Assessment 2: Person-Centered Assessment And Care
\nDue date: Sunday 3rd of May 2020 – 23:59 CST (Week 8)
\nLength: 2000 words +\/- 10% (excluding references) Markers will stop reading at the maximum allowable word count
\nReferencing: At least 5 high quality, current resources (published within the last 5 years), integrated in APA 6th style
\nRelevance: High quality aged care is dependent on a holistic and integrative approach to patient assessment and care planning. Assessment two is designed to meet the learning outcomes: 1,3,4,5,6<\/p>\n
Reading the case study answer the following questions:
\nPart 1: Assessment (1000 words)
\nHospital 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.
\no\tAlcohol withdrawal risk assessment
\no\tCognitive assessment
\no\tFalls assessment
\no\tFunctional assessment
\no\tNutritional assessment
\nPart 2: Plan and implementation (500 words)
\nNormal age-related changes, Mr Jungula\u2019s 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.
\nPart 3: A biopsychosocial approach (500 words)
\nHealthy 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: positively and negatively. Identify coping mechanisms and social support networks to promote Mr Jungala’s psychosocial well-being. Note any appropriate interdisciplinary team referrals; include rationales for same.<\/p>\n
Please download the:
\n\u2022\tAssessment instruction – NUR341_ Assessment 2_Case study.pdf NUR341_ Assessment 2_Case study.pdf – Alternative Formats
\n\u2022\tAssessment rubric NUR341_ Assessment 2_Marking rubric.doc NUR341_ Assessment 2_Marking rubric.doc – Alternative Formats
\nPresentation guidelines
\n\u2022\tComplete the footer as prompted i.e. last name_student number_NUR341_ Assessment 2
\n\u2022\tFormat your assessment with size 12 point Arial font, single spacing and double spacing for end-of-text reference list.
\n\u2022\tComplete spelling and grammar check using English (Australia) default.
\n\u2022\tA minimum of 5 peer reviewed journals or texts no more than 5 years old.
\n\u2022\tUse APA 6th referencing.
\n\u2022\t2000 word limit: Part 1 (1000 words); Part 2 (500 words); Part 3 (500 words). The end-of-text reference list is NOT included in the word count.
\n\u2022\tSave the final version of your paper using the filename of last name_student number_NUR341_ Assessment 2<\/p>\n
Double click here to fill in this footer
\n1
\nMr Willie Jungala is a 71-year-old
\ngentleman that has been admitted to
\nhospital post fall with soft tissue injury to
\nright hip.
\nHistory Assessment data
\nPatient profile Willie Jungala, 71-year-old man from Alice Springs
\nChief complaint Pain to right hip following fall
\nHistory of complaint
\nWas going to kitchen to make a sandwich and tripped on
\nkids Tonka truck. Landed on the floor on his right side.
\nFollowing fall, Willie was experiencing pain on movement
\nand difficulty weight bearing. Two teenage grandchildren
\ntried to help him up but too painful, so they called an
\nambulance.
\nPhx Hypertension, Type 2 Diabetes, Unstable Angina
\nAllergies Nil known allergies.
\nMedications
\n\u2022 Aspirin 100mg mane
\n\u2022 Perindopril 2mg mane
\n\u2022 Metformin 1000mg TDS
\n\u2022 GTN 600mcg tablets S\/L prn
\nAlcohol use Social – 2 to 3 beers (mid-strength), 2 to 3 times per week.
\nTobacco use
\nNon-smoker. Regular exposure to campfire smoke. Most
\nnights have a campfire burning – sit by campfire and enjoy
\nthe night ‘yarning’ or listening to music.
\nDrug use Nil.
\nHome environment
\nLives in town camp in house with extended family.
\nApproximately 12 family members staying at house: wife;
\ndaughter and her 4 teenage boys; daughter and her two
\ntoddlers; son’s two adult boys.
\nWork environment Was a station hand. Retired 5 years ago.
\nStress
\nSometimes. At the moment, youngest daughter that lives at
\nhome there with her two toddlers, has recently been
\ndiagnosed with cancer. A few drinks and a few laughs help
\nease the stress.
\nEducation Year 9 schooling.
\nEconomic status Own land and house out bush but staying in town for a
\nwhile.
\nEthnic background Aboriginal. Speaks Waramungu, Walpiri, Eastern and
\nCentral Arrente, Western Arrentre and English.
\nDouble click here to fill in this footer
\n2
\nReligion\/ spirituality
\nBaptised Catholic by missionaries when young. Only goes
\nto church for funerals. Willie’s spirit is strengthened by
\nfamily and country.
