What is Dyspnea?
Respiration is considered one of the primary vital signs that are monitored by healthcare providers for their patients. Out of all the vital functions in the body, respiration is unique because its regulation is not only led by automatic centers at the brainstem but also by voluntary signals coming from the cortex.
Untoward instances encountered in the control of respiration, the ventilator pump, or gas exchange mechanism will result in uncomfortable breathing also known as Dyspnea. Although the initial goal is to remedy the physiologic disturbances (e.g., gas exchange), addressing chronic cardiopulmonary disorders also plays a role in better management and monitoring of patients with dyspnea.
Signs and Symptoms of Dyspnea
What are the signs of dyspnea?
The signs and symptoms of dyspnea may be described as:
- tightness in the chest
- air hunger
- difficulty in breathing deeply
- feelings of suffocation
- decrease in oxygen saturation levels
Causes and Risk Factors of Dyspnea
What causes dyspnea?
The causes and risk factors of dyspnea revolve around the following encountered problems on the mechanisms of breathing:
- Heightened ventilatory demand. The symptoms of dyspnea are observed when hyperpnea happens while at rest, in the absence of any form of increased physical activity.
- Respiratory muscle abnormalities. Any abnormalities or weaknesses of the muscles of respiration can cause deviations between the respiratory outputs versus the achieved ventilation. This is particularly observed, for example, in patients with Chronic Obstructive Pulmonary Disease (COPD). In COPD, there is an over-inflation of the lungs and increased thoracic expansion resulting in suboptimal ventilation and the development of dyspnea.
- Abnormal ventilator impedance. In instances wherein ventilation is increasingly impeded, the level of effort needed to achieve the required output also rises. This can be true for certain respiratory conditions, such as asthma, wherein there is constriction of the patients’ airways, resulting in increased airway resistance.
- Abnormal breathing patterns. Abnormalities involving the lung tissues have dyspnea as its most common symptom. The accounted rapid shallow breathing from these conditions is a reflex response because of the activation and stimulation of the pulmonary vagal receptors.
- Blood-gas abnormalities. Dyspnea associated with changes in the blood-gas exchange can be observed for the following conditions. A decrease in the partial pressure of oxygen concentrations in the blood (hypoxemia) allows for the respiratory effort to increase through stimulation of the chemoreceptors. A low oxygen concentration in the tissues of the body (hypoxia) has a direct dyspneic effect as well. In instances of hypercapnia (increased carbon dioxide concentrations), more effort is exerted by the respiratory system because of variations in the hydrogen ion exchanges in the alveoli.
Some conditions that may cause short-term dyspnea are as follows:
- Anxiety disorders
- Pulmonary embolism
- Heart failure
- Sudden blood loss
Some conditions that may cause long-term dyspnea are mentioned below:
- Chronic obstructive pulmonary disease
- Congestive heart failure
- Pulmonary hypertension
- Lung cancer
Complications of Dyspnea
What happens if dyspnea goes untreated?
Complications of dyspnea coincide with the worsening of the underlying condition. Some of the associated complications are as follows:
- Edema or swelling of the ankles and feet. This is often associated with renal problems and therefore progresses to the accumulation of fluid in the lungs.
- Orthopneic dyspnea. Difficulty breathing when lying flat may signal a worsening condition and would warranty immediate medical intervention.
- Hyperthermia accompanied by cough and chills. This could indicate the worsening of an infection that may lead to systemic compromise and the development of Sepsis, a life-threatening condition.
- Wheezing. The presence of wheezing accompanied by dyspnea would mean tightening of the patient’s airways and fluid accumulation. If left untreated, this may lead to respiratory compromise and eventually respiratory failure and arrest.
Dyspnea Nursing Diagnosis
How is dyspnea diagnosed?
Diagnosing dyspnea involves recognizing the issues of the respiratory system and the underlying causes attributed to the condition. This can be initially assessed through a complete medical history and physical examination. However, the assessments and tests mentioned below will further aid in the initial confirmation of dyspnea.
- Lung function test – involves measurement of the lung’s capacity and volume to hold and withhold air. An example of this measurement is through a spirometer wherein the patient inhales deeply and exhales through the tool, measuring the volume of air the rate of how fast the test is accomplished.
- Pulse oximetry – involves the use of a machine, usually attached to the patient’s earlobe or finger, that measures the oxygen saturation in the capillary bed.
- Blood tests – diagnostic tools that are utilized in finding the reasons for a patient’s dyspnea. Examples of which are:
- complete blood counts to check for infection or anemia
- bleeding and clotting parameters to check for bleeding, or presence of a clot
- blood urea nitrogen and creatinine levels to measure for kidney function or when compromise will cause congestion
- Chest x-ray or CT scan – visually helps the healthcare provider in assessing for the causes of dyspnea like pneumonia, malformations of the structures of the respiratory system, or the presence of clots, to name a few.
