NUR341 Assessment 2.

NUR341 Assessment 2
Mr Willie Jungala is a 71-year-old gentleman
that has been admitted to hospital post fall with
soft tissue injury to right hip.
History Assessment data
Patient profile
Willie Jungala, 71-year-old man from Alice Springs (Northern
Territory of Australia)
Chief complaint Pain to right hip following fall: soft tissues
History of complaint
Was going to kitchen to make a sandwich and tripped on kids tonka
truck. Landed on the floor on his right side. Following fall, Willie was
experiencing pain on movement and difficulty weight bearing. Two
teenage grandchildren tried to help him up but too painful, so they
called an ambulance.
Phx Hypertension, Type 2 Diabetes, Unstable Angina (chest pain)
Allergies Nil known allergies.
Medications
 Aspirin 100mg mane
 Perindopril 2mg mane (blood pressure)
 Metformin 1000mg TDS
 GTN 600mcg tablets S/L prn (glycerine trinitrate tablets: chest
pain and coronary heart disease)
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Alcohol use Social - 2 to 3 beers (mid-strength), 2 to 3 times per week.
Tobacco use
Non-smoker. Regular exposure to campfire smoke. Most nights have
a campfire burning - sit by campfire and enjoy the night 'yarning' or
listening to music.
Drug use Nil.
Home environment
Lives in town camp in house with extended family. Approximately 12
family members staying at house: wife; daughter and her 4 teenage
boys; daughter and her two toddlers; son's two adult boys.
Work environment Was a station hand. Retired 5 years ago.
Stress
Sometimes. At the moment, youngest daughter that lives at home
there with her two toddlers, has recently been diagnosed with cancer.
A few drinks and a few laughs help ease the stress.
Education Year 9 schooling.
Economic status Own land and house out bush but staying in town for a while.
Ethnic background
Aboriginal. Speaks Waramungu, Walpiri, Eastern and Central
Arrente, Western Arrentre and English.
Religion/ spirituality
Baptised Catholic by missionaries when young. Only goes to church
for funerals. Willie's spirit is strengthened by family and country.
Sexual practice
Married. Been with wife for 51 years. Have one son and two
daughters.
ADLs Independent.
IADLs
Does not drive any more due to decreased vision (diabetic
retinopathy). Starting to get cataracts. Had glasses a few years ago
but they don't work so well any more.
Cognitive function No worries.
Diet Diabetic diet
Sleep 7-8 hours a night.
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Health check ups
Regular check-ups every few months with diabetic doctors/ clinics.
Go to medical service if need to. Moves between medical services
depending on where he is staying at.
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Physical
assessment
Assessment data
Vital signs
Temp 36.0 (37), Pulse 100, Resps 20, SpO2 94 (95 to 98) % RA, BP
150/95 (120/80) , BGL 3.9mmols/L (4.0–7.8mmol/L.), Pain 6 out of
10
CNS
 GCS 13 (mild brain injury)
 Pupils equal and reactive to light
 Lethargic, eyes open when spoken to, follows commands,
orientated to place and person; not time.
 Difficult to test muscle strength due to pain from injury to right
side
CVS
 Both feet pale in colour
 No sacral or ankle oedema
 Bilateral cool skin temperature in feet; hands warm
 Peripheral pulses present but dorsalis weak bilaterally
(peripheral neuropathy)
 Capillary refill feet and hands > 3 seconds (more)
Resp
 Shallow and regular breathing
 No reports of pain on palpation
 Chest expansion symmetrical
 Percussion- bilateral resonance in all areas
 Auscultation - no abnormal breath sounds noted
MSK  Blue/red coloured haematoma to right hip and extends to right
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buttock
 Swelling evident
 Skin intact
 Decreased range of movement around hip
 Tender on palpation of right hip area
 Reluctant to attempt walking due to pain
GIT
 Loss of appetite and nausea last few days
 No vomiting
 Regular bowel movements. Little bit constipated last two days.
 Generalised distention
 Bowel sounds in all 4 quadrants
 Mild tenderness lower abdominal area
Urinary
 Supposed to be fluid restriction. Doesn't worry about that so
much.
