Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with ...

Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD)Table 1: COPD Severity and Symptom DescriptorsDiseaseSeverityPulmonaryFunctionChanges in Level ofActivity (O’Donnell etal., 2003)Stable ClinicalSymptomsUnstable/AcuteClinical SymptomsEvidence of AcuteRespiratory FailureMild(stage I)Moderate(stage II)Severe(stage III)FEV 160 – 79%predictedFEV 1 /FVC< 70%FEV 140 – 59%predictedFEV 1 /FVC< 70%FEV 1< 40%predictedFEV 1 /FVC< 70%Dyspnea from COPDwhen hurrying on thelevel or walking up aslight hill*DYSPNEA SCORE(MRC 2)Dyspnea from COPDcausing patient to stopafter walking about100 m (or after a fewminutes) on the level*DYSPNEA SCORE(MRC 3-4)Dyspnea from COPDresulting in the patienttoo breathless to leavethe house, orbreathlessness afterundressing, or thepresence of chronicrespiratory failure orclinical signs of rightheart failure*DYSPNEA SCORE(MRC 5)1.Respiratory rate within normal limits(RR 16-28)2.Chest auscultation: breath soundsreduced, may or may not have endexpiratory wheeze and/or crackles.3.Adequate inspiratory depth andchest wall expansion, may have barrelshaped chest.4.Minimal or no respiratory accessorymuscle use.5.May have clear or white sputum.6.Daily cough.7.May not have complaints of fatigue.1.Respiratory rate above normal limits.2.Chest auscultation: breath soundsreduced, may or may not have endexpiratory wheeze and/or crackles.3.Adequate chest wall expansion.4.Minimal or moderate accessorymuscle use.5.May have clear or white sputum.6.Daily cough.7.Fatigue often present.1.Respiratory rate outside normal limits.2.Chest auscultation: air entry distant,may or may not have end expiratorywheeze and/or crackles.3.Adequate chest wall expansion.4.Moderate accessory muscle use.5.May have clear or white sputum.6.Daily cough.7.Fatigue usually present.Complaints of increasinglevel of dyspnea1. Respiratory rate mayor may not be withinnormal limits.2. Chest auscultation:breath soundsreduced, may or maynot have endexpiratory wheezeand/or crackles.3. May have shallowinspiratory depthwith reduced chestwall expansion.4. Respiratory accessorymuscle use.5. Sputum change:yellow/green/purulent/thick and/orincreased amount.6. Increased coughseverity.7. Progressive fatigue.8. Potential presence ofperipheral and/orcentral cyanosis.Pulmonary: accessory muscleuse, complaints of worseningdyspnea, complaints ofimpending doom.PaO 2 < 60 mmHg on room airPaCO 2 > 50 mmHgArterial pH < 7.28S P O 2 < 88 % [Although pulseoximetry is a valuable tool inmany disease processes, it isnot a reliable indicator ofdypnea severity in individualswith COPD.]Neuro: Restlessness, agitation,headache, disorientation,seizures, muscle twitching,decreased level of consiousness.CVS: heart rate, hypertension(early sign), hypotension (latesign), chest pain, dysrhythmias.Renal: urinary output,peripheral edema.GI: bowel sounds, nauseaand vomiting, abdominaldistention, bleeding.Skin: cool, clammy, pale, capillary refill.* Perception of dyspnea is individualized and may vary from the usual scores above. RNAO Guideline Development Panel, 200526