A hospice patient with escalating respiratory distress and peripheral edema is being assessed. Given the patient's symptoms and recent lab results showing elevated BNP levels and slightly elevated creatinine, which intervention should the nurse prioritize to best address the patient's respiratory and cardiac symptoms?

B) Administer diuretics as prescribed to reduce fluid overload.

A) Increase the oxygen flow rate to improve oxygen saturation.

B) Administer diuretics as prescribed to reduce fluid overload.

C) Elevate the patient's legs to reduce peripheral edema.

D) Encourage deep breathing exercises to improve ventilation.

A nurse is caring for a patient in a hospice facility who has developed increased dyspnea, peripheral edema, and elevated BNP levels, suggesting heart failure. Despite being on supplemental oxygen, the patient's oxygen saturation remains low, and diuretics are being considered. Which nursing intervention is most appropriate to address the patient's dyspnea while minimizing the risk of further renal impairment?

B) Position the patient in a high Fowler's position and encourage deep breathing exercises.

A) Increase the oxygen flow rate to achieve an oxygen saturation of 95%.

B) Position the patient in a high Fowler's position and encourage deep breathing exercises.

C) Administer the prescribed diuretic and monitor urine output closely.

D) Initiate non-invasive positive pressure ventilation (NIPPV) to improve gas exchange.

A patient with bilateral pleural effusions and peripheral edema is on diuretic therapy but presents with hypotension and rising creatinine levels. What is the most appropriate nursing intervention to optimize this patient's care?

C) Recommend thoracentesis to alleviate respiratory distress

A) Increase the dose of diuretics to further reduce fluid overload

B) Administer IV fluids to improve blood pressure and renal perfusion

C) Recommend thoracentesis to alleviate respiratory distress

D) Discontinue diuretic therapy to prevent further renal compromise

A patient with bilateral pleural effusions and peripheral edema is experiencing low blood pressure and rising creatinine levels after diuretic therapy. Despite supplemental oxygen, her dyspnea persists, and her oxygen saturation remains between 87% and 89%. Which intervention should the nurse prioritize to effectively manage her respiratory distress while considering her renal function?

B) Initiate thoracentesis to reduce pleural effusion volume and enhance lung expansion.

A) Increase the diuretic dosage to minimize fluid overload and improve respiratory function.

B) Initiate thoracentesis to reduce pleural effusion volume and enhance lung expansion.

C) Administer an intravenous fluid bolus to improve blood pressure and renal perfusion.

D) Reposition the patient frequently to promote lung aeration and comfort.

A patient in hospice care is experiencing increased respiratory effort with diminished breath sounds, crackles at the lung bases, and low oxygen saturation despite high-flow oxygen therapy. A thoracentesis was performed to alleviate symptoms, and 500 mL of fluid was drained. The patient's renal function is also declining, with a creatinine level of 2.0 mg/dL and a blood pressure of 88/54 mmHg. Which nursing intervention is most appropriate to prioritize at this time?

C) Monitor the patient's respiratory status and oxygen saturation closely following the thoracentesis.

A) Increase the rate of intravenous fluids to improve blood pressure and perfusion.

B) Administer a higher dose of furosemide to address fluid overload.

C) Monitor the patient's respiratory status and oxygen saturation closely following the thoracentesis.

D) Correct the patient's hyponatremia rapidly to prevent neurological complications.

A patient in hospice care is experiencing respiratory distress, prompting the healthcare team to perform a thoracentesis to relieve pleural effusion. Post-procedure, the patient's oxygen saturation improves slightly. The patient also exhibits signs of renal impairment and mild hyponatremia. Based on the case details, what is the most appropriate nursing intervention to prioritize immediately following the thoracentesis?

C) Assess the patient's respiratory status and oxygen saturation frequently.

A) Monitor the patient's electrolyte levels and adjust diuretics accordingly.

B) Educate the family on signs of potential respiratory distress to watch for at home.

