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Dyspnea or Respiratory Distress (Adult ED)

Mar.09.2020

Dyspnea or Respiratory Distress (Adult ED)

Clinical Description

  • Care of the Emergency Department patient seeking treatment for the sensation or complaint of breathlessness with or without the appearance of difficulty breathing.

Key Information

  • Dyspnea is a subjective experience. Treat the patient based on complaints or appearance, rather than relying on numerical values.
  • Similar signs and symptoms across conditions make diagnosis difficult. The most common causes originate from heart or lungs; although neuromuscular or psychologic origins should be considered.
  • If an opioid or benzodiazepine agent is used to relieve anxiety and breathlessness, closely observe for respiratory depression or deterioration.
  • Dyspnea is associated with higher mortality rates.
  • Alcohol may cause or worsen dyspnea in patients with a chronic illness.
  • Oncology patients frequently experience dyspnea related to physiology of disease or response to treatment.

Threats to Life, Limb or Function

  • airway obstruction
  • anaphylaxis
  • cardiopulmonary arrest
  • hypoxia
  • pulmonary embolism
  • sepsis

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Goal: Acute Signs/Symptoms are Managed

  • Goal: Acceptable Pain Level Achieved

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • health literacy
      • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Dyspnea or Respiratory Distress

    Associated Documentation

    • Dyspnea/Respiratory Distress Management

    Presentation

    • difficulty breathing
    • chest heaviness
    • chest tightness
    • feeling of air hunger
    • feeling of inability to take a deep breath
    • respiratory pattern irregular
    • tachycardia
    • tachypnea

    Associated Signs/Symptoms

    • accessory muscle use
    • breath sounds with wheezing or crackles
    • chest pain
    • cough
    • diaphoresis
    • difficulty speaking
    • extreme fatigue
    • hoarseness
    • jugular vein distension
    • nervousness
    • orthopnea
    • peripheral edema
    • prolonged expiratory phase
    • pursed-lip breathing
    • restlessness
    • shortness of breath
    • sighing frequently
    • sputum production
    • stridor or noisy breathing

    Potential Causes

    • anxiety
    • aspiration
    • cardiac problem, such as atrial fibrillation, heart failure or myocardial infarction
    • chronic lung disease exacerbation
    • foreign body aspiration
    • gastroesophageal reflux
    • infection
    • panic attack

    Initial Assessment

    • airway patency
    • breath sounds
    • breathing pattern
    • level of consciousness
    • peripheral oxygen saturation
    • work of breathing

    History

    • allergies
    • comorbidities
    • immunizations
    • last menstrual period (females of childbearing age)
    • medications
    • alleviating factors
    • coughing or choking
    • dysphagia
    • effort variation with position change or activity
    • hemoptysis
    • ongoing treatment side effects
    • onset, duration and precipitating events
    • past episode and treatment, such as hospitalization or intubation
    • recent exposure, illness
    • recent injury
    • smoking history and status
    • sputum production
    • treatment prior to presentation
    • use of home oxygen therapy

    Laboratory Studies

    • ABG (arterial blood gas)
    • blood glucose level
    • BNP (B-type natriuretic peptide)
    • BUN (blood urea nitrogen)
    • cardiac biomarker profile, such as creatine phosphokinase, creatine kinase, troponin
    • CBC (complete blood count) with differential
    • CRP (C-reactive protein)
    • D-dimer
    • serum creatinine
    • serum electrolytes
    • serum lactate
    • sputum culture
    • toxicology levels
    • viral culture

    Diagnostics

    • chest x-ray
    • Doppler exam
    • ECG (electrocardiogram)

    Potential Additional Testing

    • bronchoscopy
    • CTPA (computed tomography pulmonary angiogram)
    • echocardiogram
    • esophagoscopy
    • peak flow measurement
    • pregnancy test (females of childbearing age)
    • spiral chest CT (computed tomography) scan
    • ultrasonography
    • ventilation/perfusion scan

    Problem Intervention

    Provide Respiratory Support

    • Assess and monitor airway, breathing and circulation for effective oxygenation and ventilation; maintain close surveillance for deterioration.
    • Maintain open and patent airway with use of positioning, airway adjuncts and secretion clearance.
    • Position to minimize the risk of aspiration, ventilation/perfusion mismatch and breathlessness.
    • Minimize oxygen consumption and demand; limit activity, reduce fever and utilize breathing techniques.
    • Provide oxygen therapy judiciously; titrate to prevent hyperoxemia.
    • Consider inhaled beta-1 or beta-2 agonist, such as racemic epinephrine or albuterol, especially in the presence of stridor or wheezing.
    • Implement noninvasive or invasive positive pressure ventilation to support oxygenation and ventilation, as well as relieve respiratory distress.

