Dyspnea: Nursing Diagnoses, Care Plans, Assessment & Interventions

Dyspnea, often called shortness of breath (SOB), describes difficult or labored breathing, often with an increased respiratory rate. Shortness of breath is the feeling of running out of breath and not being able to breathe in and out deeply or quickly enough. Someone may describe it as being unable to “catch their breath.”

Dyspnea is not a disease but a symptom and can be acute or chronic, depending on the causative factor. Possible factors include:

• Body positions that prevent lung expansion
• Presence of bronchial secretions
• Immobility
• Respiratory muscle fatigue
• Hyperventilation
• Obesity
• History of smoking
• Conditions that may obstruct the airway or impair gas exchange
• Fluid buildup in the heart or lungs

In this article:

• Nursing Process
• Nursing Assessment
  • Review of Health History
  • Physical Assessment
  • Diagnostic Procedures
  • Anxiety
  • Impaired Gas Exchange
  • Impaired Spontaneous Ventilation
  • Ineffective Airway Clearance
  • Ineffective Breathing Pattern

  Nursing Process

  Dyspnea can be quite distressing for patients. It may increase their level of anxiety, which makes them feel even more dyspneic. Vital signs, including oxygen saturation, should be obtained immediately and frequently. A thorough history and physical examination may reveal psychiatric, cardiovascular, pulmonary, or neuromuscular conditions that can cause dyspnea. Treatment depends on the underlying cause.

  Nursing Assessment

  The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to dyspnea.

  Review of Health History

  1. Assess the patient’s experience.
  Dyspnea is labored or difficult breathing, frequently accompanied by an elevated respiratory rate, though not always. Ask about the patient’s experience, including what they were doing prior to feeling dyspneic, how long the dyspnea lasts, and if anything helps relieve it.

  2. Review the patient’s medical history.
  The following conditions may cause dyspnea:

  • Respiratory:asthma, acute or chronic obstructive pulmonary disorder (COPD), pneumonia, pulmonary embolism, lung cancer, tuberculosis, pneumothorax (collapsed lung), infections, or aspiration.
  • Cardiovascular:congestive heart failure, pulmonary edema, angina, myocardial infarction, pulmonary hypertension, and cardiac arrhythmias.
  • Neuromuscular: central nervous system (CNS) or spinal cord dysfunction, traumatic brain injuries, and myasthenia gravis.
  • Other systemic illnesses:anemia, respiratory acidosis, cirrhosis of the liver, anaphylaxis, sepsis, angioedema, obesity, and anxiety.

  3. Assess associated symptoms.
  Assess for symptoms related to SOB, like a cough, sore throat, chest pain, fever, or difficulty swallowing, that could pinpoint a possible cause or diagnosis.

  Physical Assessment

  1. Perform ABC assessment.
  ABC assessment includes airway, breathing, and circulation and immediately identifies a respiratory emergency.

  2. Perform a thorough respiratory examination.
  Observe the respiratory effort, accessory muscle use, mental status, and speaking ability to gauge the severity of the dyspnea.

  3. Check the airway for any defects.
  Assess for any obstruction or anatomical defects in the airway. A tracheal deviation may indicate the possibility of a pneumothorax. Assess the airway for foreign body aspiration.

  4. Auscultate, palpate, and percuss.
  Findings during auscultation, palpation, and percussion of the chest include:

  • Auscultation:
    • Stridor: obstruction in the airway
    • Absence of breath sounds: pneumothorax or a mass (such as a pleural effusion or cancer)
    • Wheezes: airway constriction such as in asthma or COPD
    • Rales: pneumonia or pulmonary edema
    • Presence of subcutaneous emphysema or crepitus
    • Dullness: lung consolidation and effusion
    • Hyperresonance: pneumothorax or severe bullous emphysema

    5. Check the cardiovascular status.
    A cardiac abnormality may result in dyspnea. Auscultate the heart for the following:

    • Irregular heartbeats
    • Cardiac murmurs: valve dysfunction
    • Abnormal heart gallops: ventricular dysfunction
    • Diminished heart sounds: cardiac tamponade
    • Pericardial rub: pericarditis

    6. Monitor the vital signs.
    Evaluate the following vital signs frequently:

    • Heart rate
    • Respiratory rate
    • Body temperature (a fever may identify an infectious cause)
    • Oxygen saturation

    Diagnostic Procedures

    1. Assist the patient with a chest X-ray.
    The initial diagnostic procedure to assess dyspnea is a chest X-ray, which can identify a cardiac or pulmonary disease process.

