Asthma is a chronic condition affecting the lungs. When in contact with a trigger, the muscles around the airways constrict, and inflammation and mucus in the airways make breathing difficult, causing an asthma attack. There is no cure for asthma, and untreated asthma attacks can be life-threatening, but there are many effective treatments that help manage and control this condition.
Asthma is the most common chronic condition among children. Children with asthma are extra sensitive to triggers as their smaller airways are easily affected by swelling and mucus. Approximately 50% of children “outgrow” asthma once they reach adolescence, though it may return in adulthood.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Gas Exchange
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Readiness for Enhanced Therapeutic Regimen Management
Nursing Process
Nurses can expect to have frequent contact with patients who have asthma. Asthma can present as an acute exacerbation requiring prompt treatment and close observation or as a chronic condition in the patient’s history. Nurses can support patients in the management of their disease by providing education on symptoms, triggers, and medications.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to asthma.
Review of Health History
1. Assess the patient’s general symptoms.
Common asthma signs and symptoms include:
- Persistent cough
- Audible wheezing while breathing
- Shortness of breath
- Chest tightness
2. Determine the triggers.
Some patients have worsened symptoms during weather changes or when they have a cold. Additionally, the following can trigger asthma:
- Dust
- Smoke
- Grass and tree pollen
- Animal fur and feathers
- Cockroaches
- Strong-scented soaps and perfumes
- Gasoline or strong fumes
- Exercise
- Medications
- Strong emotions
- Cold, dry air
3. Assess for other health conditions.
Certain comorbidities can overlap and worsen asthma symptoms, like:
- Obstructive sleep apnea
- COPD
- Food allergies
- GERD
- Nasal polyps
- Pregnancy
- Respiratory infections
4. Determine the patient’s risk factors.
Note the events in early life affecting the developing lungs that may provide a potential cause of asthma, such as:
- Low birth weight
- Prematurity
- Exposure to tobacco smoke
- Exposure to air pollution
- Exposure to viral respiratory infections
5. Assess the patient’s medication list.
Certain medications may trigger asthma exacerbations, including:
- Beta-blockers
- NSAIDs
- Aspirin
6. Review the patient’s family history.
The likelihood of developing asthma increases if a close relative (such as a parent or sibling) has asthma. There is a 50% probability of having asthma if both parents have asthma.
7. Review the patient’s allergies.
Asthma and allergies frequently coexist. The same factors that produce allergic rhinitis, skin, and food allergies can also result in asthma symptoms. This is called allergic asthma. Patients with the following allergic conditions should be noted:
- Eczema
- Rhinitis
- Sinusitis
- Hives
- Nasal polyps
8. Assess the patient’s environment.
Asthma prevalence rises with urbanization as asthma risk is increased by exposure to various environmental allergens and irritants, such as:
- Mold
- Dust mites
- Air pollution
- Fumes
- Dust
- Wood fires
- Occupational exposure to toxic chemicals
9. Assess the patient’s BMI.
Asthma is more likely to affect obese or overweight patients, and obesity can lead to worsening asthma symptoms and poor asthma control.
10. Assess the patient’s social history.
The patient’s socioeconomic status can reveal factors that may contribute to asthma symptoms and attacks, such as:
- Living conditions
- Smoking habits
- Workplace or school characteristics
- Employment setting
- Social support
- Illegal drug use
- Financial constraints
- Non-adherence to asthma medication
11. Assess the patient’s exacerbation history.
Acute asthma exacerbations are periods in which lung function and asthma symptoms worsen. Note the following data to understand more about the exacerbation history:
- Common initial signs and symptoms
- Immediate onset
- Triggering conditions
- Frequency of attacks in the past year
- Necessity of emergency department visits, hospital admissions, and intubations
- Effect on daily activities
- Absences from work or school
12. Assess the patient’s knowledge about asthma.
It is necessary to assess the patient’s and/or caregiver’s knowledge about the following topics to evaluate adherence and education deficits:
