Natalie Conrad, Kristen DeGrood, Andrea Faust, Frank Johnson, Lauren Meyers, Kate Poucher, Stephanie Price, Melissa Scherber

ASTHMA CARE PLAN

Asthma is often undetected and under-treated in low-income high-risk families

Standardized system-level approaches available

Screening and surveillance by public health nurses during family home visits

Evidenced-based asthma care plan through Omaha System

BACKGROUND AND ISSUES

The Omaha System was selected for this asthma care plan because: Used by many health departments in clinical software Enables PHN documentation Can describe evidence based practice Can generate data for evaluation

Problems selected for the asthma care plan: Respiration Sanitation Substance use

OMAHA SYSTEM

RESPIRATION

Category

Target Care Description Note

S Continuity of care Adherence to asthma action planS Durable Medical

EquipmentUse of peak flow meter, nebulizer, holding container

S Signs/Symptoms- Physical

Chest tightness, wheezing, cough, shortness of breath, night awakenings

TGC Durable Medical Equipment

Peak flow meter, nebulizer, and holding chamber

TGC Wellness Annual influenza vaccine, handwashingTGC Signs/Symptoms-

PhysicalIndividual triggers: viral infection, allergies, emotions/stress, exercise

TGC Environment Air Quality Index; Pollen countsTGC Anatomy/Physiology Pathophysiology of asthmaTGC Signs/Symptoms-

PhysicalEvidence of Disease/Infections: Signs and symptoms of asthma

TGC Exercises Regular physical activityTGC Medication

Action/Side EffectsPurpose/Benefits: Current asthma management practices including inhaler use, controllers and relievers, side effects

CM Medical/Dental Care Coordination among providers: Primary care, asthma care specialist, allergist, school nurse

CM Other community resources

Financial, housing, transportation, health insurance, educational support, tenants rights

Adherence to asthma action plan

Provides written guidelines on how to manage asthma including how to take medications properly, identifying allergens and irritants that exacerbate symptoms, and what to do in case of an emergency.

(National Heart, Lung, and Blood Institute, 2007)

Use of:Peak flow meterNebulizerHolding chamber

Nebulizers, holding chambers, and peak flow meters have been shown to be effective in the treatment of asthma.

(McCormack et al., 2009)

Chest tightnessWheezingCoughShortness of breathNight awakenings from asthma

Monitoring for signs and symptoms of an asthma exacerbation will ensure prompt treatment of asthma attacks.

(National Heart, Lung, and Blood Institute, 2007)

Nebulizers, holding chambers, and peak flow meters have been shown to be effective in the treatment of asthma.

(McCormack et al., 2009)

Use of:Peak flow meterNebulizerHolding chamber

Annual flu shotHandwashing

Viruses increase airway inflammation and worsen asthma symptoms. The flu shot and handwashing reduce the risk of contracting a respiratory virus.

(National Heart, Lung, and Blood Institute, 2007)

Individual Triggers:Viral infectionAllergies (grass/pollen)Emotions/stressExercise

Knowing an individuals triggers enables them to avoid such irritants and be prepared to manage asthma symptoms if they worsen in presence of a trigger.

(National Heart, Lung, and Blood Institute, 2007)

Air Quality IndexPollen Counts

Pollen has been linked to seasonal asthma so symptoms may worsen depending on the time of year. When air quality is low, exercise-induced asthma is worsened.

(National Heart, Lung, and Blood Institute, 2007)

Pathophysiology of asthma

Asthma is a disease that causes inflammation, swelling, and constriction ofairways. It involves partially reversible airway obstruction, over-active mucus glands, and airway thickening from scarring and inflammation. (National Heart, Lung, and Blood Institute, 2007)

Evidence of Disease/Infection: Signs and symptoms of asthma

Coughing, wheezing, chest tightness and SOB, without evidence of infection.

(National Heart, Lung, and Blood Institute, 2007)

Regular physical activity

Clinical Guidelines support the use of exercise to reduce the impairment for asthma.

