DYSPNOEA
Definition
refers to a difficulty in breathing.
it can be acute or chronic, recurrent, paroxysmal, or progressive.
Nursing assesssment
Causes
may be due to cardiac disease or to pulmonary disease
shortness of breath associated with pulmonary disease is due to a change in lung compliance or an increase in airways resistance, both of which will cause the work of breathing to be increased.
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sudden onset of dyspnoea occurs with conditions such as pulmonary embolism and pneumothorax.
taking history from the patient regarding the factors that trigger the patient's dyspnoea
the duration and severity of the dyspnoea should also be determined. noting the patient's ability to talk during thee attack is a guide to the severity.
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the respiratory rate, heart rate and any accompanying symptoms such as wheezing stridor and coughing must be noted.
the nurse should also note whether the onset of dyspnoea is sudden or gradual
the impact of dyspnoea on the activities of daily living of the patient
Nursing interventions
the cause should be treated by alleviating or removing the triggering factors, such as dry air or dust.
the patient should be placed in a comfortable position, usually sitting upright to facilitate breathing
the nurse should administer oxygen therapy, nebulisers and inhalers as prescribed.
Regular assessment of the respiratory status of the patient should be carried out until breathing has returned to normal.
CARE PLAN
DIFFICULTY IN BREATHING
NURSING DIAGNOSIS: Altered breathing pattern due to inadequate ventilation and oxygenation related to the disease process, manifested by dyspnoea, restlessness and cyanosis
EXPECTED OUTCOME: normal breathing pattern, patient restful and skin colour normal
NURSING INTERVENTIONS AND RATIONALE: Position the patient in the upright position and ensure that the patient is adequately supported with pillows.
- remove constrictive clothing to ensure maximum expansion of the chest; the upright position also facilitates optimum chest expansion
- give oxygen therapy as prescribed according to unit protocol
- monitor respiratory status, rate and character every 30 minutes during the acute stage and 2-hourly as the patient starts to settle down:
- monitor oxygen saturation levels, arterial blood gas levels
EVALUATION: Respiratory rate within normal range, breathing pattern normal
COUGH
NURSING DIAGNOSIS: altered comfort and disturbed rest and sleep due to cough related to respiratory tract irritation
EXPECTED OUTCOME: No cough
NURSING INTERVENTIONS AND RATIONALE
- give adequate fluids to liquefy secretions and facilitate removal of secretions
- give prescribed expectorants, mucolytics or antitussives
- observe and record cough: its frequency, sputum production and nature thereof, associated symptoms
EVALUATION: no cough, Patient rests peacefully within 12 - 24 hours
POOR APPETITE
NURSING DIAGNOSIS: Altered nutrition due to anorexiacaused by dyspnoea and/or nausea due to swallowed sputum; evidenced by reduced food intake, weight loss and increased potential for infection
EXPECTED OUTCOME: food intake normal, Resistance to infection is optimal
NURSING INTERVENTIONS AND RATIONALE:
- give small balanced meals that are easy to eat
- offer food several times during the day
- encourage patient to expectorate sputum instead of swallowing it to reduce nausea
DEHYDRATION
NURSING DIAAGNOSIS: There is a risk of fluid volume deficit due to inadequate intake related to poor nutritional intake, sweating and loss of fluid through hyperventilation and pyrexia
EXPECTED OUTCOME: normal hydration, normal vital signs, adequate food intake
NURSING INTERVENTIONS
- record all intake and output including intravenous fluids
- serve food frequently in small servings
- encourage patient to expectorate to prevent nausea and vomiting
- monitor vital signs and record