A Concept Analysis on Breathlessness - Essay Example

Concept Analysis: Conduct a Concept Analysis on Breathlessness The aim of nursing science is to develop theories to describe, explain, and understandthe nature of the phenomena, and anticipate the occurrence of phenomena, events, and situations related directly or indirectly to nursing care. Theory development can be accomplished by inductive or deductive processes or by a combination of both. The content of a theory comes from other theories, practice, or research or a combination of two or more of these sources (Nesbit, J.C. and Adesope, O.O., 2006, p. 444). Using other theories as a source of generating a theory involves a deductive process, whereas using practice experience or research findings for developing a theory requires an inductive process. Walker and Avant (1995) describe strategies of theory development that include both inductive and deductive processes. Analysis, synthesis, and derivation are applied to concepts, statements, and theories. Analysis is solely an inductive process, whereas synthesis and derivation can involve both inductive and deductive processes. Theories are also developed to provide nurses with the rationale and the guidelines for models of care to change unwanted aspects of phenomena as well as to support other aspects of phenomena. Theories thus provide the frameworks for nursing prescription as well. These emerging explanatory and perspective concepts of theories and their analyses would pose to reflect abstract representation of human beings to health and illness, to environments, to treatments, and to healthcare professionals. The concept analysis would also reveal the patterns how and under what conditions and within what contexts healthy and therapeutic relations develop in the health care system (Walker, L. & Avant, K., 1995, p 37). This project will be evolving around the concept analysis of the phenomenon of breathlessness in clinical practice. This has relevance and relationship for community, society, and the clinical practice. This would help understand the term breathlessness as to what does it imply actually in the clinical setting. Using the model of Walker and Avant (1995) as applied to the concept analysis of breathlessness, this proposes nine strategies in the book, Strategies of Theory Construction in Nursing. These are analysis of the concept that distinguishes between defining and irrelevant attributes of breathlessness by breaking this concept into simpler elements and considering similarities and differences. It will be determined by means of orderly examination, how useful, informative, and logically correct the statements are. The analytical framework will be applied to determine the strengths and weaknesses of the theory. This process will generate avenues to examine data from the perspective of new insights, and it would generate new ideas. The clinical experience and observation of the phenomena of breathlessness will explore the relationship between events and theory, and this could lead to the development of relationship statement. These empirical evidences can be collated to develop a theory. All these together would be called the phase of synthesis of the theory (Hanrahan, M., 2004, p. 19). In the next phase of derivation, new ways of thinking about breathlessness develops mainly based on relationships between phenomena, and they would lead to formulation of a new statement about breathlessness in the aspects where things are poorly understood in the current knowledge and practice. After this analysis, there would be unexplored areas where things would be poorly known, where materially no studies exist, and for which no theory exists. The ultimate aim of the concept analysis would be to explain and predict phenomena those are poorly understood (Walker, L. & Avant, K., 1995, p 37). Breathlessness As a Concept: Breathlessness occurs whenever the work of breathing is excessive. Increased force generation is required of the respiratory muscles to produce a given volume change if the chest wall or lungs are less compliant or if resistance to airflow is increased. In order to define breathlessness, it is important to understand the mechanism of breathing. Breathlessness has been defined as an abnormally uncomfortable awareness of breathing that is apparently not in conformity with the prevalent metabolic state. This is physiologically present with physical exertion. During and following exhaustive exertion, an individual may become unpleasantly aware of rapid breathing and feel short of air. This by definition is also breathlessness, but most individuals do not feel anxious out of it. This has long been acknowledged as the cardinal symptom of cardiorespiratory disease, and as a symptom, breathlessness is both a perception and the reaction to the