- Asthma triggers
- Medication use
- Coping techniques
- Family support
- Financial resources
Physical Assessment
1. Check the patient’s vital signs.
Mild exacerbation:
- Elevated respiratory rate
- Heart rate less than 100 bpm
- No pulsus paradoxus
- Spo2 > 95%
Moderate exacerbation:
- Respiratory rate increased
- Heart rate 100-120 bpm
- Pulsus paradoxus present
- SpO2 91-95%
Severe exacerbation:
- Respiratory rate > than 30 breaths per minute
- Heart rate > 120 bpm
- SpO2 < 91%
2. Perform a physical assessment.
Mild exacerbation:
- Breathlessness after activity
- Able to talk in complete sentences and lie down
Moderate exacerbation:
- Breathless while talking
- Accessory muscle use
- Retractions, nasal flaring, and abdominal breathing in children
- Poor feeding in infants and a softer cry
Severe exacerbation:
- Breathless at rest
- Tripod positioning
- Accessory muscle use
- Chest retractions
- Agitation
- Can only speak in words (instead of full sentences)
3. Note signs of respiratory failure.
In respiratory arrest, children may become drowsy and confused. Wheezing may be absent from severe airway constriction, and hypoxemia is severe with bradycardia. The patient displays diaphoresis, bradypnea, confusion, and agitation and may pull at their oxygen, stating they cannot breathe as respiratory fatigue worsens.
4. Auscultate the lung sounds.
Auscultation will reveal a bilateral, expiratory wheeze. With severe exacerbations, wheezing is present during inspiration. Absent lung sounds may be noted because air cannot enter or exit the lungs in cases of life-threatening asthma.
5. Observe the pattern of coughing.
A cough is the primary sign of nocturnal asthma. A large number of patients with asthma experience a cough at night once or twice a month, often between the early morning hours when bronchoconstriction is highest.
6. Monitor symptoms with exercise.
Exercise-induced asthma causes the same symptoms as any asthma exacerbation, though some patients also report sore throat and GI upset.
Diagnostic Procedures
1. Use a peak flow meter.
Peak flow meters are portable and easy-to-use devices that evaluate asthma symptoms compared to the patient’s baseline function. Peak flow measurements are related to acute asthma attack severity and are expressed as a specified percentage of predicted peak flow.
2. Obtain ABGs.
An arterial blood gas (ABG) test determines oxygen and carbon dioxide levels in the blood and the pH balance of the blood. Respiratory alkalosis and hypoxemia may be detected by arterial blood gas in patients with asthma.
3. Perform an ECG.
An electrocardiogram is necessary for all patients with severe asthma symptoms.
4. Assist the patient in a chest X-ray.
A chest X-ray is a vital examination tool in the diagnosis of asthma, but can be used in acute scenarios to rule out other pulmonary diseases. Patients with persistent symptoms who do not improve after treatment are recommended to undergo a chest CT scan.
5. Assist the patient in spirometry.
The preferred diagnostic test for asthma is spirometry. It will reveal an obstructive pattern that is either entirely or partially relieved by salbutamol. Spirometry should be performed to gauge the severity of the disease before starting treatment.
6. Discuss allergy testing.
Allergy skin tests and blood radioallergosorbent tests are two methods to test for common allergens that trigger asthma symptoms, such as dust mites, pet dander, or pollen.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with asthma.
Manage Acute Symptoms
1. Administer albuterol.
For acute exacerbations, an inhaled beta2 agonist like albuterol is administered immediately. Doses can be repeated three times and then every 1-4 hours as needed.
2. Administer oxygen as prescribed.
The need for supplemental oxygen during an asthma attack will depend on how severe the episode is. It is prescribed via nasal cannula or face mask when there are indications of hypoxia.
3. Administer steroids.
Oral steroids are proven to be just as effective as IV steroids. Corticosteroids alleviate airway obstruction and prevent a late-phase response.
4. Prepare for hospitalization.
Many patients with asthma improve after bronchodilator administration and can be discharged home after a few hours of observation. The patient may be admitted based on the following:
- The severity and duration of their symptoms
- Their previous severity of past exacerbations
- Their ability to adhere to their medication regimen at home
- The adequacy of a support system
ICU admission is warranted when:
- The condition worsens despite treatment
- The patient displays a change in mental status
- Respiratory arrest occurs
- Intubation is required
5. Consider alternative therapies.
Offer options for the patient. They may choose from the following:
- Allergen immunotherapy (allergy shots): for patients who demonstrate symptoms from a specific allergen in which medications are ineffective.
