Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Assessment

1.0 Nurses will acknowledge and accept the patients’ self-report of dyspnea.

1.1 All individuals identified as having dyspnea related to COPD will be assessed appropriately. Respiratory assessment should include:

  • Level of dyspnea
    • Present level of dyspnea (for patients who are able to self-report)
    • Present dyspnea should be measured using a quantitative scale such as a visual analogue or numeric rating scale
    • Present level of dyspnea (for patients who are unable to self-report) Present level of dyspnea should be measured using a quabtitative scale such as the Respiratory Distress Observation Scale (RDOS)
  • Usual level of dyspnea
  • Vital signs
  • Pulse oximetry
  • Chest auscultation
  • Chest wall movement and shape/abnormalities
  • Presence of peripheral edema
  • Accessory muscle use
  • Presence of cough and/or sputum
  • Ability to complete a full sentence
  • Level of consciousness
  • Watch for swallowing difficulties

1.2 Nurses will be able to identify stable and unstable dyspnea, and acute respiratory failure.

1.3 Every adult with dyspnea who has a history of smoking and is over the age of 40 should be screened to identify those most likely to be affected by COPD. As part of the basic dyspnea assessment, nurses should ask every patient:

  • Do you have progressive activity-related shortness of breath?
  • Do you have a persistent cough and sputum production?
  • Do you experience frequent respiratory tract infections?

1.4 For patients who have a history of smoking and are over the age of 40, nurses should advocate for spirometric testing to establish early diagnosis in at risk individuals.