    Problem Intervention

    Provide Hemodynamic Support

    • Monitor cardiovascular status.
    • Observe for, and address, cardiac dysrhythmia.
    • Position to support perfusion.
    • Evaluate fluid status; provide fluid therapy to improve blood flow, perfusion and tissue oxygenation.
    • Monitor and manage electrolyte levels; anticipate the need to correct imbalance; evaluate patient response.
    • If cardiac origin identified, consider the need for pharmacologic measures, such as a diuretic or vasoactive agent.
    • Anticipate urgent intervention in the presence of hemodynamic instability.

    Problem Intervention

    Promote Comfort and Manage Pain

    • Use a consistent pain assessment tool; evaluate pain and treatment response at regular intervals.
    • Involve patient and family in the management plan.
    • Provide nonpharmacologic strategies, such as breathing techniques, positioning, distraction and diversion.
    • Consider pharmacologic measures, such as an opioid or benzodiazepine agent, especially for palliation or breathlessness associated with anxiety or panic attack.
    • Evaluate risk for opioid use.

    Problem Intervention

    Minimize and Manage Infection

    • Assess for presence of infection and signs of early sepsis.
    • Initiate precautions to prevent the spread of infection.
    • Obtain cultures prior to initiation of antimicrobial therapy, when possible.
    • Anticipate antimicrobial therapy administration; do not delay in the presence of high suspicion or clinical indicators.

    Problem Intervention

    Provide Psychosocial Support

    • Proactively provide information; encourage questions and address concerns.
    • Provide calm, reassuring presence.
    • Recognize, identify and allow expression of emotions.
    • Promote family/caregiver presence at bedside.
    • Offer choices to enhance a sense of control.
    • Honor spiritual and cultural preferences.
    • Recognize and utilize personal coping strategies.

    Problem Intervention

    Facilitate Procedures

    • Initiate and maintain NPO (nothing by mouth) status.
    • Prepare for or assist with procedures, such as bronchoscopy, laryngoscopy, thoracentesis, chest tube placement or intubation.
    • Facilitate referral for follow-up with a dyspnea clinic, heart failure clinic, palliative care, pulmonary rehabilitation, pulmonologist, cardiologist, oncologist or neuromuscular specialist.

    Education

    General Emergency Education

    Teaching Focus

    • symptom/problem overview

    • risk factors/triggers

    • self-management

    • assistive device

    • diagnostic test

    • diet modification

    • medical device/equipment use

    • medication administration

    • opioid medication management

    • orthopaedic device

    • safe medication disposal

    • smoking cessation

    • wound care

    Population-Specific Considerations

    Forensics and Legal

    • Utilize local, state/province, federal requirements and hospital policy and protocols to manage patient care involving forensics, protective services, workman’s compensation and mandatory reportable events and illness.

    Human Trafficking

    • Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
    • Trafficked individuals may be male or female and engaged in sex work or other forced labor. High-risk signs requiring more direct questioning about exploitation include, among others, current employment in a high-risk industry, prior sexually transmitted infections, recent immigration, undocumented immigrant status and other vulnerable and minority populations.

    Geriatric

    • Dyspnea is more common in older adults, although the underlying causes are unclear.
    • Dyspnea and fatigue may be the only presenting symptoms for a geriatric patient experiencing a myocardial infarction.
    • Acute decompensated heart failure is the most common cause of admission for patients over 65 years of age. Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
    • There is a higher risk for respiratory syncytial virus, pneumonia and influenza in this population, especially those with chronic medical conditions.

    Pregnancy

    • Beyond 20 weeks gestation, supine position should be avoided. Maternal position should be lateral or lateral tilt to prevent compression of the inferior vena cava and aorta by the pregnant uterus.
    • Presentation with a complaint of shortness of breath, absence of any known comorbidities and normal pulse oximetry readings may be “benign” dyspnea of pregnancy. This may occur as a normal response to increased partial oxygen tension in pregnancy that enables adequate fetal oxygenation.
    • Potentially serious causes of dyspnea during pregnancy that should be considered include pulmonary embolism, dysrhythmia, pulmonary edema, pneumonia, asthma and cardiomyopathy.
    • Incidence of pulmonary embolism is 5 to 10 times higher in pregnancy and the early postpartum phase.
    • A pregnant abdomen may cause mechanical interference with breathing.