- Monoclonal antibody treatment: for patients with moderate to severe asthma with a positive skin test. The medication can reduce IgE levels and the release of histamine.
- Bronchial thermoplasty: applies thermal energy to the airway wall through bronchoscopy procedures to limit constriction of airways.
Prevent Future Exacerbations
1. Education on medication adherence.
Long-term control medications are taken daily or scheduled to control and prevent flares. Short-term (rescue) medications are used for symptom relief during an attack. Instruct the patients on the proper administration of the following medications:
- For long-term asthma control:
- Inhaled corticosteroids
- Leukotriene modifiers
- Combination inhalers
- Theophylline
- For short-term asthma control:
- Short-acting beta agonists
- Anticholinergics
- Oral and intravenous corticosteroids
2. Promote environmental control.
Controlling the environment is essential to prevent recurrent attacks. Removing or avoiding allergens can significantly enhance the patient’s quality of life. Advise on the following interventions to reduce exposure to allergens:
- Clean and dust homes regularly
- Use a face mask when vacuuming
- Rid the home of cockroaches (a common asthma trigger)
- Avoid exposure to smoke
- Use waterproof covers on mattresses and pillows to reduce dust mites
- Wash bedding in hot water
- Store clothing in closets and drawers
- Decrease the room humidity
- Stay indoors when pollen counts are highest
- Wear a mask when mowing the lawn
- Groom pets regularly and keep them out of bedrooms
3. Encourage lifestyle and occupational modifications.
Self-monitoring, weight loss, quitting smoking, and limiting exposure to pollution are all crucial for delaying disease progression and lowering the frequency of acute attacks.
4. Educate on long-term monitoring.
Patients should receive an asthma action plan and understand when to contact their provider or seek emergency assistance. Have the patient demonstrate how to use their peak flow meter. Ensure the patient is referred to a pulmonologist and counsel on follow-up testing like spirometry.
5. Obtain vaccinations.
Remind and schedule patients for influenza, pneumococcal, and other vaccinations as recommended, as contracting respiratory viruses can trigger asthma and cause worsening complications.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for asthma, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for asthma.
Activity Intolerance
Symptoms such as dyspnea and fatigue during an asthma exacerbation deplete energy and prevent the ability to carry out tasks.
Nursing Diagnosis: Activity Intolerance
Related to:
- Airway constriction
- Imbalance between oxygen supply and demand
As evidenced by:
- Dyspnea on exertion
- Chest tightness
- Fatigue
- Inability to play, eat, or complete tasks
- Poor sleep due to dyspnea or coughing
Expected outcomes:
- Patient will complete ADLs without dyspnea or wheezing.
- Child will participate in play without shortness of breath or coughing.
Assessment:
1. Assess for activity triggers.
Exercise-induced asthma causes a narrowing of the airways due to strenuous exercise. The nurse can assess for activities or sports the patient engages in that may be contributing to their asthma exacerbations.
2. Assess the level of limitation.
Observe the patient completing tasks, or simply transferring or ambulating. Note the level of limitation in comparison to the patient’s usual activity or their perceived degree of deficit.
3. Monitor for emotional factors affecting activity.
Asthma flare-ups can be frightening. Assess if the patient is fearful of partaking in exercise or activities for fear of an asthma attack. The nurse can help with forming a balance between appropriate exercise and necessary rest.
Interventions:
1. Encourage progressive activity.
Exercise is necessary for health. Encourage activities such as walking or yoga which are generally safe for asthmatics. The patient should limit their sedentary time and alternate between rest and activity to improve their tolerance.
2. Educate on triggers.
Educate patients to consider the elements before engaging in outdoor activity. Allergens, smoke, humidity, and cold temperatures can trigger asthma attacks.
3. Offer other activities.
Children who are not able to participate in high-endurance activities such as soccer or running can instead play games, crafts, or sports such as gymnastics or golf.
4. Plan for exercise.
Exercise-induced asthma requires preparation to prevent attacks. Medication should be taken before engaging in exercise, a thorough warm-up prepares the lungs for vigorous exercise, and the patient should monitor their respiratory status closely and know when to stop or reduce their effort.
