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Pulmonary Critical Care
I
CARE NURSES’
PERCEPTIONS OF ROUTINE
DYSPNEA ASSESSMENT
NTENSIVE
C E 1.0 Hour
This article has been designated for CE contact
hour(s). See more CE information at the end of
this article.
©2020 American Association of Critical-Care Nurses
doi:https://doi.org/10.4037/ajcc2020711
132
Background Dyspnea (breathing discomfort) is commonly
experienced by critically ill patients and at this time is
not routinely assessed and documented. Intensive care
unit nurses at the study institution recently instituted
routine assessment and documentation of dyspnea in
all patients able to report using a numeric scale ranging
from 0 to 10.
Objective To assess nurses’ perceptions of the utility of
routine dyspnea measurement, patients’ comprehension
of assessment questions, and the impact on nursing practice and to gather nurses’ suggestions for improvement.
Methods Data were obtained from interviews with intensive care unit nurses in small focus groups and an anonymous online survey randomly distributed to nurses
representing all intensive care units.
Results Intensive care unit nurses affirmed the importance of routine dyspnea assessment and documentation. Before implementing the measurement tool, nurses
often assessed for breathing discomfort in patients by
using observed signs. Most nurses agreed that routine
assessment can be used to predict patients’ outcomes
and improve patient-centered care. Nurses found the
assessment tool easy to use and reported that it did not
interfere with workflow. Nurses felt that patients were
able to provide meaningful ratings of dyspnea, similar
to ratings of pain, and often used patients’ ratings in
conjunction with observed physical signs to optimize
patient care.
Conclusion Our study shows that nurses understand
the importance of routine dyspnea assessment and that
the addition of a simple patient report scale can improve
care delivery and does not add to the burden of workflow. (American Journal of Critical Care. 2020;29:132-139)
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By Kathy M. Baker, MSN, RN, Natalia Sullivan Vragovic, MSN, RN, and Robert
B. Banzett, PhD
P
atients receiving mechanical ventilation in intensive care units (ICUs) have described
the dyspnea experience thus: “I often thought about death while I was attacked by
dyspnea”; “I wondered what’s going on with my breathing, I asked myself ‘will I die
here?’”1 Despite evidence that dyspnea causes suffering2,3 and is a predictor of adverse
patient outcomes,4,5 little information regarding routine measurement and documentation of dyspnea in the ICU has been published.
About the Authors
Kathy M. Baker is a clinical nurse specialist and Natalia
Sullivan Vragovic is a nurse practitioner in the bone
marrow transplant unit, Beth Israel Deaconess Medical
Center, Boston, Massachusetts. Robert B. Banzett is an
associate professor, Department of Medicine, Division of
Pulmonary, Critical Care, and Sleep Medicine, Beth Israel
Deaconess Medical Center and Harvard Medical School,
Boston, Massachusetts.
Corresponding author: Kathy M. Baker, 330 Brookline
Avenue (Reisman 1113), Boston, MA 02215 (email:
[email protected]).
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current standards require that organizations establish policies regarding pain assessment and treatment and conduct educational efforts to ensure
compliance,18 so clinicians in health care systems
worldwide routinely assess and document patients’
pain ratings. Although less common than pain,
dyspnea is prevalent in ICU patients and can be
more distressing.8,19
In 2013, nurses at our institution began routinely
measuring and documenting dyspnea in all medicalsurgical patients using a numeric scale ranging from
0 to 10, with 10 indicating
unbearable dyspnea. In
2015, this practice was
extended to all ICU patients,
and nurses were asked to
include dyspnea in routine
patient assessments every 4
hours. (Data entry in our
electronic documentation
system is not mandatory.)
We conducted focus sessions and an anonymous
online survey to obtain nurses’ feedback regarding
routine assessment.
Patients on medicalsurgical units who report
dyspnea are more likely
to suffer serious adverse
events in hospital.
Methods
The study design included a 2-part data collection method with qualitative (focus group interviews)
and quantitative (random anonymous survey) components. These studies were approved by the medical center’s institutional review board.
