Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Characterize the dyspnea:
Onset (sudden or gradual)
Severity (mild, moderate, severe at rest or with exertion)
Frequency (constant, episodic)
Triggers (activity, position changes)
Associated symptoms (cough, wheezing, chest tightness, anxiety)
Impact on quality of life (sleep, daily activities)
Inquire about the patient’s understanding and fear of dyspnea.
Objective:
Vital Signs: Include respiratory rate, oxygen saturation (SpO2) on room air and with exertion (if safe to assess).
Physical Exam:
General: Assess for respiratory distress (pursed-lip breathing, use of accessory muscles).
Chest: Auscultation for rales (crackling sounds), wheezing, or decreased breath sounds.
Oxygen saturation may be checked with pulse oximetry.
Palliative Performance Scale (PPS) score (optional): This score helps assess a patient’s functional ability.
Assessment:
Dyspnea likely due to underlying disease (mention the primary diagnosis).
Consider potential contributing factors to dyspnea:
Pulmonary edema (fluid buildup in the lungs)
Pleural effusion (fluid collection around the lungs)
Anxiety
Pain
Metabolic causes (acidosis)
Plan:
Treatment directed at the underlying cause (if possible):
Diuretics for pulmonary edema.
Thoracentesis for pleural effusion.
Bronchodilators for obstructive lung disease (if applicable).
Palliative Management of Dyspnea:
Oxygen Therapy: Low-flow nasal cannula oxygen to maintain SpO2 ≥ 90% for comfort, not necessarily to achieve normal levels.
Positioning: Elevate head of bed or use pillows to improve breathing comfort.
Opioids: Low doses of opioids can effectively manage dyspnea, especially when associated with anxiety or pain.
Non-invasive ventilation (NIV) (if appropriate): May be considered in some cases to provide respiratory support.
Psychosocial Support:
Address anxiety and fear related to dyspnea through patient education and emotional support.
Consider chaplaincy services or other resources to address spiritual concerns.
Follow-up:
Monitor response to treatment and adjust the plan as needed.
Regularly assess symptoms and functional status.
Maintain open communication with the patient and family about goals of care and prognosis.
Consider referral to a pulmonologist or chest physician for complex cases of dyspnea.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding the characteristics of dyspnea, associated symptoms, physical exam findings, assessment of underlying cause and contributing factors, and treatment plan focusing on comfort and symptom management. Consider the patient’s goals of care and preferences when making treatment decisions.