NRSG378: Extended Clinical Reasoning - Assessment 3 Case Study
Nursing
4th Jun 2025
2
NRSG378: Extended Clinical Reasoning
NRSG378 Assessment 3 – Case Study
Patient Details:
Lily Tran is a 42-year-old female who presented to the Emergency Department (ED) via ambulance this morning with severe shortness of breath, chest tightness, and cyanosis. She is accompanied by her partner, Alex, who reports that Lily had a history of worsening symptoms over the past 48 hours, including persistent cough and increasing fatigue. Alex states that Lily has been unwell with flu-like symptoms for the past week, but they became alarmed when she began struggling to breathe and her lips turned blue.
Lily has a known history of chronic obstructive pulmonary disease (COPD) and seasonal asthma, but Alex reports that she has been non-adherent to her prescribed inhalers. Alex also mentions that Lily has been smoking about 15 cigarettes per day since her teenage years and only recently began trying to quit using nicotine patches.
On arrival, Lily was visibly distressed and speaking in broken sentences due to breathlessness. She was placed on supplemental oxygen en route to the ED.
Assessment Findings:
Appearance: Pale, diaphoretic, and visibly anxious. Lips and nail beds are cyanotic.
Positioning: Sitting upright, leaning forward with her hands on her knees (tripod position).
Respiratory: Audible wheezing and crackles in bilateral lower lobes on auscultation. Prolonged expiratory phase noted evidenced by pursed lip breathing.
Cardiovascular: Tachycardia with weak pulses.
Neurological: Alert but fatigued, oriented to time, place, and person.
Skin: Cool and clammy.
Health Assessment Findings and Laboratory Results at Presentation:
|
Parameters |
Results |
Normal Values |
|
Heart Rate (HR) |
132 bpm |
60–100 bpm |
|
Blood Pressure (BP) |
145/90 mmHg |
Systolic BP 100-139mmHg; diastolic BP 60-89mmHg |
|
Respiratory Rate (RR) |
34 breaths/min |
12-20 breaths/min |
|
Temperature |
37.8°C |
36.5–37.5°C |
|
SpO₂ on room air |
85% |
>95% |
|
Capillary Refill Time |
3 seconds |
<2 seconds |
|
Arterial Blood Gas (ABG) |
|
|
|
pH |
7.29 |
7.35–7.45 |
|
PaO₂ |
60 mmHg |
75–100 mmHg |
|
PaCO₂ |
55 mmHg |
35–45 mmHg |
|
HCO₃ |
24 mmol/L |
22–28 mmol/L |
|
WBC |
13.2 x 10⁹/L |
4–11 x 10⁹/L |
|
C-reactive protein (CRP) |
30 mg/L
|
<5 mg/L |
|
Lactate |
3.2 mmol/L |
<1.0mmol/L |
Patient History:
Lily lives in a small apartment in Brisbane with her partner, Alex, and works full-time as a graphic designer. She has a 25-year history of smoking and has been diagnosed with COPD for the past 8 years. Alex states that Lily often neglects her health due to work demands.
Family History:
Father deceased (lung cancer at age 68).
Mother living with Type 2 diabetes mellitus.
Medical History:
Chronic Obstructive Pulmonary Disease (COPD).
Seasonal asthma.
Hypertension (baseline systolic BP is around 165mmHg)
Medications at Home:
Salbutamol MDI 4–6 puffs PRN (infrequently used).
Fluticasone/Salmeterol inhaler (non-adherent).
Amlodipine 5 mg daily.
Initial Management Orders from a Junior ED Resident:
Administer nebulised salbutamol 2.5 mg and ipratropium bromide 500 mcg STAT.
Titrate oxygen delivery to target oxygen saturations between 88-92%.
Administer IV hydrocortisone 100 mg STAT.
Perform ABG analysis 2 hours post supportive respiratory interventions.
Strict monitoring: Hourly vital signs and respiratory assessments. Escalate to JMO/Senior Nurse according to hospital early warning system criteria
Urgent chest Xray