Gestão da dispneia na pessoa em situação crítica: intervenção de enfermagem especializada / Management of dyspnea in the critically ill: specialized nursing intervention

A dispneia é percebida como sendo semelhante à asfixia, sendo um dos piores sintomas experimentados por doentes críticos, incluindo os que acabam por ser ventilados mecanicamente. A dispneia é um preditor independente de morbidade e mortalidade em populações específicas de doentes e não se limita apenas a doenças de origem pulmonar. Este trabalho expõe o culminar do percurso realizado no contexto do Curso de Mestrado em Enfermagem na Área de especialização à Pessoa em Situação Crítica da Escola Superior de Enfermagem de Lisboa, com o objetivo de desenvolver competências especializadas de enfermagem no cuidado à pessoa em situação crítica com dispneia. Adotou-se a metodologia de projeto. Realizou-se uma RIL, um estágio em Serviço de Urgência e outro em Unidade de Cuidados Intensivos. Participámos em atividades de formação e disseminação de conhecimento científico. O meu pensamento e ação foi sustentado pela filosofia de Laurie Gottlieb. As atividades realizadas possibilitaram atingir os objetivos e o desenvolvimento de competências de mestre e especializadas de enfermagem no cuidado à pessoa em situação crítica com dispneia. São várias as intervenções utilizadas para assistir os doentes na UCI e no SU com dificuldade respiratória e que mostraram efeitos benéficos na gestão da dispneia e dos fatores que a originam, como a ansiedade e a dor. A elaboração deste relatório mostrou ser benéfico na aprendizagem enquanto futura enfermeira especialista e mestre em enfermagem, havendo repercussões consequentes na área da melhoria contínua da qualidade dos cuidados.

Dyspnoea is perceived to be like asphyxia, being one of the worst symptoms experienced by critically ill patients, including those who end up being mechanically ventilated. Dyspnoea is an independent predictor of morbidity and mortality in specific patient populations and is not limited to diseases of pulmonary origin. This work exposes the culmination of the journey carried out in the context of the master's Course in Nursing in the Specialization Area for the Person in Critical Situation at the Escola Superior de Enfermagem de Lisboa, with the objective of developing specialized nursing skills in the care of the person in critical situation with dyspnoea. The design methodology was adopted. There was an RIL, an internship in an Emergency Service and another in an Intensive Care Unit. We participated in training activities and dissemination of scientific knowledge. My thinking and action were underpinned by the philosophy of Laurie Gottlieb. The activities carried out made it possible to achieve the objectives and the development of master's and specialized nursing skills in caring for people in critical situations with dyspnoea. There are several interventions used to assist patients in the ICU and ER with breathing difficulties that have shown beneficial effects in the management of dyspnoea and the factors that cause it, such as anxiety and pain. The preparation of this report proved to be beneficial in learning as a future specialist nurse and master's in nursing, with consequent repercussions in continuous improvement in the quality of care.

Long COVID and breathlessness: an overview.

This article offers a review of what is known so far about post-acute covid-19 and the underlying pathophysiology related to this condition. The main focus will be on the respiratory symptoms. It will then explore how community nurses can monitor and support patients with symptoms of breathlessness with a supporting discussion of the current recommendations for the management and treatment of patients presenting with symptoms of breathlessness. Palliation of symptoms will be highlighted but managing the supportive care needs for patients affected by COVID-19 and nearing the end of life is outside the scope of this article.

A Case of Heart Palpitations and Shortness of Breath.

Editor's note: This is the next installment in a series on electrocardiogram (ECG) interpretation. Nurses in all settings should know the basics, as medications and physiological changes can cause cardiac arrhythmias. Each article will start with a brief case scenario and an ECG strip and then take you step by step through analyzing the heart rhythm.

Field Notes From the Frontline of a COVID-19 Outbreak: Dyspnea Management for Hospitalized Patients at End-of-Life.

