A practical nurse is providing care for a hospice client who suddenly begins experiencing severe air hunger, tachypnea, and restlessness. The client has standing PRN orders for end-of-life symptom management. In what order should the nurse perform the following actions? (Arrange from first to last)
- 1Elevate the head of the client's bed to maximize lung expansion.
- 2Administer the prescribed PRN sublingual morphine.
- 3Turn on a bedside fan to direct cool air toward the client's face.
- 4Explain to the family members that these measures will help ease the client's breathing.
- 5Document the respiratory episode and the client's response to the interventions.
Answer
The correct sequence is to first elevate the head of the bed, followed by administering the sublingual morphine, directing a fan toward the client's face, supporting and educating the family, and finally documenting the event.
When a hospice client experiences severe terminal dyspnea (air hunger), the nurse must prioritize interventions using the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy of needs. The most immediate, non-pharmacological action is elevating the head of the bed to facilitate lung expansion. Next, administering the prescribed sublingual morphine is critical, as it is the primary pharmacological treatment for air hunger. Applying a fan provides additional, evidence-based symptom relief by stimulating the trigeminal nerve. Only after the client's acute physical symptoms are managed should the nurse transition to providing psychosocial support and explanation to the family. Finally, nursing documentation is completed after all direct care is safely rendered.
Step-by-Step Solution
Key Concept
Prioritization of physiological and psychosocial interventions for terminal dyspnea.