assessment of breathless patient

Assessment of breathless patient Monitor respiratory rate, rhythm and depth. Also monitor patient’s chest movement, air entry and oxygen saturation. Chest movement should be equal, bilateral and symmetrical. Air entry should be assessed by observing, listening to and feeling the chest. Breath sounds should be bilateral and audible in all lung zones. Arterial oxygen saturation can be monitored using pulse oximetry.

Assess for the noisy respirations e.g.

1.    Highly pitched ‘croaking’ respiration during inspiration is caused by laryngeal or tracheal obstruction.

2.    Musical sound ‘wheeze’ during expiration occurs when air flows through narrowed bronchi and bronchioles.

3.    ‘Ratly’ sound from chest occurs in pulmonary oedema.

4.    ‘Gurgling’ sound results in presence of fluid in upper airway.

Healthy spontaneous breathing is quiet and accomplished with minimal effort. The amount of energy expended on breathing depends on the rate and depth of breathing, airway resistance and the ease with which the lungs can be expanded. Signs of increased work of breathing include an increase in respiratory rate, noisy respiration and the use of accessory muscles such as abdominal muscles. The normal respiratory rate in adults is approximately 12-18 breaths per minute; however, breathless patients can experience different breathing patterns:

Tachypnoea is an abnormally rapid rate of breathing (>20 breaths per minute) and is usually one of the first indications of respiratory distress.

Bradypnoea is an abnormally slow rate of breathing (<12 breaths per minute) which can indicate severe deterioration in the patient’s condition.

Some patients may exhibit a Cheyne-Stokes pattern of breathing, which is characterised by periods of apnoea (cessation of respiration) alternated

with periods of hyperpnoea (overbreathing). This may be caused by left ventricular failure and cerebral injury.

Ventilation:The assessment of heart rate, skin colour and the patient’s mental status can help to provide an indication of the adequacy of ventilation. Hypoxaemia can have the following effects:

Heart rate – the breathless person will experience tachycardia initially, but severe hypoxia can cause bradycardia.

Skin colour – the skin will appear pale. Hypoxia causes catecholamine release and vasoconstriction.

Mental status – symptoms include agitation, drowsiness, confusion and impaired consciousness.

Accurate assessment of the characteristics of each individual’s breathlessness includes the severity, timing, related chest pain, cough and sputum. These characteristics help to determine the most appropriate treatment and also help in diagnosis. E.g timing: Severe asthma and LVF are experienced more commonly at night.

The monitoring of vital signs, arterial blood gases, electrocardiogram (ECG), X-ray of the chest, pulmonary function tests, exercise testing, computerised axial tomography (CAT) scan of the chest and echocardiogram will also assist in identifying the cause of breathlessness.

Signs and Symptoms

Breathlessness The first symptom most patients experience in cardiac failure is breathlessness. The left ventricle fails to eject sufficient volumes of blood into the systemic circulation there is an increase in LVEDP (left ventricular end diastolic pressure), which results in the elevation of pressure in the pulmonary vasculature and may lead to pulmonary oedema.

Nocturnal dyspnoea is another symptom of heart failure. When a patient lies down there is an increase in left ventricular filling pressures because of the increase in venous return from the peripheral extremities. Congestion of blood in the heart results in an increase in systemic venous pressure leading to widespread oedema.

Oedema Oedema is an excessive accumulation of fluid in the interstitial spaces of the tissues. Patients with congestive heart failure, can develop systemic oedema, which ranges from mild ankle oedema to gross oedema of the legs, abdomen, sacrum and scrotum.

Fatigue and lethargy Many patients with heart failure experience fatigue and lethargy, which may be caused by muscle wasting, dyspnoea and anorexia

In severe heart failure, patients may not be able to sleep because of shortness of breath and anxiety. Disturbance in sleep patterns and reduced blood flow to the brain may also cause confusion

Nursing care

When patients are admitted to hospital with heart failure it is important that nurses assess them, identify their main problems and plan their care.

Positioning may help relieve breathlessness, the most common symptom that patients present with. Sitting the patient in an upright position supported

by pillows encourages the lungs to expand, which may help to relieve breathlessness Rest is important because it reduces the oxygen demand on the heart. Oxygen therapy should be commenced as prescribed; this can be administered via nasal cannula or a face mask. The combination of sodium retention and breathlessness in heart failure causes a reduction in usual salivary excretions and makes the patient’s tongue dry and rough. The administration of humidified oxygen can help to reduce this effect because it moistens the oxygen. Regular mouth care is necessary to prevent dryness of the mouth and lips.

Diuretic therapy and fluid restriction may be prescribed to reduce and/or relieve the oedema. Once commenced, a strict record of all fluid intake and output should be kept and daily weight should be recorded. This is necessary

to assess the effectiveness of drug therapy.

