Nursing: Alcohol Withdrawal Risk Assessment, Cognitive Assessment, Falls Assessment, Functional Assessment, Nutritional Assessment

This document discusses the importance of various assessments in nursing, including alcohol withdrawal risk assessment, cognitive assessment, falls assessment, functional assessment, and nutritional assessment. It provides information on the symptoms and interventions for each assessment. The document also highlights the impact of psychosocial factors on the patient's health and suggests evidence-based health promotion measures.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Part 1
Alcohol Withdrawal Risk Assessment (AWRA)
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
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

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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 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

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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
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)

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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
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 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

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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
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
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.

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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 under the presence
of social worker. 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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