 No pain on passing urine
 2-3 days of increased urinary frequency and urgency/ wanting
to go bad
 Passed cloudy, malodorous urine approx 1 hour before fall
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Part 1: Assessment (1000 words)
Hospital policy is that Mr Jungala receive the assessments below. Detail the goal or the
purpose of these assessments and how they relate to Mr Jungala.
Assessment - Description & linkage to patient
Alcohol withdrawal risk assessment
Sutton and Jutel (2016) reported that complications associated with the alcohol withdrawal
are associated with high level of mortality and morbidity. It also demands significant
healthcare services. The alcohol withdrawal symptoms vary from person to person and
accordingly the therapeutic interventions must be designed. Mirijello et al. (2015) reported
that main symptoms associated with alcohol withdrawal include shakiness in the whole body,
sweating and loss of appetite. This is associated with increases state of anxiety,
nervousness, agitation and restlessness. In some cases there occurs vomiting and nausea
along with headache and fast heart rate. However, people who are exposed to alcohol for
long-term, alcohol withdrawal symptoms lead to the development of withdrawal seizure and
delirium tremens. Willie Jungala consumes alcohol of mild-strength at a frequency of 2 to 3
times per week. However taking into consideration of this diabetic state of body like
peripheral neuropathy and renal failure, his alcohol consumption must be ceases. So AWRA
will help to frame person-centred withdrawal symptoms management interventions. The
effective therapeutic interventions will help to keep his heart rate and anxiety and agitation
under control (signs of alcohol withdrawal) and this is crucial to avoid the vulnerability to
developing severe angina (Sutton & Jutel, 2016).
Cognitive assessment
General assessment data highlighted that there is no worries related to cognitive
function for Willie Jungala and in the domain of activities of daily living (ADL) he is
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independent. His Glass glow coma scale (GCS) is however 13 (normal: 15). GCS 13
indicates mild brain injury. Chou et al. (2017) stated that mild brain injury among older
adults increase the vulnerability of developing cognitive decline. Moreover, the current
assessment data indicates that though he is oriented to place and person but not time. He is
also showing lathery to follow commands or open eyes during communication. Qiu and
Fratiglioni (2015) also reported that older adults who are suffering from the cardiovascular
complications suffer from the vulnerability of age-related cognitive decline. This is because
the connection between brain and heart. Moreover, the level of cognitive decline increases
with the older adults who have hypertension, diabetes. Willie Jungala is 71 years old and has
hypertension plus diabetes. All these factors make him vulnerable towards encountering
cognitive decline. Thus in order to get a comprehensive overview of cognitive functioning of
Willie Jungala, cognitive assessment is important. According to the Australian Government
Department of Health (2019), Guidelines of Cognitive Assessment must be done based on
framework of Folstein Mini Mental State Exam, Mini-Cog, Geriatric depression scale,
Cornell Scale for Depression in Dementia.
Falls assessment
Ryu et al. (2017) state that older adults who are above 65 years of age are prone
towards accidental fall leading to the generation of fatal injuries that hamper the process of
activities of daily living along with increased medical cost. Willie Jungala, encountered
accidental fall by tripping on kids' tonka truck while he was going to make sandwich in
kitchen. The accidental fall resulted in soft tissue injury in the right hip along with pain (pain
score 6 out of 10). The pain is creating restriction for Wille Jungala to move and is
hampering his muscle strength for which he was administered to hospital. Thus, this reveals
the vulnerability of Willie in encountering accidental fall and its consequences. Moreover, he
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has diabetic retinopathy and he has started getting cataracts. Moreover, his is also a victim
of peripheral diabetic neuropathy, evident from his bilateral cold skin temperature. Montero‐
Odasso and Speechley (2018) reported that older adults with diabetic neuropathy and
retinopathy are more prone towards accidental fall increasing the vulnerability of injury. His
capillary refill time is also greater than 3 seconds, so cuts and wounds resulting from
accidental fall might take time to heal. Fall assessment will help to design patient-centered
care plan by occupational therapist to reduce the risk of falls.