perception. Since this is a perception, patients describe this uncomfortable experience in many different phrases. A patient with breathlessness may term it as "cannot get enough air", "air does not go all the way down", "smothering feelings or tightness or tiredness in chest", or "a choking sensation." Once it is confirmed that a patient does have breathlessness, it is of paramount importance to define the circumstances in which breathlessness occurs and to assess associated symptoms. There are clinical situations in which breathing appears labored but breathlessness would not occur. Patients with apparently normal breathing pattern may complaint about breathlessness. Therefore, clinically significant breathlessness that needs treatment and attention in the clinical area would exclude situations of exhaustive physical exertion and those with apparently normal breathing pattern. The gradation of breathlessness is also an important cluster of attributes. This is usually based on the amount of physical exertion necessary to produce the sensation of breathlessness (Harver, A., Mahler, D.A., Schwartzstein, R. M., and Baird, J.C., 2000, p. 688-690). Thus, in assessing its severity, it is important to obtain a clear understanding of the patient's general physical condition, work history, environmental conditions, and recreational habits. It is also important to consider variations in interindividual perception. In clinical practice, it is often noticed that some patients with severe disease complain of only mild breathlessness; others with mild disease may experience more severe shortness of breath. On the other end of the spectrum, sudden and unexpected breathlessness episodes at rest can be associated with many cardiopulmonary diseases. Disease entities like pulmonary embolism often manifest themselves in this form. Nocturnal episodes of breathlessness are characteristic of left ventricular failure. Breathlessness upon assuming supine position is known to happen in congestive cardiac failure where appropriate adjustment of the bed of the patient is necessary to achieve relief of symptoms (Walker, L. & Avant, K., 1995, p 39). Defining Characteristics: The symptoms of breathlessness are often related to a process, such as, obstruction of the airways or congestive heart failure, and further diagnostic and/or therapeutic attempts are proceeded with. Several different mechanisms operate to different degrees in the various clinical situations in which breathlessness is the cardinal symptom. Obstructive diseases of the airways can lead to obstruction in airflow anywhere from extrathoracic airways out to the minute airways in the periphery of the lung. Obstruction in the intrathoracic airways can occur acutely and intermittently or can be present chronically with worsening during respiratory infections. The patients with bronchial asthma may present with acute, intermittent wheezing with concomitant breathlessness. Chronic bronchitis is a very common condition where chronic cough with expectoration happen with breathlessness. Superimposed and intercurrent infection results in worsening of cough, increased expectoration of purulent sputum, and more severe breathlessness. When there is acute exacerbation of chronic bronchitis, there is a prolongation of expiration and coarse rhonchi that are generalized throughout. During such episodes, the patient may complain of breathlessness in paroxysms with wheezing. Despite the fact that severe limitation of expiratory flow and hyperinflation of lung are characteristic of these diseases, the sensory experience is often that of an inability to take in a sufficiently deep breath rather than difficulty in exhaling. There is another entity called emphysema that is characterized by many years of breathlessness on exertion that progresses to breathlessness at rest invariably accompanied by obstruction of the airways and parenchymal disease. In patients with heart disease, breathlessness occurs most commonly as a consequence of elevated pulmonary capillary pressure. This diminishes the compliance and increases the airway resistance. Compounded, they increase the work of breathing. In advanced congestive heart failure, usually involving both elevation of pulmonary and systemic venous pressures, the pulmonary function may be compromised leading to intensification of breathlessness. Two other variants of breathlessness are encountered in the clinical practice (Watson, R. D. S., Gibbs, C.R., and Lip, G.Y.H., 2000, p. 236-239). These are breathlessness in the recumbent position and attacks of breathlessness in that usually occur at night and would wake the patient from bed. In most patients with breathlessness, there is obvious clinical evidence of disease of the heart and/or lungs. Irrespective of the aetiology, the diagnostic signs of