TASK 58

You are a Nurse in Community health clinic, Brisbane, Mr. James Tung is a regular patient at your clinic

Name: Mr. James Tung

Age:70 Years

DOB:22/11/1948

Social History: Aged pensioner lives in a Storey House. Wife died 2 years ago, I son in USA Working as software engineer. Used to play bridge, chess but now doesn’t go out much

Medical History: Appendectomy at the age of 45 due to acute appendicitis

Pneumonia 2016 August.  Fall while going to shop, Broken arm

28/11/2017: Complained of worsening back pain for 2 weeks Only able to walk 10 minutes

pain diminishes when sitting. pain radiates – Lower-spine to hip and legs

X-ray taken: Ref to neurosurgeon Ref to physiotherapist

3rd December: X-ray-spinal stenosis. Neurological Assessment-severe lower back pain affecting lower legs.

Treatment options discussed; surgery epidural steroid injections and physiotherapy Patient refused physiotherapy, surgery. Prescribed ibuprofen. Dose of epidural steroid injection methylprednisolone 50mg with 1% Procaine

25/12/2017: Minor improvement in pain. 

has been taking double dose in medication. Not doing exercise as suggested

Explained not to taken more than required dose. Next epidural in March

13/12/2018: Patient extremely angry.   Wants to increse the dose of medication Decreased Mobility

Unable to stand long time for shower. Unorganized dressing.

Suggested OT Assessment but patient refused. Community nurse to Monitor his medication compliance, Assess his needs. Encourage him to see OT and physiotherapist Meals delivery service to be arranged.

Writing Task: Write a letter to a community nurse Ms.Pansford, Community Nursing, Center, 78 Masterson St.Acacia Brisbane 4110, pay home visit twice a week

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