    Quality Measures

    • NQF 0495. Median Time from ED arrival to ED Departure for Admitted ED Patients
      Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department.
      Steward: Centers for Medicare and Medicaid Services
      Care Setting: ED, Hospital
      National Quality Forum-endorsed measure
      Last Edited: 10/11/2017
    • NQF 0496. Median Time from ED arrival to ED Departure for Discharged ED Patients
      Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department.
      Steward: Centers for Medicare and Medicaid Services
      Care Setting: ED, Hospital
      National Quality Forum-endorsed measure
      Last Edited: 10/11/2017

    References

    • Additional Information: Dyspnea/Respiratory Distress Adult. PDF. Download[]
    • Al Deeb, M.; Barbic, S.; Featherstone, R.; Dankoff, J.; Barbic, D.. Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: A systematic review and meta-analysis. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine. 2014;21(8), 843-852. doi:10.1111/acem.12435 [Metasynthesis,Meta-analysis,Systematic Review]
    • American College of Emergency Physicians. Geriatric emergency department guidelines. Annals of Emergency Medicine. 2014;63(5), e7-e25. doi:10.1016/j.annemergmed.2014.02.008 Source[Quality Measures,Clinical Practice Guidelines]
    • American Heart Association. (2016). Advanced cardiovascular life support provider manual. USA: American Heart Association. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Barbetta, C.; Currow, D. C.; Johnson, M. J.. Non-opioid medications fro the relief of chronic breathlessness: Current evidence. Expert Review of Respiratory Medicine. 2017;11(4), 333-340. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Barnes, H.; McDonald, J.; Smallwood, N.; Manser, R. Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness . Cochrane Database of Systematic Reviews. 2016, March;(3) doi:10.1002/14651858.CD011008.pub2 [Metasynthesis,Meta-analysis,Systematic Review]
    • Cabezon-Gutierrez, L.; Khosravi-Shahi, P.; Custodio-Cabello, S.; Muniz-Gonzalez, F.; Cano-Aguirre Mdel, P.; Alonso-Viteri, S.. Opioids for management of episodic breathlessness or dyspnea in patients with advanced disease. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer. 2016;24(9), 4045-4055. doi:10.1007/s00520-016-3316-x [Metasynthesis,Meta-analysis,Systematic Review]
    • Centers for Disease Control and Prevention (CDC). (2017). CDC 24/7: Saving lives, protecting people Respiratory syncytial virus infection (RSV). Source[Quality Measures,Clinical Practice Guidelines]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0495. Median Time from ED Arrival to ED Departure for Admitted ED Patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0496. Median time from ED arrival to ED departure for discharged ED patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Crawford, F.; Andras, A.; Welch, K.; Sheares, K.; Keeling, D.; Chappell, F. M.. D-dimer test for excluding the diagnosis of pulmonary embolism. Cochrane Database of Systematic Reviews. 2016;(8) doi:10.1002/14651858.CD010864.pub2 [Metasynthesis,Meta-analysis,Systematic Review]
    • Da Silva Soares, D.; Nunes, C. M.; Gomes, B.. Effectiveness of emergency department based palliative care for adults with advanced disease: A systematic review. Journal of Palliative Medicine. 2016;19(6), 601-609. doi:10.1089/jpm.2015.0369 [Metasynthesis,Meta-analysis,Systematic Review]
    • Davidson, A. C.;Banham, S.; Elliott, M.; Kennedy, D.; Gelder, C.; Glossop, A.; Church, A. C.; Creagh-Brown, J. W. D.; Felton, T.; Foëx, B.; Mansfield, L.; McDonnell, L.; Parker, R.; Patterson, C. M.; Sovani, M.; Thomas, L.. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax. 2016;71(Suppl 2), ii1-ii35. [Quality Measures,Clinical Practice Guidelines]