breathlessness includes tachypnoea, nasal flaring, breathing with mouth open, suprasternal notch recession, intercostals retraction, depending on the condition restriction of expiration or inspiration, and in severe cases, evidence of hypoxaemia as evidenced by pulse oxymetry or clinical cyanosis (O'Donnell, D. E., 2006, p. 37-41). From the perspective of aetiology, it may be associated with wheezing, rhonchi, or crepitation or moist rales. In the lungs, there may absent breath sound, egophony, or bronchial breath sounds. In the heart, there may be evidence of cardiomegaly, tachycardia, or arrhythmia. The neck may demonstrate engorged neck veins. In the abdomen, there may be hepatosplenomegaly (Walker, L. & Avant, K., 1995, p 41).. Antecedents: For breathlessness to happen, there are many identified antecedents. For chronic bronchitis to become exacerbated leading to symptoms of breathlessness, it is necessary for the patient to happen a precipitating infection. For pneumothorax, an emphysema is the antecedent event. For breathlessness of asthma, an asthmatic diathesis or environmental allergic event is responsible. For breathlessness of cardiac origin, the antecedents are cardiac disease, hypertensive, ischeaemic, or otherwise. Vulvular heart disease or congenital anomalies of the heart, pulmonary embolism, cardiomyopathy may all be antecedents of breathlessness. The determinants of breathlessness can therefore be enumerated depending on clinical conditions are the extents of the cardiac or pulmonary disease, state of anxiety, severity of symptoms as indicated by the grade of breathlessness, the precipitating events such as infection or environmental insults, and exacerbation of the original condition. From another standpoint, the determinants of breathlessness could be the perceived and explicit clinical severity as indicated by respiratory rate and the compromise in tissue oxygenation that it poses to produce. In almost all cases, there are certain preceding events that cause breathlessness. In acute cases, sudden fluid overload or acute reduction of cardiac output that might result from reduction in ejection fraction of the heart may cause breathlessness due to congestive cardiac failure. In pulmonary parenchymal diseases, such as, chronic bronchitis, pneumonia, bronchitis, an acute infection usually causes the baseline situation to worsen (Calverley, P.M.A., 2003, p. 26s-30s). In clinical conditions such as pneumothorax, rupture of an emphysematous bleb; in pulmonary embolism, hypercoagulable states precipitating thromboembolism in the pulmonary vascular tree; in bronchial asthma, acute allergic events precipitating spasm of the bronchial smooth muscles usually cause the breathlessness to occur. There are certain risk factors that may predispose to the conditions that may clinically manifest as breathlessness. Emphysema and bronchial asthma has a congenital predisposition. Smoking and environmental pollutants are well-known risk factors for chronic bronchitis (De Palo, V.A., 2004, p. 157-167). An infective episodes in the upper respiratory tract due to conditions that predispose to repeated infections, such as, immune compromise, malignancy, HIV, diabetes, therapy with steroids, all are risk factors for breathlessness (Walker, L. & Avant, K., 1995, p 43). Consequences: The immediate consequences of breathlessness if deterioration of health-related quality of life. With breathlessness, the patients are often limited in their activities, most importantly activities of daily living. The sensation of dyspnea is crippling in the sense that the functional status of the patient is reduced. As a consequence quality of life and disability develop. Breathlessness is also a core feature of panic attacks. The fear of breathlessness and attacks may lead to avoidance of otherwise achievable physical activity and cause additional deconditioning. As a final common pathway irrespective of the aetiology, breathlessness produces oxygen deficit and deficit in vital capacity and compromise in tissue oxygenation and metabolic diversions from aerobic to anaerobic state. This has metabolic consequences. The perceptual consequences can be multifarious. Hypoxaemia would eventually be replaced by hypercapnia. Hypercapnia is a physiological response to breathlessness in that it drives breathing and therefore must influence the perception of motor events. The hypothesis that breathlessness is largely a sense of respiratory effort does not account for the findings that at a comparable level of ventilation, breathlessness is greater during hypercapnic hyperpnoea. Changes in alveolar ventilation that increases partial pressure of CO2 (pCO2) leading eventually to a rise in arterial carbon dioxide tension (paCO2) results in an urge to breathe. Breathlessness can be recognized as an increased