Shortness of breath? ID rapid deterioration
Patients with shortness of breath are "one of the highest priority patients" for ED nurses because of their tendency to rapidly deteriorate, says Alexandra Penzias, RN, MEd, MSN, CEN, an ED educator at Tufts Medical Center in Boston, MA. "We perform a complete set of vital signs, oxygen saturation, and peak flow measurements at triage," she says.
Many situations can result in an increase in a patient's respiratory rate, says Penzias, including pain, anxiety, congestion, injuries, pneumothorax, pulmonary embolism, congestive heart failure, chronic obstructive pulmonary disorder, and pulmonary edema.
"While all require immediate assessment, not all of these necessitate immediate intervention," she adds. According to the ED's triage acuity scoring system, the Emergency Severity Index, a triage nurse can "up triage" any patient with a respiratory rate greater than 20 breaths/minute at his or her discretion, notes Penzias.
Penzias says that this would be appropriate for a patient with a history of congestive heart failure who presents with swollen ankles, has progressive shortness of breath, which increases on exertion, and can only speak two or three words without taking a breath, with an oxygen saturation of 94%.
"An asthmatic whose shortness of breath and wheezing has necessitated increased use of their inhalers or nebulized medications would also require assessment and intervention quickly," Penzias says.
Sybil Murray, RN, an ED nurse at St. Anthony's Medical Center in St. Louis, MO, says that patients can deteriorate rapidly in the ED for many different reasons. To assess whether your patient's airway is patent, Murray says to ask these questions:
- Is the patient breathing comfortably?
- Is the patient able to sit up?
- Does the patient require supplemental oxygen?
- Is the patient able to follow commands?
- Is the patient pale or cyanotic?
- Does the patient have full range of motion of the neck?
- Do they have dentures, sleep apnea, temporomandibular joint disorder, or history of prior airway surgery or trauma?
- Is the patient obese or morbidly obese?
Murray gives these early signs that may indicate your patient's respiratory status could be declining:
- confusion or mental status changes that were not present on the initial assessment;
- changes in accessory muscle use;
- increased work of breathing, including intercostal indrawing, exaggerated chest wall movement, supraclavicular indrawing, nasal flaring, and an anxious expression.
"If you have the ability to measure end tidal carbon dioxide levels in a non-intubated patient, do this for every patient who appears short of breath," says Murray.
Hypoxic patients are usually tachycardic, adds Murray. "Look for heart rates above 100. Late hypoxia can present with a sinus bradycardia."
Look for mental status changes, discoloration of the skin or nail beds, increased respiratory rate and shallow breathing, and alteration from normal arterial blood gas values, says Chris Ruckman, RN, MBA, CEN, manager of adult emergency services at Vanderbilt University Hospital in Nashville, TN.
"These are early signs that a patient is developing an airway compromise," he says.
For more information on patients with shortness of breath, contact:
- Wendy L. Callan, RN, MSN, TNS, Trauma Nurse Coordinator, Advocate Condell Medical Center, Libertyville, IL. Phone: (847) 990-5016. Fax: (847) 573-4281. Email: firstname.lastname@example.org.
- Orchid Quiton Chefalo, RN, CEN, CCRN, Charge Nurse, Emergency Department, San Joachin Community Hospital, Bakersfield, CA. Phone: (661) 869-6011. Fax: (661) 869-6971. E-mail: Chefaloq@ah.org.
- Chris Ruckman, RN, MBA, CEN, Manager, Adult Emergency Services, Vanderbilt University Hospital, Nashville, TN. Phone: (615) 875-4606. Fax: (615) 322-1494. E-mail: christopher.ruckman@Vanderbilt.edu.
- Sybil Murray, RN, Emergency Department, St. Anthony's Medical Center, St. Louis, MO. Phone: (314) 525-1906. Fax: (314) 525-4148. E-mail: Sybil.Murray@samcstl.org.
Don't let others' assessment cloud your own judgment
Reports can be misleading
A paramedic calls in a report of a 58-year-old female with shortness of breath, oxygen saturation of 60%, and respiratory rate in the 30s, being given a nebulizer treatment.
If you hear a dire-sounding report like this, says Orchid Quiton Chefalo, RN, CEN, CCRN, charge nurse of the ED at San Joachin Community Hospital in Bakersfield, CA, don't hesitate to get everything ready for the patient to be intubated. At the same time, she says, don't let it cloud your own clinical judgment of what you see after the patient arrives.
"Make sure you reassess the patient yourself again, prior to intubation," says Chefalo. It may be that the respiratory rate is now in the 20s and her oxygen saturation is up, she says.
On the other hand, Chefalo once was told by a paramedic that a 30-year-old man was improving and was holding the pulse oximetry level up. "The paramedic kind of downplayed it, but as soon as I saw the patient, I knew better," she says, adding that the man needed rapid intubation upon arrival.
If you don't assess the patient yourself, warns Chefalo, "a patient could sit there for 15 minutes until they are really short of breath. You may then have to call a respiratory therapist and do rapid sequence intubation."
Was a chronic obstructive pulmonary disease (COPD) patient placed on a nonrebreather mask by paramedics? It may need to be removed when the patient arrives at the ED, says Chefalo. COPD patients live with a carbon dioxide level of 50 to 60 or higher, explains Chefalo, and if they suddenly get saturated with oxygen, they may become more short of breath and may have decreased level of consciousness.
"Too much is not always good," she says. "With COPD, it's carbon dioxide that drives them to trigger their breathing. If we saturate them with oxygen, it will knock out their hypoxic respiratory drive."
Instead, the patient may need to be put on a biphasic positive airway pressure or continuous positive airway pressure machine, says Chefalo. "See if the patient can tolerate just the nasal cannula. That way, you can give them the minimal oxygen that will get them perfused," she says.
Put nasal cannula in mouth, not nose
You may put a patient with chronic obstructive pulmonary disease on five liters of oxygen via nasal cannula, but his or her oxygen saturation is still low because the patient is constantly breathing from the mouth, says Orchid Quiton Chefalo, RN, CEN, CCRN, an ED charge nurse at San Joachin Community Hospital in Bakersfield, CA. "Take the nasal cannula out of the nose and put them in the patient's mouth," she recommends. "That will help the patient take in the oxygen they need."