Sample Care Area Assessment (CAA) for Feeding Tube Management

Resident Information:

• Name: Helen Parker
• ID: 789123
• Date of Assessment: YYYY-MM-DD
• Room Number: 308

Assessment Team:

• Primary Nurse: Jessica Adams
• MDS Coordinator: Richard Lee
• Registered Dietitian (RD): Amanda Brooks
• Gastroenterologist: Dr. Susan Patel
• Speech-Language Pathologist (SLP): Michael Thompson

Care Area Assessed:     

• Specify the care area: Feeding Tube Management

Step 1: Triggered Care Areas

• Triggered by Helen's recent transition to enteral feeding through a gastrostomy tube, due to progressive dysphagia associated with her neurological condition.

Step 2: Review of MDS 3.0 Findings

• Helen has been reliant on enteral nutrition for the past month, following a diagnosis that necessitated the insertion of a gastrostomy tube. She has a history of stroke, leading to significant swallowing difficulties.

Step 3: Detailed Assessment

• Clinical findings: Assessment reveals the need for meticulous feeding tube care, monitoring for potential complications, and ensuring adequate nutritional support.
• Review of medical records: Documentation of gastrostomy tube placement, nutritional regimen initiated by the RD, and ongoing monitoring of Helen's tolerance to enteral feeds.
• Consultations with interdisciplinary team members: Emphasize the importance of a comprehensive feeding protocol, regular site care, and coordination between healthcare providers to manage Helen's nutritional needs effectively.
• Resident and family interviews: Express concerns about the care and maintenance of the feeding tube and the impact on Helen's quality of life.

Step 4: Problem Identification

• Identified risks include potential for tube displacement, site infection, aspiration pneumonia, and nutritional deficiencies or imbalances.

Step 5: Care Planning

• Goal: To ensure effective feeding tube management, providing optimal nutritional support, preventing complications, and maintaining Helen's quality of life.
• Interventions:

• • Implement a standardized tube feeding protocol, including volume, rate, and type of formula, as recommended by the RD.
  • Schedule regular site care and monitoring for signs of infection or irritation by nursing staff, with training provided as needed.
  • Conduct periodic reviews by the gastroenterologist to assess tube placement and function.
  • The SLP to evaluate swallowing ability periodically and provide recommendations for any possible oral intake.
  • Educate Helen and her family on feeding tube management and care to address concerns and promote involvement in her care.

• Responsible Staff: Nursing Staff, RD, Gastroenterologist, SLP
• Timelines: Immediate implementation with ongoing evaluation at weekly interdisciplinary team meetings and adjustments based on Helen's condition and feedback.

Step 6: Interdisciplinary Team Review

• The team collaborates on Helen's care plan, ensuring a holistic approach to her feeding tube management and nutritional support.

Step 7: Resident and Family Engagement

• Engaging Helen and her family in the care planning process ensures they are informed, comfortable, and supportive of the care interventions, aligning with Helen's needs and preferences.

Step 8: Monitoring and Reassessment

• Short-Term: Daily monitoring of feeding tube function and site condition, with immediate adjustments to the feeding regimen as needed.
• Long-Term: Monthly assessments of nutritional status, tube function, and overall well-being to ensure ongoing effectiveness of the feeding tube management plan.

Documentation and Signatures:

• Signature of MDS Coordinator: Richard Lee, Date: YYYY-MM-DD
• Signature of Primary Nurse: Jessica Adams, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to review Helen's progress, discuss any challenges encountered in feeding tube management, and refine the care plan to continue supporting her nutritional needs and quality of life effectively.