Dyspnea: A Case for Nursing Diagnosis Status Audrey G. Gift, PhD, RN, Margaret Nield, PhD, RN
Dyspiica. the unpleasant subjective sensition of diffirull hrcatliing. is (IIW ol the most ccimnmn symptom experienced by patients with pullnoila1)- and cardiac disorders. This article reviews the research concerning dyspnea and proposes i t for consideration as a nursing diagnosis. The etiologies are categoiiied according t o the neurosensory. neurocheinicd. cognitive. and affective mechanisms. The defining characteristics include the sihjective words describing dyspnea. such as shortness o f breath, suffocation. and tightness. The most supported objective sign of dyspnca in the literature is an increased use o f accessory muscles o f respiration. Nursing interventions for dyspnea relief are geared toward reducing the afferent activity froni receptors in the respiratoiy muscles and dealing with the affective component of dyspnea. These interventions include pacing activities. breathing techniques, and inducing the relaxation response. Because niost research for interventions to reduce dyspnea have fcxusetl on patients with obstructive lnng disorders who have chronic dy~piiea,recomn~endationsfor further research include using acutely ill patients and those with a variety of medical conditions.
Key Words: dyspnea, nnrsing diagnosis. respiration disorders
I h . Gift is an Associate Professor at the University of Maryland, School of Nursing. She has conduc-trd a number of funded research studies and published both research and clinical papers on the topic o f dyspnea. She is currently Chairperson of the Sert i o n on Nursing of the American Thoracic Society. She has been active in the Council o f Nurse Researchers of the American Nurses’ Association and is a member of NANDA. Nursing diagnoses ai-e an integral part of her teaching of master’s students in Medical-Surgical Nui-sing.
Dr. Nield is a Clinical Nurse Researcher at Sharp Memorial Hospital in San Diego. She also has a n affiliate appointment at the [Jniversity of Washington, School o f Nursing. Her research focuses on dyspnea and the use of inagliirude estimation as a measure in dyspnea research. She is currently (:hairperson-elect of the Section o n Nursing of the American Thoracic Society.
66
Clinicians readily recognize the distressing nature of dyspnea. When dyspnea occurs in an acute, unexpected situation, individuals experience anxiety and fear of impending death. With longstanding (chronic) dyspnea, exercise capabilities are reduced, resulting in diminished activities of daily living and social isolation (Fagerhaugh, 1975; Janson-Bjerklie, Carrieri, & Hudes, 1986; McSweeny, Grant, Heaton, Adams, & Timms, 1982). Clinical nurse researchers are examining dyspnea, both when it occurs acutely and when it occurs constantly and is more chronic in nature. This research is designed to provide a better understanding of the phenomenon and to establish a research base for effective nursing therapies. Dyspnea is not listed as a nursing diagnosis, but there is a growing body of knowledge that warrants its consideration as such. The usual process for validating a diagnosis is to first propose the diagnosis to the North American Nursing Diagnosis Association (NANDA)and have the research follow. It is also possible to recognize the completed research that has established the etiologies and defining characteristics of a significant patient problem and then to label it as a nursing diagnosis. This article reviews the research on dyspnea in the format established for nursing diagnoses and proposes future research directions. Volume 2, Number 2, April/June 1991
The word dyspnea is derived from the Greek roots dys (difficult)and pnoe (breathing), thus providing the definition of dyspnea as difficult breathing (Dirks, 1978; Thomas, 1981). Dyspnea becomes distressing or unpleasant when it occurs in excess to the situation (Campbell & Guz, 1981). It is a subjective sensation, commonly referred to as a symptom, and is distinct from observable signs of respiratory distress, such as increased breathing rate (Comroe, 1974; Delp & Manning, 1981; Means & Barach, 1921). The subjective nature of the experience distinguishes it from the other respiratory nursing diagnoses already approved by NANDA. The respiratory nursing diagnoses are currently included in Taxonomy I under the pattern of Exchanging. However, since dyspnea is the subjective awareness of breathing difficulty, a more appropriate placement would be with the pattern of Feeling. The Feeling pattern already includes diagnoses, such as pain and fatigue, that are similar conceptually to the notion of dyspnea.
Etiologies The etiology of dyspnea continues to be investigated. It is, however, generally accepted that dyspnea and its intensity are related to an increased sense of effort during the inspiratory phase of ventilation (Cherniack, 1988). The etiologies leading to this increased sense of effort may be categorized according to neurosensory, neurochemical, cognitive, and affective components.
Neurosensory The neurosensory component is made up of the afferent signals from either the proprioceptors in the respiratory muscles or the mechanoreceptors in the airways and lungs. Stimulation of the receptors sends impulses to the brain stem which, in turn, sends efferent signals to the respiratory muscles to control the rate and depth of ventilation. Dyspnea depends on the level of motor output to the respiratory muscles and on how closely this motor activity approaches maximal neural activity (Cherniack, 1988). It is uncertain how the cortex becomes aware of the neural discharge, but some have proposed that the cortex Nursing Diagnosis
directly receives a copy of the motor activity of the respiratory muscles (Cherniack, 1988). Mechanical changes in the respiratory muscles may contribute to the perception of dyspnea. For example, the increased work of breathing associated with the increased residual volume and consequent changes in the length/tension of the diaphragm in patients with chronic obstructive pulmonary disease may be associated with the perception of dyspnea. Campbell and Howell (1963) hypothesized that the presence of a mechanical hindrance to breathing (such as abdominal distention or increased trapping of air in the lungs) creates an “inappropriate” relationship between the volume and flow of air actually achieved as compared with the volume and flow of air expected. Perception of a change in this relationship could then contribute to the sensation of dyspnea. Factors stimulating the airway and lung receptors, such as inhaled irritants, contribute to the perception of dyspnea. Janson-Bjerklie and colleagues (1987) demonstrated that inhalations of methacholine producing airflow obstruction in asthmatic patients resulted in the perception of dyspnea. Also, stimulation of lung receptors by fluid in the alveoli produces dyspnea (Cherniack, 1988).
