please create a nursing care plan for terminal ill case who is planning dying in place in OAH, the nursing care plan should include :Diagnosis, assessment, planning, intervention, evaulation

Assessment: Subjective & Objective Data

Planning: SMART Goals

Nursing Interventions

1. Dyspnea & Respiratory Management

• Position patient in semi-Fowler’s or side-lying with the head elevated to support comfort and ease of breathing .
• Use comfort-focused measures such as a fan, calm environment, pacing of activity, and reassurance when these align with the patient’s preferences .
• Administer hospice-prescribed medications for dyspnea or anxiety-related air hunger according to the written plan of care and agency protocol .
• Use oxygen if it has been prescribed for comfort, while recognizing that the goal at end of life is relief of distress rather than normalization of numbers .
• Provide gentle oral care and repositioning, and avoid burdensome interventions that do not improve comfort .
• Collaborate with the hospice nurse or prescriber to adjust medications for terminal secretions if noisy breathing appears distressing to the patient or family .

2. Pain & Symptom Control

• Assess pain using a validated numeric, verbal, or behavioral scale, and reassess after each intervention .
• Administer scheduled and breakthrough analgesics as prescribed, and promptly report uncontrolled pain to the hospice nurse or prescriber .
• Monitor for common end-of-life symptoms such as nausea, constipation, shortness of breath, sleeplessness, and agitation, and implement the prescribed comfort plan .
• Use non-pharmacologic comfort measures such as gentle repositioning, oral care, lip balm, warm blankets, quiet presence, massage if desired, and reduced environmental stimulation .
• Maintain skin integrity with pressure relief, moisture management, and gentle handling during turns or hygiene care .

3. Emotional & Spiritual Support

• Use therapeutic presence and active listening during each visit, allowing silence and emotional expression without rushing the patient or family .
• Encourage life review, legacy work, prayer, music, storytelling, or other personally meaningful practices if the patient desires .
• Offer chaplaincy, social work, or culturally appropriate spiritual support through the hospice or care team .
• Honor cultural preferences, including ʻohana involvement, home-based rituals, prayer, or other practices requested by the patient and family, as long as they are safe and consistent with the patient’s wishes .
• Communicate clearly and sensitively that the focus of care is comfort when death is expected soon .

4. Family Caregiver Education & Support

• Teach caregivers common signs of approaching death, such as increased sleeping, decreased intake, changes in breathing, decreased urine output, coolness, mottling, and reduced responsiveness .
• Provide the 24/7 hospice or on-call nursing number and instruct the family to call before seeking emergency transfer if the goal is to remain at home .
• Instruct caregivers on safe administration, documentation, and storage of prescribed comfort medications .
• Review when and how to give PRN medications according to the written plan of care .
• Encourage caregivers to report distress, exhaustion, uncertainty, or fear so the team can adjust support and consider respite or additional visits when available .
• Prepare the family for what to do at the time of death, including whom to call and what paperwork should be accessible .

5. Coordination with Hawaiʻi End-of-Life Resources

• Confirm that a Hawaiʻi hospice or appropriate end-of-life care provider is involved and that the written plan of care reflects the patient’s goal to remain at home .
• Clarify team roles, including nursing, prescribing clinician, social work, chaplaincy, aide services, and family caregiver responsibilities .
• If the patient asks about medical aid in dying, provide neutral information and refer to the appropriate Hawaiʻi resources and prescribing clinicians, because Hawaiʻi residents who meet eligibility criteria may voluntarily request medical aid-in-dying medication .
• Ensure advance care planning documents, DNAR orders, and comfort-focused instructions are completed, signed when required, and placed where emergency responders and caregivers can find them .
• Coordinate equipment, medications, and after-hours support early so the home environment can support the patient’s preference to die in place .

Evaluation: Ongoing, Each Visit

Revisions: Update the care plan whenever the patient’s condition, goals, symptoms, or family caregiving capacity changes, and coordinate changes through the hospice or interdisciplinary care team .

Key Hawaiʻi-specific notes: Hawaiʻi hospice rules state that the hospice provider retains professional management responsibility for services related to the terminal illness . Hawaiʻi’s medical aid-in-dying law has been effective since January 1, 2019, for eligible adult Hawaiʻi residents with a terminal illness and six months or less to live who meet the law’s requirements . The care plan should remain comfort-focused, culturally respectful, and aligned with the patient’s preference to die at home whenever safely possible .