Northern New Jersey was inside one of the worst initial coronavirus disease 2019 pandemic epicenters in the United States. At the peak of the pandemic surge in mid-April 2020, New Jersey saw 8045 hospitalized patients with severe coronavirus disease 2019 symptoms, of which 2002 were in intensive care unit beds (86.3% of statewide capacity), including 1705 requiring mechanical ventilation. Because of the severity of pulmonary dysfunction/hypoxia, the unprecedented numbers of critically ill patients, the national opioid shortage, and transmission prevention measures for standard palliative care treatment protocols in place for refractory and/or end-of-life dyspnea were found to be ineffective in providing adequate symptom relief. The aim of the following Notes From the Field is to provide concise, pragmatic, and experiential reflection by 3 palliative care advanced practice nurses from 3 different hospital systems within the pandemic epicenter. The novel methods and opioid strategies implemented by their respective palliative care teams to ensure continued effective and appropriate treatment for end-of-life dyspnea are described. These accounts include Lessons Learned in order to assist others who may need to quickly implement changes in the future due to pandemic resurgence or second-wave events.

Pre-hospital predictors of an adverse outcome among patients with dyspnoea as the main symptom assessed by pre-hospital emergency nurses - a retrospective observational study.

BACKGROUND: Dyspnoea is one of the most common reasons for patients contacting emergency medical services (EMS). Pre-hospital Emergency Nurses (PENs) are independently responsible for advanced care and to meet these patients individual needs. Patients with dyspnoea constitute a complex group, with multiple different final diagnoses and with a high risk of death. This study aimed to describe on-scene factors associated with an increased risk of a time-sensitive final diagnosis and the risk of death. METHODS: A retrospective observational study including patients aged ≥16 years, presenting mainly with dyspnoea was conducted. Patients were identified thorough an EMS database, and were assessed by PENs in the south-western part of Sweden during January to December 2017. Of 7260 missions (9% of all primary missions), 6354 were included. Among those, 4587 patients were randomly selected in conjunction with adjusting for unique patients with single occasions. Data were manually collected through both EMS- and hospital records and final diagnoses were determined through the final diagnoses verified in hospital records. Analysis was performed using multiple logistic regression and multiple imputations. RESULTS: Among all unique patients with dyspnoea as the main symptom, 13% had a time-sensitive final diagnosis. The three most frequent final time-sensitive diagnoses were cardiac diseases (4.1% of all diagnoses), infectious/inflammatory diseases (2.6%), and vascular diseases (2.4%). A history of hypertension, renal disease, symptoms of pain, abnormal respiratory rate, impaired consciousness, a pathologic ECG and a short delay until call for EMS were associated with an increased risk of a time-sensitive final diagnosis. Among patients with time-sensitive diagnoses, approximately 27% died within 30 days. Increasing age, a history of renal disease, cancer, low systolic blood pressures, impaired consciousness and abnormal body temperature were associated with an increased risk of death. CONCLUSIONS: Among patients with dyspnoea as the main symptom, age, previous medical history, deviating vital signs, ECG pattern, symptoms of pain, and a short delay until call for EMS are important factors to consider in the prehospital assessment of the combined risk of either having a time-sensitive diagnosis or death.

The Effects of the Respiratory Rehabilitation Program on Perceived Self-Efficacy and Dyspnea in Patients with Lung Cancer.

PURPOSE: This study aims to examine the effects of the respiratory rehabilitation program on perceived self-efficacy and dyspnea in patients with lung cancer. METHODS: This is a quasi-experimental research study with a two-group repeated measures design with the pretest and post-test at Week 4 and Week 8. The theory of self-efficacy by Bandura was used as the conceptual framework. The sample consisted of patients with non-small-cell lung cancer Stage 4 who visited the oncology clinic in a university hospital. Twenty-eight patients were enrolled and equally allocated to the control group and experimental group. The control group received routine nursing care only, whereas the experimental group received the respiratory rehabilitation program. The program comprised dyspnea educating, breathing exercise, using handheld fans, effective coughing, respiratory strengthening training, and follow-up by phone in the third and sixth week. Data for perceived self-efficacy and dyspnea were collected before the program start and reassessment in the fourth and eighth week. Instrumentation was composed of the respiratory rehabilitation program, demographic data, perceived self-efficacy assessment for respiratory rehabilitation, and the Cancer Dyspnea Scale. Data were analyzed using descriptive statistics and one-factor repeated measures analysis of variance and by comparing means between groups. RESULTS: The result revealed that almost all of the patients in the sample were men, and the mean age of the experimental group and control group was 65.80 years (standard deviation = 8.80) and 73.00 years (standard deviation = 7.60), respectively. There was significant different in the mean score of perceived self-efficacy and dyspnea between the experimental group and the control group (p < .050). CONCLUSION: Based on the findings of the study, the respiratory rehabilitation program should be used to promote self-efficacy and relieve dyspnea in patients with lung cancer.