    • Davis, M. D.; Walsh, B. K.; Sittig, S. E.;Restrepo, R. D.. AARC clinical practice guideline: Blood gas analysis and hemoximetry. Respiratory Care. 2013;58(10), 1694-1703. [Quality Measures,Clinical Practice Guidelines]
    • Elwan, M. H.; Roshdy, A.;Elsharkawy, E. M.; Eltahan, S. M.; Coats, T. J.. The haemodynamic dilemma in emergency care: Is fluid responsiveness the answer? A systematic review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2017;25(1), 25. doi:10.1186/s13049-017-0370-4 [Metasynthesis,Meta-analysis,Systematic Review]
    • Emergency Nurses Association (ENA). (2013, Sep). Position statement: Palliative and end-of-life care in the emergency setting. (pp.1-4). Des Plaines, IL: Emergency Nurses Association. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Epstein, E.; McDougall, M.; Thomas, P.. Intravenous fluids in hospital: Practical approaches. British Journal of Hospital Medicine. 2017;78(4), C50-C54. doi:10.12968/hmed.2017.78.4.C50 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • George, N.; Phillips, E.; Zaurova, M.; Song, C.; Lamba, S.; Grudzen, C.. Palliative care screening and assessment in the emergency department: A systematic review. Journal of Pain and Symptom Management. 2016;51(1), 108-119.e2. doi:10.1016/j.jpainsymman.2015.07.017 [Metasynthesis,Meta-analysis,Systematic Review]
    • Greenbaum, J.. Identifying victims of human trafficking in the emergency department. Clinical Pediatric Emergency Medicine. 2016;17(4), 241-248. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Hammond, B. B. (2013). In Sheehy's manual of emergency care. Cardiovascular emergencies. (pp.201-211). St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Harrison, S. L.; Apps, L.; Singh, S. J.; Steiner, M. C.; Morgan, M. D.; Robertson, N. "Consumed by breathing"-a critical interpretive meta-synthesis of the qualitative literature. Chronic Illness. 2014;10(1), 31-49. [Metasynthesis,Meta-analysis,Systematic Review]
    • Hooten, M.; Thorson, D.; Bianco, J.; Bonte, B.; Clavel Jr., A.; Hora, J.; Johnson, C.; Kirksson, E.; Noonan, M. P.; Reznikoff, C.; Schweim, K.; Wainio, J.; Walker, N.. (2016 [updated 2017, Aug]). Pain: Assessment, non-opioid treatment approaches and opioid management. (pp.160). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). Source[Quality Measures,Clinical Practice Guidelines]
    • Institute for Clinical Systems Improvement (ICSI). (2007 [revised 2013]). Palliative care for adults. Source[Quality Measures,Clinical Practice Guidelines]
    • Johnson, K. M.; Bryan, S.; Ghanbarian, S.; Sin, D. D.; Sadatsafavi, M.. Characterizing undiagnosed chronic obstructive pulmonary disease: A systematic review and meta-analysis. Respiratory Research. 2018;19(1) doi:10.1186/s12931-018-0731-1 [Metasynthesis,Meta-analysis,Systematic Review]
    • Kwekkeboom, K. L.; Bratzke, L. C.. A systematic review of relaxation, meditation, and guided imagery strategies for symptom management in heart failure. The Journal of Cardiovascular Nursing. 2016;31(5), 457-468. doi:10.1097/JCN.0000000000000274 [Metasynthesis,Meta-analysis,Systematic Review]
    • Laher, A. E.;Watermeyer, M. J.;Buchanan, S. K.;Dippenaar, N.;Simo, N. C. T.;Motara, F.;Moolla, M.. A review of hemodynamic monitoring techniques, methods and devices for the emergency physician. American Journal of Emergency Medicine. 2017;35(9), 1335-1347. doi:10.1016/j.ajem.2017.03.036 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Liang, S. Y.; Theodoro, D. L.; Schuur, J. D.; Marschall, J.;. Infection prevention in the emergency department. Annals of Emergency Medicine. 2014;64(3), 299-313. doi:10.1016/j.annemergmed.2014.02.024 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Link, M. S.;Berkow, L. C.;Kudenchuk, P. J.;Halperin, H. R.;Hess, E. P.;Moitra, V. K.;Neumar, R. W.;O'Neil, B. J.;Paxton, J. H.;Silvers, S. M.;White, R. D.;Yannopoulos, D.;Donnino, M. W.. Part 7: Adult advanced cardiovascular life support. Circulation. 2015;132(18 suppl 2), S444-S464. doi:10.1161/CIR.0000000000000261 [Quality Measures,Clinical Practice Guidelines]
