Resident Information:

• Name: Robert Wilson
• ID: 648273
• Date of Assessment: YYYY-MM-DD
• Room Number: 214

Assessment Team:       

• Primary Nurse: Carol Jennings
• MDS Coordinator: Derek Hanson
• Registered Dietitian (RD): Lisa Moreno
• Physician: Dr. James Patel

Care Area Assessed:

• Specify the care area: Dehydration/Fluid Maintenance

Step 1: Triggered Care Areas

• Triggered by Robert's recent episodes of dehydration, as evidenced by decreased urine output, dry mucous membranes, and reports of fatigue. His limited fluid intake has been noted, especially during hot weather conditions.

Step 2: Review of MDS 3.0 Findings

• Robert has a history of chronic renal insufficiency and heart failure, which necessitates careful fluid management to avoid exacerbation of these conditions. Despite these issues, there's been a lack of consistent monitoring of his fluid intake.

Step 3: Detailed Assessment

• Clinical findings: Signs of dehydration including lab findings indicating elevated serum sodium levels. Robert also has difficulty accessing fluids due to mobility limitations.
• Review of medical records: Documents chronic health issues requiring a balanced approach to fluid intake and recent lab tests suggesting dehydration.
• Consultations with interdisciplinary team members: Emphasize the need for a personalized hydration plan that considers Robert's health status and preferences.
• Resident and family interviews: Indicate that Robert prefers certain types of drinks over plain water and often forgets to drink unless prompted.

Step 4: Problem Identification

• Identified risks include acute dehydration episodes impacting Robert's overall health, and potential worsening of renal and heart conditions due to inadequate fluid maintenance.

Step 5: Care Planning

• Goal: To prevent dehydration and maintain an adequate fluid balance tailored to Robert's health needs and personal preferences.
• Interventions:

• • Implement a structured fluid intake schedule, including preferred beverages, to increase Robert's willingness to hydrate regularly.
  • Use visual aids and reminders for Robert and staff to monitor daily fluid intake closely.
  • Adjust fluid intake recommendations based on weather conditions and Robert's activity level, under the guidance of the RD and physician.
  • Provide easy access to fluids for Robert, considering his mobility limitations, possibly through the use of specialized containers or assistance from staff.
  • Regularly review and adjust fluid intake goals based on lab results, physical assessments, and changes in Robert's health status.

• Responsible Staff: Nursing Staff, RD, Physician
• Timelines: Immediate implementation with ongoing evaluation and adjustments based on hydration status assessments and Robert's feedback.

Step 6: Interdisciplinary Team Review

• The team collaborates on Robert's hydration care plan, ensuring that all interventions are feasible, effective, and centered on his specific needs and health conditions.

Step 7: Resident and Family Engagement

• Engaging Robert and his family in discussions about his hydration care plan ensures they are informed, involved, and supportive of the strategies implemented to maintain his fluid balance.

Step 8: Monitoring and Reassessment

• Short-Term: Daily monitoring of fluid intake and output, with adjustments to the hydration plan as necessary.
• Long-Term: Monthly assessments of Robert's hydration status through lab tests and physical exams to ensure ongoing effectiveness of the fluid maintenance strategy.

Documentation and Signatures:

• Signature of MDS Coordinator: Derek Hanson, Date: YYYY-MM-DD
• Signature of Primary Nurse: Carol Jennings, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

Scheduled Date: YYYY-MM-DD to review Robert's progress, address any challenges in achieving hydration goals, and refine the care plan to continue supporting his health and well-being effectively.