Impaired Gas Exchange
Impaired gas exchange in asthma occurs due to the narrowing of the airways and increased mucus production, resulting in airway occlusion and worsening of airflow obstruction.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Bronchospasm
- Airway obstruction
- Respiratory fatigue
- Inflammation
As evidenced by:
- Dyspnea
- Changes in mental status
- Abnormal vital signs
- Hypoxia
- Hypercapnia
- Cyanosis
- Agitation
Expected outcomes:
- Patient will display an improvement in ventilation and oxygenation as evidenced by ABGs within normal limits.
- Patient will be free of signs of respiratory distress.
- Patient will verbalize symptoms requiring provider notification or emergency assistance.
Assessment:
1. Assess respiratory status.
Monitor for tachypnea, bradypnea, SpO2, breathlessness at rest or with exertion, and accessory muscle use for signs of worsening respiratory distress.
2. Assess changes in mental status.
Confusion, agitation, restlessness, and drowsiness are signs of worsening gas exchange and impending respiratory failure.
3. Monitor heart rate and rhythm.
Tachycardia may be a result of hypoxemia.
Interventions:
1. Apply oxygen.
Supplemental oxygen is commonly applied during asthma exacerbations for hypoxia.
2. Monitor ABGs.
For severe asthma attacks, ABG results reveal hypoxemia, hypercarbia, and respiratory alkalosis or acidosis and guide further treatment.
3. Administer medications as prescribed.
Albuterol is a bronchodilator administered for acute asthma symptoms to open the airways. Corticosteroids are commonly administered to reverse inflammation.
4. Prepare for intubation.
A small percentage of patients with asthma exacerbations will require ICU admission and intubation. Prepare for intubation if the patient does not respond to initial treatment, demonstrates mental status changes, or if ABG results reveal impending respiratory arrest.
Ineffective Airway Clearance
Airway inflammation, bronchial hyperresponsiveness, and mucus secretion lead to airway obstruction.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Airway edema
- Mucus secretion
- Bronchoconstriction
- Respiratory infections
- Exposure to triggers
As evidenced by:
- Abnormal respiratory rate and rhythm
- Abnormal breath sounds
- Dyspnea
- Cough
- Restlessness
Expected outcomes:
- Patient will maintain a patent airway.
- Patient will be able to expectorate secretions effectively.
- Patient will display clear breath sounds.
Assessment:
1. Monitor the respiratory status.
Note changes in breathing patterns, accessory muscle use, retractions, and cough. Tachypnea, worsening wheezing or other adventitious sounds, or hypoxia may signal respiratory distress and secretion accumulation.
2. Auscultate lung fields.
Fluid accumulation in the lungs may be noticeable, as evidenced by abnormal breath sounds, like rhonchi or crackles.
3. Assess for signs of infection.
Other respiratory infections like pneumonia or influenza can worsen asthma and respiratory secretions. Assess for fever, chills, or a change in sputum color.
Interventions:
1. Elevate the head of the bed.
Sitting upright often makes breathing easier and encourages drainage of secretions.
2. Administer anticholinergics.
Ipratropium bromide is an anticholinergic that can be administered via inhaler or nebulizer that reduces mucus secretion.
3. Reduce exposure to allergens.
It is imperative to reduce allergen exposure to triggers such as dust mites, pollen, smoke, mold, or animal dander.
4. Explain and assist in the proper use of a nebulizer or MDI (metered dose inhaler).
Educating the patient and their family on the use of MDIs or nebulizers ensures that medication delivery to the airways is appropriately executed.
Ineffective Breathing Pattern
Narrowing of the airways results in inadequate pulmonary ventilation and an ineffective breathing pattern.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Inflammation and swelling to the lungs
- Airway spasming
- Increased mucus
As evidenced by:
- Dyspnea
- Coughing
- Cyanosis
- Nasal flaring
- Accessory muscle use
- Wheezing
- Tachypnea
Expected outcomes:
- Patient will display an effective breathing pattern evidenced by a respiratory rate and rhythm within normal limits without wheezing or coughing.
- Patient will verbalize potential triggers of asthma exacerbations.
- Patient will demonstrate the appropriate use of a peak flow meter.
Assessment:
1. Auscultate lung fileds.
Wheezing is a common finding with asthma as the airways are constricted from inflammation. Other adventitious sounds such as rales or rhonchi can signal possible infections which require further treatment.
