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) Clinical Reasoning Cycle and why it is important.

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

Q.N.3 Discuss the pathophysiology of COPD and how Ms Abimbola's S&S reflect the underlying pathophysiology of the condition.

Answer 1

Answer 1)

Clinical reasoning cycle is a process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on, and learn from the process.

There are eight phases of clinical reasoning and one must note that this process, though divided into phases, is a continuum. In reality, one does not always move from one step or phase to the next, but rather move back and forth from one phase to another until an accurate assessment of a patient’s health status is made.

The various phases of clinical reasoning include:                                                    Consideration of facts from the patient or situation Collection of information Processing gathered information                                                                            Identify the problem Establish goal Take action                                                                                                               Evaluation                                                                                                                Reflection                                                                                                                 Following these phases of the clinical reasoning cycle will facilitate problem-solving and decision making, allowing as a health care professional to provide the best care for your patients. Consideration of facts from the patient or situation is the Step 1.

This is the first step, where you are introduced to the particular case. Here the nurse or doctor familiarises themselves with the current status of the patient and the previous treatments already done.

As the ultimate goal of any health professional is to save lives and provide the best treatment, it is very important to evaluate the information and clues correctly for a successful diagnosis.                                                                                                               

Answer 2)

Collection of information is the Step 2.

This is a critical stage and the core of clinical reasoning. Here, we collect the data on the patient's current health status in relation to pathophysiological and pharmacological patterns, know what details are relevant, and determine potential outcomes for possible decisions you make.

In this phase, we carefully consider the past medical history of the patient, the history of presenting complaints, the current treatment plan, results of investigations done, and current vital signs. We then analyse the findings using your established knowledge of physiology, pharmacology, pathology, culture, and ethics to establish cues and draw information.

Answer3)

COPD is a group of chronic lung diseases that makes breathing difficult. It is a progressive condition, meaning that it gets worse over time. COPD has a range of effects on the lungs that reduce their ability to take in oxygen and distribute it to organs in the bloodstream. According to the American Lung Association, it is the third leading cause of death from disease in the United States. COPD typically causes coughing that produces large amounts of mucus, shortness of breath, and other symptoms.                                                                   

The diseases of COPD                                                                                   COPD incorporates several conditions: Chronic bronchitis, emphysema, refractory asthma, or a combination of all three. Each leads to a different problem with the airways and air sacs.

Causes                                                                                                                     COPD can develop due to many different factors, but the most common cause is cigarette smoke. Other common risks include environmental and genetic factors. Inhaling any pollutant can cause COPD, whether it is cigarette smoke, industrial chemicals, cooking fumes, or heavy air pollution.

Ms Abimbola’s S&S reflects various condition.                                                          She is facing shortness of breath, tiredness, production of mucus, and cough.     Shortness of breath (or breathlessness) is a common symptom of COPD because the obstruction in the breathing tubes makes it difficult to move air in and out of your lungs. Tiredness may discourage you from keeping active, which leads to greater loss of energy, which then leads to more tiredness. When this cycle begins it is sometimes hard to break. A cough is common with COPD. Coughing can be a result of the lungs trying to remove mucus (phlegm or sputum) or it can be a way for the breathing tubes to protect themselves from inhaled irritants.

In order for speedy recovery of Ms Abimbla, proper medication regularly should be provided. A regular exercise programme should be introduced to strengthen her health.