Intensive Care Nurses' Perceptions of Routine Dyspnea Assessment.

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 work-flow.

Effectiveness of nursing interventions for breathlessness in people with chronic obstructive pulmonary disease: A systematic review and meta-analysis.

AIM: To critically review and synthesize the findings of studies that evaluated the effectiveness of nursing interventions for improving breathlessness in adults with chronic obstructive pulmonary disease. BACKGROUND: Systematic reviews of nursing interventions for breathlessness in people with chronic obstructive pulmonary disease have not been specifically addressed. DESIGN: Systematic review with meta-analysis. DATA SOURCES: A systematic search of Medline, CINAHL, PsycINFO and Embase was performed for studies published between January 2000 and June 2017. REVIEW METHODS: Risk of bias, data extraction and meta-analysis were conducted using Cochrane methodology. The quality of evidence was assessed using the GRADE approach. RESULTS: Twenty papers were included. A meta-analysis of interventions performed at home, including two trials, showed a significant effect in favour of experimental groups for the symptom score of the St. George Respiratory Questionnaire compared with controls. A meta-analysis of interventions performed in clinics with home follow-up showed a significant effect in favour of experimental groups for the mastery and fatigue scores of the Chronic Respiratory Questionnaire compared with controls. In this category of intervention, an additional meta-analysis showed a significant effect in favour of experimental groups for the symptom, activity and total scores of the St. George Respiratory Questionnaire compared with controls. The quality of evidence was assessed to be very low to moderate. CONCLUSION: The results are equivocal as to whether nursing interventions performed at home and nursing interventions performed in hospital with follow-up improve breathlessness in people with chronic obstructive pulmonary disease.

Association between Manchester Triage System discriminators and nursing diagnoses. / Associações entre discriminadores do Sistema de Triagem de Manchester e diagnósticos de enfermagem.

OBJECTIVE: To analyze the association between Manchester Triage System flowchart discriminators and nursing diagnoses in adult patients classified as clinical priority I (emergency) and II (very urgent). METHOD: Cross-sectional study conducted in an emergency department in southern Brazil between April and August 2014. The sample included 219 patients. Data were collected from online patient medical records and data analysis was performed using Fisher's exact test or the chi-square test. RESULTS: 16 discriminators and 14 nursing diagnoses were identified. Associations were found between seven discriminators and five problem-focused nursing diagnoses, including the discriminator Cardiac pain and the diagnosis Acute pain. Three discriminators were associated with four risk nursing diagnoses, among these Acute neurological deficit with the diagnosis Risk of ineffective cerebral tissue perfusion. CONCLUSION: Significant associations were found between Manchester Triage System discriminators and the nursing diagnoses most frequently established in the emergency department.

Palliative care: the need of the modern era.

There is a great need for palliative care in the modern era of medicine. Despite medical advances, patients with life-limiting illnesses still suffer significantly. Palliative care emerged a half century ago as an ethos based on compassion and care for patients and their families to relieve their suffering. It entails a paradigm shift from the biomedical model to the biopsychospiritual model. Palliative care is recognised by the World Health Organization as an essential part of the continuum of universal health coverage. In 2014, the World Health Assembly approved a resolution on "Strengthening of palliative care as a component of comprehensive care throughout the life course". Despite Hong Kong's relatively good local palliative care service coverage for patients who died of cancer and end-stage renal failure, service gaps for palliative care do exist among our ageing population with non-malignant life-limiting illnesses. We strongly urge the Hong Kong Government to develop our local palliative care policy in response to the World Health Assembly's resolution. Growing international and local evidence demonstrates the impacts of palliative care on patient outcomes, caregivers, and health care. Such outcomes can be service-based, disease-based, or symptom/suffering-based. The goal of palliative care is to relieve health-related suffering. Evidence-based management of pain, breathlessness, and psychospiritual suffering are discussed. Care in the end-of-life phase should be an integral part of palliative care, promoting patient choice, advance care planning, and good death.

Non-pharmacological management of chronic breathlessness in stable chronic obstructive pulmonary disease.

This paper will review and address the pathological processes in chronic obstructive pulmonary disease (COPD), including the prevalence of comorbidities and the implications of these factors for a common disabling COPD symptom, breathlessness. It will further consider non-pharmacological strategies that community nurses can use to support breathlessness relief in the context of holistic patient care.

Using a Dyspnea Assessment Tool to Improve Care at the End of Life.