Neurochemical The neurochemical stimulus to dyspnea occurs when changes in blood gases result in stimulation of the chemoreceptors influencing the drive to breathe. Impaired gas exchange resulting in hypoxia or hypercapnia, in a person sensitive to these stimuli, causes increased frequency and depth of breathing and contributes to the perception of dyspnea (Campbell & Guz, 1981). Patients receiving mechanical ventilation report that dyspnea is most often precipitated by nursing therapies such as suctioning (Lush, Janson-Bjerklie, Carrieri, 8c Lovejoy, 1988). This effect is believed to be related to the hypoxia that accompanies suctioning. Pregnant women report shortness of breath resulting from changes in blood gases even before much uterine enlargement has occurred (Weinberger, Weiss, Cohen, Weiss, &Johnson, 1980).
Cognitive People vary in their cognitive or perceptual sensitivity to dyspnea intensity. Those with 67
chronic dyspnea have a reduced sensitivity to breathing loads. such as changes in flow or volume. This finding suggests that an adaptive response occurs with long-standing dyspnea (Nield, Kim, Schneider, & Arias, 1990). This adaptive response appears to be similar to that which occurs with other sensations, but its exact mechanism in dyspnea is utiknown.
Affective Persona experience emotional changes at times of severe dypnea. Gift and colleagues, in studies of patients with acute dyspnea, which occurs suddenly, and chronic dyspnea, which persists for sorne time, observed a higher level of anxie t y when patients reported dyspnea to be most severe (Gift, 1091; G f t 8c Cahill, 1990; Gift, Plaut, 8c Jacox, 1986). These findings are supported by patients reporting a feeling of panic o r anxiety during times o f dyspnea (Brown, Carrieri, Janson-Rjerklie, & Dodd, 1986). Other feelings reported t o occ~irduring dyspnea include fatigue o r being tired. I t is not known whether these affective feelings are etiologies o r consequences, o r whether the\- siniply occur concomitantly with dyspnea.
Medical Diagnoses Associated with Dyspnea Dyspnea occurs in patients with a variety of patiiopli7.'siolo~cconditions. The specific receptors being stimulated to produce dyspnea vary with the condition. Obstructive lung disorders, such as asthma, can result in hyperresponsiveness to inlialed ii-ril ants, mechanical changes in respirat o r y muscles, blood gas changes, and increased anxierr (Gift & Cahill, 1990). Restrictive lung disorc1t.w. such ;is pneumonia o r pulmonary fibrosis, have the potential for stimulating receptors because of fluid in the alveoli. Some pulmonary vascular disorders. such as pulmonary hypertension, produce persistent dyspnea (Janson-Bjerklie et al.. 1986). The reason for dyspnea in these patients is uncertain, but it is probably the result of r i m I oc4ieniicd changes. 1)vsprre'i can be experienced by patients with lung tliseasc: o i cardiac disease, especially when thew i 4 leakage o f fluid into the lung. Dyspnea in patients \ v i t h neiironiuscular disease is most likely the rrsult o f the neurosensory receptors indicat68
ing an imbalance between the ventilatory demand and muscular response. Dyspnea in patients with cancer, anemia, and metabolic acidosis is likely due to neurochemical changes (Cherniack, 1988; Ingram & Braunwald, 1991; Reuben, Mor, & Hiris, 1988).
Defining Characteristics The defining characteristics of a nursing diagnosis are those subjective and objective signs and symptoms manifested by the patient that would indicate that diagnosis.
Subjective Characteristics The most commonly assessed dimension of dyspnea is the intensity of the sensation experienced by the patient. Intensity has mo5t commonly been determined using a visual analogue scale that may be oriented in the horizontal or vertical position. Patients are instructed to dissect a 100-mm line to indicate where along the continuuni from 0 to 100 (with 0 being no dyspnea and 100 being dyspnea as bad as it can be) their present state of dyspnea falls (Gift, 1980). A mark high on the line would indicate severe dyspnea, whereas a mark low on the line would indicate mild dyspnea. In addition to intensity, patients also indicate different subjective qualities of dyspnea. Phrases used by patients to describe dyspnea include shortness o f breath, difficulty breathing, hard to move air, and not getting enough air. I n addition, many report sensations of suffocation, smothering, o r congestion (Dudley, Martin, 8c Holmes, 1968). Those with the medical diagnosis o f asthma are niore likely to report chest tightness UansonBjerklie et al., 1986; Simon, SchwartLstein, Weiss, Fencl, Teghtsoonian, 8c Weinberger, 1990) than those with chronic obstructive pulmonary disease. Patients with lung cancer describe dyspnea as being short of breath, but may also describe chest tightness (Brown et al., 1986). Patients also report feeling the affective symptoms reported earlier, such as anxiety and fatigue. In addition, patients have reported gastrointestinal symptoms, such as abdominal discomfort o r poor appetite, during times of dyspnea (Brown et al., 1986; Gift et al., 1986). Generally research has been limited to subjects with pulmonary o r cardiac disease, such as Volume 2, Number 2, April/June 1991
obstructive lung disorders (asthma, COPD), restrictive lung disease (pneumonia, lung cancer, interstitial lung disease), and pulmonary vascular disorders (pulmonary hypertension). Further research is needed to determine whether these sensations can be considered defining characteristics for all patients with dyspnea. Some descriptors may more likely be associated with one medical condition than another.