Focus Groups
In August 2016, we invited ICU nurses to participate in focus groups designed to assess nurses’ perceptions of the utility of routine dyspnea assessment,
ease of use, patients’ comprehension of questions,
and impact on practice and to collect suggestions
for improvement. The location, date, and time of
the sessions were arranged with local nursing leaders and invitations were sent to nurses via email 1
week before each session, with a reminder sent the
day before the session. Inclusion in the sessions was
limited to nurses on duty the day interviews were
held, and written consent was obtained. Sessions
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Recent studies show the harmful impact and high
prevalence of dyspnea in ICU patients. In one recent
study of 30 ICU patients receiving mechanical ventilation, 100% reported breathing discomfort (median
score, 4 on a scale of 0 to 10).6 In another study, 47%
of 96 patients receiving mechanical ventilation reported
dyspnea (median score, 5 on a scale of 0 to 10).7
Dyspnea was reported to be the most distressing of
10 symptoms in a survey of 171 ICU patients.8 Dyspnea in ICU patients is associated with indicators
of posttraumatic stress disorder and correlates with
duration of mechanical ventilation.3,9-11
Dyspnea is an independent predictor of morbidity and mortality in specific patient populations and
is not limited to diseases of pulmonary origin. Dyspnea is more closely associated with cardiac mortality
than is angina12,13 and is a more reliable predictor
of mortality in patients with esophageal and gastric
cancers than are symptoms such as pain, nausea,
loss of appetite, and fatigue.14,15 Patients on medicalsurgical units experiencing any dyspnea on admission
have greater than a 3-fold odds of death in the hospital.16 Assessing and documenting dyspnea are the
first steps in managing this distressing symptom.
The American Thoracic Society defines dyspnea
as a “subjective experience of breathing discomfort
that consists of qualitatively distinct sensations that
vary in intensity.”17 This statement emphasizes that
dyspnea can be perceived, and thus reported, only
by the person experiencing it. Clinicians, including
critical care nurses, respiratory therapists, and physicians, can decrease suffering and improve quality
of care by asking for dyspnea ratings from all patients
who are able to respond. The Joint Commission’s
Number of respondents (of 37)
40
30
20
10
0
Important or
very important
Moderately
important
to use uniform tool
to track every shift
for patient-centered care
for predicting outcome
Figure 1 Nurses’ opinions of the importance of dyspnea
assessment.
Results
Effect on workflow
Very positive
Positive
No effect
Negative
Very negative
0
10
20
30
Number of respondents (of 37)
Importance of Dyspnea Assessment
Thirty-seven of 48 surveys were completed (77%
response rate). Nurses reported that assessing dyspnea
with a uniform tool and tracking dyspnea at every
shift are important. They also stated that routine
measurement can be useful in predicting patients’
outcomes and can lead to improved patient-centered
care (Figure 1). Comments from the survey and focus
sessions enhanced the survey finding that nurses
believe routine assessment is important:
• “I have always completed the dyspnea assess-
Figure 2 Nurses’ opinions of the effect of routine assessment
on workflow.
were held during nurses’ nonpaid lunch breaks in
locations near the 8 ICUs. Participation was voluntary, and nurses were allowed to enter and exit throughout the session as necessary. The purposes of the
focus groups were to help us tailor the online survey
to ICU nurses and to provide verbatim comments to
illustrate the survey results.
We held two 30-minute focus sessions. Facilitators took field notes and recorded sessions to
document discussion accurately. Participants were
informed that sessions were recorded and that all
identifying information would be omitted when
the recordings were transcribed. A staff nurse (N.S.V.)
and a clinical nurse specialist (K.M.B.) led the
focus sessions. An interview guide was provided to
participants to facilitate conversation and ensure
that all discussion points were addressed. Seven and
10 nurses representing 6 of the ICUs attended the
first and second session, respectively.
134
ment when I assess respiratory distress.”
• “Dyspnea
assessment was already part of
my patient assessment if the patient was
able to report their level of respiratory
distress.”
•
“Allows for patient to explain in their own
words how they are feeling.”
Implementation of Dyspnea Assessment
Most nurses (92%) found the assessment tool
easy or very easy to administer. Most (68%) noted
the addition of dyspnea assessment did not interfere
with workflow, and some (32%) said it improved
workflow (Figure 2). Comments from the 8% of
nurses who found the tool “difficult” to administer
included the following:
• “There
are too many options for the different levels of distress . . . mild, moderate,
and severe would suffice.”
• “Our
patients often cannot rate/score their
dyspnea. They don’t understand the scale.”
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Important
Important
Important
Important
Of little or no
importance
Survey
On the basis of experience and information
obtained from the focus interviews, we made adjustments to a survey we had previously administered
to medical-surgical nurses at our institution19 to better suit the survey to ICU nurses. All of the survey
questions and responses are shown in the Supplement (available online only at www.ajcconline.org).
