The patient, "JD," is a 62-year-old Caucasian female who had stage IV non–small cell lung cancer (NSCLC) diagnosed 3 months ago. Her medical history is significant for chronic obstructive pulmonary disease (COPD). She quit smoking cigarettes more than 6 months ago after having smoked a pack per day for 40 years.
Currently she is being treated with systemic chemotherapy. In addition to the dyspnea, she reports occasional dry cough, increasing fatigue, and anorexia. She denies anxiety or depression but admits to feeling panic during "difficult breathing" episodes. Ms. D's current medications include an antinausea regimen, sustained-release morphine sulfate at a dosage of 30 mg every 12 hours, prescribed for posterior thorax pain, and two puffs of albuterol / ipratropium metered dose inhaler four times a day.
Ms. D returns to the cancer center for her second cycle of chemotherapy. Her vital signs include oral temperature 97.8º F, regular heart rate but tachycardia at 116 beats/min, shallow respiration rate of 28 breaths/min, blood pressure of 128/77 mmHg and a 3-pound weight loss since the first chemotherapy treatment. She denies pain, nausea/vomiting, constipation/diarrhea, or numbness/tingling of the extremities. She rated her fatigue at a level of 8 (on a Numerical Rating Scale [NRS] of 0 to 10, with 10 being the worst fatigue).
She reports a dyspnea rating of 7 also on a 0–10 NRS. This is an increase from her previous dyspnea score of 4. Her oxygen percent saturation at rest on room air is 94%; it desaturated to 88% with exertion, also on room air. The nurse assesses Ms. D's lung sounds and notes in general that her breath sounds are distant bilaterally and that there are absent breath sounds one-third of the way up from the base of the left lower lung field.
Ms. D appears anxious and distressed, and she expresses fear that her cancer is growing. A chest X ray was obtained which showed that the patient had a new left pleural effusion.
An ultrasound-guided thoracentesis was arranged to drain the pleural fluid. Almost 1 liter of pleural fluid was removed, which significantly improved Ms. D's breathing. Unfortunately the fluid rapidly reaccumulated over a period of 1 week, and her dyspnea returned. The ambulatory care nurse arranged for the delivery of home portable oxygen and Ms. D was given a prescription for immediate-release morphine to relieve her dyspnea on an as-needed basis. Recognizing the reactive dimension of Ms. D's dyspnea, the nurse explained to her that "dyspnea causes anxiety and anxiety causes more dyspnea; it is a vicious cycle." The nurse helped the patient to identify what causes her anxiety, which in turn may intensify her dyspnea.
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