Objective Characteristics The literature shows that the most observable or objective sign indicating the presence of dyspnea is an increased use of accessory muscles of respiration. This association has been documented by noting significantly more use of the accessory muscles of respiration in the neck at times when the patient reports dyspnea to be high than when it is reported to be mild (Gift, 1991; Gift & Cahill, 1990; Gift et al., 1986). This research is supported by the controlled experiments of Efthimiou and colleagues (1987) in which 34 patients who had severe respiratory disease were examined during an acute dyspneic episode and were found to have marked fatigue in the sternomastoid muscle. Rapid breathing rate may be another characteristic associated with the presence of dyspnea, but the research is contradictory. Respiratory rate decreases when dyspnea is decreased as a result of relaxation techniques (Renfoe, 1988). When dyspnea is decreased as a result of pharmacologic treatment, no significant change in respiratory rate is found (Gift & Cahill, 1990; Gift et al., 1986). More research is needed to document the usefulness of this objective sign as a defining characteristic of dyspnea. A final objective characteristic is pulse rate, which has been shown to be high in asthmatic patients during acute, sudden attacks of dyspnea and significantly lower in the same patients when dyspnea is reported to be mild or absent (Gift, 1991). This sign has not been included in other studies of dyspnea.
ception of excessive respiratory effort. If the sense of respiratory effort is further conceptualized as a balance between afferent stimuli to the central nervous system and efferent activity of respiratory neurons, it seems reasonable to conclude that interventions that reduce the afferent activity could alter the perception of effort and reduce the dyspnea. Energy conservation, positioning, and breathing strategies, such as pursed lip breathing, and relaxation, are interventions that are likely to reduce the afferent activity. These interventions may be initiated by the patient through a trial-anderror process, or they may be initiated by the nurse. The usefulness of energy conservation techniques during activities of daily living for patients with dyspnea has been reported by nurse researchers using a qualitative research approach (Carrieri & Janson-Bjerklie, 1986; Fagerhaugh, 1973). The research reinforces the appropriateness of pacing, slow movement, and sequencing of activities when the nurse is planning care with the patient. Positioning may reduce dyspnea in patients with severe COPD. A leaning forward position and also, for some, a supine position reduces dyspnea. Dyspnea relief is associated with decreased use of inspiratory and accessory rib-cage muscles (and, therefore, decreased afferent input from the excessive use of these muscles to the respiratory center) and enhanced diaphragm efficiency (Sharp, Druz, Moisan, Foster, & Machnack, 1980). A breathing strategy for patients with obstructive lung disease is pursed lip breathing. Pursing the lips during exhalation slows the rate of breathing. The advantage of the technique is dyspnea relief and temporary improvement of arterial blood gas values (Mueller, Petty, & Filley, 1970; Thoman, Stoker, & Ross, 1965). Lastly, another nurse-initiated strategy is relaxation. Renfroe (1988) used progressive muscle relaxation to reduce dyspnea and anxiety in patients with stable COPD. The researcher established the link between the relaxation response and dyspnea relief on a short-term basis.
Further Directions for Research Nursing Interventions Dyspnea, which has physiologic and affective components, requires a multifaceted nursing approach. First, dyspnea may be thought of as perNursing Diagnosis
Much research is still needed to assist nurses in the care of patients with dyspnea. Nursing management of the dyspneic patient includes the identification of those at risk for the diagnosis, recording the presence of dyspnea in patients, noting the 69
iptors used, identifying clinical signs, and evaluating nursing in tei-vent ions. The nurse should keep in mind that the suggested list of patients most at risk for experiencing dyspnea is only a begiiining. The list requires expansion as additional dyspneic patients are encountered ill the clinical area. The descriptors rrseti as sut,jective defining characteristics 1iei-e \ alitiated from research involving only a small portion o f the dyspneic population. I t is not k n m ~ tvhether i other dyspneic patients ~ i o u l duse the miie dtlscriptors. Nurses must listen to the desi riptors offered Iiy patients, document them in thc patient ctiart, and perfor-in the research necessari t o have them added to the list of subjective ch;w;icterist ic.s. Since tiyspnea is a subjective symptom, it is uncertain \chether there can be an objective indicator that would be present in all dyspneic patients. M o s t of the research indicating accessoi? musclc use as an indicator of dpspnea was done k v i t l i patients with obstructive lung disease. More tcsearch is needed to determine whether i t is present \\hen dyspnea occurs for other- reasons. For instance, do patients Jvitli neuromuscular disease and clyspnea also exhibit increased use of accessorv iiiuscles for respiration? If not, what would be an objective indicator of dyspnea in this gi-oup o f pat ic n t s ? Little research has been done to document iiuiing actiC)ns that are effective in the reduction of ctx spnea intensity, but research comparing nui sing nianagenient of patients ivith COPD with niaiiagemerit h!. other professionals found dyspnt'.i reduction significantly better in the nurseirim;igecl patients (Rosser et al., 1983).The nurse t ;I 1i gh t the pat i e n t to initiate self- in anage me 11t tec.liriiqurs, such as the pacing of activities to avoid dvsl)11ea and u s in g dee p breathing t ec 11n ique s . _. I hew techniques were more effective in decreasing ctvspnea than techniques used by other professioii,ils. lhe strategies patients report to be effecti\.e in tlvapnea nianagernent range from simple techniques. such ;ts repositioning, to more complex t c~ctririques,s~iclias learning pursed-lip breathing (I31-cin.11et d . , 1986; Carrieri 11. Janson-Bjerklie, 19Mi). Changing to a slower- pace in activities of ciail> living and making use of assistive devices have been effective in coping with dyspnea. Patients also report using emotional strategtes, such as a\ oiding stress, avoiding being alone, and diver70
sion. This research, however, has been limited to patients with lung cancer and those with obstructive lung disorders who experience chronic dyspnea. Some of the strategies are not possible with acutely ill patients. Those that might be possible, such as relaxation techniques, must be tested in an acutely ill population. It seems likely that strategies to promote energy conservation o r slow breathing patterns would be likely t o reduce the efferent activity from the respirator): center in the brain stern and reduce the intensity of the perception of dyspnea. These strategies and others that have a similar effect must be tested for their effectiveness in reducing dyspnea. Research is also needed t o determine whether multiple strategies based on the physiologic and affective components of dyspnea \vill be more effective if used together. A variety of dyspneic patients must be included in such research t o develop an appropriate research base for nursing nianagenient of dyspnea.
Summary Dpspnea is the subjective sensation of difficult breathing that can occur in patients with a variety o f pulnionarj~problems, cardiac disease, and cancer, as well as other conditions. It is a significant patient problem encountered by nurses in a variety of settings. Etiologies of dyspnea can be classified as neurosensory, neurocheniical, cognitive, or affective in origin. Subjective characteristics have been documented by researchers who have asked patients to describe the sensation of dyspnea and the accompanying feelings. The objective characteristic most supported in the literature is the increased use of accessory muscles of respiration. The nursing interventions reconimended are based on research in which patients described dyspnea reduction strategies, such as using a slower pace when walking o r talking with slower, longer breaths. Although there is still much research to be clone, the data available at this time form the basis for the etiologies, defining characteristics, and nursing interventions. The accumulated data also provides direction for further testing of this significant patient problem.
