Question

Powerpoint slides for COPD with the given case study by using CRC.

Ms Aaliyah Abimbola

Background information for the assignment.

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

• Interpret the information you have been given about her condition (Step 3 of the CRC) and identify three priority nursing issues you must address for Ms Abimbola (Step 4 of the CRC). Justify why they are priorities and support your discussion with evidence.

Answer 1

Interpretation of the case study:

Ms. Aliyah Abimbola, year old admitted in the Emergency department with the complaint of respiratory distress. After an initial assessment , she was diagnosed with Acute exacerbation of COPD ( Chronic Obstructive Pulmonary disease), as she had the past history of COPD.

COPD: Any of a group of disease charecterised by the pathological limitation of airflow in the airway that is not fully reversible. It may occur due to the reactive airways, congenital defects, chronic infection or smoking . The most common condition under COPD are Emphysema and Chronic bronchitis. Bronchitis causes the inflammation and resultant narrowing of bronchial tubes and increased mucous production. Emphysema is the abnormal accumulation of air in the lung tissue and the destruction of air sacs , that affect Pulmonary outward airflow.

Her occupational history shows that she developed reactive airways gradually as a result of continuous exposure to flour or dust from the Factory environment. She had recurrent attack of respiratory distress and was taking medications for the problems. In addition to this medications, she used to take the medications for Hypertension and Diabetes Mellitus, she was diagnosed with.

Physical Assessment and history collection confirmed the diagnosis of Acute exacerbation of COPD. Respiratory assessment revealed the presence of abnormal breath sounds, wheezing . A wheeze is a piping or whistling sound caused by difficult respiration . She is on the medications that can relieve her respiratory distress symptoms.

3 Priority Nursing Diagnosis:

i) Ineffective airway clearance related to broncospasm and increased production of secretions as evidenced by abnormal breath sound, wheezing and the statement of difficulty breathing.

ii) Ineffective breathing pattern related to retained secretions as evidenced by increased respiratory rate above the normal range.  

iii) Activity intolerance related to imbalance between oxygen supply and demand due to ineffective breathing as evidenced by shortness of breath and exertional dyspnoea.

Justification:

i) Ineffective airway clearance: A healthcare professional must give the priority to the physiological needs , especially the patient's breathing need. Any obstruction in the airway has to be cleared for an easy breathing. So the priority should be given to clear her airway off secretions that hinder the breathing process.

ii) Ineffective breathing pattern: After clearing the obstructions off the airway , the Health care professional should ensure that the client's breathing pattern is normal. Assist the patient by providing enough ventilation or oxygen supply as per physician's order to facilitate breathing and make sure her oxygen saturation is within normal range.

iii) Activity intolerance : As a single parent mother, and a worker , she has to be in her optimal working capacity. She has to do her Activities of daily living, looking after children and the secular work , so it is necessary to give importance to her condition of Activity intolerance.