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

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)