DYSPNEA

·         Typically a symptom of cardiopulmonary dysfunction.

·         Dyspnea is the sensation of difficult or uncomfortable breathing.

·         It’s usually reported as shortness of breath.

·         Its severity varies greatly and is usually unrelated to the severity of the underlying cause.

·         Dyspnea may arise suddenly or slowly and may subside rapidly or persist for years.

·         Most people normally experience Dyspnea when they exert themselves, and its severity depends on their physical condition.

·         In a healthy person, dyspnea is quickly relieved by rest.

·         Pathologic causes of dyspnea include pulmonary, cardiac, neuromuscular, and allergic disorders.

·         It may also be caused by anxiety.

COMMON CAUSES

·         Acute respiratory distress syndrome (ARDS)

·         Aspiration of a foreign body

·         Asthma

·         Atelectasis

·         Blast lung injury

·         Cor pulmonale

·         Emphysema

·         Flail chest

·         Heart failure

·         Inhalation injury

·         Myasthenia gravis

·         Myocardial infarction

·         Plague (Yersinia pestis)

·         Pleural effusion

·         Pneumonia

·         Pneumothorax

·         Poliomyelitis (bulbar)

·         Pulmonary edema

·         Pulmonary embolism

·         Severe acute respiratory syndrome (SARS)

·         Shock

·         Tuberculosis

·         Tularemia-Also known as rabbit fever

 

SIGNS AND SYMPTOMS

·         Clearly audible, labored breathing

·         An anxious, distressed facial expression

·         Flaring nostrils

·         Protrusion of the abdomen and/or chest

·         Gasping

·         Cyanosis

·         Signs of respiratory distress, such as tachypnea, cyanosis, restlessness, and accessory muscle use.

DIAGNOSTIC STUDIES

·        Blood tests - arterial blood gas analysis

·        Chest x-ray

·        Electrocardiograph

·        Screening spirometry

·        Complete pulmonary function testing

·        Arterial blood gas measurement

·        Echocardiography

·        Standard exercise treadmill testing

·        Complete cardiopulmonary exercise testing

MANAGEMENT

Treatments for dyspnea will depend on the underlying cause. Commonly administered -

·        a bronchodilator - to dilate bronchioles

·        an antiarrhythmic -  correct cardiac arrhythmias

·        a diuretic -  promote fluid excretion

·        an analgesic relieve pain , as needed

NURSING MANAGEMENT

1.      Impaired Spontaneous Ventilation related to respiratory muscle fatigue

·        Monitor patient’s vital signs every 15 minutes to 1 hour to detect tachypnea and tachycardia, early indicators of respiratory distress.

·        Monitor patient for nasal flaring, change in depth and pattern of breathing, use of accessory muscles, and cyanosis to detect signs of severe respiratory distress.

·        Monitor ABG levels and report deviations promptly to determine the need for changes to the therapeutic regimen.

·        Monitor hemoglobin (Hb) level and hematocrit (HCT). Low Hb level and HCT indicate decreased oxygen-carrying capacity of the blood.

·        Begin oxygen support using the smallest concentration needed to make patient comfortable. Monitor closely to avoid oxygen toxicity.

·        Elevate the head of the bed to increase comfort and to promote adequate chest expansion and diaphragmatic excursion, thereby decreasing work of breathing.

·        Help patient progress gradually from bed rest to increased activity to improve patient’s sense of well-being. Monitor vital signs and ABG levels closely. If respiratory status is compromised, return patient to bed rest to decrease basal metabolic rate and lower oxygen demands.

·        Explain procedures to patient. Describe specific sensations he may experience during each procedure to decrease anxiety.

·        Anticipate possible complications. Keep in mind that if patient decompensates while on 100% fraction of inspired oxygen nonrebreather mask, he may require endotracheal intubation. Anticipating complications facilitates prompt intervention.

·        If patient requires intubation, monitor him for spontaneous breathing and gradually

·        wean him from the ventilator. Progressive weaning helps patient to adjust physiologically and emotionally to increased work of breathing.

·        Avoid respiratory depressants, such as opioids, sedatives, and paralytics, to facilitate patient’s recovery.

·        Provide explanations to the family. Spend time with them at the bedside demonstrating ways in which to approach and support the patient without causing undue anxiety. Watching someone who is having difficult breathing makes others anxious, which just serves to compound the reaction of the patient to shortness of breath.

2. Ineffective Breathing Pattern related to respiratory muscle fatigue

·        Assess and record respiratory rate and depth at least every 4 hours to detect early signs of respiratory compromise. Also assess ABG levels, according to facility policy, to monitor oxygenation and ventilation status.

·        Auscultate breath sounds at least every 4 hours to detect decreased or adventitious breath sounds; report changes.