(National Heart, Lung, and Blood Institute, 2007)

Purpose/Benefits: Current asthma management practices including: Inhaler useControllers and relieversSide effects

Clinical guidelines support the use of medication therapy. The risk of uncontrolled asthma is weighed against the limited risks of side effects.

(National Heart, Lung, and Blood Institute, 2007)

Coordination Among Providers:Primary careAsthma care specialistsAllergistSchool Nurse

Specific clinical guidelines suggest that collaboration between healthcare providers provides better outcomes in the treatment of asthma.

(National Heart, Lung, and Blood Institute, 2007)

FinancialHousingTransportationHealth insuranceEducational supportTenants rights

Studies support the use of community based interventions such as schools and public health nurses in asthma education.

(National Heart, Lung, and Blood Institute, 2007)

SANITATION

Category

Target Care Description Note

TGC Environment Relationship to disease

S Environment Mold and moisture

S Environment Pests such as rodents, cockroaches

S Environment Feathery and/or furry pets (cat, dog, bird, hamster, other)

S Environment Dust, excess clutter

S Environment Consumer products such as cleaning products personal care products, fragranced products, and ozone air cleaners

S Environment Odors, cooking practice

S Environment Supplemental Heating Sources such as wood burning stove, fireplace, unvented kerosene or gas space heater

TGC Durable Medical Equipment

Products to reduce environmental triggers include bed and pillow encasements, HEPA vacuum cleaner, portable HEPA air cleaner, furnace filters, dehumidifiers

TGC Environment Cleaning and vacuuming (frequency and proper technique)

TGC Environment Integrated pest management, health effects of pesticides

TGC Environment Emphasize environmental triggers in bedroom/sleeping area

Relationship to disease

Self-management should be tailored to the needs of the individual taking into account cultural beliefs and practices.

(National Heart, Lung, and Blood Institute, 2007)

Mold and moisture

21% of current asthma in the U.S. is attributed to dampness or mold in homes.

(Sahakian, Park, Cox-Ganser, 2008)

Pests such as rodents, cockroaches

Studies demonstrate that efforts to maintain pest control help to reduce asthma symptoms. (Sheehan et al., 2010)

Feathery and/or furry petsCatsDogs BirdsHamstersOthers

Exposure to allergens including pets precipitates worsening of asthma. (National Heart, Lung, and Blood Institute, 2007)

Dust and excess clutter

Exposure to allergens such as dust and clutter that accumulates dust leads to the worsening of asthma.

(National Heart, Lung, and Blood Institute, 2007)

Consumer products such as:Cleaning products

Use of cleaning products has been related to new-onset asthma. Personal care productsFragranced productsOzone air cleaners

(National Heart, Lung, and Blood Institute, 2007)

OdorsCooking practices

Sprays and strong odors, particularly perfumes, can irritate the lungs and trigger asthma symptoms. (National Heart, Lung, and Blood Institute, 2007)

Supplemental Heating Sources such as:Wood burning stoveFireplaceUnvented kerosene or gas space heater

These supplemental heating sources increase the levels of NO2 inside homes and increase the prevalence and severity of respiratory symptoms.

(National Heart, Lung, and Blood Institute, 2007)

Products to reduce environmental triggers:

Bed and pillow encasementsHEPA vacuum cleanerPortable HEPA air cleanerFurnace filtersDehumidifiers

Scientists have proven using durable equipment reduces environmental triggers for asthma, provides better air quality, improves the overall quality of life for patients, and decreases the amount of asthma exacerbations.

(McCormack et al., 2009)

Cleaning and vacuuming (frequency and proper technique)

Conducting proper vacuuming and cleaning techniques reduces exposure to triggers such as pet dander, dust mites, and pollen.

(Wu and Takaro, 2007)

Integrated Pest ManagementHealth effects of pesticides

Integrated pest management (IPM) reduces the amount of sources of allergens capable of triggering asthma symptoms.