    2. Assess the lung function.
    Spirometry determines lung function if the chest x-ray is normal. It also detects respiratory muscle weakness caused by musculoskeletal or neurological disorders. The following conditions can be assessed through spirometry:

    • Asthma
    • COPD
    • Airway obstruction
    • Restrictive disease process (such as interstitial fibrosis)

    3. Obtain ABGs.
    Arterial blood gas (ABG) assesses the pH balance of the blood and acid-base irregularities. Monitor ABGs regularly for patients with dyspnea.

    4. Consider a V/Q scan.
    A ventilation/perfusion (V/Q) scan measures the airflow and blood flow in the lungs and can diagnose a pulmonary embolism.

    5. Evaluate the presence of heart conditions.
    Further investigations may be needed to diagnose heart conditions that may cause perfusion issues and dyspnea. The following tests can diagnose or rule out cardiac causes of dyspnea:

    • Echocardiography:
      • Valvular dysfunction
      • Heart dysfunction
      • Arrhythmias
      • Myocardial infarction
      • Coronary artery disease
      • Intracardiac shunting
      • Pulmonary hypertension
      • Idiopathic dyspnea

      6. Perform a complete blood count.
      Anemia can be assessed through a CBC by evaluating the red blood cell count, hemoglobin, and hematocrit. An elevated white blood cell count indicates an infectious process.

      7. Send a sample for culture and sensitivity.
      Blood cultures should be obtained if a systemic infection is suspected. In instances of pneumonia or a productive cough, a sputum sample can be obtained for testing for appropriate antibiotic treatment.

      Nursing Interventions

      Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with dyspnea.

      1. Treat the underlying cause.
      Since dyspnea can be related to an array of conditions, it’s crucial to identify the cause so treatment is not delayed. Acute dyspnea can be associated with a life-threatening cause requiring immediate intervention.

      2. Administer medications as prescribed.
      The following is a list of medications that may be employed to treat dyspnea:

      • Bronchodilators for bronchospasm
      • Diuretics for fluid overload
      • Opioids to reduce the respiratory rate
      • Benzodiazepines to relieve dyspnea from anxiety
      • Steroids to relieve inflammation
      • Antibiotics to treat infections
      • Cardiac drugs to reduce the workload of the heart
      • Epinephrine for allergic reactions

      3. Provide oxygen therapy as ordered.
      Supplemental oxygen is often given immediately to patients displaying dyspnea. Oxygen is titrated to keep the SpO2 within normal limits. If respiratory distress worsens, do not delay intubation and mechanical ventilation.

      4. Place the patient in a comfortable position.
      It may be advantageous for patients to sit up in bed or a chair. Sitting on the edge of a bed and resting their upper body on a bedside table may also provide relief (tripod position).

      5. Maintain lung function.
      Patients with chronic lung or heart diseases causing dyspnea can be reminded to pace themselves and set priorities. Frequent rest breaks may be necessary when performing ADLs. Instruct on using assistive devices to complete tasks and sit down when possible, such as when showering or grooming.

      6. Instruct on breathing techniques.
      Instruct on pursed-lip or diaphragmatic breathing for controlled breathing when feeling breathless.

      7. Provide a relaxing environment.
      Patients with dyspnea benefit from a cool, low-humidity environment. A patient’s face being exposed to a fan or breeze from an open window can alleviate their feeling of being out of breath.

