Practice Recommendations

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

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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 quantitative scale such as the respiratory Distress observation scale (rDos)
• Usual level of dyspnea
  • Usual dyspnea should be measured using a quantitative scale such as the Medical  Research Council (MRC) Dyspnea scale

• 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

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

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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?

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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.

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1.5 Nurses will be able to implement appropriate nursing interventions for all levels of dyspnea including acute episodes of respiratory distress:

• Acknowledgment and acceptance of patients’ self-report of present level of dyspnea
• Medications
• Controlled oxygen therapy
• Secretion clearance strategies
• Non-invasive or invasive ventilation modalities
• Energy conserving strategies
• Relaxation techniques
• Nutritional strategies
• Breathing retraining strategies

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2.1 Nurses must remain with patients during episodes of acute respiratory distress.

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2.2 Smoking cessation strategies should be instituted for patients who smoke:

• Refer to RNAO (2007) guideline, Integrating Smoking Cessation into Daily Nursing Practice
• Use of nicotine replacement and other smoking cessation modalities during hospitalization for acute exacerbation.

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3.0 Nurses should provide appropriate administration of the following pharmacological agents as prescribed:

• Bronchodilators (Level of Evidence = Ib)
  • Beta 2 Agonists
  • Anticholinergics
  • Methylxanthines
• Oxygen (Level of Evidence = Ib)
• Corticosteroids (Level of Evidence = Ib)
• Combination Treatments (Level of evidence = Ia)
• Antibiotics (Level of Evidence = Ia)
• Psychotropics (Level of Evidence = IV)
• Opioids (Level of Evidence = IV)

3.1 Nurses will assess patients’ inhaler device technique to ensure accurate use. Nurses will coach patients with sub-optimal technique in proper inhaler/device technique.

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3.2 Nurses will be able to discuss the main categories of medications with their patients including:

• Trade and generic names
• Indications
• Doses
• Side effects
• Mode of administration
• Pharmacokinetics
• Nursing considerations

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3.3 Annual influenza vaccination should be recommended for individuals who do not have a contraindication.

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3.4 COPD patients should receive a pneumococcal vaccine at least once in their lives (high risk patients every 5 to 10 years).

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4.0 Nurses will assess for hypoxemia/hypoxia and administer appropriate oxygen therapy for individuals for all levels of dyspnea.

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5.0 Nurses should support disease self-management strategies including:

• Action plan development (Level of evidence = Ib)
  • Awareness of baseline symptoms and activity level
  • Recognition of factors that worsen symptoms
  • Early symptom recognition of acute exacerbation/infection

5.1 Nurses should promote exercise training.

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5.2 Nurses should promote pulmonary rehabilitation.

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6.0 Nurses working with patients with advanced illness causing dyspnea and their families will have the appropriate knowledge and skills to:

• encourage and promote ongoing dialogue regarding patient values, desired outcomes and treatment options,
• ameliorate dyspnea and other distressing physical, emotional, social and spiritual symptoms using appropriate integrative and pharmacological approaches,
• work collaboratively with an inter-professional team to ensure the highest quality of life possible for the person experiencing dyspnea at the end-of-life.

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