance; thus, supporting the development of allergy (McCance & Huether, 2014).
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The Pathophysiology of the Disease Process
In studying the pathophysiology of asthma, the role of inflammation is always considered with the current evidence indicating that the inflammation pattern variability is a concern (Rote & McCance, 2018). Hence, during treatment, it is necessary to consider the phenotypic differences. Secondly, allergic reactions as part of the environmental factors are vital in understanding the pathobiology of the disease (Horak et al., 2016). The early onset of the illness also adds some knowledge and consideration in understanding the etiology of the disease. For instance, the persistence pattern depends on early as well as recognizable risk elements like recurrent wheezing, atopic disease and overall, the parental disease history (McCance & Huether, 2014).
The first explanation of pathophysiology of asthma is airway inflammation. It mostly comes from the mucus secretion and airway edema, leading to bronchial reactivity and airflow obstruction. Therefore, the condition occurs from the varying degrees of mucus hypersecretion, infiltration of eosinophil and mononuclear cells and remodeling of the airway (Rote & McCance, 2018). The normal cells responsible for airway inflammation include epithelial cells, mast cells, T lymphocytes activated cells and macrophages (Horak et al., 2016). T lymphocytes are responsible for airway inflammation regulation by releasing numerous cytokines. However, epithelial cells, endothelial cells, as well as fibroblasts leads are responsible for the chronicity of asthma. Eventually, the cell-driven mediators affect the tone of the smooth muscles, and from this, structural changes occur of which the airway becomes remodeled. Both bronchial hyperactivity and airway hyperresponsiveness denote the exaggerated response to endogenous and exogenous stimuli (Horak et al., 2016). Overall, the degree or extent of hyperresponsiveness of airway depends on asthma’s clinical severity. However, chronic inflammation comes from the augmented bronchial hyperresponsiveness leading to bronchospasms as well as other normal symptoms like shortness of breath, wheezing, coughing due to allergens exposure and viruses (Horak et al., 2016).
Airway inflammation is as a result of the imbalance between two parallel or opposing Th lymphocytes populations, Th1 and Th2. For instance, Th1 is responsible for producing interleukin IL-2 and the IFN-α, crucial for providing cellular defense mechanism during infection (Horak et al., 2016). In contrast, Th2, produce the cytokines family of IL-9, 1L-4, 1L-6 and IL-13 whose roles are to mediate the allergic inflammation (McCance & Huether, 2014).
There is also the airflow obstruction hypothesis in explaining the pathophysiology of asthma due to various changes like acute constriction of bronchus plug formation due to chronic mucous production, airway edema as well as remodeling of the airway (McCance & Huether, 2014). Acute bronchoconstriction is due to the release of the immunoglobulin E-dependent mediator after aeroallergens exposure and always the primary element of the early asthmatic response (Horak et al., 2016). Airway edema happens between 6 and 24 hours after the allergen challenge. The formation of chronic mucous plug contains serum protein exudate along with cell debris which always takes weeks to be resolved. The remodeling of the airway is characterized by structural changes because of the prolonged inflammation and most often, affect the degree of reversibility (Horak et al., 2016). The obstruction of airway contributes to increased airflow resistance and a decrease in the expiratory flow. The changes contribute to the decline in air expulsion and often lead to hyperinflation.
The third mechanism for asthma formation is bronchial hyperresponsiveness (McCance & Huether, 2014). Although hyperinflation accounts for the obstruction of airflow, the action is limited when the respiratory track’s tidal volume matches the volume of air within the pulmonary dead space (Horak et al., 2016). As a result, there is the alveolar hypoventilation. The uneven airflow resistance changes lead to irregular supply of air and altered circulation. There is also the vasoconstriction triggered by alveolar hypoxia.
The Standard of Practice for the Selected Disease Process
The standard management of asthma mostly takes place during hospitalization for worsening cases, more so increased respiratory distress. Hence, in most status asthmaticus, the standard treatment focuses much on stabilizing and improving the related respiratory symptoms (McCance & Huether, 2014). The necessary escalation accompanies the practice, and all focused at de-escalation of monitoring, treatment, and respiratory support.