      8. Limit physical exertion.
      Reduce breathlessness by using durable medical equipment in performing ADLs, such as:

      • Portable oxygen
      • Walker
      • Wheelchair
      • Bedside commode

      9. Reduce anxiety.
      Anxiety can cause and aggravate dyspnea. The nurse can provide a reassuring presence and remain with the patient until their dyspnea subsides. The following relaxation strategies could help a patient manage the emotional aspect of dyspnea:

      • Guided imagery
      • Diversionary activities
      • Music therapy

      10. Collaborate with a respiratory therapist.
      Collaborate with respiratory therapists who assist with dyspnea by:

      • Administering oxygen therapy
      • Providing inhaled medicine
      • Monitoring lung function

      11. Discuss complementary and alternative medicine (CAM).
      In the treatment of dyspnea, acupressure or acupuncture may also be helpful. CAM may improve breathing, increase relaxation, and reduce anxiety.

      Nursing Care Plans

      Once the nurse identifies nursing diagnoses for dyspnea, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for dyspnea.

      Anxiety

      Anxiety associated with dyspnea can be caused by the triggered fight-or-flight response resulting in hyperventilation and shortness of breath.

      Related to:

      • Fight or flight response of the body
      • Anxiety
      • Stress
      • Panic attacks
      • Decreased carbon dioxide in the blood

      As evidenced by:

      • Increased tension
      • Gasping for air
      • Hyperventilation
      • A feeling of choking or suffocation
      • Restlessness
      • Dizziness
      • Lightheadedness
      • Diaphoresis

      Expected outcomes:

      • Patient will be able to verbalize the causes of their anxiety.
      • Patient will be able to manifest a regular breathing pattern and rhythm.
      • Patient will be able to demonstrate a respiratory rate and oxygen saturation within normal limits.

      Assessment:

      1. Assess the patient’s anxiety level.
      Shortness of breath can both be caused by and exacerbated by anxiety. As the anxiety increases, shortness of breath worsens.

      2. Anticipate hyperventilation.
      Anxiety results in shallow and quick breaths in the upper lungs (hyperventilation), which causes the release of too much CO2.

      Interventions:

      1. Provide reassurance.
      Anxiety coupled with dyspnea can be alarming for the patient. Remind them they are safe and provide reassurance in a calm, patient manner. Stay with them until the panic dissipates.

      2. Consider mental health support.
      Patients with a chronic history of anxiety or panic episodes may need therapy or counseling in learning to recognize and cope with anxiety to prevent episodes of dyspnea.

      3. Teach mindful breathing.
      Mindful breathing is paying close attention to how the breath enters and exits the body to decrease stress and anxiety. Teach the patient to deliberately inflate the chest and abdomen while breathing via the diaphragm. Exhale slowly through the nose counting for several seconds. Belly breathing results in slower, controlled breathing.

      4. Administer anti-anxiety medications as ordered.
      Benzodiazepines induce relaxation and decrease the feeling of anxiety to reduce symptoms of dyspnea.

      Impaired Gas Exchange

      Shortness of breath may disrupt the exchange of oxygen and carbon dioxide.

      Related to:

      • Pulmonary embolism
      • Heart failure
      • COPD
      • Anemia
      • Anxiety
      • Infectious process

      As evidenced by:

      • Reports of being short of breath
      • Restlessness
      • Tachycardia
      • Confusion
      • Hypoxia
      • Nasal flaring
      • Cyanosis
      • Change in mental status
      • Abnormal ABGs

      Expected outcomes:

      • Patient will maintain optimal gas exchange as evidenced by unlabored respirations at 12-20 per minute and oximetry results within normal range.
      • Patient will maintain clear lung fields on auscultation.

      Assessment:

      1. Assess respiratory status.
      Increased respiratory rate, irregular breathing, use of accessory muscles, nasal flaring, abdominal breathing, and cyanosis indicate impaired gas exchange.

      2. Assess the lung sounds.
      Auscultate the lungs for wheezing, rales, crackles, or absent sounds that can indicate obstruction, fluid overload, pneumonia, or pneumothorax.

      3. Review diagnostic tests.
      A chest X-ray often reveals the cause of dyspnea. Review other tests such as EKG, echocardiogram, ABGs, CT scans, and blood work that evaluate possible causes of impaired gas exchange and dyspnea.