- Electrocardiogram (ECG) – because of the connection of the heart on respirations, assessment with an ECG is beneficial so as to rule out any deviations that may be causing the dyspnea to begin with.
Dyspnea Nursing Interventions
What are nursing interventions for dyspnea?
The goal of treatment for dyspnea is the control of the pathological mechanisms that relate to the condition.
- Reduction of respiratory demand. This could be achieved through either reduction of the metabolic load or decrease in the central drive. Examples are exercise training or supplemental oxygen therapy.
- Reduction of ventilator impedance. This could be achieved through the counterbalance of lung hyperinflation or reduction of resistive load. Examples are continuous positive airway pressure (CPAP) or the use of medications.
- Improvement of inspiratory muscle function. Examples of interventions include improvement of nutrition and proper patient positioning.
- Alterations of central perception. Examples are desensitization and patient education.
The different treatment options for dyspnea revolve around treating the underlying condition with a combination of supplemental, pharmacological, and medical regimens.
These treatments either address the various pathological mechanisms that are present in dyspnea. The treatment options are:
- Exercise training – This decreases lactic acid production and improves the aerobic capacity of the patient.
- Supplemental oxygen therapy – This reduces the hypoxic drive coming from the peripheral chemoreceptors, thereby assisting in controlling the respiratory rate and depth.
- Pharmacologic therapy
- Opioids – This type of medicine acts on the neural signals that control respirations and therefore alleviating the intensity and effort of breathing.
- Anxiolytic – This type of medication relieves dyspnea by depressing hypoxic or hypercapnic pathways and the emotional attributes of dyspnea.
- Steroids – Relieves shortness of breath through reduction of edema and inflammation.
- Bronchodilators – Reduces resistive load (in asthmatics) and reverses bronchoconstriction (as in COPD).
- Beta 2-adrenergic agonists, anticholinergics, and Beta 2-agonist – These medications assist in lowering air volumes in the lungs.
- Alter respiratory afferent signals
- Vibration – This intervention, when applied in the outer chest wall, suppresses the signals from the respiratory center in the brainstem, thereby decreasing respiratory effort.
- Inhaled medications – Inhaled agents may help with relieving the discomfort brought about by dyspnea through the relaxation of respiratory tissues.
- Application of CPAP – This treatment is often utilized on asthmatics suffering acute bronchoconstriction. It helps by counterbalancing the effect of inspiratory threshold and reduction of dissociations in respirations.
- Nutritional supplementation – Adequate nutrition offers a reduction of energy requirements and support of the respiratory demand associated with dyspnea.
- Positioning – Changes in position assists the patient for better lung expansion (e.g., leaning forward position).
- Cognitive-behavioral approach – These may include relaxation techniques, distraction approaches that will help with anxiety-related dyspnea.
- Desensitization – Desensitization in controlled environments allows for the patient to cope with stressors and increase the threshold.
Dyspnea Nursing Care Plan Examples
What are the nursing care plans for dyspnea?
Nursing Care Plan 1
Nursing Diagnosis: Ineffective Breathing Pattern related to underlying condition as evidenced by abnormal breathing rate, rhythm and depth, and the use of respiratory accessory muscles.
Desired Outcome: The patient will maintain an effective breathing pattern as shown by normal and relaxed breathing and the absence of dyspnea.
|Assess and record respirations, including the rate and depth at least every 4 hours.||Continuous monitoring of respirations will enable the healthcare provider to address alterations and prevent further respiratory compromise|
|Auscultate breath sounds at least every 4 hours.||To detect adventitious or abnormal breath sounds that may need immediate management.|
|Assist in patient positioning for maximum breathing.||A sitting position allows for better chest expansion|
|Encourage deep breathing exercises.||These promote deep inspirations that increase oxygenation to the body and prevent atelectasis.|
|Encourage the use of the diaphragm in breathing for patients with chronic conditions.||This technique relaxes the respiratory muscles, thereby increasing the oxygen levels in the body.|
|Schedule activities of daily living and rest periods of the patient.||To conserve the patient’s energy levels, avoid overexertion, and allow for the body to recover from activities.|
|Advise taking of small, frequent meals.||To avoid crowding in the diaphragm that may complicate breathing|
|Educate the patient on pursed-lip breathing, abdominal breathing, relaxation techniques.||To allow the patient in improving ventilation and participating in maintaining health status.|
Nursing Care Plan 2
Nursing Diagnosis: Ineffective Airway Clearance related to the increased production of secretions as evidenced by abnormal breath sounds and inability to clear airway secretions.
