Question

You are the RN on a morning shift on the respiratory ward of a large inner-city hospital. At 10:30 AM you receive a patient from the Emergency Department.

This is the hand-over you receive.

I	My name is Catriona and I am the A&E RN who has been caring for Ms Aaliyah Abimbola. Thank you so much for taking this patient so quickly. We’re so busy we haven’t time to do much for her apart from get her ready to bring up here.
S	Ms Abimbola is a 56-year-old woman with a past history of COPD who was admitted to A&E via ambulance at 8am today in acute respiratory distress. She became acutely short of breath this morning while making breakfast and called an ambulance.
B	I only got the chance to ask her a few admission questions before I was told to bring her up here. She was able to tell me: She saw her GP two weeks ago due to increasing shortness of breath and fatigue and he gave her ‘some breathing medication’ (inhalers). She has had to use these with increasing frequency since then. Ms Abimbola has been working at the flour mill 50 hours per week recently. This has made it tough to look after her three daughters because she’s a single parent. She has a medical past history of moderate sleep apnoea for which she uses CPAP to sleep overnight, Type 2 Diabetes and hypertension diagnosed 3 years ago. She has never smoked but has a long history of severe exposure to industrial dust. Her children are at school but the oldest one knows she’s in hospital.
A	On arrival in A&E she was acutely short of breath with an expiratory and inspiratory wheeze. Her Sat’s were 93% on room air & her GCS was 15. We haven’t had time to do much for her apart from give her a couple of nebulisers. She has an interim medical diagnosis of acute exacerbation of COPD
R	Medical orders: 5mg salbutamol nebuliser as necessary, repeat every 20 minutes for 1 hour. O2 therapy to maintain SpO2 > 92%. Needs to have an ABG and a sputum sample collected for MC&S. Monitor vital ob’s half hourly and the respiratory medical team will be here soon to review her. Notify RMO if her condition gets worse.

Your initial assessment findings on the ward for Ms Abimbola are as follows:

Medications

Metoprolol 100mg daily, Aspirin 100mg daily, Atorvastatin 20mg mane, Glibenclamide (Daonil) 5mg orally daily before breakfast, Salbutamol sulphate (Ventolin) 100mcg inhaler as required for symptom relief (1-2 puffs as required), Fluticasone propionate/salmeterol xinafoate (Seretide) 50/25 inhaler (2 puffs BD)

Current vital observations:

BP 142/96mmHg

HR 96bpm

RR 24 bpm

SpO2 93% on RA

T 36.7C

Health assessment findings:

Height 158cm, Weight 93kg,

Total cholesterol level - 5.2mmol/L

Fasting BGL - 9.6mmol/L

Inspiratory and expiratory wheeze. speaking in short phrases taking 2-3 breaths between each phrase before continuing to speak.

Alert and orientated to time, place, and person.

Further information you gather from her medical history and as part of her admission questions:

Ms Aaliyah Abimbola is a 56 year old female who emigrated from Africa 20 years ago. Ms Abimbola is a single parent with three female children (ages 14, 17 and 18) living in the inner-west of Melbourne.

Ms Abimbola went to her local health care clinic 2 weeks ago complaining of increasing shortness of breath and lack of energy. She says she was given some breathing medication (inhalers) by the doctor and told to take it easy for a few days. She has been struggling to get from the ground floor living area to the upstairs bedrooms without resting half-way to catch her breath. She says sometimes the medication helps her catch her breath but she still has to rest half way even with the medication.

Ms Abimbola has been working at the local flour mill since she arrived in Melbourne from Africa 20 years ago. She has never smoked but says the dust at the flour mill often makes her cough. Her job for the first 3 years was filling bags with flour until that process became fully automated. She then got promoted to running one of the flour grinding machines. 2 years later she got another promotion to shift supervisor in the milling and packaging section. She says her clothes were always covered in white dust at the end of every shift. "I used to look like a ghost at the end on my shift. We all did!" The flour mill made it mandatory to wear a mask and other protective equipment when you're working in the factory about eight years ago. However, Ms Abimbola has been working in the office for the last 6 years and no-one wears protective equipment in the office as it's not necessary. She says there's always a fine layer of dust on the paperwork in the office because the 'flour just gets everywhere no matter how often you clean or how careful you are."