References B r o m , '11.L. Carrieri, V., Janson-Bjerklie, S . , & Dodd, M.J. (1 986). Lung cancer and dyspnea: The Volume 2, Number 2, April/June 1991
patient’s perception. Oncology Nursing Forum, 13(5),19-24. Campbell, E.J.M. & Guz, A. (1981). Breathlessness. In T.F. Hornbein (Ed.), Regulation of breathing (pp. 118 1-1 192). New York: Mercel Dekker. Campbell, E.J.M. & Howell, J.B.L. (1963). The sensation of breathlessness. British Medical Bulletin, 19, 36-40. Carrieri, V.K. & Janson-Bjerklie, S. (1986). Strategies patients use to manage the sensation of dyspnea. WesternJournal of Nursing Research, 8, 284-305. Cherniack, N.S. (1988). Dyspnea. In J.E. Murray & J.A. Nadel (Eds.), Textbook of respiratory medicine (pp. 389-396). Philadelphia: Saunders. Comroe, J.H. (1974). Physiology of respiration. (2nd ed.). Chicago: Year Book Medical Publishers. Delp, M.H. & Manning, R.T. (1981). Major’s physical diagnosis: An introduction to the clinical process, (9th ed.). Chicago: Year Book Medical Publishers. Dirks, J.F. (1978). Denotation of dyspnea. Journal of the American Medical Association, 240, 2 1-22. Dudley, D.L., Martin, C.J., & Holmes, T.H. (1968). Dyspnea: Psychologic and physiologic observations. Journal of Psychosomatic Research, 11, 325339. Efthimiou, J., Fleming, J., & Spiro, S.G. (1987). Sternomastoid muscle function and fatigue in breathless patients with severe respiratory disease. American Review ofRespiratory Disease, 136, 1099-1 105. Fagerhaugh, S.Y. (1973). Getting around with emphysema. American Journal of Nursing, 73, 94-99. Gift, A.G. (1989). Dyspnea assessment guide. Critical Care Nurse, 9(8),79-88. Gift, A.G. (1991). Psychologic and physiologic aspects of acute dyspnea in asthmatics. Nursing Research, (in press). Gift, A.G., & Cahill, C. (1990). Psychologic aspects of dyspnea in chronic obstructive pulmonary disease: A pilot study. Heart €9Lung, 19, 252-257. Gift, A.G., Plaut, S.M., & Jacox, A.K. (1986). Psychologic and physiologic factors related to dyspnea in subjects with chronic obstructive pulmonary disease. Heart &Lung, 15, 595-601. Ingram, R.H., & Braunwald, E. (1991). Dyspnea and pulmonary edema. In G.W. Thorn (Ed.), Harrison’.$Principles of Intern1 Medicine, (pp. 220-224). New York: McGraw-Hill. Janson-Bjerklie, S., Ruma, S.S., Stulbarg, M., & Carrieri, V.K. (1987). Predictors of dyspnea intensity in asthma. Nursing Research, 36, 179-183. Janson-Bjerklie, S., Carrieri, V.K., & Hudes, M. (1986). The sensations of pulmonary dyspnea. Nursing Research, 35, 154-1 59.
Nursing Diagnosis
Lush, M.T., Janson-Bjerklie, S., Carrieri, V.K., & Lovejoy, N. (1988). Dyspnea in the ventilator-assisted patient. Heart &Lung, 17, 528-535. McSweeney, J., Grant, I., Heaton, R.K., Adams, K.A., & Timms, R.M. (1982). Life quality of patients with chronic obstructive pulmonary disease. Archives of Internal Medicine, 142, 473-478. Means, J.H., & Barach, A.L. (1921). The symptomatic treatment of pneumonia. The Journal of the American Medical Association, 77, 1217-1 223. Mueller, R.E., Petty, T.L., & Filley, G.F. (1970). Ventilation and arterial blood gas changes induced by pursed lips breathing. Journal of Applied PhysiolO ~ Y , 28, 784-789. Nield, M.A., Kim, M.J., Schneider, L., & Arias, A.I. (1990). Dyspnea and muscle function in sarcoidosis and COPD. American Review of Respiratory Disease, 141, A324. Renfoe, K.L. (1988). Effect of progressive relaxation on dyspnea and state anxiety in patients with chronic obstructive pulmonary disease. Heart @ Lung, 17, 408-413. Reuben, D.B., Mor, V., & Hiris, J. (1988). Clinical symptoms and length of survival in patients with terminal cancer. Archives of lnternul Medicine, 148, 1586-1591. Rosser, R., Denford, J., Heslop, A., Kinston, W., Macklin, D., Minty, K., Moynigan, C., Muir, B., Rein, L., & Guz, A. (1983). Breathlessness and psychiatric morbidity in chronic bronchitis and emphysema: A study of psychotherapeutic management. Psychological Medicine, l?, 93-1 10. Simon, P.M., Schwartzstein, R.M., Weiss, J.W., Fencl, V., Teghtsoonian, & Weinberger, S. (1990). Distinguishable types of dyspnea in patients with shortness of breath. American Review of Respiratory Disease, 142, 1009-1014. Sharp, J.T., Druz, W.S., Mnisan, T., Foster, J., & Machnack, W. (1980). Postural relief of dyspnea in severe chronic obstructive pulmonary disease. American Review of Respiratory Disease, 122, 201211. Thoman, R.L., Stoker, G.L., & Ross, J.C. (1965). The efficacy of pursed-lips breathing in patients with chronic obstructive pulmonary disease. American Review of Respiratory Disease, 93, 100-106. Thomas, C.L. (1981). Taber’s Cyclopedic Medical Dictionary, (14th ed.). Philadelphia: F.A. Davis. Weinberger, S.E., Weiss, S.T., Cohen, W.R., Weiss, J.W., &Johnson, T.S. (1980). State of the art: Pregnancy and lung. American Review of Respiratory Disease, 121, 559-577.