\nSexual practice Married. Been with wife for 51 years. Have one son and two
\ndaughters.
\nADLs Independent.
\nIADLs
\nDoes not drive any more due to decreased vision (diabetic
\nretinopathy). Starting to get cataracts. Had glasses a few
\nyears ago but they don’t work so well anymore.
\nCognitive function No worries.
\nDiet Diabetic diet
\nSleep 7-8 hours a night.
\nHealth check ups<\/p>\n
Regular check-ups every few months with diabetic doctors\/
\nclinics. Go to medical service if need to. Moves between
\nmedical services depending on where he is staying at.
\nPhysical
\nassessment Assessment data
\nVital signs Temp 36.0, Pulse 100, Respiration 20, SpO2 94% RA, BP
\n150\/95, BGL 3.9mmols\/L, Pain 6 out of 10
\nCNS
\n\u2022 GCS 13
\n\u2022 Pupils equal and reactive to light
\n\u2022 Lethargic, eyes open when spoken to, follows
\ncommands, orientated to place and person; not time.
\n\u2022 Difficult to test muscle strength due to pain from injury to
\nright side
\nCVS
\n\u2022 Both feet pale in colour
\n\u2022 No sacral or ankle oedema
\n\u2022 Bilateral cool skin temperature in feet; hands warm
\n\u2022 Peripheral pulses present but dorsalis weak bilaterally
\n\u2022 Capillary refill feet and hands > 3 seconds
\nResp
\n\u2022 Shallow and regular breathing
\n\u2022 No reports of pain on palpation
\n\u2022 Chest expansion symmetrical
\n\u2022 Percussion- bilateral resonance in all areas
\n\u2022 Auscultation – no abnormal breath sounds noted
\nMSK
\n\u2022 Blue\/red coloured haematoma to right hip and extends to
\nright buttock
\n\u2022 Swelling evident
\n\u2022 Skin intact
\n\u2022 Decreased range of movement around hip
\n\u2022 Tender on palpation of right hip area
\n\u2022 Reluctant to attempt walking due to pain
\nDouble click here to fill in this footer
\n3
\nGIT
\n\u2022 Loss of appetite and nausea last few days
\n\u2022 No vomiting
\n\u2022 Regular bowel movements. Little bit constipated last two
\ndays.
\n\u2022 Generalised distention
\n\u2022 Bowel sounds in all 4 quadrants
\n\u2022 Mild tenderness lower abdominal area
\nUrinary
\n\u2022 Supposed to be fluid restriction. Doesn’t worry about that
\nso much.
\n\u2022 No pain on passing urine
\n\u2022 2-3 days of increased urinary frequency and urgency\/
\nwanting to go bad
\n\u2022 Passed cloudy, malodorous urine approx 1 hour before
\nfall
\nPsychosocial vital signs & Patient response
\nPerception
\n“Pretty good for my age. I’ve got diabetes and chronic renal failure, but a lot of my
\nmob do. I just got this angina last year but usually it isn’t too bad; the tablets work
\nwell. Bad luck I tripped over that bloody Tonker truck and hurt my hip”.
\nSupport
\n“I got my wife and my girls at home, and their kids. I’ll be right. I don’t want to put too
\nmuch pressure on my youngest daughter, she’s got enough to worry about with that
\ncancer. We can usually call out to family or friends and they can help me out if I
\nneed. For example, I can’t drive now so I can ask around and someone will usually
\nbe around to come over and give me a lift to town for shopping, Centrelink, banking
\nor doctors.”
\nCoping
\n“Most of the time just sitting down and relaxing and not stressing too much but
\nsometimes, maybe 2 or 3 nights a week, I sit down and have a few beers.” “When it
\nis too much I just take off out bush for a while.”
\nAnxiety\/ Level of anxiety
\n“Yeah a little bit. I don’t want to fall like that again and I don’t want to get another
\nurine infection; that was no good”
\n“Level of anxiety right now, medium”.
\nDouble click here to fill in this footer
\n4
\nPart 1: Assessment (1000 words)
\nHospital policy is that Mr Jungala receive the assessments below. Detail the goal or
\nthe purpose of these assessments and how they relate to Mr Jungala.