The patient’s vital signs should be monitored and recorded as appropriate for their condition. Nursing documentation should be clearly charted and include the details of oxygen delivery: date and time the patient was commenced on oxygen therapy; the type of delivery device used; the oxygen flow rate; respiratory effort; breath sounds; skin colour; and any changes in the patient’s mental state.

One of main roles in oxygen therapy is to support, reassure and gain the patient’s confidence to maintain compliance with treatment. To promote and ensure patient safety during oxygen administration, nurses should ensure that the correct procedure is followed according to local guidelines. The effectiveness of oxygen delivery needs to be monitored regularly as the patient’s requirements for oxygen might fluctuate as his or her condition changes.

Patients with severe heart failure may not be able to maintain personal hygiene. The nurse needs to assess patients to see how much they can do and what the nurse needs to assist them with. These patients will require assistance with all care, which includes full bed bath, eye care, mouth care and urinary catheter care (if one is in place). This may cause embarrassment for patients so the nurse needs to be aware of this and be sympathetic, caring and maintain the patient’s dignity at all times.

From admission, it is vital that these patients are nursed on a pressure-relieving mattress to try to prevent the development of skin damage. By using a pressure ulcer assessment tool such as Waterlow (1995), the nurse can identify if the patient is at risk of developing an ulcer, and what treatment or equipment is necessary to help prevent this (Harding 1999). The patient should be encouraged to move position frequently or, if he or she is unable, nursing staff should assist in changing the patient’s position. This will help to prevent the formation of pressure ulcers.

Treatments/Drugs

1. Diuretics Therapy: Diuretics are the first-line treatment for patients with heart failure, and help to relieve the symptoms of shortness of breath and oedema. Furosemide and bumetanide (loop diuretics) work in the loop of Henle by increasing the secretion of sodium and water. The most common adverse effects of these drugs are hypokalaemia (low potassium) and dehydration. Regular monitoring of the patient’s urea and electrolytes is necessary to detect hypokalaemia. This can be treated with amiloride and spironolactone (potassium-sparing diuretics) or potassium supplements. Care should be taken when administering intravenous (IV) furosemide because it may cause tinnitus and deafness if given too quickly. IV infusion of furosemide should be given at a rate of 4mg/minute, however, single bolus dosages up to 50mg can be given more rapidly (British National Formulary (BNF) 2004).

Bendroflumethiazide and Metolazone (thiazides) which act by inhibiting sodium and chloride reabsorption in the distal tubule (Figure 1), which results in increased sodium and water secretion.

amiloride and spironolactone work by increasing sodium and chloride excretion in the distal tubule and cause the retention of potassium. However,

this group of diuretics is relatively weak and is usually prescribed in conjunction with thiazides or loop diuretics.

2. ACE inhibitors: ACE inhibitors such as captopril, ramipril and enalapril work on the renin-angiotensin-aldosterone system. Renin is released from the

kidney in response to a drop in blood pressure, and converts angiotensin I to angiotensin II, a potent vasoconstrictor, and in addition stimulates the release of aldosterone, causing the retention of sodium and water. This leads to an increase in the circulating blood that, in turn, leads to an increase in blood pressure. By inhibiting angiotensin II, the blood pressure is lowered. Caution should be taken when administering ACE inhibitors, especially for the first time, because they can cause a profound drop in blood pressure. It is recommended that a small ‘trial dose’ should be given to the patient to assess the effects of the medication. The patient should be lying down and under close observation with regular monitoring of his or her blood pressure.

3. Beta-blockers:  Beta-blockers such as atenolol, bisoprolol and propranolol were once contraindicated in patients with heart failure. However, medical trials have shown that selective beta-blockers, such as carvedilol, reduce mortality, and, in combination with diuretics and ACE inhibitors, improve the symptoms of left ventricular failure. Beta-receptors are divided into beta I and beta II. Beta I receptors are mainly found in the heart while beta II receptors are found in the lungs and blood vessels. Stimulation of beta I receptors causes an increase in the heart rate and an increase in the force of contraction. Stimulation of beta II receptors causes peripheral and bronchial dilation. Administration of beta-blockers slows the heart rate and reduces oxygen demand.

02 therapy

To ensure safe and effective treatment, oxygen prescriptions should include the flow rate, delivery system, duration and monitoring of treatment. Oxygen can be delivered to treat hypoxaemia (deficiency of oxygen in arterial blood), to decrease the work of breathing or reduce myocardial workload.

Nasal cannulae or nasal prongs are safe and easy to use, disposable, prevent

rebreathing and are comfortable for long periods. Oxygen is delivered through plastic cannulae in the patient’s nostrils. An advantage is that the administration of oxygen can continue while the patient is eating or talking. Nasal cannulae or prongs are less claustrophobic than conventional masks and, as a result, are often well tolerated by patients. It is possible to deliver oxygen percentages of 24-44 per cent at flow rates of 1-6 litres/minute