      Interventions:

      1. Monitor oxygen saturation levels continuously.
      Using a pulse oximeter to monitor oxygen saturation is helpful in the early detection of changes in oxygenation. The normal range for oxygen saturation is 95-100%.

      2. Assist into a position of comfort.
      Leaning forward can help decrease dyspnea in patients with obstructive diseases. Sitting up allows the lungs to expand.

      3. Administer oxygen as prescribed.
      The patient may require supplemental oxygen as dyspnea progresses.

      4. Administer medications.
      Medication administration depends on the underlying cause. Antibiotics, bronchodilators, corticosteroids, opioids, and expectorants are useful in treating causes of dyspnea.

      5. Schedule care and conserve energy.
      Schedule nursing care to minimize fatigue. Instruct on energy conservation through sitting instead of standing, eating smaller meals, and using assistive devices to complete tasks and ADLs.

      Impaired Spontaneous Ventilation

      In cases of severe dyspnea, mechanical ventilation may be required to initiate or sustain spontaneous breaths.

      Nursing Diagnosis: Impaired Spontaneous Ventilation

      Related to:

      • Chronic conditions (heart failure, COPD)
      • Acute respiratory distress syndrome
      • Respiratory muscle fatigue
      • Respiratory infection

      As evidenced by:

      • Adventitious breath sounds
      • Apprehension
      • Increased or decreased respiratory rate
      • Restlessness
      • Decreased SpO2
      • Increased pCO2
      • Dyspnea
      • Accessory muscle use

      Expected outcomes:

      • Patient will demonstrate ABGs within normal limits.
      • Patient will be free from dyspnea and respiratory distress.
      • Patient will participate in efforts to wean off ventilation.

      Assessment:

      1. Observe changes in the patient’s level of consciousness.
      Watch out for signs such as disorientation, irritability, restlessness, stupor, somnolence, and lethargy, which indicate worsening hypoxia.

      2. Monitor vital signs.
      Monitor the blood pressure, heart rate, respiratory rate, and oxygen saturation level continuously. Tachycardia and alterations in the respiratory rate and SpO2 indicate respiratory distress.

      3. Auscultate the lungs for abnormal breath sounds.
      Depending on the causative factor of the dyspnea, the patient may present with varying breath sounds. Rhonchi occurs when air passes through bronchial tubes that contain fluid or mucus. Crackles occur when alveoli are filled with fluid. Wheezing is heard in patients who have narrowed or inflamed bronchial tubes. Stridor occurs when the upper airway narrows.

      Interventions:

      1. Consider the client’s history when administering oxygen.
      Oxygen should be administered at the lowest concentration indicated to prevent toxicity. Consider the delivery method, concentration, and use of humidification with certain patient populations.

      2. Collaborate with the respiratory therapist.
      When administering oxygen or other ventilation methods, collaborate with the respiratory therapist to ensure appropriate titration or ventilator settings.

      3. Assist with ventilation implementation.
      If the respiratory status worsens, the patient with COPD, asthma, or pneumonia may require noninvasive positive pressure ventilation (NPPV). Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) may be useful for pulmonary edema. If apnea occurs with worsening respiratory muscle fatigue, acidosis, or hypoxia, intubation and mechanical ventilation is required.

      4. Closely monitor ABGs.
      Arterial blood gas results, end-tidal CO2 levels, and pulse oximetry are monitored closely to ensure ventilation and acid-base balance.

      Ineffective Airway Clearance

      Ineffective airway clearance associated with shortness of breath (dyspnea) can be caused by obstruction or narrowing of the airway.