Desired Outcome: The patient will maintain clear airways as shown by normal breath sounds and enhanced removal of secretions.
|Auscultate the lungs for the presence of adventitious breath sounds.||Abnormal breath sounds from the pooling of secretions in the airways indicate ineffective airway clearance|
|Note for mental status changes.||Increasing restlessness and decreasing GCS score can be initial signs of hypoxia|
|Ensure humidified oxygen support.||Increasing humidity of inspired air will assist with the removal of secretions by liquefaction.|
|Render postural drainage, chest percussion, and vibration as ordered.||Chest physiotherapy will help in mobilizing tenacious secretions in the airways.|
|Provide regular oral care for the patient.||Oral care helps remove the expectorated secretions in the mouth and prevent secondary infections.|
|Educate the patient on the proper coughing technique. (e.g., Taking a deep breath, holding for 2 seconds, then consecutively coughing for 2 or 3 times).||Coughing is the most effective and convenient way of mobilizing secretions. Deep breathing exercises promote good oxygenation.|
|Educate the patient on the importance of complying with the prescribed treatment regimen.||Compliance with the treatment regimen allows for the safe administration and effective control of respiratory conditions.|
Nursing Care Plan 3
Nursing Diagnosis: Impaired Gas Exchange related to hypoventilation and altered oxygen carrying capacity of the blood as evidenced by abnormal arterial blood gases, altered mental state, and delayed capillary refill of nail beds.
Desired Outcome: Patient maintains optimal gas exchange as shown by arterial blood gases within normal range, recommencement of usual mental status, and capillary refill within 2-3 seconds.
|Monitor oxygen saturation through pulse oximetry||Pulse oximeters are useful tools in monitoring for oxygen saturations of the patient. Oxygen saturation of 95% to 100% is normal.|
|Take note of ABG results and their corresponding changes||Increasing PaCO2 and decreasing PaO2 may indicate respiratory acidosis. Respiratory alkalosis is the decrease in PaCO2 and the increase in HCO3 levels in the blood. Any ABG changes may result in acute respiratory failure.|
|Maintain oxygen support as indicated and as ordered.||Oxygen support is required to maintain PaO2 levels within satisfactory levels and maintenance of physiologic functions.|
|Position the patient’s head of the bed elevated in semi-fowler’s position.||Upright position allows for better lung expansion and improved breathing.|
|Suction secretions as necessary.||Clearing the patient’s airway allows for better oxygenation and promotion of physiologic processes.|
|Provide reassurance to the patient.||Uncontrolled anxiety further increases dyspnea and respiratory effort.|
|Consider and prepare for eventual intubation and mechanical ventilation of the patient.||Early utilization of these advanced techniques will prevent acute respiratory arrest and maintain adequate respiratory support for the patient.|
Nursing Care Plan 4
Nursing Diagnosis: Risk for decreased Cardiac Output related to increased pulmonary blood pressure, as evidenced by an irregular heartbeat, heart rate of 122, dyspnea upon exertion, leg edema, and fatigue
Desired outcome: The patient will be able to maintain adequate cardiac output.
|Assess the patient’s vital signs and characteristics of a heartbeat at least every 4 hours. Assess breath sounds via auscultation. Observe for signs of decreasing peripheral tissue perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin.||To assist in creating an accurate diagnosis and monitor the effectiveness of medical treatment. Breath sounds of crackles/rales are important signs of heart failure. The presence of signs of decreasing peripheral tissue perfusion indicates deterioration of the patient’s status which requires immediate referral to the physician.|
|Administer the cardiac medications and diuretics as prescribed.||To alleviate the symptoms of cor pulmonale and heart failure and to treat the underlying condition.|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target range.|
|Educate patients on stress management, deep breathing exercises, and relaxation techniques.||Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. Chronic stress may also cause an increase in adrenaline levels, which tend to increase the heart rate, respiratory rate, and blood sugar levels.|
Nursing Care Plan 5
Nursing Diagnosis: Activity intolerance related to an imbalance between oxygen supply and demand as evidenced by fatigue, overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion
Desired Outcome: The patient will demonstrate active participation in necessary and desired activities and demonstrate an increase in activity levels.
|Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.||To create a baseline of activity levels and mental status related to fatigue and activity intolerance.|
|Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with 60-90 minutes of undisturbed rest.||To gradually increase the patient’s tolerance to physical activity. To prevent exacerbation of COPD by allowing the patient to pace activity versus rest.|
|Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.||To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.|
|Refer the patient to the physiotherapy/occupational therapy team as required.||To provide more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.|
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.