Functional assessment
Functional assessment for the older adults deals with comprehensive assessment of
activities of daily living (ADLs) like bathing, dressing, toileting, transfers, feeding and
grooming. Functional assessment also encompass ability to execute instrumental activities
of daily living (IADLs) like taking own medication, grocery shopping, meal preparation, using
mobile phones, driving or transportation, management of self finance, housekeeping and
laundry (Ward et al., 2015). The assessment data in IADLs highlights that Willie Jungala is
unable to drive anymore for his eyesight problem. Moreover, the accidental fall is generating
pain and he is at present unable to walk properly. A comprehensive functional assessment
will help to ascertain his performance in other domains of IDLs (he has normal ADLs) and
thereby helping to frame the nursing intervention. For example, if difficulty is highlighted in
medication management then education will be given to the family members to assist Willie
Jungala in administering self-medication. This will help to increase therapy adherence while
increasing the disease outcome. Injurious fall also hamper the ADLs and IADLs and in that
case community dwelling older adults are subjective to functional assessment over the
parameters of gait speed with the help to chair stand test. This will help to evaluate both the
risk of accidental fall and functional assessment (Ward et al., 2015).
Nutritional assessment
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Nutritional assessment is in-depth evaluation of subjective and objective data associated with
individual's food and nutritional food intake, lifestyle and past medical history. Based on the
data, like physical assessment data (physical appearance) and anthropometric measurement
(height, weight, BMI wait : hip ratio, waist circumference) nutritional status of a person is
assessed. Nutritional assessment for Willie Jungala is important because lately he is suffering
from lack of appetite along with nausea. He was constipated for the last two days. He is also
on diabetic diet and at present his blood glucose level is slightly below the normal (3.9
mmols/L; normal: 4.0 to 7.8 mmols/L). A proper nutritional assessment will help to frame a
person-centered diet plan and thus helping to promote the concept of healthy ageing.
Lorenzo-López et al. (2017) stated that healthy diet plan is an important aspect of promotion
of good health among the older adults. Eating nutritious and palatable diet helps to reduce the
vulnerability of developing cardio-vascular disease and accidental fall along with decrease in
the severity of diabetes followed by effective weight management.
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Part 2: Plan and implementation (500 words)
Normal age-related changes, Mr Jungula’s co-morbidities, acute illness and medications
may have contributed to his fall. Choose one factor and outline your nursing actions and
referrals you would execute; include rationales for same.
Write answer here……
The factor that might have contributed to accidental fall in Mr. Jungala is his
problematic eyesight. The case study reports that he does not drive any more due to
decreased vision. He is also starting to get cataracts. Though he has glasses a few years
ago but he do not use it anymore as he thinks that it does not work anymore. Richardson,
Eckner, Allet, Kim and Ashton-Miller (2017) reported that older adults who have poor
eyesight are prone to accidental fall arising from tripping and hitting over any objects, as they
are unable to see the object lying over the floor clearly. In case of Mr. Jungala also the fall
occurred as he tripped over the kids tonka truck while his way to kitchen. This highlights that
he has vision problems and his unwillingness to use the spectacles have further affected his
visionary ability. So nursing interventions for the reducing the risk of accidental fall for Mr.
Jungual will be educate Mr. Jungual and his family members regarding the current state of
his eyesight. Both Mr. Jungual and his family members will be educated about importance of
wearing specs in order to gain proper eyesight. This will be followed by framing of strategies
for effective management of the leg space area in Mr. Jungala’s house. The education to the
family members of Mr. Jungala will include fixing a definite play zone for the toddlers so that
Mr. Jungala might not trip over toys cars. The nursing education will also be directed towards
giving assistance to Mr. Jungala on his way to bathroom, installation of side rails in beds and
staircase, lowering the height of the bed and use of shoes with high traction soles for
prevention of falls. Education will be given to his family members and Mr. Jungual to consult
with an ophthalmologist in order to gain assistance for cataract management and revised
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lens power of the spectacles. Hwang and Woo (2018) highlighted that older adults suffering
from the diabetic retinopathy and is experiencing problem with the cataract formation are
prone to accidental falls. Effective consultation with a professional ophthalmologist will help
to improve the eyesight while reducing the chances of accidental fall. The patient education
will help to generate disease awareness and at the same time helps to increase therapy
adherence.