Discuss the evidence-based pharmacological treatments in your state (Nevada) and how they affect management of the selected disease in your community
Most treatments like sublingual immunotherapy in Nevada have been subject to evidence-based evaluation which has been recommended because of its alternative use in place of the traditional shots for allergy. The treatment is implemented on the premise of research confirming its effectiveness in South America and European countries. The research has also identified the treatment as being effective and safe for treating allergic rhinitis. Although most of the pharmaceutical treatments of asthma are evidence-based, Nevada is not part of the Center for Disease and Control, and most of its treatment options have not been assessed and evaluated in comparison to other states.
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Discuss clinical guidelines for assessment, diagnosis, and patient education for the selected disease process
The evaluation for asthma is an all-inclusive process as it begins with assessing the history of the patient and focusing on physical examination. The two processes are crucial when initiating stabilization of the patient under respiratory distress (Horak et al., 2016). Hence, complete physical and history examination should be done as soon as possible since significant morbidities are often exhibited that can be useful in influencing the overall disease management. However, chest radiography or laboratory studies may be necessary for the patients with severe symptoms like severe chest pain, toxic appearance or when there are other unusual clinical features (McCance & Huether, 2014). Nevertheless in most hospital settings, many recommend the implementation of asthma pathways liking the ongoing assessments and any response to the therapeutic management. In such assessments, the patients are placed on the pathway as depending on the initial evaluation and are recommended an appropriate therapy (Horak et al., 2016). When the patient shows the signs of improvement in the severity of the signs, the therapy intensity is reduced, and monitoring is also limited. Upon reaching a threshold for the therapy where the symptoms can be managed and maintained at home, the condition is medically ready for discharge.
Diagnosis of asthma can be undertaken through physical examination, especially looking at the client’s ears, nose, chest, lungs, and skin. The exam can include lung function test for detecting how one the patient is exhaling air from the lungs. On the other hand, X-ray of the lungs or even extended to sinuses is necessary (McCance & Huether, 2014). Lung function tests measure the patient’s breathing, commonly done before or after inhaling the bronchodilator which helps in opening the airways. Spirometry can be recommended for confirming asthma by having the patient breathe into a mouthpiece connected to the equipment to measure the amount of air one can breathe in during exhalation and inhalation, including the rate of flow (Horak et al., 2016). Peak airflow is also used for diagnosis, as a small device that one breathes into majorly helps in measuring the rate by which one is forcing air in and out of the lungs. The test is done by having the patient breathing in deeply as possible and then blowing air into the device hard and with higher frequency possible. There are also trigger tests, especially when one has standard results and have been experiencing symptoms and exhibiting signs of asthma as the doctor will use the triggers in provoking mild reactions (Horak et al., 2016). However, when one does not have asthma, there will be no reaction.
The key to patient education in asthma management stresses the need for integrating the practice in all the aspects of care management (Horak et al., 2016). Education rests on the responsibility of the entire healthcare team, including pharmacists, nurses, and respiratory therapists (McCance & Huether, 2014). For clinicians, one of the considerations during treatment is basing the process on self-monitoring techniques, asthma facts, inhaler use, the necessity, and role of medications along with the environmental control measures. The treatment goals ought to be inclusive of the family and the patient (McCance & Huether, 2014). Besides, there should be a plan including well written documentation of individualized treatment and management plan for daily care. Hence, education should result in an action plan (Rote & McCance, 2018).
Standard of Practice for Managing Asthma in Nevada
Just like nationwide practice recommendation and guideline on prevention and control, Nevada follows the national guideline of identifying triggers of asthma at home as the central focus for treatment and management. The state also incorporates the need to address more than a trigger condition at home including the use of multiple strategies for reducing the triggers. The state has also ensured and followed the national recommendation on coalitions and communities building resources for promoting policies which are asthma friend, more so for the low-income communities.
Discuss characteristics of and resources for a patient who manages the selected disease well, including access to care, treatment options, life expectancy, and outcomes.
Asthma, by far, has profound implications for the families because so often, there are member families of the families who may be affected. Hence, access to care for the persons managing the disease at a personal level should be subject to the healthcare professionals having an understanding of health plans on treatment and cure (McCance & Huether, 2014). Therefore, being a disease that brings a toll on the families, at times, access to care is a problem. In this case, there is need to have proper health plans for those who may have improper accessibility to medication, treatment and diagnostic tests (McCance & Huether, 2014).
