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.
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