NUR341 - Assignment 2 Written Assignment Task CDU Casuarina Campus, Ellengowan Drive, Brinkin,...

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NUR341 - Assignment 2 Written Assignment Task
CDU Casuarina Campus, Ellengowan Drive,
Brinkin, Northern Te
itory, Australia 0811
CRICOS Provider No. 00300K (NT/VIC) | 03286A (NSW)
RTO Provider No. 0373 | ABN XXXXXXXXXX
Read the clinical scenario and the answer the assessment questions in an essay format.

Clinical Scenario

Ms Florence ‘Flo’ Ljukuta 70year old female admitted to hospital post fall with soft tissue injury to right
hip still unable to ambulate. Flo can not recall the event and up to 2-3mins post fall.

Parameter Assessment data
Patient profile Florence ‘Flo’ Ljukuta 70-year-old female from Alice Springs
Presenting complaint Pain to right hip unable to ambulate. No facture on x-ray
History of complaint Tripped on the back steps leading into the house after hanging cloths on the line.
Landed on the concrete pathway on her right side. Following the fall, Flo
experienced pain on movement and unable to ambulate independently. Assisted
to community health clinic and refe
ed to hospital.
Phx Hypertension, Type 2 diabetes, Angina, Hypercholesteremia, Asthma,
Osteoarthritis. Complete hysterectomy 30years ago for treatment of endometrial
cancer.
Allergies Nil Known Allergies
Medications • Aspirin 100mg mane
• Perindopril 2mg mane
• Metformin XR 2g mane
• GTN 600mcg tablets S/L prn
• Osteo paracetamol 1330mg TDS
• Salbutamol inhaler 2-4 puffs PRN
Ethnicity/language Aboriginal. Speaks Waramungu, Walpiri, Eastern and Western A
entre, English
Alcohol use Few wines or beers with family and friend 3-4 times per week
Tobacco use Smoker ½ packet per day/ whole family smokes. Regular exposure to campfire and
passive smoke
Drug use Nil
Home environment Cu
ently lives in town camp in 3
d house with extended family. Approximately
13 family members staying at the house.
Flo’s husband who requires assistance due to physical deficits from a stroke.
Adult daughter and her 4 teenage boys
Adult daughter and her 2 toddlers
Adult son and his partner and their new baby
Adult son
Work environment Retired 10 years. Previously manager of community health clinic
Stress Cu
ently eldest daughter has been diagnosed with
east cancer
Education VET level certificate
Economic status Family land and house in remote community but staying in town to be with
children and support needs for husband
Religion/spirituality Baptised Catholic by missionaries when young
ADLs Independent prior to fall
IADLs Does not drive anymore due to decreased vision (diabetic retinopathy). Starting to
develop cataracts. Had glasses a few years ago but they don’t help much now.
NUR341 - Assignment 2 Written Assignment Task
CDU Casuarina Campus, Ellengowan Drive,
Brinkin, Northern Te
itory, Australia 0811
CRICOS Provider No. 00300K (NT/VIC) | 03286A (NSW)
RTO Provider No. 0373 | ABN XXXXXXXXXX
Cognitive function No concerns identified
Diet Diabetic diet when able
Sleep 7-8 hours per night but cu
ently
oken sleep due to caring for others
Health check ups Regular check ups every few months with diabetic doctors/clinics.

Physical Assessment

Parameter Assessment data
Vital signs Temp: 36OC, HR: 100bpm regular, RR: 22bpm, SpO2: 94% RA, BP: 150/95,
BGL: 7.8mmol/L, Pain: 7/10
CNS GCS 13
Pupils equal and reactive to light
Lethargic, eyes open when spoken to, follows commands, orientated to
place and person not time/date
Unable to test muscle strength due to pain from injury
CVS Both feet pale in colour
No sacral or ankle oedema
Feet bilateral cool skin temperature/ hands warm
Peripheral pulses present, dorsalis weak bilaterally
Capillary refill feet and hand >3seconds
Resp Shallow and regular
Palpation: no pain
Chest expansion symmetrical
Percussion: bilateral resonance in all areas
Auscultation: mild wheeze on exhalation
MSK Blue
ed coloured haematoma to right hip extends to right buttock
Swelling evident
Skin intact
Decreased range of movement
Very tender on palpation
Reluctant to walk or move due to pain
GIT Loss of appetite and mild nausea over last few days
No vomiting
Regular bowel movements, constipation last 2 days
Generalised distention
Bowel sounds present
Mild tenderness lower abdominal area
Urinary No pain on passing urine
2-3 days increased urinary frequency/urgency
Passed cloudy, malodorous urine approx. 1hour prior to fall

NUR341 - Assignment 2 Written Assignment Task
CDU Casuarina Campus, Ellengowan Drive,
Brinkin, Northern Te
itory, Australia 0811
CRICOS Provider No. 00300K (NT/VIC) | 03286A (NSW)
RTO Provider No. 0373 | ABN XXXXXXXXXX

Assessment Questions

Question 1: Assessments (recommend 1500words)

Hospital policy requires Flo to receive the following assessments completed on admission to the ward.

• Falls assessment
• Functional assessment
• Pressure injury risk assessment

Students must:
• Detail the goal or purpose of each assessment
• Provide an example of a tool used in Australian hospitals including the frequency it should be
completed
• Explain how each assessment relates to Flo’s presentation
• Explain how abnormal findings are managed by the nurse

Question 2: Plan and implementation (recommend 500words)

The following four (4) factors have contributed to Flo’s cu
ent fall and health status:

1. Normal age-related changes
2. Como
idities
3. Acute illness
4. Medication

Students must choose one (1) of the factors (above) and identify the health promotion or education you
as the nurse would provide in preparation for discharge. This must include two (2) refe
als to support
services and your rationale for each refe
al.

