Sample Care Area Assessment (CAA) for Nutritional Status

Resident Information:

• Name: John Doe
• ID: 123456
• Date of Assessment: YYYY-MM-DD
• Room Number: 101

Assessment Team:

• Primary Nurse: Alice Martin
• MDS Coordinator: George Smith
• Registered Dietitian (RD): Emily Thompson
• Physician: Dr. Sarah Johnson

Care Area Assessed:

• Specify the care area: Nutritional Status

Step 1: Triggered Care Areas

• Triggered by John's recent unintentional weight loss and reported decrease in appetite. Lab values indicate potential nutritional deficiencies.

Step 2: Review of MDS 3.0 Findings

• John has a history of chronic conditions, including hypertension and type 2 diabetes, which require careful dietary management. Despite a generally balanced diet, he consumes less than 75% of most meals and has experienced a 5% weight loss over the last month.

Step 3: Detailed Assessment

• Clinical findings: Unintentional weight loss, reduced meal consumption, and potential nutritional deficiencies that could impact John's chronic conditions and overall health.
• Review of medical records: Notes on dietary preferences, recent lab results indicating possible deficiencies in vitamins and minerals, and historical weight trends.
• Consultations with interdisciplinary team members: Highlight the need for a personalized nutrition plan, possibly including dietary supplements, to address deficiencies and support John's health.
• Resident and family interviews: Reveal a lack of interest in meals, partly due to taste preferences and meal presentation.

Step 4: Problem Identification

• Risks include worsening of chronic conditions due to inadequate nutrition, further unintentional weight loss, and the potential for malnutrition.

Step 5: Care Planning

• Goal: To improve John's nutritional status through tailored dietary interventions, ensuring his needs are met in line with his chronic conditions and promoting overall health and well-being.
• Interventions:

• • Consult with the RD to develop a personalized nutrition plan that accommodates John's taste preferences, dietary restrictions, and nutritional needs.
  • Introduce dietary supplements as recommended by the RD to address specific deficiencies.
  • Implement regular nutritional monitoring, including weight checks and lab tests, to assess the effectiveness of the nutrition plan and make adjustments as needed.
  • Enhance meal presentation and variety to increase meal appeal and encourage greater consumption.
  • Educate John and his family on the importance of nutrition in managing his chronic conditions and maintaining health.

• Responsible Staff: RD, Nursing Staff, Physician
• Timelines: Immediate implementation with ongoing monitoring and adjustments based on John's response and nutritional status assessments.

Step 6: Interdisciplinary Team Review

• The team collaborates on John's nutritional care plan, emphasizing the critical role of nutrition in managing his health conditions and enhancing his quality of life.

Step 7: Resident and Family Engagement

• Engaging John and his family in discussions about his nutrition care plan ensures they understand the rationale behind dietary interventions and supports their active participation in his care.

Step 8: Monitoring and Reassessment

• Short-Term: Weekly monitoring of meal consumption and monthly weight checks to gauge the initial impact of dietary changes.
• Long-Term: Ongoing assessment of John's nutritional status through regular lab tests and RD evaluations to ensure his nutritional needs continue to be met effectively.

Documentation and Signatures:

• Signature of MDS Coordinator: George Smith, Date: YYYY-MM-DD
• Signature of Primary Nurse: Alice Martin, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to review John's progress, discuss any challenges in improving his nutritional status, and adjust the care plan as necessary to optimize his dietary intake and health outcomes.