2. Monitor respiratory status.
Monitor closely for changes in respiratory status in order to intervene quickly. Increased respiratory rates and decreasing oxygen saturation levels signal respiratory distress.
3. Monitor ABGs.
Respiratory alkalosis can develop from hyperventilation. Respiratory acidosis occurs from severe asthma and can develop into respiratory failure if prolonged.
Interventions:
1. Administer bronchodilators and corticosteroids.
Bronchodilators such as Albuterol help relax the muscles around the airways. Inhaled corticosteroids reduce inflammation and mucus. Corticosteroids should be given after bronchodilators.
2. Instruct on peak flow meters.
Peak flow meters can be used daily to monitor how well air is moving in and out of the lungs. Peak flow meters can often detect changes in the airway before symptoms occur and can signal to the patient to take their medication to prevent an attack.
3. Help the patient identify their triggers.
Each individual will have their own asthma triggers. Common triggers include dust, pet hair, pollen, mold, pollution, infections, high humidity, and even stress. Identifying triggers helps prevent asthma exacerbations.
4. Promote calm, relaxed breathing.
The nurse should remain with the patient when experiencing an asthma exacerbation. Keep them supported in an upright position, reassure them, and assist with even, controlled, diaphragmatic breathing.
Readiness for Enhanced Therapeutic Regimen Management
Children may take an interest in managing their asthma and making their own decisions. Even toddlers can learn how to use inhalers and spacers. Parents and healthcare professionals can support children in managing their treatment.
Nursing Diagnosis: Readiness for Enhanced Therapeutic Regimen Management
Related to:
- To be developed
As evidenced by:
- Expressed desire to learn about asthma
- Interest in inhalers and medical devices
- Displays adherence to medication regimen
- Verbalizes correct information regarding disease
Expected outcomes:
- Child correctly states symptoms of an asthma attack and when to seek help.
- Child correctly uses inhalers at prescribed intervals.
- Child remains free of asthma attacks.
Assessment:
1. Assess for readiness to learn and make decisions.
A child may display obvious signs of readiness such as asking questions or taking the initiative to take their medication. Assess the child’s decision-making ability as well as responsibility in managing their asthma.
2. Assess for a dependable support system.
A child will only be successful if they are supported by their parents, caregivers, and teachers. It is a collaborative team effort to support a child in their independence.
3. Assess the child’s understanding of the disease.
Ensure the child understands generally how asthma affects their lungs and when they need to seek help. Inquire about their medication regimens and assess their knowledge on when and how to take medications.
Interventions:
1. Provide games and videos to promote learning.
Children often learn best with interactive learning. Provide videos appropriate to their educational level about asthma symptoms, triggers, and medications.
2. Make tracking symptoms fun.
Help a child keep track of their asthma symptoms with a planner or calendar. They can draw or use stickers to feel involved in managing their disease while also learning about how symptoms correlate with triggers.
3. Observe for proper use of inhalers and devices.
Children should become familiar with their inhalers from a young age and should not be afraid of them. Have the child demonstrate proper use, cleaning, and storage of inhalers, spaces, and nebulizers.
4. Create an action plan.
Parents, healthcare providers, and teachers should collaborate on an action plan. The child should have a copy of the action plan to share with adults when needed and also understand when to seek help from a school nurse and feel confident discussing their needs with teachers or guardians.
References
- Allergies and asthma: Double trouble. (2021, May 14). Mayo Clinic. Retrieved October 2023, from https://www.mayoclinic.org/diseases-conditions/asthma/in-depth/allergies-and-asthma/art-20047458
- American Lung Association. (2023, August 30). The link between asthma and weight. Retrieved October 2023, from https://www.lung.org/blog/the-link-between-asthma-weight
- Asthma – Diagnosis and treatment – Mayo Clinic. (2022, March 5). Top-ranked Hospital in the Nation – Mayo Clinic. Retrieved October 2023, from https://www.mayoclinic.org/diseases-conditions/asthma/diagnosis-treatment/drc-20369660
- Asthma. (2023, May 4). World Health Organization (WHO). Retrieved October 2023, from https://www.who.int/news-room/fact-sheets/detail/asthma
- Asthma: Types, causes, symptoms, diagnosis & treatment. (2022, January 19). Cleveland Clinic. Retrieved October 2023, from https://my.clevelandclinic.org/health/diseases/6424-asthma#symptoms-and-causes
- Asthma and Children Fact Sheet. (2020, October 23). American Lung Association. Retrieved March 8, 2022, from https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/learn-about-asthma/asthma-children-facts-sheet
- Asthma in Infants and Young Children |. (n.d.). Asthma and Allergy Foundation. Retrieved March 8, 2022, from https://asthmaandallergies.org/asthma-allergies/asthma-in-infants-and-young-children/
- Asthma Medication and Treatment. (n.d.). Allergy & Asthma Network. Retrieved March 8, 2022, from https://allergyasthmanetwork.org/what-is-asthma/how-is-asthma-treated/
- Beers, M.H., Fletcher, A.J., Jones, T.V., Porter, R., Berkwits, M., Kaplan, J.L. (2003). The Merck Manual of Medical Information (2 nd Edition). Merck and Co., Inc.