In September 2016, the modified survey was distributed via a Web-based software platform (REDCap,
hosted at Harvard Catalyst–Beth Israel Deaconess
Medical Center) to 48 registered nurses (14% of the
ICU nursing staff) selected randomly from each of
the ICUs. Nurses were given 4 weeks to complete the
survey. Study researchers and local unit leaders sent
reminders via email. The survey allowed participants
to add comments; some of the more illustrative are
included in the Results.
Patient is unresponsive
the scale simpler . . . normal, worse
than normal, worse than it’s ever been before.”
• “I
typically ask if they are having difficulty
breathing or feeling short of breath. If the
answer is no, I presume that the number
rating is 0/10 as I would presume with the
pain scale. . . .”
• “I
document ‘0’ if the patient responds no
if their diagnosis and my assessment support
this. [I] ask more questions or rephrase . . .
if objective findings suggest otherwise.”
• “If
the patient does not appear to be in any
distress, oxygen saturations are fine on room
air, etc, and they report no, I would document a ‘0.’ If their breathing is off baseline,
I will investigate further.”
Nurses in focus sessions and the survey recalled
patients who responded no to the initial question
but then gave a nonzero rating. Nurses felt that the
initial response of no was often because patients with
chronic disorders become accustomed to living with
breathing discomfort:
• “I have noticed that patients often give
themselves a 1-3 rating even when they
answer no.”
• “A
patient with COPD [chronic obstructive
pulmonary disease] may say no, but their
baseline dyspnea score could be 4, so it is
important to obtain the baseline report.”
• “Every
patient has a different baseline level
. . . such as with COPD, asthma patients. It
is important to ask the number as their baseline may be 3.”
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Patient seems more
uncomfortable than self-report
Patient seems less
uncomfortable than self-report
0
5
10
Number of respondents (of 22 total)
Figure 3 Reasons nurses use patients’ physical signs rather
than patients’ self-reports of dyspnea.
Patient’s Report Versus Observed Signs to
Assess Dyspnea
Dyspnea training for nurses in our hospital
includes the concept that dyspnea, like pain, is
defined as the patient’s experience, so the patient’s
report is the best indicator of severity. However,
ICU nurses reported that they often supplement or
even supplant patients’ reports with their own estimates from observed signs. Nurses used physical
signs to modify patients’ reports most often because
the patient was unresponsive or was unable to use
the number scale for some other reason. Comments
included the following:
• “I don’t complete the dyspnea score if the
patient cannot give the report.”
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Practicalities of Assessment
Most nurses reported using more than 1 phrase
to explain to the patient what they were supposed
to rate. Many (65%) included the phrase “breathing
discomfort,” as contained in the American Thoracic
Society’s definition of dyspnea. Other phrases commonly used were “difficulty breathing/trouble breathing” (92%), “short of breath” (73%), and “can’t catch
your breath” (57%).
Most nurses (76%) reported first asking a yes/
no question (eg, “Are you having any breathing difficulty?”) when assessing for dyspnea. For patients who
responded no, 42% of nurses said they recorded a
score of 0 without asking the patient to provide a
number rating. The following comments explain
this process:
Patient is unable to use scale
Reason
• “Make
• “Often patients are intubated, confused, deliri-
ous, or have dementia and cannot answer.”
Nurses reported using physical signs rather than
patients’ reports twice as often for patients who seemed
more uncomfortable than they claimed as for patients
who seemed less uncomfortable than they claimed
(Figure 3). Nurses reported assessing respiratory distress with the following physical signs listed in the
survey (in descending order of frequency of selection):
accessory muscle use, tachypnea, difficulty speaking,
restless movements, heart rate, nasal flaring, ventilator dyssynchrony, and fearful facial expression.
The online survey confirmed that ICU nurses
often used some combination of patient’s report
and observed signs to obtain a rating for dyspnea;
15 of 36 respondents said they always use a combination. Six nurses report they always used the patient’s
report alone, and only 3 nurses said they always used
physical signs alone.
