Video Case Study - Nursing Care at the End of Life

Nurse Leslie works in a hospice house and is caring for Esther, an 89-year-old with a history of end-stage chronic obstructive pulmonary disease, or COPD. In collaboration with the registered nurse, RN Zach, Nurse Leslie goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Esther’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Leslie recognizes important cues, including Esther’s vital signs which are temperature 99 F or 37.2 C, heart rate 98 beats per minute, and blood pressure 88/42 mmHg. Her radial pulse is weak and thready. Esther’s breathing pattern is shallow, and there’s an audible gurgling sound as she breathes in and out. Nurse Leslie notices that Esther’s skin looks mottled and pale, and that it feels cool to the touch. She also notes that Esther appears restless and uncomfortable.

Next, Nurse Leslie analyzes these cues. She reviews the electronic health record, or EHR, and sees that Esther has a current Do Not Resuscitate, or DNR, order and is on comfort care. She also notes that Esther’s urine output was 90 milliliters over the past 12 hours.

Nurse Leslie knows that as death approaches, body functions begin to slow. Blood pressure and heart rate decrease, and pulses become weak. Then, as circulation slows, there’s less urine output due to decreased renal perfusion, and extremities can become edematous, mottled, dusky, and cool, since there’s less circulation to the periphery. Respirations become slow and irregular; and as death nears, a build-up of saliva and mucus in the throat and upper airways cause breathing to sound wet and gurgling. Episodes of apnea and hyperventilation, called Cheyne-Stokes respirations, may also occur. Nurse Leslie realizes that Esther needs supportive care at the end of her life.

Now, using the information she has gathered, along with Esther’s medical history, Nurse Leslie reports her findings to RN Zach, and together they choose the priority hypothesis of impaired comfort.

They generate solutions to address Esther’s impaired comfort as she approaches the end of life that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Esther’s restlessness will decrease by the end of the shift.
Nurse Leslie then takes action to implement these solutions.

Nurse Leslie and RN Zach review the EHR and note the health care provider has ordered PRN medications for Esther that can help decrease restlessness and increase her comfort.

Then, according to the principles of safe medication administration, RN Zach administers the prescribed IV lorazepam to treat Esther’s restlessness, and Nurse Leslie applies a scopolamine patch to help lessen the secretions building up in Esther’s airways.

RN Zach and Nurse Leslie work together to reposition Esther so that she’s more comfortable. Next, Nurse Leslie dims the lights and plays soft music in the background.