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- Fanta, C. H., & Cahill, K. N. (2023, August 3). UpToDate. Evidence-Based Clinical Decision Support System| UpToDate | Wolters Kluwer. Retrieved October 2023, from https://www.uptodate.com/contents/acute-exacerbations-of-asthma-in-adults-home-and-office-management
- Haghighi, A. S. (2021, October 21). Oxygen therapy for asthma: What to know. Medical and health information. Retrieved October 2023, from https://www.medicalnewstoday.com/articles/asthma-oxygen-therapy
- Hashmi, M. F., Tariq, M., & Cataletto, M. E. (2023, August 8). Asthma – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved October 2023, from https://www.ncbi.nlm.nih.gov/books/NBK430901/
- Help your child manage their own asthma | Asthma + Lung UK. (2019, June). Asthma UK. Retrieved March 8, 2022, from https://www.asthma.org.uk/advice/child/manage/help/
- How is severe asthma diagnosed? (2022, October 31). Asthma + Lung UK. Retrieved October 2023, from https://www.asthmaandlung.org.uk/conditions/severe-asthma/how-severe-asthma-diagnosed
- Is asthma inherited? (2020, April 23). Baptist Health. Retrieved October 2023, from https://www.baptisthealth.com/blog/family-health/is-asthma-inherited
- Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., Harding, M. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th Edition). Mosby, an imprint of Elsevier Inc.
- Morris, M. J. (2023, July 31). Asthma clinical presentation: History, physical examination, Nonpulmonary manifestations. Diseases & Conditions – Medscape Reference. Retrieved October 2023, from https://emedicine.medscape.com/article/296301-clinical#b3
- National Heart, Lung, and Blood Institute, & U.S. Department of Health and Human Services- National Institutes of Health. (2020, December). Can immunotherapy help with the treatment of allergic asthma? Advancing Heart, Lung, Blood, and Sleep Research & Innovation | NHLBI, NIH. Retrieved October 2023, from https://www.nhlbi.nih.gov/sites/default/files/publications/Immunotherapy-Allergic-Asthma.pdf
- Papiris, S., Kotanidou, A., Malagari, K., & Roussos, C. (2002). Clinical review: Severe asthma. Crit Care, 6(1), 30-44. https://doi.org/10.1186/cc1451
- Smeltzer, S.C., Bare, B.G. (2003). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing (10 th Edition). Lippincott Williams & Wilkins
- Swearingen, P.L. (2016). All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric. Mosby, an imprint of Elsevier Inc.
- Using a Peak Flow Meter to Manage Asthma | AAFA.org. (2017, December). Asthma and Allergy Foundation of America | AAFA. Retrieved March 8, 2022, from https://www.aafa.org/asthma/asthma-diagnosis/lung-function-tests/peak-flow-meters.aspx
- Vasileiadis, I., Alevrakis, E., Ampelioti, S., Vagionas, D., Rovina, N., & Koutsoukou, A. (2019). Acid-Base Disturbances in Patients with Asthma: A Literature Review and Comments on Their Pathophysiology. Journal of clinical medicine, 8(4), 563. https://doi.org/10.3390/jcm8040563
- What Is Exercise Induced Asthma? | AAFA.org. (2015, October). Asthma and Allergy Foundation of America | AAFA. Retrieved March 8, 2022, from https://www.aafa.org/exercise-induced-asthma/