71
Dyspiica. the unpleasant subjective sensition of diffirull hrcatliing. is (IIW ol the most ccimnmn symptom experienced by patients with pullnoila1)- and cardiac disorders. This article reviews the research concerning dyspnea and proposes i t for consideration as a nursing diagnosis. The etiologies are categoiiied according t o the neurosensory. neurocheinicd. cognitive. and affective mechanisms. The defining characteristics include the sihjective words describing dyspnea. such as shortness o f breath, suffocation. and tightness. The most supported objective sign of dyspnca in the literature is an increased use o f accessory muscles o f respiration. Nursing interventions for dyspnea relief are geared toward reducing the afferent activity froni receptors in the respiratoiy muscles and dealing with the affective component of dyspnea. These interventions include pacing activities. breathing techniques, and inducing the relaxation response. Because niost research for interventions to reduce dyspnea have fcxusetl on patients with obstructive lnng disorders who have chronic dy~piiea,recomn~endationsfor further research include using acutely ill patients and those with a variety of medical conditions.
Key Words: dyspnea, nnrsing diagnosis. respiration disorders
I h . Gift is an Associate Professor at the University of Maryland, School of Nursing. She has conduc-trd a number of funded research studies and published both research and clinical papers on the topic o f dyspnea. She is currently Chairperson of the Sert i o n on Nursing of the American Thoracic Society. She has been active in the Council o f Nurse Researchers of the American Nurses’ Association and is a member of NANDA. Nursing diagnoses ai-e an integral part of her teaching of master’s students in Medical-Surgical Nui-sing.
Dr. Nield is a Clinical Nurse Researcher at Sharp Memorial Hospital in San Diego. She also has a n affiliate appointment at the [Jniversity of Washington, School o f Nursing. Her research focuses on dyspnea and the use of inagliirude estimation as a measure in dyspnea research. She is currently (:hairperson-elect of the Section o n Nursing of the American Thoracic Society.
66
Clinicians readily recognize the distressing nature of dyspnea. When dyspnea occurs in an acute, unexpected situation, individuals experience anxiety and fear of impending death. With longstanding (chronic) dyspnea, exercise capabilities are reduced, resulting in diminished activities of daily living and social isolation (Fagerhaugh, 1975; Janson-Bjerklie, Carrieri, & Hudes, 1986; McSweeny, Grant, Heaton, Adams, & Timms, 1982). Clinical nurse researchers are examining dyspnea, both when it occurs acutely and when it occurs constantly and is more chronic in nature. This research is designed to provide a better understanding of the phenomenon and to establish a research base for effective nursing therapies. Dyspnea is not listed as a nursing diagnosis, but there is a growing body of knowledge that warrants its consideration as such. The usual process for validating a diagnosis is to first propose the diagnosis to the North American Nursing Diagnosis Association (NANDA)and have the research follow. It is also possible to recognize the completed research that has established the etiologies and defining characteristics of a significant patient problem and then to label it as a nursing diagnosis. This article reviews the research on dyspnea in the format established for nursing diagnoses and proposes future research directions. Volume 2, Number 2, April/June 1991
The word dyspnea is derived from the Greek roots dys (difficult)and pnoe (breathing), thus providing the definition of dyspnea as difficult breathing (Dirks, 1978; Thomas, 1981). Dyspnea becomes distressing or unpleasant when it occurs in excess to the situation (Campbell & Guz, 1981). It is a subjective sensation, commonly referred to as a symptom, and is distinct from observable signs of respiratory distress, such as increased breathing rate (Comroe, 1974; Delp & Manning, 1981; Means & Barach, 1921). The subjective nature of the experience distinguishes it from the other respiratory nursing diagnoses already approved by NANDA. The respiratory nursing diagnoses are currently included in Taxonomy I under the pattern of Exchanging. However, since dyspnea is the subjective awareness of breathing difficulty, a more appropriate placement would be with the pattern of Feeling. The Feeling pattern already includes diagnoses, such as pain and fatigue, that are similar conceptually to the notion of dyspnea.
Etiologies The etiology of dyspnea continues to be investigated. It is, however, generally accepted that dyspnea and its intensity are related to an increased sense of effort during the inspiratory phase of ventilation (Cherniack, 1988). The etiologies leading to this increased sense of effort may be categorized according to neurosensory, neurochemical, cognitive, and affective components.
Neurosensory The neurosensory component is made up of the afferent signals from either the proprioceptors in the respiratory muscles or the mechanoreceptors in the airways and lungs. Stimulation of the receptors sends impulses to the brain stem which, in turn, sends efferent signals to the respiratory muscles to control the rate and depth of ventilation. Dyspnea depends on the level of motor output to the respiratory muscles and on how closely this motor activity approaches maximal neural activity (Cherniack, 1988). It is uncertain how the cortex becomes aware of the neural discharge, but some have proposed that the cortex Nursing Diagnosis
directly receives a copy of the motor activity of the respiratory muscles (Cherniack, 1988). Mechanical changes in the respiratory muscles may contribute to the perception of dyspnea. For example, the increased work of breathing associated with the increased residual volume and consequent changes in the length/tension of the diaphragm in patients with chronic obstructive pulmonary disease may be associated with the perception of dyspnea. Campbell and Howell (1963) hypothesized that the presence of a mechanical hindrance to breathing (such as abdominal distention or increased trapping of air in the lungs) creates an “inappropriate” relationship between the volume and flow of air actually achieved as compared with the volume and flow of air expected. Perception of a change in this relationship could then contribute to the sensation of dyspnea. Factors stimulating the airway and lung receptors, such as inhaled irritants, contribute to the perception of dyspnea. Janson-Bjerklie and colleagues (1987) demonstrated that inhalations of methacholine producing airflow obstruction in asthmatic patients resulted in the perception of dyspnea. Also, stimulation of lung receptors by fluid in the alveoli produces dyspnea (Cherniack, 1988).
