NURS 6912 Week 4 dyspnea management plan example

Breathless Crossing the Kitchen: A Dyspnea Management Plan for a 72-Year-Old With Advanced Heart Failure, and a Page for the Husband Who Keeps Calling 911

Student Name

College of Nursing, Walden University

NURS 6912: Symptom Management for the Hospice and Palliative Care Clinician

Instructor Name

Month Day, Year

Breathless Crossing the Kitchen: A Dyspnea Management Plan for a 72-Year-Old With Advanced Heart Failure, and a Page for the Husband Who Keeps Calling 911

Situation

A retired school librarian, 72, lives with heart failure that has reached its advanced stage despite treatment her cardiologist describes as optimized. Her ejection fraction is severely reduced, three hospital stays have come in the last twelve months and she is not a candidate for a heart transplant or a ventricular assist device. She is now breathless walking from the living room across the kitchen and sleeps propped on three pillows. Twice in the past month her husband, frightened by her gasping, has called an ambulance; both times she was evaluated in the emergency department and sent home the same night. She has said the hospital is for something new, not for the breathlessness she already lives with. The palliative care team is building a plan with her cardiology team.

Heart failure causes a heavy symptom burden, and palliative care alongside cardiology care is recommended for patients with advanced disease, with breathlessness among the main targets (Kavalieratos et al., 2017). Her diuretics and heart failure medicines remain with cardiology; this plan addresses the breathlessness that persists despite them.

Assessment

Breathlessness is a subjective experience, so the primary measure is her own rating. At rest she rates it 2 of 10; walking across the kitchen, 7 of 10; during the frightening night episodes, 9 of 10. She has given up cooking, going to church and sleeping in the bed she shared with her husband, since lying flatter brings on breathlessness. The episodes that frighten her most come at night, when she wakes breathless and feels she is suffocating.

Her oxygen saturation at rest is 94 percent on room air and falls only to 91 percent when she crosses the kitchen. Saturation is recorded as one finding, but it is not the measure of her distress: her breathlessness is severe while her saturation is near normal. Using saturation as the guide would lead the team to tell her she is fine when she feels she is drowning.

For the later period, when she may be too weak or drowsy to rate her own breathlessness, the team will use the Respiratory Distress Observation Scale, which scores observable signs such as heart rate, respiratory rate, restlessness, use of accessory muscles, grunting at the end of breath, nasal flaring and a look of fear (Campbell et al., 2010).

Management Using the Breathing, Thinking, Functioning Model

The Breathing, Thinking, Functioning model organizes breathlessness management around three reactions that sustain breathlessness: inefficient breathing patterns, the thoughts and emotions breathlessness provokes, and the loss of activity and fitness that follows (Spathis et al., 2017). Each part of her plan targets one of those cycles.

Breathing

Cool air on the face. She will keep a small battery fan by her chair and bed and hold it toward her nose and mouth when breathless. In a randomized crossover trial, a handheld fan directed to the face reduced breathlessness compared with directing it to the legs (Galbraith et al., 2010).

Positions that ease the work of breathing. Sitting upright and leaning forward with forearms resting on a table, or perched at the bedside with her arms folded over a stack of pillows, reduces the effort of breathing. A wedge or adjustable bed will let her sleep upright beside her husband.

Breathing techniques. Breathing out slowly through pursed lips, and a recovery technique for after exertion, will be practiced with the nurse until she can do them without thinking.

Medicines for refractory breathlessness. The palliative physician will discuss with cardiology whether a low-dose opioid for persistent breathlessness is appropriate for her. That decision, and any dose, rests with the prescribers.

Thinking

Breathlessness provokes fear, and fear quickens breathing, which worsens breathlessness. Her night episodes follow this pattern. The plan includes a written breathlessness plan she can read in an episode: sit up, turn on the fan, breathe out slowly, count, and tell herself that this has passed before. The nurse will explain what is happening in her body during an episode, since understanding reduces the sense of catastrophe. If anxiety remains high, the team will consider referral for brief psychological support.

Functioning

Losing activities feeds the cycle by reducing fitness and increasing isolation. The plan uses pacing: breaking tasks into smaller parts, sitting to prepare food and planning rest before and after exertion. She and the occupational therapist will choose one valued activity to recover first. She has chosen making Sunday dinner with her husband doing the lifting and carrying. A shower chair and a stool in the kitchen reduce effort for daily tasks.

A Page for Her Husband

Her husband is part of this plan because his fear shapes what happens during her episodes. He will receive his own page, written for him and reviewed with him by the nurse:

What you are seeing. When she wakes gasping, her breathlessness is frightening but, in most episodes, it is the same breathlessness she has during the day, made worse by lying down and by fear. It usually eases within minutes with the steps below.

What you can do. Help her sit up and lean forward. Hand her the fan and turn it toward her face. Open a window or turn on a room fan. Breathe slowly with her and count out loud. Stay with her and speak calmly.

When to call. Call the palliative care line, day or night, if an episode does not ease after fifteen minutes of these steps, or if she has chest pain, new confusion, or a fever. Call 911 only if she faints, cannot speak or has chest pain that does not settle, or if she asks you to.

Why this page exists. She has told the team that the hospital is for something new, not for the breathlessness she already lives with. Following this page helps you give her what she has asked for, and the nurse on the line can help you decide at any hour.

Evaluation

The plan will be evaluated at each visit using her breathlessness ratings at rest, on exertion and during episodes; the number of night episodes and 911 calls; whether she has recovered Sunday dinner; and whether her husband feels able to manage an episode. The Respiratory Distress Observation Scale will replace her self-rating if she can no longer provide it.

References

Campbell, M. L., Templin, T., & Walch, J. (2010). A Respiratory Distress Observation Scale for patients unable to self-report dyspnea. Journal of Palliative Medicine, 13(3), 285-290. https://doi.org/10.1089/jpm.2009.0229

Galbraith, S., Fagan, P., Perkins, P., Lynch, A., & Booth, S. (2010). Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. Journal of Pain and Symptom Management, 39(5), 831-838. https://doi.org/10.1016/j.jpainsymman.2009.09.024

Kavalieratos, D., Gelfman, L. P., Tycon, L. E., Riegel, B., Bekelman, D. B., Ikejiani, D. Z., Goldstein, N., Kimmel, S. E., Bakitas, M. A., & Arnold, R. M. (2017). Palliative care in heart failure: Rationale, evidence, and future priorities. Journal of the American College of Cardiology, 70(15), 1919-1930. https://doi.org/10.1016/j.jacc.2017.08.036

Spathis, A., Booth, S., Moffat, C., Hurst, R., Ryan, R., Chin, C., & Burkin, J. (2017). The Breathing, Thinking, Functioning clinical model: A proposal to facilitate evidence-based breathlessness management in chronic respiratory disease. NPJ Primary Care Respiratory Medicine, 27, Article 27. https://doi.org/10.1038/s41533-017-0024-z