Nurses in the focus groups and in the survey
suggested that a solution to this conflict might be
to provide a separate scale allowing nurses to report
their respiratory distress estimates according to
observed signs. Comments regarding the use of
observed physical signs rather than the patient’s
report included the following:
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135
Table
Actions taken by physicians in response to patients’
reports of respiratory distress
Percentage of 36 nurses who responded that physicians would …
Frequency
Request vital
signs and/or
oxygen saturation
Always
56
Usually
Order laboratory
or imaging
studies
Order an
intervention to
relieve dyspnea
Evaluate the
patient
Request that
nurses reassess
the patient later
Take none of
these actions
3
14
33
53
3
39
39
33
42
28
0
Half the time
3
47
47
22
11
8
Seldom
0
8
6
3
8
25
Never
3
3
0
0
0
61
the ICU, most patients cannot speak due
to the ventilator or altered mental status . . .
it is important to use nonverbal cues from
the patient to assess.”
• “Patients
who are clearly labored sometimes
say their breathing is ‘not bad, 3/10.’ This . . .
is sometimes because at baseline their breathing is terrible or they just don’t realize how
hard they are working to breathe, whether
because of delirium or they just don’t realize.”
Patients’ Ability to Rate Dyspnea
Seventy percent of ICU nurses reported that
patients give a meaningful rating for dyspnea at least
half of the time, and 81% reported that patients give a
meaningful rating for pain at least half of the time.
In other words, nurses had slightly less confidence in
patients’ dyspnea ratings than in their pain ratings.
Interventions After Dyspnea Assessment
For patients who report increasing shortness of
breath, nearly all nurses (95%) said that they employ
nonpharmacologic interventions such as repositioning techniques and coaching the patient to take slow,
deep breaths. Many (60%)
reported assessing the
need for narcotics. Nearly
all nurses (86%) said
they notify a physician
when shortness of breath
increases, and 65% summon a respiratory therapist. Fifty-seven percent
of nurses surveyed said it
would be useful to have an algorithm with specific
options for the treatment of dyspnea (eg, repositioning, facial fan, morphine).
Nurses reported that physicians would always
or usually take the following actions when their
patients reported increased respiratory distress:
request vital signs and/or oxygen saturation (95%),
Most nurses found the
dyspnea assessment tool
easy to administer and
noted that using it did not
interfere with workflow.
136
order laboratory or imaging studies (42%), order a
pharmacologic or nonpharmacologic intervention
to relieve dyspnea (47%), evaluate the patient (75%),
or request that nurses reassess the patient later
(81%). Rarely (3% of the time), nurses reported that
the physician responsible would take none of these
actions (see Table).
Discussion
Our data show that most ICU nurses feel it is
important to routinely assess and document dyspnea. Most nurses in our study found that the
single-dimension scale was easy to use and did
not impede workflow. We found 3 areas for possible improvement. (1) Descriptive terms used to ask
patients to rate their dyspnea are not uniform. (2)
Nurses reported frequently asking a yes/no question (eg, “Are you having shortness of breath?”)
and recording a response of no as a 0 rating rather
than asking the patient for a rating. (3) Nurses
reported frequently using observed signs to modify
or supplant the patient’s rating.
Importance of Dyspnea Assessment
Consistent with the results of our earlier survey of
medical-surgical nurses,20 most ICU nurses stated that
measuring dyspnea with a standard tool and periodically documenting dyspnea are important. Nurses
also agreed that routine assessment can improve care
delivery and patients’ outcomes. Dyspnea in ICU
patients is clearly correlated with suffering that may
lead to long-term harmful sequelae, including posttraumatic stress disorder. Patients experiencing moderate to severe dyspnea during hospitalization may
be at increased risk for negative outcomes.4
Many ICU nurses reported that they had always
included dyspnea in their patient assessments but
had not used a standard scale or routinely documented findings. Nurses reported that incorporating routine measurement is easy and that providing
a standard entry on the electronic form could even
improve workflow.
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• “In
10
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9
8
Breathlessness rating
7
6
5
4
3
2
1
0
Patient report
Nurse estimate
Figure 4 Differences between patients’ reports of “breathlessness” and nurses’ estimates of breathlessness; data from
Haugdahl et al.21 Patients undergoing spontaneous breathing
trials were asked, “Do you have a sensation of breathlessness?” by using a scale of 0 to 10, with 0 indicating “no, not at
all” and 10 indicating “yes, worst imaginable.” Nurses were
asked to estimate the patient’s breathlessness by using the
same scale. This figure shows the data for 62 patients who
rated breathlessness 4 or greater, with corresponding nurses’
estimates (there were overlaps, eg, in 5 instances the patient
rated dyspnea 5 and the nurse rated dyspnea 2). Bold dashed
line indicates group mean.
assessment of respiratory distress would provide a
better way to document this disagreement.