Dyspnea is experienced by 15% to 70% of patients at end of life. Because of cognitive changes before death, patients may be unable to self-report dyspnea, which requires nurses to accurately assess and initiate symptom management. This study compared practicing nurses' experiential practice in the assessment and management of dyspnea in patients unable to self-report to practice using of the Respiratory Distress Observation Scale (RDOS). This pre-experimental pretest/posttest study evaluated nurse outcomes following a structured educational program aimed at preparing them to use the RDOS. Nurses (n = 39) who provide end-of-life care were recruited for the study. After receiving the educational program, there was not a significant difference in the nurse's ability to assess the patient's overall level of perceived comfort and determine a differential diagnosis. There was, however, improvement in the nurse's ability to correctly determine a patient's level of dyspnea (P = .021) and also in their ability to select appropriate treatment options. This study demonstrates applicability of the RDOS to the end-of-life population replacing experiential practice with an evidence-based tool for the assessment and treatment of dyspnea in patients who cannot self-report.

Managing chronic breathlessness in the community.

Breathlessness or dyspnoea is a subjective experience that can be described as an unpleasant or uncomfortable awareness of breathing. It is a subjective experience for patients and often they learn to adapt to the limitations caused by their condition, which makes their breathlessness less apparent to others. Breathlessness can be subdivided in the context of chronic refractory breathlessness, such as acute breathlessness, which is either an episodic breathlessness or breathlessness crisis. Chronic refractory breathlessness is defined as breathlessness at rest or on minimal exertion that will persist chronically despite optimal treatment of the underlying causative factors. The role of the community nurse in managing the breathless patient should involve differentiating between different types of breathlessness and knowing how to effectively manage it in a holistic manner.

Chronic Obstructive Pulmonary Disease: Clinical Implications for Patients With Lung Cancer

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the most common smoking-related illness. COPD often is underemphasized as a comorbidity except when considering issues surrounding surgical treatment options. OBJECTIVES: This article aims to provide nurses with an overview of the pharmacologic and nonpharmacologic treatment implications of COPD. METHODS: Definitions, differentials, and treatment considerations are provided, and clinical implications and resources are described. FINDINGS: The added burden of dyspnea, fatigue, and psychological distress related to COPD may affect the overall outcome and quality of life (QOL) of patients with lung cancer. Attention to the prevention, assessment, and treatment of lung cancer and COPD and related symptomatology will help maximize patients' QOL.

Efectividad de un programa de rehabilitación respiratoria en pacientes con enfermedad pulmonar obstructiva crónica / Effectiveness of a respiratory rehabilitation programme in patients with chronic obstructive pulmonary disease

Objetivo: Evaluar la efectividad de un programa de rehabilitación respiratoria (RR) multidisciplinar en pacientes con enfermedad pulmonar obstructiva crónica grave o muy grave preprograma RR, al terminar el programa y al año de haber realizado la RR midiendo los cambios producidos en: la capacidad de ejercicio (test de marcha), mejoría en la tolerancia al esfuerzo (volumen espiratorio forzado [FEV1]) y en la calidad de vida relacionada con la salud. Método: Diseño cuasi experimental con un solo grupo. Se incluyeron a pacientes con diagnóstico de enfermedad pulmonar obstructiva crónica grave o muy grave (estadios III y IV de la clasificación GOLD) que entraron en el programa de RR entre 2011 y 2012. Se recogieron datos demográficos, calidad de vida relacionada con la salud general (SF-36) y específica para enfermos respiratorios (Cuestionario Respiratorio St. George), FEV1% y test de capacidad de ejercicio (prueba de la marcha de 6min). La recogida de datos se realizó preprograma RR, al terminar el programa de RR y al año de haber acabado el programa. Resultados: No se observaron diferencias significativas en los valores de FEV1%. Respecto a la capacidad de ejercicio se observó un aumento de la distancia recorrida en el test de marcha, que se modificó significativamente después del entrenamiento, de 377±59,7 a 415±79m al año (p<0,01). Se observó una mejoría estadísticamente significativa en las 3 dimensiones del Cuestionario Respiratorio St. George. Las medias de las puntuaciones obtenidas de la calidad de vida relacionada con la salud mejoraron significativamente en todas las dimensiones excepto en la dimensión rol emocional del cuestionario SF-36. Conclusión Un programa de RR de 8 semanas de duración mejora la capacidad de realizar ejercicio, la disnea y la calidad de vida en pacientes con enfermedad pulmonar obstructiva crónica grave y muy grave (AU)