Ms Abimbola is currently averaging 50 hours/week which means she needs to work on most weekends. Since the Covid 19 lockdown the factory has increased production to 24 hours a day 7 days a week. That means the office is also extremely busy. Ms Abimbola has always accepted any overtime on offer to help pay the rent for their house and cover the school fees for the Catholic school her children attend. She is adamant that she wants them to get a good education so they can make the most of the opportunities she never had in Africa. She has always been socially active within her Church community, but due to her increased working hours this has restricted her ability to attend mass and contribute to her community. She states that she needs to “prioritise any free time I have so I can spend it with the kids, especially my oldest who is doing VCE this year”. She has two close friends at church who help with looking after her children when she has to work late or on weekends.

Ms Abimbola states that she tries to exercise when she has time and walks to the train station every day to get to work. It used to take 8 minutes each way but lately it takes at least 20 minutes including rest stops to catch her breath. She also does a lot of walking at the flour mill taking paperwork to the production supervisors and picking up reports for processing. However, she has had to ask one of the younger staff to get the reports and deliver the orders more and more over the last year or so as she get's too short of breath when she walks too far too quickly.

Ms Abimbola has not spoken to her husband since she and the children left him 6 years ago. She says he used to work at the flour mill but was sacked for being drunk at work eight years ago. He had a hard time finding work so drank heavily and became violent. She took the children and left him after he hit the middle child for spilling his coffee. She doesn't know where he lives and has had no contact with him for over 4 years.

Family history

Her father died from a stroke in 2005.

Question

Q.N.1 Q.N.1 Discuss the key elements of Step 1 of the CRC and why it is important by

Q.N.2 Discuss the key elements of Step 2 of the CRC and why it is important.

Q.N.2 Discuss the pathophysiology of COPD and how Ms Abimbola's S&S reflect the underlying pathophysiology of the condition.

Answer 1

Q.N; 1 Key elements of Step 1 of CRC

Caring, Respectful and Compassionate health service is one of the important aspect of a nursing care. The first steps is introducing about the nurse herself and  identifying the patient and her associated problems. This will provide a feling to the patient that she is cared, protected and safegaurded by the caring nurse.

The clinical reasoning Cycle is the process by which the nurse collect the dats, process of information to understand the patients problems, plan for the care and impliment those plans for the well being of the patients later followed by evaluation.

The step one of CRC is to consider the patients situation. This provide the patient a feeling of security ,warmth and comfort in the new situation.

Q.N.2 The key elements of Step 2 of the CRC  

The step 2 of CRC is collecting causes and information. A detailed history and clues regarding the patient will provide an understanding of the health status, current medications, past history, family history etc. These will aid in planning proper nursing care to the patient by the health team. Here the nurse will collect all available data from the family members, previous health records etc.

Q.N: 2 Pathophysiology of COPD

Chronic Obstructive Pulmonary Disease is a obstructive airway disease due to poor airflow.This is a typically worsening disease over time.COPD develops as a significant and chronic inflammatory response to inhaled irritants like smoke, air pollution and other kinds of irritants.

The pathophysiology of COPD is due to incompletely reversible poor airflow and inability to breathe out fully (air trapping) exist. The poor airflow is the result of breakdown of lung tissue known as emphysema, and small airways disease known as bronchiolitis.

Emphysema is a lung condition featuring an abnormal accumulation of air due to enlargement and destruction of the lung's many tiny air sacs resulting in the formation of scar tissue. The destruction of the air sacs and formation of scar tissue is permanent. As a result the air will be trapped inside the air sacs making breathing more difficult. The client need to struggle for exhalation.

Narrowing of the airways/ bronchiolitis occurs due to inflammation and scarring within them. This contributes to the inability to breathe out fully. This can result in more air from the previous breath remaining within the lungs when the next breath is started, resulting in an increase in the total volume of air in the lungs at any given time, a process called Hyperinflated lungs.

Mrs.Abimbolas signs and symptoms such as shortness of breath, expiratory and inspiratory wheeze, HR 96bpm, RR 24 bpm, SpO2 93% are due to the underlying pathophysiology. Expiratory and inspiratory wheeze and shortness of brath is due to narrowing of the airways due to bronchiolitis. The fall in SpO2 is due to shortness of braeth and air trapping. Speaking in short phrases taking 2-3 breaths between each phrase before continuing to speak is due to increased air demand in the body.