Nurses in our study felt that patients could
provide meaningful dyspnea ratings nearly as often
as meaningful pain ratings. This finding was very
similar to our findings with medical-surgical nurses.
When ICU nurses were concerned that a patient’s
rating did not truly reflect the patient’s discomfort,
they responded by asking further questions or rephrasing and by using objective findings to modify the
patient’s report.
Need for a Universal Dyspnea Assessment Tool
Implementing routine assessment with a tool that
is easy, fast, and inexpensive can lead to early recognition of deterioration in a patient’s status and subsequent interventions to improve symptom management.
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Areas for Improvement
Uniform Language. Although a widely used plainlanguage definition of dyspnea (breathing discomfort)
exists, many nurses used other terms (eg, shortness
of breath or breathing difficulty) when describing
to patients what they should rate. This difference
undoubtedly leads to more variance in the data,
but no direct evidence shows whether this is an
important problem in clinical measurements.
Response of No Versus Rating of 0. Many nurses
reported asking a yes/no question about dyspnea and
recording responses of no as 0. It takes only a few seconds more to collect a rating from the patient, and pertinent information may be lost by using this shortcut.
Patient’s Report Versus Nurse’s Observation. By
definition, dyspnea is a patient’s own experience of
breathing discomfort, so measuring dyspnea requires
asking the patient. Only patients know how much
discomfort they are experiencing, so a patient’s report
of symptoms is often considered the gold standard.
Several studies have shown that clinicians’ estimates
of dyspnea are poorly correlated with patients’ reports
(R2 values ranging from 0.2 to 0.4).6,8,21,22 Although
these correlations may be statistically significant in
populations, one can have little confidence in estimating the discomfort of a given patient. One study
showed that in patients who reported a dyspnea rating of 4 or greater (on a scale of 0 to 10), 47% of
nurses underestimated the patient’s dyspnea rating
by at least 4 points (Figure 4).21
A reliable patient report is unavailable in some
instances (eg, cognitively impaired or unresponsive
patients). In these cases, nurses use their best alternative to fill the information gap and properly care
for the patient. Although well intended, this method
creates difficulty in interpreting the record. A comparison of the results of this study and those of our
earlier study20 indicates that this problem is much
more common in ICU patients, who are more likely
to be impaired because of heavier sedation and more
severe illness. Nurses who used physical signs to substitute for or modify the patient’s report did so 92%
of the time because the patient was unresponsive (eg,
sedated). We suggest that this information gap would
be best documented by providing nurses with a separate scale to note their own assessment of respiratory
distress, rather than by having nurses act as proxies
for a patient’s report. Less commonly, nurses modified patients’ ratings because patients appeared more
uncomfortable than their reports suggested (the nurses
thereby erred on the side of providing improved symptom relief) or patients appeared less uncomfortable
than their reports suggested (uncommon in our survey). A separate scale to note the clinician’s
Treatment Practices
Once dyspnea is recognized, management includes
pharmacologic and nonpharmacologic interventions2,30
that are implemented while pursuing an accurate diagnosis so the underlying cause can be appropriately
treated. Nurses readily reported using interventions
such as repositioning; remaining with the patient;
coaching slow, deep breathing and providing reassurance; and notifying the physician or respiratory
therapist. Physicians often request closer monitoring, additional laboratory or imaging studies, and
pharmacologic interventions. Most nurses surveyed
(57%) reported that a treatment algorithm for acutely
dyspneic patients would be useful.
Study Limitations
The nurses at our institution may not be representative of nurses at all hospitals. Ours is an academic
138
tertiary care hospital, and several of the attending
physicians in our medical ICUs work closely with
researchers in our dyspnea laboratory. These physicians may have influenced the level of dyspnea
awareness among nurses and respiratory therapists.
(Our sample was drawn about equally from medical
and surgical ICUs.)
Conclusion
Implementation of dyspnea assessment and documentation in the ICU requires acceptance and support by the nurses who perform these assessments.
A significant barrier to adoption of yet another nursing
requirement is the perception that it will impede workflow, burden busy nurses, and cause resentment. Our
study of front-line ICU nurses shows, on the contrary,
that routine dyspnea measurement is feasible in the
highly stressful critical care environment, that nurses
were able to readily incorporate it into their practice,
and that nurses endorse it as important to patient care.