    • Martindale, J. L.; Wakai, A.; Collins, S. P.; Levy, P. D.; Diercks, D.; Hiestand, B. C.; Fermann, G. J.; deSouza, I.; Sinert, R.;. Diagnosing acute heart failure in the emergency department: A systematic review and meta-analysis. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine. 2016;23(3), 223-242. doi:10.1111/1cem.12878 [Metasynthesis,Meta-analysis,Systematic Review]
    • Molasiotis, A.. Pharmacologic and non-pharmacologic management of dyspnea. Journal of Thoracic Oncology. 2015;10(9), S143. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • National Institute for Health and Care Excellence. (2013 [Updated 2017]). Intravenous fluid therapy in adults in hospital . Source[Quality Measures,Clinical Practice Guidelines]
    • National Institute for Health and Care Excellence. (2015). Care of dying adults in the last days of life [NG31]. Source[Quality Measures,Clinical Practice Guidelines]
    • National Institute for Health and Care Excellence. (2016). Sepsis: Recognition, diagnosis and early management. (NICE guideline [NG51]). Source[Quality Measures,Clinical Practice Guidelines]
    • O'Driscoll, B. R.; Howard, L. S.; Earis, J.; Mak, V.; British Thoracic Society Emergency Oxygen Guideline Group. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017, Jun;72(Suppl 1), ii1-ii90. [Quality Measures,Clinical Practice Guidelines]
    • Parshall, M. B.; Schwartzstein, R. M.; Adams, L.; Banzett, R. B.; Manning, H. L.; Bourbeau, J.; Calverley, P. M.; Gift, A. G.; Harver, A.; Banzett, R. B. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American Journal of Respiratory and Critical Care Medicine. 2012;185(4)[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Pesola, G. R.; Ahsan, H.;. Dyspnea as an independent predictor of mortality. The Clinical Respiratory Journal. 2016;10(2), 142-152. doi:10.1111/crj.12191 [Metasynthesis,Meta-analysis,Systematic Review]
    • Registered Nurses' Association of Ontario. (2013). Assessment and management of pain. Source[Quality Measures,Clinical Practice Guidelines]
    • Registered Nurses' Association of Ontario. (2015). Person- and family-centred care. Source[Quality Measures,Clinical Practice Guidelines]
    • Renier, W.; Winckelmann, K. H.; Verbakel, J. Y.; Aertgeerts, B.; Buntinx, F.. Signs and symptoms in adult patients with acute dyspnea: A systematic review and meta-analysis. European Journal of Emergency Medicine: Official Journal of the European Society for Emergency Medicine. 2018;25(1), 3-11. doi:10.1097/MEJ.0000000000000429 [Metasynthesis,Meta-analysis,Systematic Review]
    • Rhodes, A.; Evans, L. E.; Alhazzani, W.; Levy, M. M.; Antonelli, M.; Ferrer, R.; Kumar, A.; Sevransky, J. E.; Sprung, C. L.; Nunnally, M. E.; Rochwerg, B.; Rubenfeld, G. D.; Angus, D. C.; Annane, D.; Beale, R. J.; Bellinghan, G. J.; Bernard, G. R.; Chiche, J. D.; Coopersmith, C.; De Backer, D. P.; French, C. J.; Fujishima, S.; Gerlach, H.; Hidalgo, J. L.; Hollenberg, S. M.; Jones, A. E.; Karnad, D. R.; Kleinpell, R. M.; Koh, Y.; Lisboa, T. C.; Machado, F. R.; Marini, J. J.; Marshall, J. C.; Mazuski, J. E.; McIntyre, L. A.; McLean, A. S.; Mehta, S.; Moreno, R. P.; Myburgh, J.; Navalesi, P.; Nishida, O.; Osborn, T. M.; Perner, A.; Plunkett, C. M.; Ranieri, M.; Schorr, C. A.; Seckel, M. A.; Seymour, C. W.; Shieh, L.; Shukri, K. A.; Simpson, S. Q.; Singer, M.; Thompson, B. T.; Townsend, S. R.; Van der Poll, T.; Vincent, J. L.; Wiersinga, W. J.; Zimmerman, J. L.; Dellinger, R. P. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Medicine. 2017;43(3), 304-377. doi:10.1007/s00134-017-4683-6 [Quality Measures,Clinical Practice Guidelines]
