Resident Information:

• Name: [Resident's Name]
• ID: [Resident ID]
• Assessment Reference Date: [Date]
• Triggered Care Area: Cognitive Loss/Dementia

1. Assessment Summary:

• MDS Findings: Loss of STM and LTM, with a BIMS rating of 10. Diagnosed with dementia and cognitive loss.
• Clinical Observations: Exhibits symptoms of depression. Challenges in recognizing others and self-awareness noted.
• Medical History Review: Extensive assistance required with ADLs. Conditions include blindness and decreased hearing. Long-term resident.

2. In-depth Assessment:               

• Review of Symptoms: Moderate difficulty in knowing others and comprehending oneself. Displays signs of isolation and depression.
• Risk Factors Identified: Long-term memory loss, short-term memory loss, sensory impairments, and existing depression.
• Complications/Contributing Factors: Isolation, further cognitive impairment.
• Potential Triggers or Causes: Ongoing cognitive decline, sensory loss contributing to isolation and depression.

3. Interdisciplinary Team (IDT) Evaluation:

• Medical: Continued evaluation and management of depression with antidepressants. Referral to a physician confirmed.
• Nursing: Implement non-pharmacological interventions to support mood and cognitive function.
• Social Services: Engage in isolation-prevention activities tailored to the resident's preferences and abilities.
• Rehabilitation Services: Adaptive strategies for ADLs considering sensory impairments.

4. Care Planning: Individualization

• Goal: Reduce risks associated with Cognitive Loss/Dementia, manage depressive symptoms, and improve quality of life.
• Interventions:

• • Personalized engagement activities to prevent isolation.
  • Environment modifications to accommodate sensory impairments and enhance orientation.
  • Regular reassessment of antidepressant effectiveness and side effects.
  • Encourage family and social interactions within the resident's comfort.

5. Monitoring and Reassessment:

• Short-Term: Daily monitoring for changes in mood and cognitive status, responsiveness to interventions.
• Long-Term: Weekly reassessment of cognitive function and adaptation of care plan as necessary.

6. Documentation and Communication:

• Documentation: Entries in the medical record detailing assessments, care plan updates, and resident's response to interventions.
• Communication: Regular updates to the resident's family on condition, care adjustments, and any significant changes.

7. IDT Meeting Follow-Up:

• Scheduled Date: [Date]

• • To discuss the resident's progress, evaluate the effectiveness of interventions, and adjust the care plan accordingly.