Community Nurse Assessment and care

Essay Case Scenario
Option 2: Chronic Pain John Ryan is a 66 year old male with a history of chronic back pain related to spinal stenosis, and degeneration of the left hip. He has been reviewed in the Outpatient Pain Clinic on a monthly basis for the past 4 months, after a sudden increase in pain and changes in his level of activity. His pain specialist is concerned about his level of function at home and has referred John to the community nursing service for an initial assessment and review.
Medical history
–    John has spinal stenosis which was diagnosed in his early forties. He has significant pain in his lower back and hip, slight (L) leg weakness and slight loss of sensation in both his feet. He is generally fit, but slightly overweight.
–    His most recent observations are as follows:  BP: 135/80•  P: 60 bpm,•  R: 18 bpm,•  Height: 180 cm•  Weight 95 kg.•
–    Current medications:  Ibuprofen 400 mg 6qh•  Baclofen 20 mg BD•  Diazepam 2.5mg – 5mg PRN•
Social history:
–    John is an engineer with a mining company who spends his time equally between the mine in a remote location as a Fly In, Fly Out (FIFO) worker. He has an office location in the CBD for his locally based work. John is married to Donna and they have two adult children, both married. Donna works part time as office manager for a small company and is hoping they can retire soon so they can travel and see more of their grandchildren. Their daughter Jean (37 years) lives with her husband and three small children in a large coastal community, 45 minutes drive from John and Donna’s home. Their son Robert (39 years) lives with his partner in another major interstate city.

Current Issue
–    John reports being woken up by pain at night. During the day, he has pain if he sits still for too long, but also if he walks or rides a bike for too long, and the time he can spend on these activities varies. John states he is sick of the hours of focused exercise he needs to do to keep his core muscles strong and to keep him mobile and flexible. He is also sick of always having to take pain medications that have not been effective. In addition he reported being ‘fed up with being aware of my back and hip all the time and feeling limited because of them’. Recently, whilst playing with his four-year-old grandchild, swinging him through the air, John experienced a significant flare in his level of pain. John has been alternating between being angry about having ongoing pain, and being depressed because he is increasingly unable to do the activities he has always done. He was a keen hiker and had dreams of spending his retirement hiking in remote places. Now he can barely walk five kilometers on level ground without pain. He was also a keen bicycle rider. Initially this helped with his pain management. But increasingly, he is losing interest in riding as it also causes increased pain. John has been seen by a physiotherapist on a regular basis over the years, but he stopped going, because he felt they were not helping him, as he was progressively experiencing more pain. He has increasing bilateral leg weakness, bilateral muscle wasting and reduced sensation in both feet. He experiences blisters on his feet as a result of pressure on his feet, which he ignores. The specialist at the Pain Clinic is also concerned about John’s level of medication adherence.

Assessment Focus
–    You are the Registered Nurse from the Community Nursing Service.
–    You will be undertaking an initial visit to John’s home.
–    Prioritise and provide a rationale for the activities you will undertake as part of this initial visit and identify two (2) priorities for your follow-up visit
1.    Identify 2 priorities of care for your follow-up visit; explain the reason why it is prioritized more than the other treatment care. Give evidence to support your opinion(2-4 references needed)
a.    Pain management  priority
b.    Depression and anxiety management priority
2.    Identify and provide rationale for the activity that you commence during the visit as a community nurse: (use ADPIE for initial assessment)
a.    Assessment
i.    Pain assessment (priorities); exacerbation of his spinal stenosis; give evidence of why the pain gets worse (references needed)
ii.    Based on A-G initial assessment, provide the proper assessment according to John’s condition. (not all A-G assessment is applicable for John); Give evidence on why you provide those assessment for John?
b.    Diagnoses
i.    Based on current issues; what other things that need to be diagnosed in order to improve John’s living situation
1.    Back to A-G assessment, see what can you diagnose from the A-G result; e.g. (mobility issue, wound, mental health,etc)
2.    Link every possible issue to the Main issue; e.g. poor exercise increase his pain level or poor diet decrease his strength to do exercise and lead to increase in pain lvl.
c.    Planning
i.    Based on the diagnoses that you provide; provide each of the treatment for the complication; remember you are Community nurse.
1.    Symptom management
2.    Pain relief
3.    Depression management
4.    Mobility Management
5.    Patient education (meds and the importance of activity)
6.    Issue with workplace
7.    Issue with family
d.    Implement

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