·        Assist patient to a comfortable position, such as by supporting upper extremities with pillows, providing overbed table with a pillow to lean on, and elevating head of bed. These measures promote comfort, chest expansion, and ventilation of basilar lung fields.

·        Perform chest physiotherapy to aid mobilization and secretion removal if ordered. Percussion, vibration, and postural drainage enhance airway clearance and respiratory effort.

·        Provide rest periods between breathing enhancement measures to avoid fatigue.

·        Help patient with ADLs as needed, to conserve energy and avoid overexertion and fatigue.

·        Administer oxygen as ordered. Supplemental oxygen helps reduce hypoxemia and relieve respiratory distress.

·        Suction airway as needed. Retained secretions alter the ventilatory response, thus reducing oxygen, leading to hypoxemia.

·        Schedule necessary activities to provide periods of rest. This prevents fatigue and reduces oxygen demands.

·        Teach patient about:

o   pursed-lip breathing

o   abdominal breathing

o   performing relaxation techniques

o   taking prescribed medications (ensuring accuracy of dose and frequency and monitoring adverse effects)

o   scheduling activities to avoid fatigue and provide for rest periods

·        These measures allow patient to participate in maintaining health status and improve ventilation.

·        Refer patient for evaluation of exercise potential and development of individualized exercise program. Exercise promotes conditioning of respiratory muscles and patient’s sense of well-being.

3. Activity Intolerance related to imbalance between oxygen supply and demand

·        Discuss with patient the need for activity. Lack of activity causes physical deconditioning and may also have a negative impact on psychological well-being.

·        Identify activities patient considers desirable and meaningful. Engaging patient in activities that have personal meaning give the patient a greater sense of independence and may motivate patient to continue developing tolerance.

·        Encourage patient to help plan activity progression, being sure to include activities he con- siders essential. Participation in planning may encourage patient compliance with the plan.

·        Instruct and help patient to alternate periods of rest and activity. Providing rest periods prevents fatigue and encourages patient to continue improving activity tolerance.

·        Remove barriers that prevent patient from achieving goals that have been established to minimize factors that may decrease patient’s exercise tolerance.

·        Monitor physiologic responses to increased activity (including respirations, pulse oximetry, heart rate and rhythm, and blood pressure). Document the time after each period of exercise. Wait 5 minutes and measure physiologic responses. Values should return to normal within 5 minutes or less.

·        Teach patient how to conserve energy while performing ADLs—for example, sitting in a chair while dressing, wearing lightweight clothing that fastens with Velcro or a few large buttons, and wearing slip-on shoes. These measures reduce cellular metabolism and oxy- gen demand.

·        Teach patient exercises for increasing strength and endurance to improve breathing and promote general physical reconditioning.

·        Support and encourage activity to patient’s level of tolerance to help foster patient’s independence.

·        Before discharge, formulate a plan with patient and caregivers that will enable the patient either to continue functioning at maximum activity tolerance or to gradually increase tolerance. For example, teach patient and caregivers to monitor patient’s pulse during activities, to recognize need for oxygen (if prescribed), and to use oxygen equipment properly. Participation in discharge planning encourages patient satisfaction and compliance.

4. Anxiety related to situational crisis

Defining Characteristics

Behavioral	Physiologic	Affective	Cognitive
·    Diminished productivity ·    Scanning and vigilance ·    Poor eye contact ·    Restlessness ·    Extraneous movement ·    Expressed concerns due to change in life events ·    Insomnia ·    Fidgeting	·    Quivering voice ·    Shakiness ·    Increased respiration ·    Dilated pupils ·    Increased perspiration ·    Trembling ·    Increased tension	·    Regretful ·    Irritable ·    Anguished ·    Fearful ·    Jittery ·    Uncertain ·    Wary ·    Distressed	·    Blocking of thoughts ·    Confusion ·    Preoccupation ·    Forgetfulness ·    Impaired attention ·    Rumination

Interventions

·        Spend 10 minutes with patient twice per shift. Convey a willingness to listen. Offer under- standing and empathy;

·        Give patient clear, concise explanations of anything that’s about to occur.

·        Avoid information overload:

·        Listen attentively; allow patient to express feelings verbally.

·        Identify and reduce as many environmental stressors (including people) as possible.

·        Have patient state what kinds of activities promote feelings of comfort, and encourage patient to perform them. This gives patient a sense of control.

·        Remain with patient during severe anxiety. Anxiety is usually related to fear of being left alone.

·        Include patient in decisions related to care, when feasible.

·        Support family members in coping with patient’s anxious behaviour. Involving family members in process of reassurance and explanation allays patient’s anxiety as well as their own.

·        Allow extra visiting periods with family if this seems to allay patient’s anxiety.

·        Teach patient relaxation techniques to be performed at least every 4 hours, such as guided imagery, progressive muscle relaxation, and meditation.

·        Offer relaxing types of music to patient for quiet listening periods.