Partnerships in Chronicity

Assessment 1: Information Sheet and Case Scenarios

For this assessment you are given a choice between two case scenarios. The scenarios are your referral information and no additional information is available.

Each student is to select one scenario on which to base their assessment. The completed assessment is to be submitted through the appropriate turn-it-in drop box on the NRSG366 LEO site. The Assessment One marking criteria in the unit outline is to be used to guide the preparation of this assessment.

When submitting your assessment, please do not use the scenario as part of your response.

Option 1: Epilepsy

Jessica Williamson is a 28 year old woman with a past history of epilepsy. Two weeks ago Jessica was out socially, drinking alcohol at a dance club. Jessica experienced a seizure whilst on the dance floor. Upon arrival at the local Emergency Department, paramedic staff reported that she had experienced a full tonic-clonic seizure that lasted for three minutes, during which she lost consciousness. Jessica was assessed and admitted. During her hospitalisation, Jessica was stabilised and discharged from hospital 1 week after the episode. Her discharge medications included an anticonvulsant.

On discharge Jessica was asked to attend her GP for follow-up.

Medical History

Jessica was diagnosed with epilepsy in late adolescence. Initially the seizures were very difficult to control using anticonvulsants but her condition stabilised 5 years ago. Three months ago she weaned herself off her anticonvulsants as she wanted to fall pregnant. During her hospitalization she was recommenced on her anticonvulsant.

Four years ago Jessica was diagnosed with Type 2 Diabetes Mellitus. Jessica was taught to control her blood glucose levels using diet and oral hypoglycaemics, this is now decreasingly effective. Her most recent observations include:

• BP: 150/90

• P: 115 regular

• Height: 158 cms

• Weight: 122 kgs

• BGL 12.9

Her current medications are: • Epilim 1 gm BD

• Metformin 850mg BD

Social History

Jessica lives in a two-storey house with her current partner of six years, Martin. Jessica's parents live overseas where her mother has been posted for work. Jessica is an only child. She works as a real estate agent selling homes and covers a large geographic area involving long and irregular work hours. This can involve her driving long distances and for long periods of time. Jessica enjoys her work and the challenges of being independent at work and at home. Despite being advised by her GP that she must not drive after suffering this recent seizure, Jessica continues to do so.

Current Issue

Following the follow-up appointment with the GP, the GP was concerned about Jessica's seemingly poor acceptance of her medical diagnoses and her compliance with the treatment regime for both her diabetes and epilepsy. Jessica indicated she did not need any more prescriptions for her anticonvulsants at the moment.

Jessica is not particularly careful about monitoring her blood sugar levels. She says she often forgets, and tends to check when she "feels fuzzy".

As this is your first visit to Jessica in her home, justify and discuss the immediate plan of care for her.

Assessment Focus

You are the Registered Nurse from the Community Nursing Service.

You will be undertaking an initial visit to Jessica's home.

Prioritise and provide a rationale for the activities you will undertake as part of this initial visit and identify two priorities for your follow-up visit.

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.