The effective asthma treatment begins with the identification and avoidance of allergens known to trigger the symptoms (McCance & Huether, 2014). Other treatment options including drug therapies and having a personal plan for action during severe attacks are also vital. The patient should also be equipped with peak flow meter for measuring the amount of air being pushed out of the lungs. Additional behavioral changes and environmental adjustment are equally necessary for the management of the disease. Proper asthma medication is essential for treating the condition. The recommended treatments include quick-relief treatments as well as long-term control drugs (McCance & Huether, 2014). Besides, the patients can benefit from immunotherapy or allergy shots.
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However, for the treatment or medication, the resources are subject to the attitude of the patients, especially being reluctant because of the side effects as well as the cost of buying the drugs (McCance & Huether, 2014). Therefore, a patient needs to have an allergist to provide advice on the right medicine or even a combination for managing asthma. The goal of treatment is for the client to feel better but with least amount of medication. The quick-relief medicines are administered when the first sign of the symptoms are observed to provide immediate relief. There are the anticholinergics and beta2-agonists as short-acting medicines (Noga, 1992). The medications are bronchodilators since they help one to expand the passageways into the bronchi and as such, allow room for more air passing through the airway thereby improving the patient’s breathing (Noga, 1992). The medications are also essential in clearing mucus from the lung, and from this effect, mucus can move freely through coughing. Some of the long-term control medications, to be taken on a daily basis for preventing symptoms may include cromolyn sodium, inhaled corticosteroids, and antileukotrienes (McCance & Huether, 2014).
The treatment of asthma is subjected to the accessibility to good medical care (Qamar, Pappalardo, Arora & Press, 2011). Hence, the life expectancy depends on the socioeconomic background of the patient. Better health care plan denotes longer lifespan as one can afford proper medication and remove environmental triggers like mold and carpeting. Poor socio-economic background translates to more asthma triggers, fewer opportunities for doctor visits, no money to pay for prescription drugs; therefore, uncontrolled asthma attack which may shorten the life of the patient. Overall, the outcome of the care management depends on a patient-centered approach in the health care system and policy formulation. To ascertain the effects of patient-centered treatment, Qamar et al. (2011) found out that patients are concerned with being well-versed with asthma knowledge, simplified treatment regimens, and tailored or customized management plans. The outcome is also defined by the discord between patients and physicians about beliefs, needs, and expectations that patients have about asthma (Qamar et al., 2011). Any treatment plan or approach to managing asthma should be based on a patient-centered approach to asthma management. It also includes the government making sure that affordable issues and concerns have been addressed such that patients are attached to the Affordable Care Plans like Medicare.
Analyze disparities between management of the selected disease on a national and international level.
The National Quality Strategy has always focused on ensuring better care through the improvement of quality emphasizing more and better patient-centered care, safe, reliable, access and the achievement of meaningful health outcomes (American Pharmacists Association, 2013). It also focuses on healthy people and with this comes the emphasis on improving the US population through the support of the assured interventions to confront social, behavioral, and environmental health determines besides delivering better health care quality. The third element is affordable care, mostly for decreasing the price of maintenance for households, individuals, establishments and overall, the government. In the USA, the disparities in asthma treatment and management are manifested among the low-income communities. For example, among the Puerto Ricans, there are higher rates of attacks and overall deaths. Nationwide, children have two folds greater rates of visiting emergency units and hospitalizations. In comparison to white children, prevalence is higher at 2.4 times among Puerto Ricans, 1.6 times for the African Americans and Alaska or Native Indians at 1.3 times (National Heart, Lung and Blood Institute, 2018). Internationally, there are 334 million suffering from asthma. Initially, the burden was much manifested in both low and high-income countries (Global Asthma Network, 2014). Historically, the disease attributed to high-income countries but as of currently, the middle and low-income countries are burdened by the disease.
Discuss three or four factors (e.g., financial resources, access to care, insured/uninsured, Medicare/Medicaid) that contribute to a patient being able to manage the selected disease
Financial resources are needed for buying personal care management tools like inhalers and also access to medication (Qamar et al., 2011). Therefore, patients need proper accessibility and availability of financial resources. For example, control-based management has been empirically proven and attested to reduce asthma severity. The model is a complex treatment that depends on assessing, adjusting, and reviewing the symptoms. Hence, without proper financial resources or the client not covered by Medicare and lack of health insurance will mean that the individual will not afford to implement the model to its perfection. Lack of financial resources, no insurance cover, Medicaid and no accessibility to care implies that one is at risk of serious attacks because the symptoms are not controlled. It also means that even drug therapy and other therapeutic interventions will not be available for the client (US Department of Health and Human Services., 2016). Besides, in all treatments, the patient-centered approach has been recommended as a necessary area for managing asthma (Qamar et al., 2011). However, with limited financial resources, it translates to the patient not having the chance to benefit from the recommended patient-centered clinical intervention (Frandsen & Pennington, 2013). Lack of insurance cover or Medicaid limits accessibility to quality which the National Quality Strategy has focused on addressing through availability and affordability of healthcare services (US Department of Health and Human Services., 2016).