(Kass et al., 2009)

Emphasize environmental triggers in bedroom or sleeping area

Having limited triggers in the sleeping area allows for better sleep patterns and fewer asthma exacerbations.

(Wu and Takaro, 2007)

SUBSTANCE USE

Category

Target Care Description Note

S Substance use cessation Use patternS Environment Environmental tobacco smokeCM Other community resource Telephone

information/reassurance: direct referrals may be make to smoking cessation programs on behalf of clients

Substance use pattern

Knowing the patterns of use when using a substance can aid in success rate of quitting a substance and reducing overall risk of asthma development and asthma exacerbation.

(Heath et al., 2009)

Environmental tobacco smoke

Exposure to environmental tobacco smoke increases risk factors for development of asthma as well as causes of asthma exacerbations.

(Gilmour et al., 2007)

Telephone information/reassurance:Direct referrals may be made to smoking cessation programs on behalf of clients

Follow up phone calls can aid in referrals to other substance cessation programs and increases the likelihood of success when attempting to quit a substance.

(Wadland et al., 2007)

RESOURCES

Gilmour, M. , Jaakkola , M. , London, S. , Nel , A. , & Rogers , C . (2006). How exposure toenv ironmental tobacco smoke, outdoor a i r po l lutants , and increased pol len burdens i influences the inc idence of asthma. Envi ronmental Heal th Perspect ives , 114(4) ,627-633. Heath, J . , Young, S. , Bennett , S. , G inn, M. , & Cox, G. (2009) . Ev idence-based smoking

cessat ion intervent ions for pat ients wi th acute respi ratory d isorders . Annual Review Of Nurs ing Research, 27273-296. doi :10 .1891/0739-6686.27.273 Kass, D. , McKelvey, W., Car l ton, E . , Hernandez, M. , Chew, G. , Nagle, S. , & Evans, D. (2009). Effect iveness of an integrated pest management intervent ion in contro l l ing cockroaches, mice, and al lergens in New York C ity publ ic housing . Envi ronmental Heal th Perspect ives , 117 (8) , 1219-1225. doi :10 .1289/ehp.0800149 McCormack, M. , Breysse, P. , Matsui , E . , Hansel , N. , Wi l l iams, D. , Curt in-Brosnan, J . , & Diette, G. (2009) . In-home part ic le concentrat ions and chi ldhood asthma morbidi ty. Envi ronmental Heal th Perspect ives , 117 (2) , 294-298. do i : 10.1289/ehp.11770 National Heart , Lung, and B lood Inst i tute. (2007). Expert Panel Report 3 : Guidel ines for the Diagnos is and Management of Asthma (3rd ed.) . Sahakian, N. M. , Park , J . H. , & Cox- Ganser, J . M. (2008). Dampness and mold in the indoor envi ronment: impl icat ions for asthma. Immunology & Al lergy Cl in ics of North America, 28 (3) , 485-505.

BIBLIOGRAPHY

Sheehan, W. J . , Rangsithienchai, P. A. , Wood, R. A. , Rivard, D. , Chinratanapisi t , S. ,

Perzanowski , M. S. , Phipatanakul, W. (2010) . Pest and al lergen exposure and abatement in inner-ci ty asthma: A work group report of the American Academy of Al lergy, Asthma & Immunology Indoor Al lergy/Air Pol lut ion Committee. Journal of Al lergy & Cl in ical Immunology, 125 9(31)0, 0507151-578X1. Wadland, W., Holtrop, J . , Weismantel , D. , Pathak, P. , Fadel, H. , & Powell , J .

(2007). Practice-based referrals to a tobacco cessat ion quit l ine: assessing the impact of comparat ive feedback vs general reminders. Annals Of Family Medic ine, 5(2), 135-142. Wu, F. , & Takaro, T. (2007). Childhood asthma and environmental interventions. Environmental Health Perspect ives, 115 (6), 971-975.

BIBLIOGRAPHY

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