This case study introduces you to Margaret McNolan, an 80-year-old woman living

This case study introduces you to Margaret McNolan, an 80-year-old woman living in a small town of 800
people near a medium sized regional city in southeast Queensland. “Marg” was previously married and has
two children, Matt (58yo) and Helen (55yo). Marg was divorced in her mid-30s but remarried Tony in her late
60s; Tony died only three years ago, although his own family remains involved in Marg’s life.
Marg’s life has been hard. She has always lived in her town, married a local man and raised her two children
there. After her first husband left suddenly, Marg had to work at the local dairy factory to make ends meet.
Her kids moved away once they left school, although Helen now lives in the nearby city. Marg is something of a
local character in the town – she’s a straight-talking, no-nonsense woman whose strident opinions on most
matters are both admired and feared!
Diagnosis and prognosis
After Tony’s death, Marg finally went to their GP about her shortness of breath and chronic cough, which she’d
put down to the exhausting demands of caregiving and, she reluctantly admitted, her decades-old, heavy
smoking habit. After investigation, it was established that Marg had chronic obstructive airways disease
(COPD) with a post-bronchodilator FEV1/FVC <0.7 In the three years since, Marg has become more and more frail, with marked weight loss and increased breathlessness even at rest, which is severe at times. She uses intranasal oxygen via a concentrator at home. Helen has been asking to be appointed as her mother’s Enduring Power of Attorney and Marg has dismissed her requests, suggesting that Tony’s son Ken, a lawyer, should do it. This remains unresolved. Clinical presentation Marg has been admitted to the medical ward in the regional hospital following a sudden increase in her shortness of breath. She is alone, although her daughter is on her way. On physical examination, you observe that Marg is obviously short of breath, with an audible wheeze, and requires great effort to breathe in and out. Her respiratory rate is 26 breaths/min and her pulse rate is 110. Marg’s temperature is 38.0°C and her cough is intermittent but productive of dirty yellow phlegm. She has dusky discolouration of the nail beds and lips, and says she fees ‘utterly exhausted’. She has a mild tremor in the hands. Marg reports being ‘bunged up for days’ (ie: constipated). She seems very agitated and anxious. Marg’s current medication is: • Ventolin inhaler, 2 doses every 4 hours • Ultibro Breezhaler (110/50), 1 doses in the morning • Diazepam 5mg tablet 2 times a day prn • Coloxyl & Senna 2 tablets at night • Temazepam 20mg capsule nocte prn • Intranasal oxygen 94% on 3L/min Instructions: • Create a new Word document to address the questions below. • There is no requirement for an Introduction or Conclusion – but you must include a Reference List. • Please number your answers to correspond to the numbering of these questions. • Don’t write out or cut and paste the questions onto your answers. • The total word count is 2000 words. As a guide, each answer should be around 220 words however there is flexibility in this, and it is the total word count that will be counted by the markers. It is essential, however, that each question is answered comprehensively. 3 PART ONE: CLINICAL ASSESSMENT 1. What is the likely trajectory of Marg’s illness? You can use a diagram to illustrate. Explain the 5-year life expectancy of someone with COPD. 2. Those with a multidimensional symptom experience require multidimensional assessment. How would you undertake an assessment of Marg’s case? 3. Consider your approach to the assessment of Marg’s fatigue. How could you assess the functional impact of her fatigue? 4. Consider your approach to the assessment of Marg’s constipation. What elements of her bowel function should you assess? What assessment tool/s might be helpful to assess her constipation? 5. Explain which social elements are important to consider in your assessment of Marg if she is to return home. PART TWO: CARE MANAGEMENT 6. Identify the likely members of the multidisciplinary team for Marg during her hospitalisation. Select two of these and explain how their roles address the care needs identified during assessment. 7. Consider your approach to the management of Marg’s fatigue. What interventions might be required during her hospitalisation and upon her return home? 8. Consider your approach to the management of Marg’s constipation. What interventions might be required during her hospitalisation and upon her return home? 9. Explain how a discussion of goals of care could inform Marg’s discharge and care at home. Who are some of the key people in her circles of support? Select two of these and explain how they might support Marg at home.