The Joint Commission established standards for pain
assessment and intervention decades ago in response
to the national report of undertreated pain. We believe
that the same standards should exist for dyspnea.
ACKNOWLEDGMENTS
The authors are very grateful to the unit nurses for their
enthusiastic participation, the Lois E. Silverman Department of Nursing for enabling and supporting this project,
and Dr Robert W. Lansing for his generous time and
valuable input.
FINANCIAL DISCLOSURES
This study was supported by NIH grant NR10006 to
Robert B. Banzett.
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Intensive care unit nurses strongly endorsed the use
of a standard tool to measure dyspnea and to record
and track it at every shift. The 0-to-10 numeric scale
was chosen for its brevity and ease of use, for its
consistency with the common pain assessment tool,
and because 10-point scales are broadly recognized
and understood by the general population. Other
assessment scales exist and can provide a much richer
collection of data23,24 but are more cumbersome to
use and thus may not gain acceptance for routine
screening in the busy inpatient setting. Nurses in
focus sessions indicated that a simpler tool may be
easier for patients to comprehend; further studies to
compare such scales may be useful.
Because nurses and physicians evaluating dyspnea on the basis of physical signs nearly always
underestimate the patient’s reported dyspnea,21 a
uniform, systematic tool to evaluate signs of dyspnea in nonverbal patients would be useful. The
Respiratory Distress Observation Scale is a recently
developed instrument for the behavioral assessment of respiratory distress.25 This tool is intended
for use only in patients who are unable to communicate. Validation trials in patients able to provide
a dyspnea rating have shown a statistically significant
correlation; at best the Respiratory Distress Observation Scale explains about half the variance in patients’
ratings (ie, R2 values generally ranging from 0.4 to 0.5
but sometimes ranging as low as 0.1).25-28 A modified version has been developed for ICU patients.29
The Respiratory Distress Observation Scale and other
observation scales may prove to be acceptable surrogates for dyspnea ratings in patients unable to report
but require further psychometric testing in ICU patients
unable to report.
21. Haugdahl HS, Storli SL, Meland B, Dybwik K, Romild U,
Klepstad P. Underestimation of patient breathlessness by
nurses and physicians during a spontaneous breathing
trial. Am J Respir Crit Care Med. 2015;192(12):1440-1448.
22. Hayes AW, Philip J, Spruyt OW. Patient reporting and doctor recognition of dyspnoea in a comprehensive cancer
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23. Banzett RB, O’Donnell CR, Guilfoyle TE, et al. Multidimensional Dyspnea Profile: an instrument for clinical and laboratory research. Eur Respir J. 2015;45(6):1681-1691.
24. Yorke J, Moosavi SH, Shuldham C, Jones PW. Quantification
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testing of the Dyspnoea-12. Thorax. 2010;65(1):21-26.
25. Campbell ML, Templin T, Walch J. A respiratory distress
observation scale for patients unable to self-report dyspnea. J Palliat Med. 2010;13(3):285-290.
26. Hui D, Morgado M, Vidal M, et al. Dyspnea in hospitalized
advanced cancer patients: subjective and physiologic correlates. J Palliat Med. 2013;16(3):274-280.
27. Chan YH, Wu HS, Yen CC, Campbell ML. Psychometric evaluation of the Chinese Respiratory Distress Observation Scale
on critically ill patients with cardiopulmonary diseases. J
Nurs Res. 2018;26(5):340-347.
28. Zhuang Q, Yang GM, Neo SH, Cheung YB. Validity, reliability,
and diagnostic accuracy of the Respiratory Distress Observation Scale for assessment of dyspnea in adult palliative
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29. Persichini R, Gay F, Schmidt M, et al. Diagnostic accuracy of
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30. Booth S, Burkin J, Moffat C, Spathis A. Managing Breathlessness in Clinical Practice. London, England: Springer; 2014.
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disorder in critically ill patients. Neurobiol Learn Mem. 2002;
78(3):596-609.
12. Abidov A, Rozanski A, Hachamovitch R, et al. Prognostic significance of dyspnea in patients referred for cardiac stress
testing. N Engl J Med. 2005;353(18):1889-1898.
13. Bøtker MT, Stengaard C, Andersen MS, et al. Dyspnea, a highrisk symptom in patients suspected of myocardial infarction
in the ambulance? A population-based follow-up study.
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16. Stevens J, Dechen T, Sheridan A, et al. Patient mortality,
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17. Parshall MB, Schwartzstein RM, Adams L, et al; American
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Crit Care Med. 2012;185(4):435-452.