      Related to:

      • Obstruction in the airway
      • Narrowing of the airway
      • Blood backing up in the lungs
      • Fluid accumulation in the lungs
      • Increased mucus production
      • Inability to cough or clear secretions

      As evidenced by:

      • Irregular breathing pattern
      • Shallow and rapid breaths
      • Chest tightness
      • A feeling of choking or suffocation
      • Breathlessness
      • Alterations in oxygen saturation
      • Alterations in respiratory rate
      • Alterations in respiratory rhythm
      • Alterations in respiratory depth
      • Changes in arterial blood gas
      • Use of accessory muscles
      • Abnormal chest X-ray
      • Adventitious breath sounds

      Expected outcomes:

      • Patient will maintain a patent airway.
      • Patient will be able to attain oxygen saturation of 95-100%.
      • Patient will demonstrate clear breath sounds.
      • Patient will demonstrate the ability to clear their airway.

      Assessment:

      1. Determine the causative factors.
      Shortness of breath is a symptom, not a disease. Focusing on the causative factor (obstruction or narrowing of the airway) resulting in ineffective airway clearance will guide treatment.

      2. Assess the patient’s respiratory status.
      Closely monitor and document respiratory rate, depth, pattern, and O2 saturation as ordered.

      3. Observe for other dyspnea-related symptoms.
      Coughing, grabbing of the neck, skin color changes, and difficulty in speaking can signal obstruction in the airway.

      4. Listen to the breath sounds.
      A restriction of airflow in the trachea (windpipe) or the throat causes a wheezing-like sound. High-pitched sounds are caused by narrowed airways.

      5. Review arterial blood gas (ABGs).
      ABGs reflect conditions that influence the respiratory, circulatory, and metabolic systems.

      Interventions:

      1. Place the patient on the side or elevate the head of the bed.
      Place the patient on their side or raise the head of the bed for optimal breathing and to prevent obstruction caused by secretions.

      2. Suction secretions from the airway as needed.
      Suctioning is essential for normal breathing as it removes mucus from the airway. if secretions are left in the airway, they may become infected and cause a chest infection.

      3. Administer medications as prescribed.
      Bronchodilators dilate the lung passageways while mucolytics and expectorants help remove chest congestion by thinning and loosening mucus in the airways.

      4. Teach coughing and deep breathing exercises.
      Breathing exercises will improve gas exchange, clear the lungs, and reduce the risk of pneumonia. Teach the patient to take deep breaths and cough to mobilize and expel secretions every hour when awake.

      5. Promote smoking cessation.
      Smoking damages the alveoli and airways in the lungs. Encourage smoking cessation and offer resources to quit.

      6. Collaborate with respiratory therapists (RT).
      Respiratory therapists are knowledgeable about respiratory medications and interventions and assist the doctors in the insertion of airway tools (such as ET tubes) when required.

      Ineffective Breathing Pattern

      Ineffective breathing pattern associated with dyspnea is caused by alterations in the gas exchange (inspiration and expiration mechanisms) resulting in insufficient ventilation.

      Related to:

      • Anxiety
      • Acute Pain
      • Fatigue
      • Respiratory muscle fatigue
      • Hyperventilation
      • Obesity
      • Body positions that prevent lung expansion
      • Chest wall and diaphragm deformities
      • Presence of bronchial secretions
      • Age
      • History of smoking
      • Conditions that impair inspiration and expiration mechanisms (such as spinal cord injuries)
      • Pneumothorax

      As evidenced by:

      • Irregular breathing pattern
      • Shallow rapid breaths
      • Asymmetric respirations
      • Pursed lip breathing
      • Grunting
      • Nasal flaring
      • Mouth breathing
      • Gasping for air
      • Chest retractions
      • Breathlessness
      • Alterations in oxygen saturation
      • Alterations in respiratory rate
      • Alterations in respiratory rhythm
      • Alterations in respiratory depth
      • Changes in arterial blood gas
      • Use of accessory muscles

      Expected outcomes:

      • Patient will demonstrate a regular respiratory rate and rhythm.
      • Patient will maintain an oxygen saturation of 95-100%.
      • Patient will demonstrate clear breath sounds.
      • Patient will demonstrate respirations without the use of accessory muscles, nasal flaring, or grunting.

      Assessment:

      1. Identify the causative factors.
      Decipher between a physical or emotional cause (such as anxiety, pain, infection, etc.) to effectively relieve the shortness of breath resulting in an ineffective breathing pattern.