    • Ringer, T.; Moller, D.; Mutsaers, A.. Distress in caregivers accompanying patients to an emergency department: A scoping review. Journal of Emergency Medicine. 2017;53(4), 493-508. [Metasynthesis,Meta-analysis,Systematic Review]
    • Shankar, K. N.; Bhatia, B. K.; Schuur, J. D.. Toward patient-centered care: A systematic review of older adults' views of quality emergency care. Annals of Emergency Medicine. 2014;63(5), 529-550. [Metasynthesis,Meta-analysis,Systematic Review]
    • Simon, S. T.; Higginson, I. J.; Booth, S.; Harding, R.; Weingärtner, V.; Bausewein, C. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database of Systematic Reviews. 2016;(10) doi:10.1002/14651858.CD007354.pub3 [Metasynthesis,Meta-analysis,Systematic Review]
    • Sterling, S. A.; Miller, R.; Pryor, J.; Puskarich, M. A.; Jones, A. E. The impact of timing of antibiotics on outcomes in severe sepsis and septic shock:  A systematic review and meta-analysis. Critical Care Medicine. 2015;43(9), 1907-1915. [Metasynthesis,Meta-analysis,Systematic Review]
    • Troiano, N. H.; Witcher, P. M.; McMurtry Baird, S.. (2019). AWHONN: High-risk & critical care obstetrics. Philadelphia: Wolters Kluwer. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • U. S. Department of Health and Human Services. (2017). Human trafficking webinar for health care providers: SOAR to health and wellness. Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • van Mourik, Y.; Rutten, F. H.; Moons, K. G.; Bertens, L. C.; Hoes, A. W.; Reitsma, J. B.. Prevalence and underlying causes of dyspnoea in older people: A systematic review. Age and Ageing. 2014;43(3), 319-326. doi:10.1093/ageing/afu001 [Metasynthesis,Meta-analysis,Systematic Review]
    • Vandyk, A. D.; Harrison, M. B.; MacArtney, G.; Ross-White, A.; Stacey, D.. Emergency department visits for symptoms experienced by oncology patients: A systematic review. Supportive Care in Cancer. 2012;20(8), 1589-1599. doi:10.1007/s00520-012-1459-y [Metasynthesis,Meta-analysis,Systematic Review]
    • Verberkt, C. A.; van den Beuken-van Everdingen, M. H. J.; Schols, J. M. G. A.; Datla, S.; Dirksen, C. D.; Johnson, M. J.; van Kuijk, S. M. J.; Wouters, E. F. M.; Janssen, D. J. A.. Respiratory adverse effects of opioids for breathlessness: A systematic review and meta-analysis. European Respiratory Journal. 2017;50(5) doi:10.1183/13993003.01153-2017 [Metasynthesis,Meta-analysis,Systematic Review]
    • Viniol, A.; Beidatsch, D.; Frese, T.; Bergmann, M.; Grevenrath, P.; Schmidt, L.; Schwarm, S.; Haasenritter, J.; Bösner, S.; Becker, A.. Studies of the symptom dyspnoea: A systematic review. BMC Family Practice. 2015;16, 152. doi:10.1186/s12875-015-0373-z Source[Metasynthesis,Meta-analysis,Systematic Review]
    • Wang, D. H.. Beyond code status: Palliative care begins in the emergency department. Annals of Emergency Medicine. 2017;69(4), 437-443. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Wensley, C.; Botti, M.; Mckillop, A.; Merry, A. F.. A framework of comfort for practice: An integrative review identifying the multiple influences on patients' experience of comfort in healthcare settings. International Journal of Quality in Health Care. 2017;29(2), 151-162. doi:10.1093/intqhc/mzw158 Source[Metasynthesis,Meta-analysis,Systematic Review]
    • Wolf, L.; Storer, A.; Barnason, S.; Brim, C.; Halpern, J.; Leviner, S.; Lindauer, C.; Patrick, V. C.; Proehl, J. A.; Williams, J.; Bradford, J. Y. (2012). Clinical practice guideline: Family presence during invasive procedures and resuscitation. United States: Emergency Nurses Association. [Quality Measures,Clinical Practice Guidelines]

    Disclaimer

    Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.