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.
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
comm unity 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:
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o 8?: 135/80
0 P: 60 bpm,
o R: 18 bpm,
0 Height: 180 cm
a Weight 95 kg.
Current medications:
o ibuprofen 400 mg 6qh
o Baclofen 20 mg 80
o Oiazepam 25mg – 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 can 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 tune 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. lie was a keen hiker and had dreams of spending his retirement hiking in
NRSG366 Assessment task 1:
This assessment asks you to function in the role of the community nurse. It is asking you to provide a discussion of how you would plan and implement safe and effective strategies for meeting the needs of your client.
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