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Background: The integration of a quantitative assessment of dyspnea in nursing records (NR) allows adjusting nursing care delivery to each patient’s needs. Objectives: To compare NR and the self-assessment of dyspnea intensity using the Numerical Rating Scale (NRS) in patients with advanced progressive chronic disease and palliative care needs who were admitted to internal medicine wards. Methodology: A quantitative study was conducted using a cross-sectional, descriptive, and observational approach. The NRS was applied to assess dyspnea intensity. Seventy-seven NR were selected using a non-random, purposive sampling technique. Results: Nurses diagnosed dyspnea at rest and/or functional dyspnea correctly without using a dyspnea assessment tool. Not all patients diagnosed with dyspnea had nursing care plans. In addition, the specific nursing interventions do not consider all dimensions of total dyspnea. Conclusion: Quantitative NR allow for a more accurate identification, monitoring, and management of dyspnea. A more systematic approach to dyspnea in patients with palliative care needs is required.

Dyspnea in palliative care: nursing records and self-assessment of dyspnea