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Explain how a lack of the factors discussed in part A4 leads to an unmanaged disease process
Lack of financial services, reduced or limited accessibility, and lack of insurance cover or Medicaid program leads to limited chances for severe asthma exacerbation management. When a patient experiences acute exacerbations, the condition is life-threatening and sometimes requires proper medical emergency attention (Qamar et al., 2011). The situation leads to unmanaged disease process because no diagnosis is made to identify the severity and etiology of the disease. It also means that there are no considerations for physician care management as well as the development of clinically-proven (based on evidence-based knowledge) for personal management, especially home management, of asthma. For instance, Horak et al. (2016) reported that in a country like Austria, between 50 and 100 people die in the country from asthma on a yearly basis. Hence, lack of health care resources like financial services, limited access to care, no insurance, or Medicaid means that crucial processes like clinical emergency management will not be available. Usually, it is best and safest handling emergency cases in hospital emergency room to prevent deaths. A person who lacks care management will also fall risks of frequent attacks and even suffer from other related diseases or comorbidities which are usually identified during hospital diagnosis.
Lack of financial resources, accessibility to health care service, insurance, and no Medicaid means that proper management processes like the stages of managing asthma exacerbation will not be possible because its effectiveness depends on the adherence to all stages. The situation will mean that all stages including home or self-management will not be appropriately ensured because the patient will lack the techniques and resources like medication and devices like inhalers for doing so (Horak et al., 2016). The management process will also lack a family physician for helping with the care management at home while at worse, limited chances for emergency management at the hospital. The absence of the four factors also means that the client will miss out on essential asthma training learn about the crucial information about asthma, how to use the right inhalation technique and be accessing a written plan of action for asthma management (McCance & Huether, 2014). The patient will equally miss out on severity, symptoms, not access differential diagnosis criteria or information, and overall, lack of therapeutic intervention.
Describe Characteristics of a Patient with Unmanaged Asthma
A patient with unmanaged asthma experiences symptoms twice a week and the attacks become more frequent with time (Qamar et al., 2011). For instance, the standard indicator of proper control is when the disease or condition occurs twice or less. However, unmanaged asthma implies prolonged and frequent attacks. Frequent coughing during night times becomes common with unmanaged asthma. Therefore, the symptoms will include a person experiencing the night or early morning coughs for over two times a month. On the other hand, the patient will be more prone to using rescue medication, and oral corticosteroids become common because they are used during short bursts (Noga, 1992). Frequent use of the drugs is an indication of poorly managed asthma. Nonetheless, the peak flow meter readings become lower for a patient with poorly controlled asthma, especially when 15% off the standard threshold will be an indication of the individual suffering from nighttime asthma as one of the symptoms denoting uncontrolled asthma (Qamar et al., 2011).
Analyze how the selected disease process affects patients, families, and populations in your community.
Asthma has profound effects on society. For the population, the results are manifested in resource allocation to the healthcare sector. Economic burden affects the communities by increasing expenditure on the health care system, individuals, families, and general society (McCance & Huether, 2014). Asthma means that the patients and families incur more costs for hospitalization, including the financial burden on the family on business due to unproductive days. The family and the patient also has to spend more on health coverage like insurance and Medicaid. Asthma also affects the community or society on missed school days for children, missed work days and more economic loss to the population when it results in death (Qamar et al., 2011). The most affected are the elderly was it leads to the deterioration of their physical state and eventual death.
Discuss the financial costs associated with the selected disease process for patients, families, and populations from diagnosis to treatment.
