Shortness of Breath Management (Ambulatory) - CEALERTDon appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions. Show
Take extra care with a patient whose airway patency cannot be maintained. These patients are not appropriate for the ambulatory care setting and must be managed in an emergency care setting.undefined#ref6">6 OVERVIEWShortness of breath, also known as dyspnea, is defined as a subjective feeling of difficulty breathing or breathlessness.6 Shortness of breath may be caused by many different conditions, such as acute respiratory failure (ARF), chronic obstructive pulmonary disease (COPD), acute respiratory distress syndrome (ARDS), pulmonary embolism (PE), pneumonia, or asthma. This skill discusses shortness of breath as a whole and how to evaluate, monitor, and manage patients with shortness of breath in an ambulatory setting. Shortness of breath may be diagnosed based on patient presentation along with a detailed history and physical. Symptoms the patient may present with, in addition to shortness of breath, include tachypnea, tachycardia, abnormal breath sounds, restlessness, decreased oxygen saturation, anxiety, chest pain, diaphoresis, pursed-lip breathing, increased work of breathing, use of accessory muscles, and cough. A cough in conjunction with shortness of breath may be considered normal if it occurs as a lung defense mechanism.6 Some patients may even present with difficulty speaking in full sentences. This symptom is more common in patients suffering from asthma.6 A detailed history needs to be collected during the patient evaluation. Social habits, travel history, and work atmosphere are important portions of the history for every patient presenting with shortness of breath. During the physical evaluation, baseline vital signs, such as respiratory rate or oxygen saturation, may be abnormal or decreased. Oxygen saturation levels are considered normal for any patient on room air at or above 95%.4 Lung sounds and skin condition should also be a key portion of the physical examination. Abnormal or adventitious lung sounds can help determine a diagnosis. Skin conditions such as cyanosis, a blue or gray discoloration of the skin, should be documented and reported to the clinical team leader promptly; however, cyanosis may be normal or baseline for patients with chronic lung disease. Cyanosis is easily recognized in the areas around the eyes, lips, and nail beds. Causative factors for shortness of breath may be diagnosed in the ambulatory setting with diagnostic tools such as x-ray, ultrasonography, and laboratory blood specimen collection. Chest x-rays precede all other studies in determining the cause of the patient’s shortness of breath.4 In many cases, chest x-rays can help guide a more accurate patient diagnosis, depending on the etiology of the shortness of breath. Ultrasonography of a lower limb may be ordered if a PE is suspected. Laboratory blood tests associated with patients experiencing shortness of breath depend on the patient’s presentation and history and include the d-dimer; cardiac enzymes; prothrombin time (PT) and international normalized ratio (INR), if the patient is taking an antiplatelet medication; and complete blood count (CBC). Common risk factors for shortness of breath include tobacco inhalation (e.g., cigarettes, vaping), environmental pollution or occupational exposure, respiratory infection, allergic reaction, emotional stress, exercise, reflux esophagitis, inhaled irritants, and medications such as non-selective beta-blocking agents.6 The respiratory and cardiovascular status should be evaluated when the patient is experiencing shortness of breath. The patient’s quality, quantity, and effort of respiration should be noted.
Cheyne-Stokes may be seen in sleeping individuals who have conditions such as central nervous system disease, heart failure, or sleep apnea. In an ambulatory setting, noninvasive treatments to manage a patient experiencing shortness of breath include increasing oxygenation with an oxygen delivery device (e.g., nasal cannula, simple mask, partial nonrebreather mask). The goal of oxygen therapy is to keep the patient’s arterial oxygen saturation above 90%;1 however, depending on the patient’s history of chronic lung disease, the patient’s arterial oxygen saturation may be below 90%. If the patient’s respiratory status deteriorates, the health care team member should anticipate the need for more aggressive measures, such as invasive treatments (e.g., intubation, mechanical ventilation). If invasive treatments are needed, then the patient needs to be stabilized and transferred to a higher level of care. Oxygen delivery devices include nasal cannulas, simple face masks, and partial rebreather and nonrebreather face masks. A nasal cannula is the most common device used for oxygen administration.1 A nasal cannula (Figure 1) is a simple method that still gives the patient freedom to move, speak, and eat without being encumbered. A nasal cannula is ideal for patients requiring lower concentrations of oxygen ranging from 1 to 6 L.1 A simple face mask (Figure 2) is, ideally, used for patients that only need oxygen for short periods of time because it covers the patient’s nose and mouth, limiting freedom and the ability to conduct daily tasks such as eating. A simple face mask allows for 6 to 12 L of oxygen to be administered.1 A partial nonrebreather mask is ideal for short-term use as well but is intended for use with patients who require higher levels of oxygen concentrations, ranging from 10 to 15 L.1 For both partial rebreather and nonrebreather face masks (Figure 3), an attached bag allows the patient improved inhalation of exhaled oxygen-rich air along with flowing oxygen. Depending on the cause of shortness of breath, pharmacologic agents (e.g., bronchodilators, steroids, antibiotics, pain medications) may be prescribed as part of the patient’s treatments.6 EDUCATION
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ADDITIONAL READINGSClinical Overview. (2019, updated 2021). Acute respiratory distress syndrome in adults. Retrieved February 25, 2022, from https://www.clinicalkey.com Elsevier Skills Levels of Evidence
Which position should the nurse use for a patient experiencing dyspnea?With numerous applications, Fowler's position is used for patients who have difficulty breathing because, in this position, gravity pulls the diaphragm downward allowing greater chest and lung expansion.
Which independent nursing intervention is a priority for a patient who is experiencing dyspnea?According to NOC and NIC Linkages to NANDA-I and Clinical Conditions and Nursing Interventions Classification (NIC), Anxiety Reduction and Respiratory Monitoring are common categories of independent nursing interventions used to care for patients experiencing dyspnea and alterations in oxygenation.
How do you facilitate respiration in a patient with dyspnoea?Positions to facilitate efficient breathing in dyspnoeic people include:. "High side-lying.. Sitting upright in a chair with supporting arms; for many patients, it is easier to breathe in this position than in bed. ... . Sitting leaning forward from the waist, arms resting on pillows on a table, feet on the floor.. What should I ask a patient with dyspnea?In asking patients about dyspnea, the following types of questions are helpful: When do you feel short of breath? What activities bring on shortness of breath? (Be specific: Walking up 2 flights of stairs, walking ½ mile level ground, mowing lawn) Could you do these same activities without symptoms 3m ago?
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