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17(5):528-535.
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yields wide acceptance. BMC Nurs. 2017;16:3.
To purchase electronic or print reprints, contact American
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Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050
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C E 1.0 Hour Category A
Notice to CE enrollees:
This article has been designated for CE contact hour(s). The evaluation demonstrates your knowledge of the
following objectives:
1. Identify why patients who report dyspnea are at increased risk of adverse outcomes, including higher mortality rates in the hospital.
2. Describe how routine dyspnea assessment can lead to early recognition of a patient’s clinical decline and
improve symptom management.
3. Recognize that nurses and physicians evaluating dyspnea on the basis of clinical signs routinely underestimate patients’ reports of dyspnea.
To complete the evaluation for CE contact hour(s) for this article #A2029022, visit www.ajcconline.org and
click the “CE Articles” button. No CE evaluation fee for AACN members. This expires on March 1, 2023.
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AJCC AMERICAN JOURNAL OF CRITICAL CARE, March 2020, Volume 29, No. 2
139
Supplement
Dyspnea survey questions and nurses’ responses
Question
Where do you currently work?
MICU/SICU
MICU A
MICU B
SICU
NSICU
TSICU
CCU
CVICU
5
2
3
8
1
7
6
5
34
1
1
What is your age? (optional)
<25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
No response
2
13
2
5
4
2
2
2
1
3
What ethnicity do you identify with? (optional)
Hispanic or Latino
Non-Hispanic or Latino
No response
0
29
6
What race do you identify with? (optional)
Indian/Alaska native
Native Hawaiian/Pacific Islander
Asian
Black or African American
White
Other
No response
0
0
2
0
30
0
4
How many years have you worked as an ICU nurse?
<1
1-3
4-6
7-9
>10
2
9
7
2
17
How many years have you worked as an ICU nurse
at BIDMC?
<1
1-3
4-6
7-9
>10
5
13
2
3
14
No. of
responses
Question
How important is it to use a uniform tool to assess for dyspnea?
Very important
7
Important
19
Moderately important
Of little importance
Not important
8
2
1
How important is it to track dyspnea every shift?
Very important
Important
Moderately important
Of little importance
Not important
16
16
4
1
0
How often is your assessment of the severity of
respiratory distress meaningfully less than the
patient’s rating of dyspnea?
Always
90% of the time
80% of the time
70% of the time
60% of the time
50% of the time
40% of the time
30% of the time
20% of the time
10% of the time
Never
3
0
3
1
0
7
4
4
6
3
6
How often is your assessment of the severity of
respiratory distress meaningfully greater than the
patient’s rating of dyspnea?
Always
90% of the time
80% of the time
70% of the time
60% of the time
50% of the time
40% of the time
30% of the time
20% of the time
10% of the time
Never
2
1
3
5
1
9
5
4
4
2
1
How important is the addition of routine dyspnea
assessment in improving patient-centered care?
Very important
Important
Moderately important
Of little importance
Not important
8
19
5
4
1
How important is the addition of routine dyspnea
assessment in predicting adverse patient
outcomes?
Very important
Important
Moderately important
Of little importance
Not important
9
17
5
6
0
Continued
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What gender do you identify with? (optional)
Female
Male
No response
No. of
responses
Supplement
Continued
Question
No. of
responses
0
3
24
10
How has the implementation of routine dyspnea
assessment affected your workflow?
Very positively
Positively
No effect
Negatively
Very negatively
1
11
25
0
0
In your opinion, would it be useful to have an
algorithm with specific options for the treatment
of dyspnea? (eg, repositioning, facial fan, morphine)
Very useful
Somewhat useful
Not useful
Unsure
3
18
13
3
Which of the following words or phrases do you
use to explain to the patient what they are
supposed to rate? (Please check all that apply)
Short of breath
Dyspnea
Breathing discomfort
Difficulty breathing/trouble breathing
Can’t catch your breath
None of the above
27
4
24
34
21
0
Some nurses begin symptom assessment by asking
the patient a yes/no question, for instance “are
you feeling any breathing discomfort.”
A) Do you first ask a yes/no question?
Yes
No
28
9
B) If the patient responds “no,” do you document
“0” without asking the patient to provide a
number rating?
Yes
No
14
19
In my opinion, patients give a meaningful number
rating for pain?