Another referral will include an occupational therapist. Elliott and Leland (2018)
reported that consultation with an occupational therapist would help in generating a plan for
renovation of the living area and leg space inside the room along with increase in the indoor
lightening and use of walking aids. Use of walking aids like walking sticks or walker will help
to improve the gait balance and reducing the chance of accidental falls. On the other hand,
increased indoor lightening will help to gain proper vision and preventing the chance of
tripping over objects.
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Part 3: A biopsychosocial approach (500 words)
Psychosocial vital signs Patient response
Perception
"Pretty good for my age. I've got diabetes
and chronic renal failure, but a lot of my mob
do. I just got this angina last year but usually
it isn't too bad; the tablets work well. Bad
luck I tripped over that bloody Tonker truck
and hurt my hip".
Support
"I got my wife and my girls at home, and their
kids. I'll be right. I don't want to put too much
pressure on my youngest daughter, she's got
enough to worry about with that cancer. We
can usually call out to family or friends and
they can help me out if I need. For example,
I can't drive now so I can ask around and
someone will usually be around to come over
and give me a lift to town for shopping,
Centrelink, banking or doctors."
Coping
"Most of the time just sitting down and
relaxing and not stressing too much but
sometimes, maybe 2 or 3 nights a week, I sit
down and have a few beers." "When it is too
much I just take off out bush for a while."
Anxiety "Yeah a little bit. I don't want to fall like that
again and I don't want to get another urine
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Level of anxiety
infection; that was no good"
"Level of anxiety right now, medium".
Healthy ageing involves promoting one's physical, mental and social well-being. Consider Mr
Jungala's psychosocial vital signs.
 Identify what factors impact on Mr Jungala's psychosocial health.
 Note which members of the interdisciplinary team would you refer to; include
rationales for same.
 Identify evidence-based health promotion measures to optimise Mr Jungala's
physical, mental and social well-being.
Write answer here…..
The factors that impact on Mr. Jungala's psychosocial health is the current heath
condition of his younger daughter who have been diagnosed with cancer. He was found
saying that he do not want to stress her younger daughter. Klainin-Yobas, Oo, Suzanne Yew
and Lau (2015) reported that older adults who have wards suffering from fatal disease like
cancer are more likely to suffer from depression and anxiety that hampers the mental health.
The case study however, highlights Mr. Jungala have a healthy social life as he has found
saying that “We can usually call out to family or friends and they can help me out if I need”.
He loves the presence of his family members and thus can be said that he is happy to
socialize.
The multidisciplinary team member whom I would refer for effective management of
Mr. Jungala’s health is a mental health counselor. The role of the medical health counselor
will be indulge in face-to-face interaction with Mr. Jungala in order to understand what force
him to sip a few glasses of alcohol for 2 to 3 nights per week or why is he saying that “When
it is too much I just take off out bush for a while”. The counseling with mental health
counselor will be followed by person-centered interventions framed by mental health
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psychotherapist. This will involve mindfulness based therapy or music therapy in order to
reduce stress or anxiety. Gu Strauss, Bond and Cavanagh (2015) stated that non-
pharmacological intervention like mindfulness-based therapy is effective in reducing stress
and anxiety over older adults and thereby helping to improve the health related quality of life
of the older adults. On the other hand taking alcohol on weekly basis is harmful for Mr.
Jungala as he has hypertension, angina along with diabetes. Replacing alcohol intake with
non-pharmacological interventions can be proved to be beneficial for his physical health.
Evidence-based health promotion measures for Mr. Jungala will cover SNAPE:
Smoking, nutrition, alcohol, physical activity, emotional wellbeing. This will include physical
health education in order to generate health awareness and disease self-management skills.
Mackey, Doody, Werner and Fullen (2016) reported that as per nursing evidence-based
practice, it is the duty of the nursing professional to educate the patient about the disease
progression in order to increase health-related awareness, therapy adherence and
promotion of self-management skills.
For the improvement in the mental and social well-being, the evidence-based
practice interventions will include framing of community based group activities. In case of Mr.