Neurochemical The neurochemical stimulus to dyspnea occurs when changes in blood gases result in stimulation of the chemoreceptors influencing the drive to breathe. Impaired gas exchange resulting in hypoxia or hypercapnia, in a person sensitive to these stimuli, causes increased frequency and depth of breathing and contributes to the perception of dyspnea (Campbell & Guz, 1981). Patients receiving mechanical ventilation report that dyspnea is most often precipitated by nursing therapies such as suctioning (Lush, Janson-Bjerklie, Carrieri, 8c Lovejoy, 1988). This effect is believed to be related to the hypoxia that accompanies suctioning. Pregnant women report shortness of breath resulting from changes in blood gases even before much uterine enlargement has occurred (Weinberger, Weiss, Cohen, Weiss, &Johnson, 1980).
Cognitive People vary in their cognitive or perceptual sensitivity to dyspnea intensity. Those with 67
chronic dyspnea have a reduced sensitivity to breathing loads. such as changes in flow or volume. This finding suggests that an adaptive response occurs with long-standing dyspnea (Nield, Kim, Schneider, & Arias, 1990). This adaptive response appears to be similar to that which occurs with other sensations, but its exact mechanism in dyspnea is utiknown.
Affective Persona experience emotional changes at times of severe dypnea. Gift and colleagues, in studies of patients with acute dyspnea, which occurs suddenly, and chronic dyspnea, which persists for sorne time, observed a higher level of anxie t y when patients reported dyspnea to be most severe (Gift, 1091; G f t 8c Cahill, 1990; Gift, Plaut, 8c Jacox, 1986). These findings are supported by patients reporting a feeling of panic o r anxiety during times o f dyspnea (Brown, Carrieri, Janson-Rjerklie, & Dodd, 1986). Other feelings reported t o occ~irduring dyspnea include fatigue o r being tired. I t is not known whether these affective feelings are etiologies o r consequences, o r whether the\- siniply occur concomitantly with dyspnea.
Medical Diagnoses Associated with Dyspnea Dyspnea occurs in patients with a variety of patiiopli7.'siolo~cconditions. The specific receptors being stimulated to produce dyspnea vary with the condition. Obstructive lung disorders, such as asthma, can result in hyperresponsiveness to inlialed ii-ril ants, mechanical changes in respirat o r y muscles, blood gas changes, and increased anxierr (Gift & Cahill, 1990). Restrictive lung disorc1t.w. such ;is pneumonia o r pulmonary fibrosis, have the potential for stimulating receptors because of fluid in the alveoli. Some pulmonary vascular disorders. such as pulmonary hypertension, produce persistent dyspnea (Janson-Bjerklie et al.. 1986). The reason for dyspnea in these patients is uncertain, but it is probably the result of r i m I oc4ieniicd changes. 1)vsprre'i can be experienced by patients with lung tliseasc: o i cardiac disease, especially when thew i 4 leakage o f fluid into the lung. Dyspnea in patients \ v i t h neiironiuscular disease is most likely the rrsult o f the neurosensory receptors indicat68
ing an imbalance between the ventilatory demand and muscular response. Dyspnea in patients with cancer, anemia, and metabolic acidosis is likely due to neurochemical changes (Cherniack, 1988; Ingram & Braunwald, 1991; Reuben, Mor, & Hiris, 1988).
Defining Characteristics The defining characteristics of a nursing diagnosis are those subjective and objective signs and symptoms manifested by the patient that would indicate that diagnosis.
Subjective Characteristics The most commonly assessed dimension of dyspnea is the intensity of the sensation experienced by the patient. Intensity has mo5t commonly been determined using a visual analogue scale that may be oriented in the horizontal or vertical position. Patients are instructed to dissect a 100-mm line to indicate where along the continuuni from 0 to 100 (with 0 being no dyspnea and 100 being dyspnea as bad as it can be) their present state of dyspnea falls (Gift, 1980). A mark high on the line would indicate severe dyspnea, whereas a mark low on the line would indicate mild dyspnea. In addition to intensity, patients also indicate different subjective qualities of dyspnea. Phrases used by patients to describe dyspnea include shortness o f breath, difficulty breathing, hard to move air, and not getting enough air. I n addition, many report sensations of suffocation, smothering, o r congestion (Dudley, Martin, 8c Holmes, 1968). Those with the medical diagnosis o f asthma are niore likely to report chest tightness UansonBjerklie et al., 1986; Simon, SchwartLstein, Weiss, Fencl, Teghtsoonian, 8c Weinberger, 1990) than those with chronic obstructive pulmonary disease. Patients with lung cancer describe dyspnea as being short of breath, but may also describe chest tightness (Brown et al., 1986). Patients also report feeling the affective symptoms reported earlier, such as anxiety and fatigue. In addition, patients have reported gastrointestinal symptoms, such as abdominal discomfort o r poor appetite, during times of dyspnea (Brown et al., 1986; Gift et al., 1986). Generally research has been limited to subjects with pulmonary o r cardiac disease, such as Volume 2, Number 2, April/June 1991
obstructive lung disorders (asthma, COPD), restrictive lung disease (pneumonia, lung cancer, interstitial lung disease), and pulmonary vascular disorders (pulmonary hypertension). Further research is needed to determine whether these sensations can be considered defining characteristics for all patients with dyspnea. Some descriptors may more likely be associated with one medical condition than another.
Objective Characteristics The literature shows that the most observable or objective sign indicating the presence of dyspnea is an increased use of accessory muscles of respiration. This association has been documented by noting significantly more use of the accessory muscles of respiration in the neck at times when the patient reports dyspnea to be high than when it is reported to be mild (Gift, 1991; Gift & Cahill, 1990; Gift et al., 1986). This research is supported by the controlled experiments of Efthimiou and colleagues (1987) in which 34 patients who had severe respiratory disease were examined during an acute dyspneic episode and were found to have marked fatigue in the sternomastoid muscle. Rapid breathing rate may be another characteristic associated with the presence of dyspnea, but the research is contradictory. Respiratory rate decreases when dyspnea is decreased as a result of relaxation techniques (Renfoe, 1988). When dyspnea is decreased as a result of pharmacologic treatment, no significant change in respiratory rate is found (Gift & Cahill, 1990; Gift et al., 1986). More research is needed to document the usefulness of this objective sign as a defining characteristic of dyspnea. A final objective characteristic is pulse rate, which has been shown to be high in asthmatic patients during acute, sudden attacks of dyspnea and significantly lower in the same patients when dyspnea is reported to be mild or absent (Gift, 1991). This sign has not been included in other studies of dyspnea.