Always
90% of the time
80% of the time
70% of the time
60% of the time
50% of the time
40% of the time
30% of the time
20% of the time
10% of the time
Never
0
4
12
4
2
8
3
2
2
0
0
In my opinion, patients give a meaningful number
rating for dyspnea?
Always
90% of the time
80% of the time
70% of the time
60% of the time
50% of the time
40% of the time
30% of the time
20% of the time
10% of the time
Never
1
4
8
3
3
7
3
2
3
3
0
Do you find it helpful to have standard words
(none, mild, moderate, severe, unbearable)
alongside the number scale to help communicate
with patients who have difficulty using a
number scale?
Yes
Uncertain
No
24
8
5
Do you think it would be helpful to have a pictorial
scale to help communicate with patients who have
difficulty using a number scale?
Yes
Uncertain
No
14
12
11
When you use physical signs to assess respiratory
distress, what signs do you use?
Tachypnea
Difficulty speaking
Accessory muscle use
Heart rate
Nasal flaring
Restless movements
Fearful facial expression
Ventilator dyssynchrony
35
35
36
32
32
33
27
29
How often do you use only the patient’s report to
provide a number for dyspnea?
Always
90% of the time
80% of the time
70% of the time
60% of the time
50% of the time
40% of the time
30% of the time
20% of the time
10% of the time
Never
6
3
3
1
0
9
1
1
2
1
9
Continued
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How easy or difficult is it to administer the
dyspnea assessment?
Very difficult
Difficult
Easy
Very easy
No. of
responses
Question
Supplement
Continued
Question
No. of
responses
Question
No. of
responses
34
25
25
13
When you report a patient’s dyspnea rating to the
physician responsible for the patient…
A) The physician requests vital signs and/or
oxygen saturation.
Always
Usually
Half the time
Seldom
Never
20
14
1
0
1
3
2
2
0
3
10
0
4
2
1
9
A) What are your reasons for using physical signs
rather than patient report? (Select all that apply)
Patient is unresponsive (eg, sedated)
Patient is unable to use number scale
Patient seems more uncomfortable than they claim
Patient seems less uncomfortable than they claim
12
4
4
2
How often do you combine the patient’s report
with observed physical signs of respiratory
distress to provide a number for dyspnea?
Always
90% of the time
80% of the time
70% of the time
60% of the time
50% of the time
40% of the time
30% of the time
20% of the time
10% of the time
Never
B) The physician orders laboratory or imaging studies.
Always
Usually
Half the time
Seldom
Never
1
14
17
3
1
15
3
3
4
1
2
1
1
2
0
4
C) The physician orders an intervention to relieve
dyspnea (pharmacologic or nonpharmacologic)
Always
Usually
Half the time
Seldom
Never
5
12
17
2
0
In your opinion would it be useful to have a
separate scale for RNs to record their
observations of respiratory distress?
Yes
No
D) The physician evaluates the patient.
Always
Usually
Half the time
Seldom
Never
12
15
8
1
0
21
15
When your patient complains of increasing shortness
of breath what are your actions? (Select all that apply)
Coach slow, deep breathing
Reposition
Summon respiratory therapist
Notify physician
Provide facial fan
35
35
24
32
11
E) The physician requests nursing to reassess the
patient later.
Always
Usually
Half the time
Seldom
Never
19
10
4
3
0
F) The physician takes none of these actions.
Always
Usually
Half the time
Seldom
Never
1
0
3
9
22
Assess need for narcotics
22
Abbreviations: BIDMC, Beth Israel Deaconess Medical Center; CCU, coronary care unit; CVICU, cardiovascular intensive care unit; ICU, intensive care unit;
MICU, medical intensive care unit; NSICU, neuroscience intensive care unit; RN, registered nurse; SICU, surgical intensive care unit; TSICU, trauma/surgical
intensive care unit.
Downloaded from http://aacnjournals.org/ajcconline/article-pdf/29/2/132/125370/132.pdf by Agus wahyudi on 22 August 2020
What are your reasons for using physical signs to
substitute for or modify patient report? (Select
all that apply)
Patient is unresponsive (eg, sedated)
Patient is unable to use number scale
Patient seems more uncomfortable than they claim
Patient seems less uncomfortable than they claim
How often do you use only observed physical
signs of respiratory distress to provide a number
for dyspnea?
Always
90% of the time
80% of the time
70% of the time
60% of the time
50% of the time
40% of the time
30% of the time
20% of the time
10% of the time
Never
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