For diagnosis, patients and families have to spend or direct financial resources for health insurance coverage. In most cases, asthma patients are under health insurance cover. Hence, they have to pay for the diagnosis, including physical examinations because they are charged services. Severe conditions require complex tests and diagnoses like X-rays and lab tests which the patients and the families have to spend much of their money on the process (Qamar et al., 2011). There are also concerns for the population increased; as more diagnosis is done, the health care system has to spend more public funds, through taxation, to run the diagnostics. It means more medical fund reimbursement from the government which comes in the form of increased tax. For the individualized or self-management, the patient and the family have to cater for the entire household expenditure on personal equipment and medication. It will even call for hiring a family physician for home management. More is spent on medicine, and this also affects the population through increased expenditure from the government to fund the healthcare facilities to afford the drugs, which are also expensive.
Promoting Best Practices for Asthma Management
Discuss three strategies you could use to implement best practices for managing the selected disease in your current healthcare organization.
The first strategy for managing asthma at my current healthcare organization is focusing on care transition towards home care (American Pharmacists Association, 2013). Hence, the transition model will be the most useful, based on ensuring that the management plan focuses on helping the patient to transition from hospital to home care. In this case, the comprehensive management plan will entail implementing other practices like personal treatment plan education, proper pharmaceutical or drug therapy, therapeutic intervention and at best, drafting a personalized healthcare management customization based on the severity of the disease. The next strategy will be to ensure pharmacy involvement during the transition process to help the client move from inpatient to home setting (American Pharmacists Association, 2013). The principal focus should be to help the client and the family to have proper home management and care plan for pharmaceutical intervention. It will, therefore, involve collaborating with the family physician and providing all the necessary pharmaceutical information to help with the home transition. All the suggestions and recommendations have to be institutionalized. Therefore, the third strategy is to operationalize and scale up the process for the implementation by the hospital (American Pharmacists Association, 2013). The aim will be to have the recommended best practices become part of the routine management of asthma, and as such, make or prepare best practice guidelines, goals, and objective the treatment to become foremost practice benchmark for asthma.
Discuss an appropriate method to evaluate the implementation of each of the strategies from part C1.
For the emphasis on transition to the home setting, customary metrics will be used in evaluating the effectiveness of the implementation of the strategy (American Pharmacists Association, 2013). Therefore, it will involve looking at the hospital readmissions, the length of the hospital stay, visits within the emergency department. Besides, other elements like medication errors like therapy duplication, omitting the needed drug and patient satisfaction. For pharmacy involvement in the transition towards home setting, the method for assessing or evaluating the implementation is looking at how the pharmacy team has been effectively integrated into the management and care for the asthma patients. Thus, it will implicate looking at how pharmacy residents, student interns, and the pharmacy technicians have collaborated in ensuring that the right medication is available for each asthma case based on severity and frequency. The third method for evaluating the effectiveness of the recommendations is considering the extent of collaboration to ensure that all the recommended practices have been institutionalized and become part of the practice guidelines for asthma management in the organization (American Pharmacists Association, 2013). It will involve looking at the extent and level of commitment of the entire team and have they are willing to standardize the current recommended practice guidelines for asthma management towards home transition.
- American Pharmacists Association, (2013). ASHP-APhA Medication Management in Care Transitions Best Practices.
- Frandsen, G. & Pennington, S.S. (2013). Abrams’ clinical drug therapy: Rationales for nursing practice. (10th ed). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins Print ISBN: 9781609137113, 1609137116
- Global Asthma Network, (2014). The Global Asthma Report 2014. Retrieved http://www.globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf
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- McCance, K.L., Huether, S.E. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, Missouri: Mosby Elsevier. ISBN: 978-0-323-08854-1
- National Heart, Lung and Blood Institute, 2018. Reducing Asthma Disparities. Retrieved from https://www.nhlbi.nih.gov/health-pro/resources/lung/naci/discover/disparities.htm
- Noga, P. M. (1992). Clinical drug therapy. Rationales for nursing practice. Current Opinion in Cardiology, 7(1), 73.
- Qamar, N., Pappalardo, A. A., Arora, V. M., & Press, V. G. (2011). Patient-centered care and its effect on outcomes in the treatment of asthma. Patient related outcome measures, 2, 81.
- Rote, N.S & McCance, K.L. (2018, January). Physiology: The Basis for Disease in Adults and Children.
- US Department of Health and Human Services. (2016). 2015 national healthcare quality and disparities report and 5th anniversary update on the national quality strategy. AHRQ Publication, (16-0015).