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Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.
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#ref5">5
Shortness of breath, also known as dyspnea, is defined as a subjective feeling of difficulty breathing or breathlessness.5 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.5 Some patients may even present with difficulty speaking in full sentences. This symptom is more common in patients suffering from asthma.5
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.5 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.5
The patient’s respiratory and cardiovascular status should be evaluated when he or she 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.5
Positioning a patient with shortness of breath must be performed immediately in a life-threatening situation. Verify the correct patient only if it does not delay the procedure.
Rationale: Signs and symptoms of shortness of breath and hypoxia may include breathlessness, increased anxiety, pursed-lip breathing, increased work of breathing, or use of accessory muscles.
Rationale: These techniques help prevent the patient from sliding toward the foot of the bed.
Use pillows for only a limited time because of pressure created on the popliteal vessels. Observe for leg edema as indicated.
Rationale: This position helps patients with respiratory distress related to COPD. It also may help relieve dyspnea related to pulmonary edema.
Rationale: An improperly fitting mask may not provide adequate oxygen administration.
Rationale: Laboratory tests for shortness of breath include d-dimer and cardiac enzymes.
Rationale: Reevaluating the patient’s oxygen status determines whether the level of oxygenation is appropriate or if the plan of treatment needs to be adjusted.
Clinical Overview. (2019). Acute respiratory distress syndrome in adults. Retrieved April 13, 2020, from https://www.clinicalkey.com
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