Jungala this will include gardening activities with his aboriginals friends. Nicklett, Anderson
and Yen (2016) reports that community based gardening activities help to promote physical
activity and thus reducing the tenure of prolong sedentary life. Since, Mr. Jungala leads a
sedentary life; mild to moderate physical activity as executed through gardening will help to
improve his physical health status. Moreover, indulging in group-based activities will help to
increase social participation. Staying with aboriginal friends will also help in improving his
current mental state. The study conducted by Macniven et al. (2016) highlighted that for the
aboriginals older adults, the group-based activities with other aboriginal service users not
only help to increase the level of participation, but at the same time helps to improve the
mental state of mind by reducing depression and anxiety.
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References
Australian Government Department of Health. (2019). Cognitive Assessment Screening for
delirium: the process involved. Access date: 2nd May 2019. Retrieved from:
http://www.health.gov.au/internet/publications/publishing.nsf/Content/
CA2578620005D57ACA25794B001825B2/$File/CogAsess.pdf
Chou, R., Totten, A. M., Pappas, M., Carney, N., Dandy, S., Grusing, S., ... & Newgard, C.
(2017). Glasgow coma scale for field triage of trauma: a systematic review. Retrieved
from: https://www.ncbi.nlm.nih.gov/books/NBK410016/
Elliott, S., & Leland, N. E. (2018). Occupational therapy fall prevention interventions for
community-dwelling older adults: A systematic review. American journal of
occupational therapy, 72(4), 7204190040p1-7204190040p11.
doi:10.5014/ajot.2018.030494
Gu, J., Strauss, C., Bond, R., & Cavanagh, K. (2015). How do mindfulness-based cognitive
therapy and mindfulness-based stress reduction improve mental health and
wellbeing? A systematic review and meta-analysis of mediation studies. Clinical
psychology review, 37, 1-12. https://doi.org/10.1016/j.cpr.2015.01.006
Hwang, S., & Woo, Y. (2018). Fall prevention strategies in community-dwelling older adults
aged 65 or over with type 2 diabetes mellitus: a systematic review and meta-
analysis. Physical Therapy Rehabilitation Science, 7(4), 197-203.
https://doi.org/10.14474/ptrs.2018.7.4.197
Klainin-Yobas, P., Oo, W. N., Suzanne Yew, P. Y., & Lau, Y. (2015). Effects of relaxation
interventions on depression and anxiety among older adults: a systematic
review. Aging & mental health, 19(12), 1043-1055.
https://doi.org/10.1080/13607863.2014.997191
Lorenzo-López, L., Maseda, A., de Labra, C., Regueiro-Folgueira, L., Rodríguez-Villamil, J.
L., & Millán-Calenti, J. C. (2017). Nutritional determinants of frailty in older adults: A
systematic review. BMC geriatrics, 17(1), 108. https://doi.org/10.1186/s12877-017-
0496-2
Mackey, L. M., Doody, C., Werner, E. L., & Fullen, B. (2016). Self-management skills in
chronic disease management: what role does health literacy have?. Medical Decision
Making, 36(6), 741-759. https://doi.org/10.1177/0272989X16638330
Macniven, R., Richards, J., Gubhaju, L., Joshy, G., Bauman, A., Banks, E., & Eades, S.
(2016). Physical activity, healthy lifestyle behaviors, neighborhood environment
characteristics and social support among Australian Aboriginal and non-Aboriginal
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adults. Preventive medicine reports, 3, 203-210.
https://doi.org/10.1016/j.pmedr.2016.01.006
Mirijello, A., D’Angelo, C., Ferrulli, A., Vassallo, G., Antonelli, M., Caputo, F., Leggio, L.,
Gasbarrini, A. and Addolorato, G., 2015. Identification and management of alcohol
withdrawal syndrome. Drugs, 75(4), pp.353-365. https://doi.org/10.1007/s40265-
015-0358-1
Montero‐Odasso, M., & Speechley, M. (2018). Falls in cognitively impaired older adults:
implications for risk assessment and prevention. Journal of the American Geriatrics
Society, 66(2), 367-375. https://doi.org/10.1111/jgs.15219
Nicklett, E. J., Anderson, L. A., & Yen, I. H. (2016). Gardening activities and physical health
among older adults: A review of the evidence. Journal of Applied Gerontology, 35(6),
678-690. https://doi.org/10.1177/0733464814563608
Qiu, C., & Fratiglioni, L. (2015). A major role for cardiovascular burden in age-related
cognitive decline. Nature Reviews Cardiology, 12(5), 267. Retrieved from:
https://www.nature.com/articles/nrcardio.2014.223
Richardson, J. K., Eckner, J. T., Allet, L., Kim, H., & Ashton-Miller, J. (2017). Complex and
simple clinical reaction times are associated with gait, balance, and major fall injury in
older subjects with diabetic peripheral neuropathy. American journal of physical
medicine & rehabilitation, 96(1), 8. doi: 10.1097/PHM.0000000000000604
Ryu, E., Juhn, Y. J., Wheeler, P. H., Hathcock, M. A., Wi, C. I., Olson, J. E., ... & Takahashi,
P. Y. (2017). Individual housing-based socioeconomic status predicts risk of
accidental falls among adults. Annals of epidemiology, 27(7), 415-420.