Objective: To evaluate the effectiveness of the multidisciplinary respiratory rehabilitation (RR) programme in patients with severe or very severe chronic obstructive pulmonary disease pre the RR programme, at the end of the programme and one year after the RR, measuring changes in ability to exercise (walking test), effort tolerance(forced expiratory volume (FEV1)) and health-related quality of life. Method: Quasi-experimental single group design. We included patients diagnosed with severe or very severe chronic obstructive pulmonary disease (stages III and IV of the GOLD classification) who entered the rehabilitation programme for the years 2011 and 2012. Demographic data, questionnaires on general health-related quality of life (SF-36) and specific to respiratory patients (St George's Respiratory Questionnaire), FEV1% and exercise capacity test (running test 6minutes) were collected. Data were collected before the RR programme, at the end of the RR programme and a year after completing the program. Results: No significant differences in FEV1% values were observed. Regarding exercise capacity, an increase in distance walked in the walking test was noted, which changed significantly after training, 377±59.7 to 415±79 m after one year (P<.01). A statistically significant improvement in mean scores of HRQoL was observed, except for the emotional role dimension of the SF-36 questionnaire. Conclusion: A pulmonary rehabilitation programme for 8 weeks improved the exercise capacity, dyspnoea and quality of life of patients with severe and very severe chronic obstructive pulmonary disease (AU)

Evaluación de la motivación para la cesación tabáquica en pacientes hospitalizados / Assessing motivation to smoking cessation in hospitalized patients

Objetivo: Evaluación del nivel de motivación para la cesación tabáquica en los pacientes que ingresan en un hospital de agudos, identificación de los factores que predicen el inicio del cambio y establecimiento de un grupo de riesgo susceptible de intervención. Método: Estudio transversal descriptivo. Evaluación retrospectiva de las historias clínicas de 248 pacientes fumadores mayores de 18 años ingresados en unidades médicas y quirúrgicas de un hospital comarcal, entre mayo de 2014 y abril de 2015. Se valoraron datos sociodemográficos, variables relacionadas con la necesidad de respirar, consumo de cigarros/día, motivación para la cesación tabáquica, interés manifestado y antecedentes de patología respiratoria e ingresos previos. Resultados: El resultado del test de Richmond indicó que el 54% de los pacientes (n=134) tenía una baja motivación para dejar de fumar frente al 11,7% (n=29) que manifestaron una alta motivación. El grupo de pacientes que quería recibir ayuda (n=77) estaba constituido fundamentalmente por hombres (p=0,009), ingresados a cargo de especialidades médicas (p=0,026) principalmente cardiología (51,%) y consumidores de 11-29 cigarrillos/día (p=0,015). La presencia de disnea al ingreso, antecedentes de patología respiratoria e ingreso en el año previo por motivos respiratorios no constituyeron variables predictivas para obtener una respuesta motivadora hacia la cesación tabáquica. Conclusión: Se evidencia un grupo de pacientes afectados respiratoriamente con baja motivación para dejar de fumar que no quieren recibir ayuda y que deben ser considerados grupo diana para planificar estrategias motivadoras para el inicio del cambio (AU)

Aim: To assess motivation to quit smoking in patients admitted to an acute care hospital, determine predictors of readiness to change, and identify a risk group that requires targeted motivational interviewing. Methods: A cross-sectional descriptive study. A retrospective study was performed on the medical records of 248 patients aged >18 years with smoking habits admitted to the medical and surgery units of a district hospital between May 2014 and April 2015. The data collected included sociodemographic data, data on respiratory function, number of cigarettes smoked per day, motivation to quit smoking, patient-reported readiness to quit, history of respiratory diseases and previous admissions. Results: The Richmond test revealed that 54% of patients (n=134) were poorly motivated to quit smoking vs. 11.74% (n=29) who reported to be highly motivated. The group of patients who reported to be willing to receive support (n=77) was prevailingly composed of men (p=.009) admitted to a medical care unit (p=.026) -mainly the Unit of Cardiology (51%)- who smoked 11/29 cigarettes/day (p=.015). Dyspnoea at admission, a history of respiratory disease and previous admissions for respiratory problems were not predictors of readiness to quit. Conclusions: This study identifies a risk group of patients with respiratory disease, low motivation to quit smoking and poor readiness to receive smoke cessation support, that should be the target of motivational approaches to behavior change (AU)