ception of excessive respiratory effort. If the sense of respiratory effort is further conceptualized as a balance between afferent stimuli to the central nervous system and efferent activity of respiratory neurons, it seems reasonable to conclude that interventions that reduce the afferent activity could alter the perception of effort and reduce the dyspnea. Energy conservation, positioning, and breathing strategies, such as pursed lip breathing, and relaxation, are interventions that are likely to reduce the afferent activity. These interventions may be initiated by the patient through a trial-anderror process, or they may be initiated by the nurse. The usefulness of energy conservation techniques during activities of daily living for patients with dyspnea has been reported by nurse researchers using a qualitative research approach (Carrieri & Janson-Bjerklie, 1986; Fagerhaugh, 1973). The research reinforces the appropriateness of pacing, slow movement, and sequencing of activities when the nurse is planning care with the patient. Positioning may reduce dyspnea in patients with severe COPD. A leaning forward position and also, for some, a supine position reduces dyspnea. Dyspnea relief is associated with decreased use of inspiratory and accessory rib-cage muscles (and, therefore, decreased afferent input from the excessive use of these muscles to the respiratory center) and enhanced diaphragm efficiency (Sharp, Druz, Moisan, Foster, & Machnack, 1980). A breathing strategy for patients with obstructive lung disease is pursed lip breathing. Pursing the lips during exhalation slows the rate of breathing. The advantage of the technique is dyspnea relief and temporary improvement of arterial blood gas values (Mueller, Petty, & Filley, 1970; Thoman, Stoker, & Ross, 1965). Lastly, another nurse-initiated strategy is relaxation. Renfroe (1988) used progressive muscle relaxation to reduce dyspnea and anxiety in patients with stable COPD. The researcher established the link between the relaxation response and dyspnea relief on a short-term basis.
Further Directions for Research Nursing Interventions Dyspnea, which has physiologic and affective components, requires a multifaceted nursing approach. First, dyspnea may be thought of as perNursing Diagnosis
Much research is still needed to assist nurses in the care of patients with dyspnea. Nursing management of the dyspneic patient includes the identification of those at risk for the diagnosis, recording the presence of dyspnea in patients, noting the 69
iptors used, identifying clinical signs, and evaluating nursing in tei-vent ions. The nurse should keep in mind that the suggested list of patients most at risk for experiencing dyspnea is only a begiiining. The list requires expansion as additional dyspneic patients are encountered ill the clinical area. The descriptors rrseti as sut,jective defining characteristics 1iei-e \ alitiated from research involving only a small portion o f the dyspneic population. I t is not k n m ~ tvhether i other dyspneic patients ~ i o u l duse the miie dtlscriptors. Nurses must listen to the desi riptors offered Iiy patients, document them in thc patient ctiart, and perfor-in the research necessari t o have them added to the list of subjective ch;w;icterist ic.s. Since tiyspnea is a subjective symptom, it is uncertain \chether there can be an objective indicator that would be present in all dyspneic patients. M o s t of the research indicating accessoi? musclc use as an indicator of dpspnea was done k v i t l i patients with obstructive lung disease. More tcsearch is needed to determine whether i t is present \\hen dyspnea occurs for other- reasons. For instance, do patients Jvitli neuromuscular disease and clyspnea also exhibit increased use of accessorv iiiuscles for respiration? If not, what would be an objective indicator of dyspnea in this gi-oup o f pat ic n t s ? Little research has been done to document iiuiing actiC)ns that are effective in the reduction of ctx spnea intensity, but research comparing nui sing nianagenient of patients ivith COPD with niaiiagemerit h!. other professionals found dyspnt'.i reduction significantly better in the nurseirim;igecl patients (Rosser et al., 1983).The nurse t ;I 1i gh t the pat i e n t to initiate self- in anage me 11t tec.liriiqurs, such as the pacing of activities to avoid dvsl)11ea and u s in g dee p breathing t ec 11n ique s . _. I hew techniques were more effective in decreasing ctvspnea than techniques used by other professioii,ils. lhe strategies patients report to be effecti\.e in tlvapnea nianagernent range from simple techniques. such ;ts repositioning, to more complex t c~ctririques,s~iclias learning pursed-lip breathing (I31-cin.11et d . , 1986; Carrieri 11. Janson-Bjerklie, 19Mi). Changing to a slower- pace in activities of ciail> living and making use of assistive devices have been effective in coping with dyspnea. Patients also report using emotional strategtes, such as a\ oiding stress, avoiding being alone, and diver70
sion. This research, however, has been limited to patients with lung cancer and those with obstructive lung disorders who experience chronic dyspnea. Some of the strategies are not possible with acutely ill patients. Those that might be possible, such as relaxation techniques, must be tested in an acutely ill population. It seems likely that strategies to promote energy conservation o r slow breathing patterns would be likely t o reduce the efferent activity from the respirator): center in the brain stern and reduce the intensity of the perception of dyspnea. These strategies and others that have a similar effect must be tested for their effectiveness in reducing dyspnea. Research is also needed t o determine whether multiple strategies based on the physiologic and affective components of dyspnea \vill be more effective if used together. A variety of dyspneic patients must be included in such research t o develop an appropriate research base for nursing nianagenient of dyspnea.
Summary Dpspnea is the subjective sensation of difficult breathing that can occur in patients with a variety o f pulnionarj~problems, cardiac disease, and cancer, as well as other conditions. It is a significant patient problem encountered by nurses in a variety of settings. Etiologies of dyspnea can be classified as neurosensory, neurocheniical, cognitive, or affective in origin. Subjective characteristics have been documented by researchers who have asked patients to describe the sensation of dyspnea and the accompanying feelings. The objective characteristic most supported in the literature is the increased use of accessory muscles of respiration. The nursing interventions reconimended are based on research in which patients described dyspnea reduction strategies, such as using a slower pace when walking o r talking with slower, longer breaths. Although there is still much research to be clone, the data available at this time form the basis for the etiologies, defining characteristics, and nursing interventions. The accumulated data also provides direction for further testing of this significant patient problem.