C) Assess the patient's respiratory status and oxygen saturation frequently.

D) Initiate a fluid restriction to manage the patient's hyponatremia.

A patient with a history of recurrent pleural effusion and worsening renal function is now experiencing increased respiratory distress and hyponatremia. Which nursing intervention should be prioritized to address the patient's current clinical status?

C) Implement non-invasive positive pressure ventilation to alleviate respiratory distress.

A) Administer a hypertonic saline solution to quickly correct hyponatremia.

B) Increase high-flow oxygen delivery to improve oxygen saturation levels.

C) Implement non-invasive positive pressure ventilation to alleviate respiratory distress.

D) Initiate oral fluid restriction to prevent further dilutional hyponatremia.

A patient presents with increased fatigue, mild confusion, and decreased alertness. Her sodium level is 128 mEq/L, and blood pressure is 86/52 mmHg. Considering these clinical findings, what is the nurse's priority intervention?

A) Administer a hypertonic saline solution.

B) Increase the patient's oral fluid intake.

C) Prepare to administer prescribed vasopressors.

D) Initiate seizure precautions.

A patient with re-accumulation of pleural fluid, hyponatremia, and mild left ventricular dysfunction is receiving hospice care. The healthcare team is planning a thoracentesis and adjusting her treatment plan. Which nursing intervention is the most appropriate to prioritize in this scenario?

C) Monitor and document the patient's mental status and respiratory effort closely.

A) Increase the rate of high-flow oxygen therapy to improve oxygenation.

B) Administer hypertonic saline to rapidly correct the serum sodium level.

C) Monitor and document the patient's mental status and respiratory effort closely.

D) Restrict fluid intake to prevent further dilutional hyponatremia.

A patient with significant re-accumulation of pleural fluid and mild left ventricular dysfunction is showing increased respiratory distress. The healthcare team decides to perform another thoracentesis and carefully manage the patient's fluid intake. What is the most appropriate nursing consideration when implementing this plan?

B) Monitor the patient's serum sodium levels closely to prevent further hyponatremia.

A) Administer diuretics as prescribed to enhance fluid removal.

B) Monitor the patient's serum sodium levels closely to prevent further hyponatremia.

C) Increase the patient's oral fluid intake to counteract hypovolemia.

D) Place the patient in the Trendelenburg position to improve ventilation.

hospice care - Nursing Case Study

Pathophysiology

• Primary mechanism: Progressive organ failure – As the disease advances, vital organs such as the heart, lungs, or kidneys gradually lose function, leading to systemic decline. This failure is often irreversible and results in diminished physiological reserves, impacting quality of life.

• Secondary mechanism: Metabolic dysregulation – In terminal illnesses, metabolic processes become inefficient, causing imbalances such as cachexia or electrolyte disturbances. These imbalances contribute to fatigue, weakness, and increased vulnerability to infections.

• Key complication: Symptom burden – Patients experience a high symptom burden, including pain, dyspnea, and fatigue, which necessitates palliative interventions. Effective symptom management becomes crucial to maintain comfort and dignity in the final stages of life.

Patient Profile

Demographics:

78-year-old female, retired school teacher

History:

• Key past medical history: Metastatic breast cancer, hypertension, type 2 diabetes

• Current medications: Morphine sulfate, Metformin, Lisinopril, Dexamethasone

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing shortness of breath and fatigue

• Key symptoms: Persistent cough, loss of appetite, swelling in lower extremities

• Vital signs: Blood pressure 100/60 mmHg, heart rate 110 bpm, respiratory rate 28 breaths/min, temperature 99.1°F, oxygen saturation 88% on room air

Section 1

During a follow-up visit to the hospice care facility, the nursing team conducts an initial assessment of the patient, noting several significant changes in her condition. Her respiratory distress has escalated, manifesting as an increased respiratory rate of 32 breaths per minute. Auscultation reveals diminished breath sounds and crackles at the lung bases, suggesting fluid accumulation. The patient's oxygen saturation has dropped further to 85% on room air, prompting the initiation of supplemental oxygen therapy. Despite oxygen support, her dyspnea persists, indicating a potential exacerbation of her underlying pulmonary condition.

