36. Sample Care Area Assessment (CAA) for Urinary Continence and Indwelling Catheter Management

Resident Information:

• Name: Jane Doe
• ID: 789123
• Date of Assessment: YYYY-MM-DD
• Room Number: 204

Assessment Team:      

• Primary Nurse: Emily Harris
• MDS Coordinator: Laura Gomez
• Physical Therapist: John Carter
• Occupational Therapist: Angela Lee
• Social Worker: Richard Kim
• Dietary Consultant: Sophia Martin
• Urologist: Dr. Michael Johnson

Care Area Assessed:

• Specify the care area: Urinary Continence and Indwelling Catheter Management

Step 1: Triggered Care Areas

• Triggered due to episodes of urinary incontinence, exacerbated by CHF management with diuretic therapy (Lasix 40 mg daily). The resident requires assistance for toileting and is on a scheduled toileting plan.

Step 2: Review of MDS 3.0 Findings

• Occasional incontinence of urine reported, with an existing diagnosis of CHF. The resident is under Lasix therapy, necessitating frequent urination and increasing the risk of incontinence-related complications such as skin rashes, breakdown, falls, isolation, and urinary infections.

Step 3: Detailed Assessment

• Clinical findings: Improvement noted in incontinence episodes over the past three months due to a structured toileting schedule. However, the resident remains at risk for associated complications due to the ongoing need for diuretics.
• Review of medical records: Confirms CHF diagnosis and Lasix prescription. No current referrals to specialists beyond the managing cardiologist and urologist.
• Consultations with interdisciplinary team members: Emphasized the importance of maintaining skin integrity, monitoring for signs of urinary infections, and ensuring the resident's mobility to reduce fall risks.
• Resident and family interviews: Indicate satisfaction with current improvements but express concerns about long-term management and potential for increased dependency.

Step 4: Problem Identification

• Despite improvements, ongoing risks include skin integrity issues, potential for falls, social isolation due to incontinence embarrassment, and urinary tract infections.

Step 5: Care Planning

• Goal: To maintain and enhance urinary continence, manage the use of an indwelling catheter (if applicable), prevent complications related to incontinence and catheter use, and support the resident's dignity and independence.
• Interventions:

• • Continue with the scheduled toileting plan, adjusting timings if necessary based on the resident's response and fluid intake patterns.
  • Regular skin assessments by nursing staff to detect and treat early signs of skin breakdown or rashes.
  • Collaboration with a urologist for ongoing evaluation of Lasix effects and potential urinary system impacts.
  • Implement fall prevention strategies, considering the resident's frequent toileting needs.
  • Engage the resident in social activities to mitigate feelings of isolation and promote a sense of community and belonging.

• Responsible Staff: Nursing staff for daily care and monitoring, urologist for medical management, social worker for emotional and social support.
• Timelines: Immediate start with bi-weekly reviews to monitor progress and effectiveness of the toileting schedule and monthly evaluations for skin integrity and overall urinary management.

Step 6: Interdisciplinary Team Review

• Agreement on the care plan's continuation and emphasis on proactive monitoring to prevent complications. The team acknowledges the importance of regular reassessment to adapt the plan as the resident's condition evolves.

Step 7: Resident and Family Engagement

• The resident and family have been actively involved in discussing the care plan, providing insights into the resident's preferences and concerns. Their feedback is integral to ensuring the care approach is respectful, dignified, and aligned with the resident's goals.

Step 8: Monitoring and Reassessment

• Short-Term: Continuous monitoring of the resident's response to the toileting plan and skin integrity.
• Long-Term: Ongoing evaluation of the resident's overall well-being, urinary continence status, and adaptation of care strategies to meet changing needs and preferences.

Documentation and Signatures:

• Signature of MDS Coordinator: Laura Gomez, Date: YYYY-MM-DD
• Signature of Primary Nurse: Emily Harris, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to review the resident's status, discuss any necessary adjustments to the care plan, and ensure continued progress towards achieving the outlined goals.