Note from the National Guideline Clearinghouse (NGC): In February 2007, the Registered Nurses Association of Ontario amended the current practice recommendations for this topic. Through the review process, no recommendations were deleted. However, a number of recommendations were re-worded for clarity or to reflect new knowledge. These have been noted below as "changed" or "unchanged." Three new recommendations have been added.
The levels of evidence supporting each recommendation (Level I–V) are defined at the end of the "Major Recommendations" field.
Assessment of Asthma Control
Recommendation 1.0 (Unchanged)
All individuals identified as having asthma, or suspected of having asthma, will have their level of asthma control assessed by the nurse.
Recommendation 1.1 (Unchanged)
Every client should be screened to identify those most likely to be affected by asthma. As part of the basic respiratory assessment, nurses should ask every client two questions:
- Have you ever been told by a physician or a health care provider that you have asthma?
- Have you ever used a puffer/inhaler or asthma medication for breathing problems?
(Level of Evidence = IV)
Recommendation 1.2 (Unchanged)
For individuals identified as having asthma or suspected of having asthma, the level of asthma control should be assessed by the nurse. Nurses should be knowledgeable about the acceptable parameters of asthma control, which are:
- Use of inhaled short-acting beta2 agonist <4 times/week (unless for exercise)
- Having daytime asthma symptoms <4 times/week
- Experience of night-time asthma symptoms <1 time/week
- Normal physical activity levels
- No absence from work or school
- Infrequent and mild exacerbations
(Level of Evidence = IV)
Recommendation 1.3 (Unchanged)
For individuals identified as potentially having uncontrolled asthma, the level of acuity needs to be assessed by the nurse and an appropriate medical referral provided (i.e., urgent care or follow-up appointment). (Level of Evidence = IV)
Asthma Education
Recommendation 2.0 (Unchanged)
Asthma education, provided by the nurse, must be an essential component of care.
Recommendation 2.1 (Unchanged)
The client's asthma knowledge and skills should be assessed and where gaps are identified, asthma education should be provided. (Level of Evidence = I)
Recommendation 2.2 (Changed February 2007)
Education should include as a minimum, the following:
- Basic facts about asthma
- Roles/rationale for medications
- Device technique(s)
- Self-monitoring
- Action plans
- Smoking cessation (if applicable)
(Level of Evidence = IV)
Action Plans
Recommendation 3.0 (New February 2007)
Every client with asthma should have an individualized written asthma action plan for guided self-management.
(Level of Evidence = I)
Recommendation 3.1 (Changed February 2007)
An action plan should be developed in partnership with the healthcare professional and be based on the evaluation of symptoms with or without peak flow measurement.
(Level of Evidence = I)
Recommendation 3.2 (Unchanged)
For every client with asthma, the nurse needs to assess his/her understanding of the asthma action plan. If a client does not have an action plan, the nurse needs to provide a sample action plan, explain its purpose and use, and coach the client to complete the plan with his/her asthma care provider. (Level of Evidence = V)
Recommendation 3.3 (Unchanged)
Where deemed appropriate, the nurse should assess, assist, and educate clients in measuring peak expiratory flow rates. A standardized format should be used for teaching clients how to use peak flow measurements. (Level of Evidence = IV)
Medications
Recommendation 4.0 (Changed February 2007)
Nurses will understand and discuss asthma medications with their clients.
Recommendation 4.1 (Changed February 2007)
Nurses will understand and discuss the two main categories of asthma medications (controllers and relievers) with their clients. (Level of Evidence = IV)
Recommendation 4.2 (Changed February 2007)
Clients with asthma will have their inhaler/device technique assessed by the nurse to ensure accurate use. Clients with suboptimal technique will be coached in proper inhaler/device use. (Level of Evidence = I)
Referrals
Recommendation 5.0 (Changed February 2007)
The nurse will facilitate referrals for clients with asthma as appropriate.
Recommendation 5.1 (Changed February 2007)
Clients with poorly controlled asthma will be advised to see a physician. (Level of Evidence = II)
Recommendation 5.2 (Changed February 2007)
Clients with asthma should be offered links to community resources. (Level of Evidence = IV)
Recommendation 5.3 (Changed February 2007)
Clients with asthma should be referred to an asthma educator in their community, if appropriate and available. (Level of Evidence = IV)
Education
Recommendation 6.0 (Changed February 2007)
Nurses working with clients with asthma must have the appropriate knowledge and skills to:
- Identify the level of asthma control
- Provide basic asthma education
- Conduct appropriate referrals to physician and community resources
(Level of Evidence = IV)
Organization and Policy
Recommendation 7.0 (New February 2007)
Access to asthma education should be available within a community. (Level of Evidence = V)
Recommendation 8.0 (New February 2007)
It is essential that asthma educators obtain and maintain the certified asthma educator (CAE) designation.
Recommendation 9.0 (Unchanged)
Organizations should have available placebos and spacer devices for teaching, sample templates of action plans, educational materials, and resources for client and nurse education and, where indicated, peak flow monitoring equipment. (Level of Evidence = IV)
Recommendation 10.0 (Unchanged)
Organizations must promote a collaborative practice model within an interdisciplinary team to enhance asthma care. (Level of Evidence = IV)
Recommendation 11.0 (Unchanged)
Organizations need to ensure that a critical mass of health professionals are educated and supported to implement the asthma best practice guidelines in order to ensure sustainability. (Level of Evidence = V)
Recommendation 12.0 (Changed February 2007)
Agencies and funders need to allocate appropriate resources to ensure adequate staffing and a positive healthy work environment in order to provide asthma care consistent with best practice. (Level of Evidence = V)
Recommendation 13.0 (New February 2007)
Healthcare organizations will use key indicators outcome measurements, and observational strategies that allow them to monitor:
- The implementation of guidelines
- The impact of the guidelines on optimizing client care
- Efficiencies, or cost effectiveness achieved
(Level of Evidence = IV)
Recommendation 14.0 (Unchanged)
Nursing best practice guidelines can be successfully implemented only when there are adequate planning, resources, organizational and administrative support, and appropriate facilitation. Organizations may develop a plan for implementation that includes:
- An assessment of organizational readiness and barriers to education
- Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process
- Dedication of a qualified individual to provide the support needed for the education and implementation process
- Ongoing opportunities for discussion and education to reinforce the importance of best practices
- Opportunities for reflection on personal and organizational experience in implementing guidelines
(Level of Evidence = IV)
Refer to the "Description of the Implementation Strategy" field for more information.
Definitions:
Level I: Evidence is based on randomized controlled trials (or meta-analysis of such trials) of adequate size to ensure a low risk of incorporating false-positive or false-negative results.
Level II: Evidence is based on randomized trials that are too small to provide Level I evidence. They may show either positive trends that are not statistically significant or no trends and are associated with a high risk of false-negative results.
Level III: Evidence is based on non-randomized controlled or cohort studies, case series, case-control studies, or cross-sectional studies.
Level IV: Evidence is based on the opinion of respected authorities or expert committees as indicated in published consensus conferences or guidelines.
Level V: Evidence is based on the opinion of those who have written and reviewed the guideline, based on their experience, knowledge of the relevant literature, and discussion with their peers.
