Case Study

Mr. Juan Cruz, 78 years of age, is a male patient who is receiving hospice care

for his terminal illnesses which include lung cancer and chronic obstructive pulmonary

disease (COPD). He developed bilateral pleural effusion (the fluid that accumulates in

the pleural space of each lung), which has compromised his lung expansion. He states

that he is short of breath and feels anxious that the next breath will be his last. The

patient is admitted to the hospital for a thoracentesis (an invasive procedure used to

drain the fluid from the pleural space so the lung can expand). The thoracentesis is

being used as a palliative measure to relieve the discomfort he is experiencing.

Low-dose morphine is prescribed to provide relief from dyspnea or discomfort. The

patient is prescribed Proventil (albuterol) inhaler 2 puffs per day, as needed, and Flovent

(fluticasone propionate) inhaler 2 puffs twice a day. The patient has 2 L/min of oxygen

ordered per nasal cannula as needed for comfort.

 Nursing Care Plan

Assessment Nursing Planning Implementation Rationale Evaluation

Diagnosis

Ineffective Goals were met.

Subjective Breathing Short Term Independent
Pattern Short Term
● Shortness of After 3 hours of ● Monitor vital signs, ● The rate may be faster
related to
breath nursing intervention, specifically the ABGs or slower than usual. After 3 hours of
decreased
the patient will be and respiratory rate and Depth may be difficult nursing
lung
● Feel anxious able to: depths. to evaluate but is intervention, the
expansion as
that the next usually described as patient was able
evidenced by
breath will ● Demonstrate shallow, normal, or to:
dyspnea
be his last. appropriate deep.
coping behaviors ● Demonstrated
and methods to ● Auscultate and percuss ● Abnormal breath appropriate
improve the chest for the sounds are indicative coping
Objective breathing presence, absence, and of numerous problems behaviors and
patterns. character of breath and must be evaluated methods in
● The client sounds. further. improving
developed breathing
bilateral ● Elevate the head of the ● To remote patterns.
pleural bed and/or assist the physiological and
effusion patient to sit up in a psychological ease of
chair. maximal inspiration.
Long Term Long Term
● Encourage adequate ● To limit fatigue and
After 2 days of rest periods in between After 2 days of
shortness of breath.
nursing intervention, activities. nursing
the patient will be intervention, the
able to: patient was able
● Maintain an to:
effective
 breathing pattern, Dependent ● Maintained an
as evidenced by effective
relaxed breathing ● Administer diuretics as ● Diuretic medications breathing
at normal rate ordered. eliminate body fluid pattern, as
and depth and and hence may help to evidenced by
absence of reduce fluid relaxed
dyspnea. accumulation in the breathing at
lung spaces, which normal rate and
● Indicate feeling can increase lung depth and
comfortable while expansion. absence of
breathing. dyspnea.
● Administer oxygen as ● For managing the
● Demonstrates ordered. underlying pulmonary ● Indicated feeling
maximum lung condition, respiratory comfortable
expansion with distress, or cyanosis. while breathing.
adequate
ventilation. ● Demonstrated
Collaborative maximum lung
expansion with
● Refer to a respiratory ● Chest physiotherapy
adequate
therapist for chest helps to eliminate
ventilation.
physiotherapy if the secretion and promote
condition of the client the expansion of the
worsens. lungs.
A. What nursing measures should the nurse use to manage the patient’s
dyspnea?

● The best nursing measures that should be managed in a patient with

dyspnea is to schedule daily activities and the rest of the patient. This is to
conserve the patient's energy levels, avoid overexertion. And most
importantly, nurses should include in the nursing measures on how to
teach the patient the proper breathing techniques or physical activities to
at least manage the dyspnea of the patient.

● A nurse can use a variety of nursing measures to help alleviate dyspnea

and thus improve a patient's overall quality of life. Nurses are in a unique
position to help patients with dyspnea by using evidence-based
interventions like immediate- release oral or parenteral opioids. Nurses
should assess breathlessness in addition to initiating treatments; provide
dyspnea support and information to patients and their families; teach
patients breathing control, relaxation, and distraction techniques; and
assist patients in setting realistic goals for participation in social activities.

● Patients with dyspnea are prone to stress, anxiety and feeling of

helplessness which may lead to complications due to distress.
Communicating with the client and making your presence known can help
keep the patient informed and prevent the client from feeling further
stressed due to isolation accompanied by dyspnea. It is also important to
teach patients with dyspnea breathing techniques to manage dyspnea and
alleviate the stress and confusion the patient is under. Nurses have the
advantage to intervene with the environment and knowledge of the patient
due to their role as an observer and a caregiver of the patient, this means
nurses have the advantage of observing the patient and intervening with
appropriate measures according to the situation of the patient.
B. The patient complains that he has no appetite and struggles to eat and
breathe. What nursing measures should the nurse implement to manage this
physiologic response to terminal illnesses?

● The nurse may keep nutritious snacks by the bed (fruit juices, milkshakes
in insulated drink containers with straws).
● The nurse should plan meals during times when family members can be
present to foster a better consumption of food and entertainment.
● The nurse may permit the patient to decline food and drink when he
desires.
● Provide oral hygiene, allow patients to do it independently if possible.
● During mealtimes, oxygen should be provided and delivered using a nasal
cannula.
● Patients with dyspnea have trouble swallowing and drinking. Throughout
the day, serve small portions of preferred dishes and snacks.
● Patients should be encouraged to consume up to 2 liters of liquids per day
unless contraindicated, to reduce the risk of dehydration, which can cause
constipation, dry mouth, and sputum retention. The nurse may provide ice
chips that could be frozen fruit juice other than water.
● Keep in mind that cold foods could be easier to tolerate than hot ones.
● Offer mild fish, chicken, turkey, eggs, cheese, and peanut butter. The
flavor of meat, particularly beef, can be bitter and unpleasant. Include
milkshakes, drinks to replace meals, or other liquid supplements.
 References
Doenges, M., Moorhouse, M., & Murr, A. (2022). Nurse's pocket guide: Diagnoses,

prioritized interventions, and rationales (16th ed.). F.A DAVIS.

Scoditti, E., Massaro, M., Garbarino, S., & Toraldo, D. M. (2019). Role of Diet in

Chronic Obstructive Pulmonary Disease Prevention and Treatment. Nutrients, 11(6),

1357. https://doi.org/10.3390/nu11061357