In addition to respiratory complications, the patient exhibits signs of peripheral edema, now extending to her thighs, with pitting noted upon palpation. This swelling, combined with her hypotensive state (blood pressure 94/58 mmHg), raises concern for worsening cardiac function, possibly secondary to metastatic disease burden or treatment side effects. Laboratory results from a recent blood draw show elevated B-type natriuretic peptide (BNP) levels, suggesting heart failure as a contributing factor to her symptoms. Her renal function tests indicate a slight elevation in creatinine, pointing toward compromised kidney function, potentially due to both organ failure and medication effects.

The healthcare team decides to adjust her care plan, emphasizing aggressive symptom management to enhance comfort. Diuretics are considered to address fluid overload, while ensuring close monitoring of her renal status. The palliative care team is consulted to reassess her pain management regimen and explore options for alleviating her severe dyspnea. These interventions aim to improve the patient's quality of life in her remaining days, with a focus on dignity and comfort. The team prepares to discuss these changes with the patient and her family, ensuring that her end-of-life care aligns with her wishes and goals.

Section 2

Following the adjustment in the patient’s care plan, the nursing team closely monitors her response to the interventions. Within 48 hours of initiating diuretic therapy, there is a noticeable reduction in peripheral edema, with pitting now localized primarily to her lower legs. However, her blood pressure remains low, recorded at 90/55 mmHg, necessitating careful balancing of fluid removal and maintaining hemodynamic stability. Repeat laboratory tests reveal that her creatinine levels have risen modestly to 1.7 mg/dL, indicating that her renal function is strained by the increased diuresis. The healthcare team discusses potential modifications to her diuretic regimen to prevent further renal compromise while still managing her fluid status effectively.

Meanwhile, despite the supplemental oxygen therapy, the patient's dyspnea shows only marginal improvement. Her oxygen saturation fluctuates between 87% and 89%, even with increased oxygen flow. A bedside chest X-ray confirms bilateral pleural effusions, which may be contributing to her persistent respiratory distress. The palliative care team, in collaboration with the nursing staff, considers additional interventions such as thoracentesis to relieve some of her respiratory burden. Moreover, they explore non-pharmacological approaches, including repositioning and relaxation techniques, to enhance her comfort.

As the team implements these strategies, they convene another family meeting to discuss the evolving clinical picture and reiterate the goals of care. The patient’s family is informed of the potential risks and benefits of each intervention, emphasizing the focus on quality of life and symptom relief. The patient's daughter expresses gratitude for the team's dedication and mentions her mother's desire to maintain as much independence as possible, guiding the care team in their ongoing efforts to honor her wishes. This dialogue reinforces the importance of clear communication and shared decision-making in end-of-life care.

Section 3

In the days following the implementation of the revised care plan, the patient's condition presents new challenges. Her respiratory status becomes increasingly concerning, as she begins to exhibit increased respiratory effort and accessory muscle use. Her respiratory rate climbs to 28 breaths per minute, and auscultation reveals diminished breath sounds with crackles at the lung bases. Her oxygen saturation continues to hover around 86-88% despite high-flow oxygen therapy. Recognizing the potential for further respiratory decline, the healthcare team opts to proceed with thoracentesis. The procedure successfully drains 500 mL of fluid from the right pleural space, offering temporary relief, as evidenced by a slight improvement in her respiratory rate and oxygenation levels, which rise to 90% post-procedure.

Simultaneously, the patient's renal function requires vigilant monitoring. Her creatinine level has increased to 2.0 mg/dL, prompting the team to adjust her diuretic regimen by reducing the dose of furosemide and introducing a potassium-sparing diuretic to minimize renal strain. This adjustment is made with caution, as they strive to maintain an equilibrium between fluid overload and renal function. Her blood pressure remains low, recorded at 88/54 mmHg, necessitating careful titration of medications and fluid management. The patient's electrolytes are also closely monitored, revealing a mild hyponatremia with a sodium level of 130 mEq/L, which requires gradual correction to prevent neurological complications.