      2. Observe for other respiratory symptoms.
      Irregular breathing (hyperventilating), nasal flaring, mouth breathing, gasping for air, and use of accessory muscles are symptoms of an ineffective breathing pattern that require immediate attention.

      3. Obtain a chest x-ray.
      An ineffective breathing pattern requires investigation for respiratory infections, lung trauma, chronic airway changes, cancer, etc., to manage effectively.

      Interventions:

      1. Relax the respiratory muscles.
      Morphine reduces the rate of breathing and anti-anxiety drugs can promote relaxation which prevents hyperventilation.

      2. Promote bronchodilation.
      Bronchodilation produced by beta-adrenergic agonist drugs relaxes the smooth muscles of the airways.

      3. Apply oxygen.
      For oxygen saturation levels below 95% or altered ABGs, apply oxygen to improve ventilation and perfusion.

      4. Educate on chronic conditions.
      Asthma, COPD, emphysema, CHF, and more require specific interventions to control respiratory distress. Educate on the use of inhalers and medications, lifestyle modifications, breathing exercises, and diet changes.

      References

      1. Dewit, S. C., Stromberg, H., & Dallred, C. (2017). Medical-surgical nursing: Concepts & practice (3rd ed.). Elsevier Health Sciences.
      2. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
      3. Do Prado, P. R., de Cássia Bettencourt, A. R., & Lopes, J. D. (n.d.). Related factors of the nursing diagnosis ineffective breathing pattern in an intensive care unit. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6781423/
      4. Dyspnea. Chest Foundation. https://foundation.chestnet.org/lung-health-a-z/shortness-of-breath/. Accessed on Mar 15, 2023
      5. Dyspnea (Shortness of breath): Causes, symptoms & treatment. (2022, November 11). Cleveland Clinic. Retrieved October 2023, from https://my.clevelandclinic.org/health/symptoms/16942-dyspnea
      6. Everything You Need To Know About Dyspnea. Healthline. https://www.healthline.com/health/dyspnea. Accessed on Mar 15, 2023
      7. Hashmi, M. F., Modi, P., Basit, H. B., & Sharma., S. S. (2022, May 1). Dyspnea – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK499965/
      8. Hashmi, M. F., Modi, P., Basit, H., & Sharma, S. (2023, February 19). Dyspnea – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved October 2023, from https://www.ncbi.nlm.nih.gov/books/NBK499965/
      9. Ignatavicius, MS, RN, CNE, ANEF, D. D., Workman, PhD, RN, FAAN, M. L., Rebar, PhD, MBA, RN, COI, C. R., & Heimgartner, MSN, RN, COI, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care (9th ed., pp. 1386-1388). Elsevier.
      10. Indelicato, R. A. (2007, February 2). Palliative care and the management of dyspnea. Medscape. Retrieved October 2023, from https://www.medscape.com/viewarticle/551364_6
      11. Leader, D. (2022, October 4). What people with COPD should know about V/Q mismatch. Verywell Health. Retrieved October 2023, from https://www.verywellhealth.com/what-is-vq-mismatch-in-the-lungs-914928
      12. Shortness of Breath. Mayo Clinic. https://www.mayoclinic.org/symptoms/shortness-of-breath/basics/definition/sym-20050890. Accessed on Mar 15, 2023
      13. Silvestri, L. A., Silvestri, A. E., & Grimm, J. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
      Published on October 15, 2022

      

      Kathleen Salvador is a registered nurse and a nurse educator holding a Master’s degree. She has more than 10 years of clinical and teaching experience and worked as a licensed Nursing Specialist in JCI-accredited hospitals in the Middle East. Her nursing career has brought her through a variety of specializations, including medical-surgical, emergency, outpatient, oncology, and long-term care.

      • Nursing Process
      • Nursing Assessment
        • Review of Health History
        • Physical Assessment
        • Diagnostic Procedures
        • Anxiety
        • Impaired Gas Exchange
        • Impaired Spontaneous Ventilation
        • Ineffective Airway Clearance
        • Ineffective Breathing Pattern

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