Assessment 2: Person-Centered Assessment And Care
Due date: Sunday 3rd of May 2020 – 23:59 CST (Week 8)
Length: 2000 words +/- 10% (excluding references) Markers will stop reading at the maximum allowable word count
Referencing: At least 5 high quality, current resources (published within the last 5 years), integrated in APA 6th style
Relevance: 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
Reading the case study answer the following questions:
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.
o Alcohol withdrawal risk assessment
o Cognitive assessment
o Falls assessment
o Functional assessment
o Nutritional assessment
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.
Part 3: A biopsychosocial approach (500 words)
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: 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.
Please download the:
• Assessment instruction – NUR341_ Assessment 2_Case study.pdf NUR341_ Assessment 2_Case study.pdf – Alternative Formats
• Assessment rubric NUR341_ Assessment 2_Marking rubric.doc NUR341_ Assessment 2_Marking rubric.doc – Alternative Formats
Presentation guidelines
• Complete the footer as prompted i.e. last name_student number_NUR341_ Assessment 2
• Format your assessment with size 12 point Arial font, single spacing and double spacing for end-of-text reference list.
• Complete spelling and grammar check using English (Australia) default.
• A minimum of 5 peer reviewed journals or texts no more than 5 years old.
• Use APA 6th referencing.
• 2000 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.
• Save the final version of your paper using the filename of last name_student number_NUR341_ Assessment 2
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1
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
Chief complaint Pain to right hip following fall
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
Allergies Nil known allergies.
Medications
• Aspirin 100mg mane
• Perindopril 2mg mane
• Metformin 1000mg TDS
• GTN 600mcg tablets S/L prn
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.
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2
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 anymore.
Cognitive function No worries.
Diet Diabetic diet
Sleep 7-8 hours a night.
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.
Physical
assessment Assessment data
Vital signs Temp 36.0, Pulse 100, Respiration 20, SpO2 94% RA, BP
150/95, BGL 3.9mmols/L, Pain 6 out of 10
CNS
• GCS 13
• 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
• Capillary refill feet and hands > 3 seconds
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 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
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3
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
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/ Level of anxiety
“Yeah a little bit. I don’t want to fall like that again and I don’t want to get another
urine infection; that was no good”
“Level of anxiety right now, medium”.
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4
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.
• Alcohol withdrawal risk assessment
• Cognitive assessment
• Falls assessment
• Functional assessment
• Nutritional assessment
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.
Part 3: A biopsychosocial approach (500 words)
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: 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.
Double click here to fill in this footer
5
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
relevance.
15-22
Usually provides a
succinct description of
the purpose/goal of the
assessments noted;
satisfactory linkage of
patient data; shows
relevance.
23-30
Consistently provides
a succinct description
of the purpose/goal of
the assessments
noted; perceptive
linkage of patient data;
shows 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 Assessment
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
significant (>5); APA
6
th guidelines are
poorly adhered to for
in-text referencing and
the end-of-text
reference list (>5
errors).
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
minimal (< 5); APA 6th
guidelines are used to
format in-text
referencing and the
end-of-text reference
list (<5 errors).
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 minimal (<
3); APA 6
th guidelines
are used to format intext referencing and
the end-of-text
reference list (< 3
errors).
