Mr Jungala's Case Study

Mr Willie Jungala is a 71-year-old gentleman that has been admitted to hospital post fall with soft tissue injury to right hip.

 

 

 

 

 

 

 

 

 

from the case study :

 

Hospital policy is that Mr Jungala receive the assessments below. For this assessment, the student needs to:

1. Detail the goal or the purpose of each assessment,

2. give an example of a tool used in the Australian hospitals and the frequency it is utilised.

3. Explain how this assessment is related to Mr Jungala case and who you would report abnormal findings to.

 

The assessments are the following:

Image transcription text

Physical Assessment data Temp 36.0, Pulse 100, Resps 20, Sp02 94% RA,

BP 150:95, BGL 3.9mmolle, Pain 6 out of '1 0 G83 '13 Pupils equal and

reactive to light Lethargic, eves open when spoken to, follows c... Show more

Image transcription text

History Assessment data Patient profile Willie Jungala, 71-year-old man from

Alice Springs Chief complaint Pain to right hip following fall Was going to

kitchen to make a sandwich and tripped on kids tonka truck. La... Show more

Cognitive assessment

Falls assessment

Functional assessment"

1. Physical Assessment

 Goal/Purpose:

 

 Assess Vital Signs: In order to understand about the general health of Mr Jungala pathophysiologic alterations that are acute must be evaluated.

 Pain Assessment: So as to understand how much pain the patient feels and how it slows him and his recovery process as Mr. Jungala down.

 Neurological Status: For this reason, it can be a method of screening for neurological deficits that may indicate complication.

 Example Tool:

 

 Vital Signs Chart: The Australian hospitals use EHR systems containing the principles of the vital signs checking that is usually done and noted – like peri operatively, or at least once every 4 hours for patients admitted to the hospital.

 Relation to Mr.  Jungala’s Case:Connection to Mr. Jungala’s Case:

 

 Vital Signs: The patient has hypertension, which is recorded at 150/95; the patient’s oxygen level is at 94% RA, this may have been occasioned by stress or other effects that come from the fall. These have to be assumed in order to avoid or manage their impacts at the correct time.

 Pain Assessment: In this case the level of reported pain was 6/10 PA and to promote healing well needs to be controlled.

 Neurological Status: Sleeping and sedation have to be checked to identify whether there were complications at all for example head injury during the fight.

 Report Abnormal Findings To:

 

 Primary Nurse/Healthcare Provider: Any frequent changes which may exist should be communicated so that time appropriate actions can be embarked on – there should be the time reactions and alterations.

 Medical Team: Any variations for instance a high blood pressure that is always high, low levels of oxygen should be communicated to the doctor on call.

 2. History Assessment

 Goal/Purpose:

 

 Gather Comprehensive Background: In achieving this following aspects are of paramount importance; an overall impression of the patient and medical history of the patient.

 Example Tool:

 

 Patient History Form: At times used in recording patients’ private, health and other relevant information in Australian hospitals. This is normally received at the first visit of the client and may be changed from time to time.

 Relation to Mr.  Jungala’s Case:Connection to Mr. Jewla’s Case:

 

 Background Information: The patient has history of the fall and current pain which will be used to assess the degree of his injury and on how to handle him.

 Report Abnormal Findings To:

 

 Healthcare Team: Any matter that may be ‘contradictory’ or any matter concerning or potentially affecting the regime should be reported to the medical team.

 3. Cognitive Assessment

 Goal/Purpose:

 

 Assess Mental Status: To evaluate the degree of mental state and consciousness of Mr. Jungala since they may block his understanding of the further treatment and safety orders.

 Example Tool:

 

 Mini-Mental State Examination (MMSE): done to assess mental state, can be done at admission, then as necessary at certain time intervals.

 Relation to Mr.  Jungala’s Case:In relation with Mr. Jungala’s case there are down sides as follows:

 

 Lethargy and Responsiveness: Since he is reported to be currently Presented as lethargic, and only awakens when spoken to, it would be valuable to do a cognitive assessment in order to assess increased clues or new acute changes in this patient’s mental status following the fall and the findings on the imaging.

 Report Abnormal Findings To:

 

 Healthcare Provider/Neurologist: Any change in the patient’s cognitive status should be reported to the other doctor or a Neurologist for review and appropriate management.

 4. Falls Assessment

 Goal/Purpose:

 

 Evaluate Risk Factors: In order to search for any antecedent conditioning that may have attributed to the fall of Mr. Jungala and for the purpose of averting similar incidences in future.

 Example Tool:

 

 Falls Risk Assessment Tool (FRAT): Admitted in NSW Public Hospitals for the purpose of assessing their risk of falls. This assessment is normally conducted often at the time the patient is admitted and at other times according to the severity of the clinical condition of the patient.

 Relation to Mr.  Jungala’s Case:Connection to Mr. Jungala ’s case:

 

 Risk Identification: It can also be used to prevent other falls in future due to some causes and or reasons that has been discussed above especially given Mr. Jungala’s age and the nature of fracture that he has.

 Report Abnormal Findings To:

 

 Fall Prevention Team/Nurse: High risk factors if seen should be reported to the fall prevention team or the nurse to be taken through intervention measures to minimize future cases of falls.

 Summary:

 In the treatment as well as recovery process of Mr. Jungala each of the assessments act as useful in focusing. The physical assessment offers the information concerning the patients’ current health threats; the history assessment gives background information; the cognitive assessment tests the patient’s consciousness; and the falls assessment prevents the threats for such cases. And it can contain such results as increased temperature, tachycardia or hypertension, and any other pathology that requires a patent to be treated in a certain way.

 

 References:

 

 Safety and Quality in Health care South Australia. (2020). The following are national safety and quality Health Service standards:The following are national safety and quality Health Service standards:

 The above work has been developed with the assistance of the Australian Institute of Health and Welfare. (2021). Vital signs monitoring guidelines.