Associações entre discriminadores do Sistema de Triagem de Manchester e diagnósticos de enfermagem / Asociación entre el Sistema de Triage Manchester y el diagnóstico de enfermería / Association between Manchester Triage System discriminators and nursing diagnoses

Resumo OBJETIVO Analisar associações entre discriminadores do Sistema de Triagem de Manchester e Diagnósticos de Enfermagem em pacientes adultos, classificados com prioridade clínica I (emergência) e II (muito urgente). MÉTODO Estudo transversal realizado na unidade de emergência do sul do Brasil, entre abril e agosto de 2014. Amostra de 219 pacientes. Os dados foram coletados no prontuário online e analisados estatisticamente, com teste exato de Fisher ou qui-quadrado. RESULTADOS Encontrou-se 16 discriminadores e 14 diagnósticos de enfermagem. Houve associação entre sete discriminadores e cinco diagnósticos de enfermagem do tipo foco no problema, dentre Dor precordial ou cardíaca com o diagnóstico Dor aguda. Também houve associação entre três discriminadores com quatro diagnósticos de enfermagem de risco, dentre Déficit neurológico agudo com o diagnóstico Risco de perfusão tissular cerebral ineficaz. CONCLUSÃO Existem associações significativas entre discriminadores do Sistema de Triagem de Manchester e diagnósticos de enfermagem mais frequentemente estabelecidos na Unidade de Emergência.

Resumen OBJETIVO Analizar asociaciones entre los discernidores del Sistema Triaje de Manchester y los Diagnósticos de Enfermería en pacientes adultos con prioridad clínica I (emergencia) y II (muy urgente). MÉTODO Estudio transversal realizado en la unidad de emergencia del sur de Brasil, entre abril y agosto de 2014, con la muestra de 219 pacientes. La colecta de datos fue realizada en el prontuario online de los pacientes. El análisis estadístico fue realizado con el uso del Test Exacto de Fisher o chi-cuadrado. RESULTADOS Fue identificado el uso de 16 discernidores y 14 diagnósticos de enfermería. Hubo una asociación entre siete discernidores y cinco diagnósticos de enfermería del tipo foco en el problema, entre estos Dolor precordial o cardíaca y Dolor agudo. También hubo asociación entre tres discernidores y cuatro diagnósticos de enfermería de riesgo, entre estos Déficit neurológico agudo con el diagnóstico Riesgo de perfusión tisular cerebral ineficaz. CONCLUSIÓN Existen asociaciones significativas entre los discernidores del Sistema Triaje de Manchester y los diagnósticos de enfermería más frecuente establecidos en la Unidad de Emergencia.

Abstract OBJECTIVE To analyze the association between Manchester Triage System flowchart discriminators and nursing diagnoses in adult patients classified as clinical priority I (emergency) and II (very urgent). METHOD Cross-sectional study conducted in an emergency department in southern Brazil between April and August 2014. The sample included 219 patients. Data were collected from online patient medical records and data analysis was performed using Fisher's exact test or the chi-square test. RESULTS 16 discriminators and 14 nursing diagnoses were identified. Associations were found between seven discriminators and five problem-focused nursing diagnoses, including the discriminator Cardiac pain and the diagnosis Acute pain. Three discriminators were associated with four risk nursing diagnoses, among these Acute neurological deficit with the diagnosis Risk of ineffective cerebral tissue perfusion. CONCLUSION Significant associations were found between Manchester Triage System discriminators and the nursing diagnoses most frequently established in the emergency department.

Assessment and management of refractory breathlessness in interstitial lung disease.

Interstitial lung disease (ILD) refers to a cluster of fibroinflammatory conditions. There are limited treatment options and most patients have severe dyspnoea. The prognosis is poor. This study aims to evaluate current literature on the assessment and management of refractory breathlessness in ILD. Few tools are available to assess dyspnoea in advanced respiratory disease. Holistic assessment requires a combination of tools but there are few disease specific tools. The role of opioids is well established in the reduction of breathlessness, but there is insufficient evidence that benzodiazepines are beneficial. Non-pharmcolological breathlessness intervention services can give patients mastery of their disease, reduced distress due to breathlessness and were more cost effective. More research on holistic interventions for use in advanced disease needs to be done. Patient-reported outcome measures could elicit valuable evidence to describe the benefit of breathlessness management services in advanced respiratory disease.