The healthcare team continues to engage in frequent discussions with the patient's family, ensuring they are informed and involved in decision-making. The patient's daughter appreciates the team's efforts to balance aggressive symptom management with her mother's comfort and dignity in mind. As they navigate these new complications, the team remains committed to a palliative approach, prioritizing the patient's quality of life and comfort above all. This delicate balance of clinical interventions and compassionate care reflects the complexity of managing hospice patients with multiple, evolving issues.

Section 4

As the days progress, the patient's condition continues to evolve, presenting new challenges for the healthcare team. Despite the temporary relief following thoracentesis, the patient's respiratory status remains fragile. Her respiratory rate has stabilized at 26 breaths per minute, but her oxygen saturation has once again dipped to 85-87%, even with high-flow oxygen. Auscultation now reveals more pronounced crackles, particularly at the lung bases, suggesting the possibility of recurrent pleural effusion or the development of pulmonary edema. The nursing team diligently monitors her respiratory effort, noting increased use of accessory muscles and episodic periods of dyspnea at rest.

In addition to respiratory concerns, the patient's renal function exhibits further decline. Her creatinine level has increased to 2.3 mg/dL, indicating worsening renal impairment. The potassium-sparing diuretic has provided some benefit, as her potassium level remains stable at 4.2 mEq/L, but her sodium level has dropped to 128 mEq/L, intensifying the risk of hyponatremia-related complications. Her blood pressure remains low at 86/52 mmHg, adding complexity to the management of her fluid status. In response, the team decides to initiate a cautious increase in oral fluid intake and considers the introduction of vasopressors to support her hemodynamics if necessary.

The patient's family is kept fully informed of these developments. Her daughter expresses concern over her mother's increasing fatigue and altered mental status, as the patient now demonstrates mild confusion and decreased alertness, likely secondary to the evolving hyponatremia and overall physiological stress. The healthcare team re-evaluates the care plan, emphasizing the importance of maintaining the patient's comfort while addressing these new complications. They continue to balance aggressive symptom management with the overarching goal of preserving the patient's dignity and quality of life, recognizing the intimate intersection of clinical interventions and empathetic care in hospice settings.

Section 5

As the healthcare team continues to navigate the complexities of the patient's condition, a new set of diagnostic results presents additional challenges. A repeat chest X-ray and ultrasound reveal a significant re-accumulation of pleural fluid, contributing to the persistent crackles and dyspnea observed on examination. The patient is showing signs of increased respiratory distress, as evidenced by intercostal retractions and nasal flaring, despite the high-flow oxygen therapy. Additionally, a portable echocardiogram suggests mild left ventricular dysfunction, potentially contributing to the pulmonary congestion and raising concerns about evolving cardiac involvement.

Laboratory results further complicate the clinical picture. Her serum sodium has decreased further to 126 mEq/L, exacerbating her confusion and lethargy. The patient's blood urea nitrogen (BUN) has risen to 35 mg/dL, reflecting acute kidney stress in the context of her declining renal function. Her blood pressure remains critically low, hovering around 84/50 mmHg, prompting the team to cautiously introduce low-dose norepinephrine to stabilize her hemodynamics without compromising her already delicate fluid balance.

The intersection of these findings requires the healthcare team to refine their clinical reasoning, prioritizing the patient's respiratory support and addressing her electrolyte imbalances. A plan is devised to perform another thoracentesis to alleviate respiratory symptoms while carefully managing her fluid intake to prevent exacerbating her hyponatremia. The team remains vigilant in monitoring her mental status and hemodynamic parameters, understanding that each intervention must align with the hospice philosophy of care, ensuring that the patient's comfort and dignity remain at the forefront of all clinical decisions.