\n\u2022 Alcohol withdrawal risk assessment
\n\u2022 Cognitive assessment
\n\u2022 Falls assessment
\n\u2022 Functional assessment
\n\u2022 Nutritional assessment
\nPart 2: Plan and implementation (500 words)
\nNormal age-related changes, Mr Jungula\u2019s co-morbidities, acute illness and
\nmedications may have contributed to his fall. Choose one factor and outline your
\nnursing actions and referrals you would execute; include rationales for same.
\nPart 3: A biopsychosocial approach (500 words)
\nHealthy ageing involves promoting one’s physical, mental and social well-being.
\nConsider Mr Jungala’s psychosocial vital signs. Identify what factors impact on Mr
\nJungala’s psychosocial health: positively and negatively. Identify coping mechanisms
\nand social support networks to promote Mr Jungala’s psychosocial well-being. Note
\nany appropriate interdisciplinary team referrals; include rationales for same.
\nDouble click here to fill in this footer
\n5
\nNUR341 Assessment 2 Marking Rubric
\nNeeds development Competent Exemplary
\nPresentation 0-2
\nGreater than 2
\npresentation
\nguidelines not abided
\nby; Poor adherence to
\nacademic writing
\nconventions;
\nInsufficient attention to
\nspelling, grammar
\npunctuation or syntax
\n(> 5 errors); little
\nevidence of critical
\nthinking and analysis
\n3-4
\nLess than 1 – 2
\npresentation
\nguidelines not abided
\nby; Academic writing
\nconventions
\npredominantly
\nfollowed; Consistent
\nattention to spelling,
\ngrammar punctuation
\nor syntax (< 5 errors);
\nsatisfactory critical
\nthinking and analysis
\n5
\nFollows ALL
\npresentation
\nguidelines accurately;
\nAcademic writing
\nconventions followed
\nat all time; Excellent
\nattention to spelling,
\ngrammar punctuation
\nor syntax errors (no
\nerrors); excellent
\ncritical thinking and
\nanalysis
\nContent
\nPart 1
\n0-14
\nInconsistently provides
\na clear description of
\nthe purpose\/goal of the
\nassessments noted;
\ngeneralises linkage;
\ndoes not shows
\nrelevance.
\n15-22
\nUsually provides a
\nsuccinct description of
\nthe purpose\/goal of the
\nassessments noted;
\nsatisfactory linkage of
\npatient data; shows
\nrelevance.
\n23-30
\nConsistently provides
\na succinct description
\nof the purpose\/goal of
\nthe assessments
\nnoted; perceptive
\nlinkage of patient data;
\nshows relevance.
\nContent
\nPart 2
\nOmits standard actions
\nand referrals; weak
\nrationales for same.
\nProvides generic
\nactions and referrals;
\nstandard rationales for
\nsame.
\nConsistently provides
\ntailored actions and
\nreferrals; clear
\nrationales for same.
\nContent
\nPart 3
\nContent descriptive.
\nLittle evidence of
\nanalysis; inadequate
\nreferrals and rationale
\nfor same; inadequate
\nhealth promotion
\nmeasures.
\nSatisfactory analysis;
\ngeneral
\nreferrals and rationale
\nfor same; general
\nhealth promotion
\nmeasures.
\nAnalytical content
\ndemonstrates
\nexcellent critical
\nthinking and Assessment
\nskills; salient
\nreferrals and rationale
\nfor same; tailored
\nhealth promotion
\nmeasures.
\nResearch &
\nreferencing
\n0-2
\nLess than 7 peer
\nreviewed journals or
\ntexts are used to build
\nand support argument;
\nSome journals and
\ntexts are more than 5
\nyears old; The use of
\ndirect quotes is
\nsignificant (>5); APA
\n6
\nth guidelines are
\npoorly adhered to for
\nin-text referencing and
\nthe end-of-text
\nreference list (>5
\nerrors).
\n3-4
\n7 to 10 peer reviewed
\njournals or texts are
\nused to build and
\nsupport argument; No
\nmore than 1 journal or
\ntext is no more than 5
\nyears old; The use of
\ndirect quotes is
\nminimal (< 5); APA 6th
\nguidelines are used to
\nformat in-text
\nreferencing and the
\nend-of-text reference
\nlist (<5 errors).
\n5
\nA minimum of 10 peer
\nreviewed journals or
\ntexts are used to build
\nand support argument;
\nJournals and texts are
\nno more than 5 years
\nold; The use of direct
\nquotes is minimal (<
\n3); APA 6
\nth guidelines
\nare used to format intext referencing and
\nthe end-of-text
\nreference list (< 3
\nerrors).<\/p>\n","protected":false},"excerpt":{"rendered":"
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