urge to breathe, while the sense of effort to breathe decreases. There is evidence that qualitatively different sensations can result from voluntary or cortical drives to breathe versus reflex or brainstem drives to breathe, consistent with the possibility that with this, discharges from the medullary respiratory centers give rise to the prominent symptom of air hunger, and corollary discharge from the cortical motor center gives rise to a sense of breathing effort (Woollard, M. and Greaves, I., 2004, p. 341-349). In most of the cases, the urgency of breathlessness produces a situation of seeking medical care, and depending on the severity, the patient may be admitted in the inpatient setting for the underlying cause of breathlessness (Walker, L. & Avant, K., 1995, p 44). The concept analysis of breathlessness is based on assumptions that breathing connotes life; therefore, breathlessness at least indicate lesser degrees of life and arouses a sense of impending death in the suffering patients. This includes both difficulty getting air in and out. Many people suffer breathlessness in their life, and for some, it can be a frequent phenomenon or chronic state. In all, this can be a very frightening and terrifying experience that brings them to the care of healthcare professionals. The goals of this analysis are to identify the antecedents of breathlessness so as to eliminate or minimize the negative effect or even prevent it from occurring. This will help the nurse to appreciate the feelings and thinking of the person who experiences breathlessness as an acute or chronic problem (Walker, L. & Avant, K., 1995, p 46). Application to Nursing: This is client who is 64 years old male. This patient has a known history of 24-pack-year smoking. The patient has an antecedent history of chronic obstructive pulmonary disease, and on presentation, the patient was having severe breathlessness with peripheral cyanosis. The respiration was hurried, and the patient was obviously distressed. The patient had all the defining criteria of breathlessness in that breathing was conscious, unpleasant effort, developing when ventilation required by the patient exceeded the capacity of the lungs, and the patient expressed air hunger. The patient had a respiratory infection and congestive heart failure. The primary changes in the lungs were smoking-induced chronic bronchitis leading to increased pulmonary vascular resistance that led to congestive cardiac failure. A little household work had precipitated the condition. As a consequence, the patient was anxious and apprehensive. There was obvious fear. The patient had several sleepless nights, and he appeared exhausted and fatigued. The chest wall was tight. The patient had poor appetite, could not care for self, he was not able to talk (Bailey, P.H., 2004, p. 760-778). There was evidence of dehydration, and the patient felt dizzy. The associated hypoxia and hypercapnia led to acid-base imbalance that needed adjustments of fluid balance in the hospital. This case could be differentiated from related cases of other presentations where the patient could present with breathlessness only. The borderline cases could be differentiated by meticulous examination where the antecedents could be ruled out. In contrast to an eupnoeic individual, this patient had all the defining criteria present (Walker, L. & Avant, K., 1995, p 37-54). References Bailey, P.H., (2004). The Dyspnea-Anxiety-Dyspnea Cycle-COPD Patients' Stories of Breathlessness: "It's Scary /When you Can't Breathe". Qual Health Res; 14: 760 - 778. Calverley, P.M.A., (2003). Respiratory failure in chronic obstructive pulmonary disease. Eur. Respir. J.; 22: 26S - 30s. De Palo, V.A., (2004). Pulmonary Disease: Pneumonia, Chronic Obstructive Pulmonary Disease, Asthma, and Thromboembolic Disease. J Am Podiatr Med Assoc; 94: 157 - 167. Hanrahan, M., (2004). Practice development: a concept analysis. British Journal of Infection Control; 5: 19 - 22. Harver, A., Mahler, D.A., Schwartzstein, R. M., and Baird, J.C., (2000). Descriptors of Breathlessness in Healthy Individuals : Distinct and Separable Constructs. Chest; 118: 679 - 690. Nesbit, J.C. and Adesope, O.O., (2006). Learning With Concept and Knowledge Maps: A Meta-Analysis. Review of Educational Research; 76: 413 - 448. O'Donnell, D. E., (2006). Impacting patient-centred outcomes in COPD: breathlessness and exercise tolerance. Eur. Respir. Rev.; 15: 37 - 41. Walker, L. & Avant, K. (1995). Concept analysis. In L. Walker & K. Avant, Strategies for theory construction in nursing (3rd ed.) pp.37-54. Watson, R. D. S., Gibbs, C.R., and Lip, G.Y.H., (2000). ABC of heart failure: Clinical features and complications. BMJ, Jan 2000; 320: 236 - 239. Woollard, M. and Greaves, I., (2004). 4 Shortness of breath. Emerg. Med. J.; 21: 341 - 350. Read More