Please note: if a student details more than one factor, the marker will address and mark only the first
factor outlined.

Presentation guidelines
• Complete the footer with last name_student number_NUR341_ Assessment 2
• Format your assessment with size 12 Arial/Cali
i or similar font, 1.5 spacing
• 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 CDU APA 7th referencing style
• 2000word limit: recommend Part XXXXXXXXXXwords) and Part XXXXXXXXXXwords). The end-of-text
eference 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 and submit as a word document

nur341-assignment-2-task-gnm5k5bg.pdf

Dr. Saloni · Accepted Answer

11
Case Study of Flo
Contents
Question 1: Assessments    1
Falls assessment    1
Goal    1
Tool    1
Relates to Flo’s presentation    2
Management of Abnormal Findings    2
Functional assessment    2
Goal    2
Tool    3
Relates to Flo’s presentation    3
Management of Abnormal Findings    3
Pressure injury risk assessment    4
Goal    4
Tool    4
Relates to Flo’s presentation    4
Management of Abnormal Findings    5
Question 2: Plan and implementation    5
References    6
Question 1: Assessments

Falls assessment

Goal
A fall risk assessment aims to determine if individuals are at a minimal, moderate, or excessive risk of falling. If this assessment determines that Flo is at a higher risk, her caregiver or health care provider may recommend ways to prevent falls and lower the potential for harm. An individual who has fallen without damaging herself should have her gait and balance evaluated; an individual who has balance and gait anomalies should be evaluated further. A history of someone falling without damage or gait or balance difficulties does not necessitate additional evaluation beyond a yearly fall risk assessment (Clark et al., 2020).

Tool
FRAT (fall risk assessment tool)
The fall risk assessment tool has the capability to precisely assess fall vulnerability as well as provide a reliable framework for making decisions about measures that can be beneficial in lowering the risk of falls. Multiple focused intervention programmes based on complete risk assessment have led to a considerable decline in falls in interventional studies in assisted living facilities. Similar findings have been found in subacute healthcare settings. It is a four-item fall-risk assessment measure designed for use in residential and subacute care settings by nurses. It determines who is prone to falling and who does not, with a minimum of e
or (Sun & Sosnoff, 2018).

Relates to Flo’s presentation
In Flo's representation, FRAT can form the basis for the acquisition of fall risk-related data. The questions pertain to seen or documented risk factors or behaviours of Flo, like age and como
idities that the admitting nurse would identify immediately after admission. In this case, Flo's existing medications and physiological risk factors will be evaluated. These serve as clinical markers for the prevalence of fall risk and underpinning factors associated with it that can aid in the development of a strategic plan. It is suggested that any information be validated by Flo's caregiver or family member (Wabe et al., 2022).

Management of Abnormal Findings
When a patient is diagnosed with abnormal findings, a nursing care plan that incorporates treatments focused on prevention strategies is often devised. When determining core treatments to ensure the safety of Flo from falling, an action plan employs clinical judgement and knowledge, including tailored care plans depending on actual falls as well as injury risk indicators (Clark et al., 2020). Such interventions may include mentioning on the medical record and on Flo's door that the client is at strong risk for falls, relocating her to rooms nea
y the nursing station to enhance observation, reassessing patients after new episodes of ailment or medication changes, limiting bed height and side rails for the patient who climbs out of bed, and providing fall prevention education to staff and patients. According to studies, employing restraints daily does not lower the occu
ence of falls (Wabe et al., 2022).
Moreover, the utilisation of a trunk restraint is related to an increased incidence of fractures and falls in patients. Provide assistance aids for ambulation and transfer of the patient. Wheelchairs should be used as little as possible since they can be utilised as a restraint measure. Medication and retraining in the utilisation of adequate adaptive equipment can be beneficial in minimising the incidence of falls, as well as the injury and loss of self-confidence that accompanies them (Clark et al., 2020).

Functional assessment

Goal
Functional assessment is a powerful approach for objectively documenting a patient's functional state, progressing through the phase of treatment, and justifying a homebound position. A functional assessment examination can also be utilised to justify going to physical therapy treatments (Maddux et al., 2018). The assessment of the elderly patient must include a functional assessment. This assessment is usually undertaken through the past and may emerge as a component of the history of the cu
ent illness. The assessment of daily living activities delivers additional information on the patient's capacities and the impacts of the disease. The functional assessment generally acts as a baseline against which the effects of sickness or intervention can be measured (Kimura, 2021).

Tool
FMI (the Functional Independence Measure)
FIM is a non-diagnostic tool that was designed as a measurement of dysfunction for several populations. An FIM is an instrument. Functional changes are a critical outcome metric for rehabilitation events (Kimura, 2021). The FIM tool consists of 18 items, which are scored on a seven-point ordinal level, with the larger the value for an item, the more likely it indicates that the patient can do the tasks tested by that object independently. The FIM is shown to require 30–45 minutes to perform and analyze, with the 7-minute respite for baseline data collection. The total number...

NUR341 - Assignment 2 Written Assignment Task CDU Casuarina Campus, Ellengowan Drive, Brinkin, Northern Territory, Australia 0811 CRICOS Provider No. 00300K (NT/VIC) | 03286A (NSW) RTO Provider No....

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