By Kaye Prather, RRT-NPS, AE-C
Imagine for a minute you’re the person in a classic Dudley Do-Right cartoon. You are tied to a railroad track. The train is coming, you can feel the vibration of the rails. You can see the train in the distance and your heart starts pounding. You try to work free with no success. Now the train is closer and Dudley Do-Right comes into sight. The train’s whistle is blowing; you struggle against the ropes and can’t get free. Dudley looks down at you and asks what is wrong? By this time you can barely speak to explain you cannot get untied and the train is almost on top of you. Dudley tells you to, JUST RELAX. The train’s whistle is blowing, you can feel the ground shake, your heart is racing, and smoke from the engine makes it difficult to breathe. Dudley acts inpatient, he doesn’t seem to know why you are so upset and says, “Why don’t you, JUST RELAX, while I go call for help”. How would you feel? A little PANICKED, I’ll bet!
You can improve communication by not saying relax. No one including you has ever relaxed on command.
Use active listening: Acknowledge this is a scary situation, thereby validating the patient’s fears. This is the first step to earning trust. It is easier to trust someone that understands and/or accepts you.
Focus on feelings: Being short of breath affects the patient emotionally, causing anxiety. There are no right or wrong emotions. Your acceptance of the patient’s feelings will earn their trust and they’ll be more open, allowing you to better serve them. This will make your job much easier and will meet best practice goals.
Don’t offer advice: The patient knows their body, illnesses, and emotions. If you feel you have something to offer that will make a difference, ask if you can make a suggestion. Then offer it in a non-clinical way that is easily understood by the patient and family.
Accept your patient’s frame of reference: What a patient believes, their perspective, is real and true to them. Accepting their perspective will earn their trust and respect; use their frame of reference to explain what is going on or answering their questions. This will make it easier for you to care for them.
Mind over matter: Try to get the patient’s mind on something other than fear/anxiety. Talk to them; tell them what is happening to them, understanding will lessen their fear. Get them to talk about their family, work, and hobbies. Listen to them. Making the time to get the patient through a crisis will save you work in the course of their stay.
Total communication: When in a crisis use total communication. Both facial and body language will comfort and calm the patient. A smile or a wink will reassure a frightened patient. Gestures become very important when caring for the hard of hearing. Calming gestures such as holding the patient’s hand or arm, a touch to the brow, human touch is a basic need and may be enough to break the cycle of anxiety. A patient is afraid in a crisis, fear is primal. Calm and hushed tones work as well.
A calm patient has a decreased heart rate, decreased rate of breathing, decreased oxygen consumption, decreased carbon dioxide production and decreased work of breathing. These are all outcomes we are working towards. Next, determine the degree and the cause of the SOB (shortness of breath) causing the anxiety. Once you have reviewed the patient’s history and assessed their current distress; let the patient know what is going on, what test and/or procedures will be needed and how you plan to improve their situation.
Assessment of the Patient:
Degree of SOB (shortness of breath), decreased SpO2/SAT.
Mild to moderate SOB (shortness of breath): The patient is talking and/or eating.
Moderate SOB (shortness of breath): The patient’s work of breathing is increased, you notice it is becoming difficult for the patient to talk and they are more anxious.
Moderate to severe SOB (shortness of breath): The patient has to work very hard to breathe, it is difficult for the patient to talk in complete sentences and their anxiety level has a marked increase.
Severe SOB (shortness of breath): The patient is using accessory muscles to breath, they have difficulty speaking in one-word sentences and their anxiety level is high.
Once you have accessed the level of SOB (shortness of breath). There are some simple questions to ask yourself. What is my patient’s history?
- CHF (congestive heart failure): what are my patient’s I/O’s, has the patient’s blood pressure been increased/stabilized with fluids?
- COPD (chronic obstructive pulmonary disease): is there a history of CO2 retention or air trapping? Patients with a history of air trapping are prone to anxiety, it is difficult to take a deep breath due to the difficulty of getting the air out. A CO2 retainer’s drive to breath is based on CO2 not the lack of O2. The patient’s medical history of blood gases will confirm CO2 retention.
- Asthma/hyper airway disease: bronchospasm can close the patient’s airway very quickly. Do you or the patient know what their triggers are? Allergy(airborne or food), stress, irritants are possible triggers.
- Renal insufficiency: when the kidneys are not working the patient’s HCO3 is affected. When this happens the lungs compensate, the patient’s frequency of breathing will increase or decrease accordingly.
- Fluid overload may cause a pressure imbalance in the lungs allowing fluid to seep into the lung bases and/or extra fluid in the interstitium decreasing gas exchange and increasing work of breathing.
- Fear of being in a strange and scary place. The hospital is such a place.
- When a person is in pain their O2 consumption increases. Their work of breathing, heart rate, respiratory rate and anxiety level is affected. Patients just after surgery are sensitive to the pain medications we give them. A patient can suffer from respiratory depression, their ventilation decreases.
- SOB (shortness of breath) in and of itself causes anxiety that can spiral into a life-threatening
- Bronchospasm is the abnormal narrowing and partial to full obstruction of the bronchi. This can come on quickly. The patient may have an unproductive cough and wheezing. Bronchospasm is triggered. Find the trigger/s this will enable the patient and can reduce anxiety.
- Exercise/Exertion. The smallest exertion increases CO2 production and O2 consumption, which increases their work of breathing, then SOB (shortness of breath).
Understanding the causes of anxiety and/or a decrease in SpO2/SAT better prepares you to serve/care for your patient’s needs. Anxiety can be an alarming, mysterious event for both the patient and caregiver. Understand what is occurring in your patient. You will then be able to improve the patient’s metabolic, oxygen, fluid, in a way that reassures the patient. There are three things, I hope you have gained:
First, an open mind; that you will use the concepts regarding communication to create your own personal effective style.
Second, to have an understanding of the cause of SOB (shortness of breath) which can bring on anxiety. This will give you a course of action to give timely care to your patients.
Third, assessment skills that give you the confidence to keep calm and efficient patient care.
Kaye Prather RRT-NPS, AE-C started her healthcare career late in life. She went back to school at age 49, graduating an accelerated program as valedictorian. During her career, she has in worked acute care, rehab, home care, pulmonary rehab and as a contract trainer.