https://doi.org/10.1016/j.annepidem.2017.05.019
Sutton, L. J., & Jutel, A. (2016). Alcohol withdrawal syndrome in critically ill patients:
identification, assessment, and management. Critical care nurse, 36(1), 28-38.
doi: 10.4037/ccn2016420
Ward, R. E., Leveille, S. G., Beauchamp, M. K., Travison, T., Alexander, N., Jette, A. M., &
Bean, J. F. (2015). Functional performance as a predictor of injurious falls in older
adults. Journal of the American Geriatrics Society, 63(2), 315-320.
https://doi.org/10.1111/jgs.13203
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NUR341 Assessment 2
NUR341 Assessment 2 Marking Rubric
Needs
development
Competent Exemplary
Presentation 0-2
Greater than 2
presentation
guidelines not
abided by; Poor
adherence to
academic writing
conventions;
Insufficient attention
to spelling, grammar
punctuation or
syntax (> 5 errors);
little evidence of
critical thinking and
analysis
3-4
Less than 1 - 2
presentation
guidelines not
abided by; Academic
writing conventions
predominantly
followed; Consistent
attention to spelling,
grammar
punctuation or
syntax (< 5 errors);
satisfactory critical
thinking and analysis
5
Follows ALL
presentation
guidelines
accurately;
Academic writing
conventions followed
at all time; Excellent
attention to spelling,
grammar
punctuation or
syntax errors (no
errors); excellent
critical thinking and
analysis
Content
Part 1
0-14
Inconsistently
provides a clear
description of the
purpose/goal of the
assessments noted;
generalises linkage;
does not shows
15-22
Usually provides a
succinct description
of the purpose/goal
of the assessments
noted; satisfactory
linkage of patient
data; shows
23-30
Consistently
provides a succinct
description of the
purpose/goal of the
assessments noted;
perceptive linkage of
patient data; shows
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relevance. relevance. relevance.
Content
Part 2
Omits standard
actions and
referrals; weak
rationales for same.
Provides generic
actions and
referrals; standard
rationales for same.
Consistently
provides tailored
actions and
referrals; clear
rationales for same.
Content
Part 3
Content descriptive.
Little evidence of
analysis; inadequate
referrals and
rationale for same;
inadequate health
promotion
measures.
Satisfactory
analysis; general
referrals and
rationale for same;
general health
promotion
measures.
Analytical content
demonstrates
excellent critical
thinking and
evaluation skills;
salient
referrals and
rationale for same;
tailored health
promotion
measures.
Research &
referencing
0-2
Less than 7 peer
reviewed journals or
texts are used to
build and support
argument; Some
journals and texts
are more than 5
years old; The use
of direct quotes is
3-4
7 to 10 peer
reviewed journals or
texts are used to
build and support
argument; No more
than 1 journal or text
is no more than 5
years old; The use
of direct quotes is
5
A minimum of 10
peer reviewed
journals or texts are
used to build and
support argument;
Journals and texts
are no more than 5
years old; The use
of direct quotes is
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significant (>5); APA
6th guidelines are
poorly adhered to for
in-text referencing
and the end-of-text
reference list (>5
errors).
minimal (< 5); APA
6th guidelines are
used to format in-
text referencing and
the end-of-text
reference list (<5
errors).
minimal (< 3); APA
6th guidelines are
used to format in-
text referencing and
the end-of-text
reference list (< 3
errors).
Total: /40.
Marker:
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