References B r o m , '11.L. Carrieri, V., Janson-Bjerklie, S . , & Dodd, M.J. (1 986). Lung cancer and dyspnea: The Volume 2, Number 2, April/June 1991
patient’s perception. Oncology Nursing Forum, 13(5),19-24. Campbell, E.J.M. & Guz, A. (1981). Breathlessness. In T.F. Hornbein (Ed.), Regulation of breathing (pp. 118 1-1 192). New York: Mercel Dekker. Campbell, E.J.M. & Howell, J.B.L. (1963). The sensation of breathlessness. British Medical Bulletin, 19, 36-40. Carrieri, V.K. & Janson-Bjerklie, S. (1986). Strategies patients use to manage the sensation of dyspnea. WesternJournal of Nursing Research, 8, 284-305. Cherniack, N.S. (1988). Dyspnea. In J.E. Murray & J.A. Nadel (Eds.), Textbook of respiratory medicine (pp. 389-396). Philadelphia: Saunders. Comroe, J.H. (1974). Physiology of respiration. (2nd ed.). Chicago: Year Book Medical Publishers. Delp, M.H. & Manning, R.T. (1981). Major’s physical diagnosis: An introduction to the clinical process, (9th ed.). Chicago: Year Book Medical Publishers. Dirks, J.F. (1978). Denotation of dyspnea. Journal of the American Medical Association, 240, 2 1-22. Dudley, D.L., Martin, C.J., & Holmes, T.H. (1968). Dyspnea: Psychologic and physiologic observations. Journal of Psychosomatic Research, 11, 325339. Efthimiou, J., Fleming, J., & Spiro, S.G. (1987). Sternomastoid muscle function and fatigue in breathless patients with severe respiratory disease. American Review ofRespiratory Disease, 136, 1099-1 105. Fagerhaugh, S.Y. (1973). Getting around with emphysema. American Journal of Nursing, 73, 94-99. Gift, A.G. (1989). Dyspnea assessment guide. Critical Care Nurse, 9(8),79-88. Gift, A.G. (1991). Psychologic and physiologic aspects of acute dyspnea in asthmatics. Nursing Research, (in press). Gift, A.G., & Cahill, C. (1990). Psychologic aspects of dyspnea in chronic obstructive pulmonary disease: A pilot study. Heart €9Lung, 19, 252-257. Gift, A.G., Plaut, S.M., & Jacox, A.K. (1986). Psychologic and physiologic factors related to dyspnea in subjects with chronic obstructive pulmonary disease. Heart &Lung, 15, 595-601. Ingram, R.H., & Braunwald, E. (1991). Dyspnea and pulmonary edema. In G.W. Thorn (Ed.), Harrison’.$Principles of Intern1 Medicine, (pp. 220-224). New York: McGraw-Hill. Janson-Bjerklie, S., Ruma, S.S., Stulbarg, M., & Carrieri, V.K. (1987). Predictors of dyspnea intensity in asthma. Nursing Research, 36, 179-183. Janson-Bjerklie, S., Carrieri, V.K., & Hudes, M. (1986). The sensations of pulmonary dyspnea. Nursing Research, 35, 154-1 59.
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Lush, M.T., Janson-Bjerklie, S., Carrieri, V.K., & Lovejoy, N. (1988). Dyspnea in the ventilator-assisted patient. Heart &Lung, 17, 528-535. McSweeney, J., Grant, I., Heaton, R.K., Adams, K.A., & Timms, R.M. (1982). Life quality of patients with chronic obstructive pulmonary disease. Archives of Internal Medicine, 142, 473-478. Means, J.H., & Barach, A.L. (1921). The symptomatic treatment of pneumonia. The Journal of the American Medical Association, 77, 1217-1 223. Mueller, R.E., Petty, T.L., & Filley, G.F. (1970). Ventilation and arterial blood gas changes induced by pursed lips breathing. Journal of Applied PhysiolO ~ Y , 28, 784-789. Nield, M.A., Kim, M.J., Schneider, L., & Arias, A.I. (1990). Dyspnea and muscle function in sarcoidosis and COPD. American Review of Respiratory Disease, 141, A324. Renfoe, K.L. (1988). Effect of progressive relaxation on dyspnea and state anxiety in patients with chronic obstructive pulmonary disease. Heart @ Lung, 17, 408-413. Reuben, D.B., Mor, V., & Hiris, J. (1988). Clinical symptoms and length of survival in patients with terminal cancer. Archives of lnternul Medicine, 148, 1586-1591. Rosser, R., Denford, J., Heslop, A., Kinston, W., Macklin, D., Minty, K., Moynigan, C., Muir, B., Rein, L., & Guz, A. (1983). Breathlessness and psychiatric morbidity in chronic bronchitis and emphysema: A study of psychotherapeutic management. Psychological Medicine, l?, 93-1 10. Simon, P.M., Schwartzstein, R.M., Weiss, J.W., Fencl, V., Teghtsoonian, & Weinberger, S. (1990). Distinguishable types of dyspnea in patients with shortness of breath. American Review of Respiratory Disease, 142, 1009-1014. Sharp, J.T., Druz, W.S., Mnisan, T., Foster, J., & Machnack, W. (1980). Postural relief of dyspnea in severe chronic obstructive pulmonary disease. American Review of Respiratory Disease, 122, 201211. Thoman, R.L., Stoker, G.L., & Ross, J.C. (1965). The efficacy of pursed-lips breathing in patients with chronic obstructive pulmonary disease. American Review of Respiratory Disease, 93, 100-106. Thomas, C.L. (1981). Taber’s Cyclopedic Medical Dictionary, (14th ed.). Philadelphia: F.A. Davis. Weinberger, S.E., Weiss, S.T., Cohen, W.R., Weiss, J.W., &Johnson, T.S. (1980). State of the art: Pregnancy and lung. American Review of Respiratory Disease, 121, 559-577.
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