Sample Care Area Assessment (CAA) for Managing Behavior Symptoms in TBI

Resident Information:

• Name: Daniel Roberts
• ID: 987654
• Date of Assessment: YYYY-MM-DD
• Room Number: 350

Assessment Team:             

• Primary Nurse: Lisa Thompson
• MDS Coordinator: Greg Allen
• Social Worker (SW): Rachel Martinez
• Neurologist: Dr. Emily Chang
• Gastroenterologist: Dr. Michael Lee

Care Area Assessed:

• Specify the care area: Behavior Symptoms

Step 1: Triggered Care Areas

• Triggered by Daniel's verbal outbursts towards staff, particularly linked to his need for toileting, reflecting poor impulse control as a result of TBI.

Step 2: Review of MDS 3.0 Findings

• Daniel, recently admitted to the Living Center, exhibits frequent verbal behavioral symptoms, exacerbated by constipation issues. His TBI diagnosis contributes to challenges in impulse control, affecting his interactions and overall well-being.

Step 3: Detailed Assessment

• Clinical findings: TBI with resultant impulse control issues, compounded by discomfort from constipation.
• Review of medical records: Confirms TBI diagnosis and constipation. Recent orders for bowel medication and the initiation of a toileting plan noted.
• Consultations with interdisciplinary team members: Focus on managing constipation to alleviate discomfort and potentially reduce behavioral symptoms. The plan includes positive reinforcement strategies for appropriate requests for assistance.
• Resident and family interviews: Highlight Daniel's frustration with his current physical and cognitive limitations. Family emphasizes his prior independence and the significant adjustment to living center life.

Step 4: Problem Identification

• Identified risks include exacerbation of verbal behavioral symptoms due to constipation and TBI-related impulse control difficulties. There's a need for a comprehensive approach to manage symptoms and improve Daniel's quality of life.

Step 5: Care Planning

• Goal: To mitigate verbal behavioral symptoms through effective management of constipation, implementation of a personalized toileting plan, and reinforcement of positive behaviors.
• Interventions:

• • Initiate a bowel regimen as prescribed to manage constipation effectively.
  • Develop a scheduled toileting plan to pre-emptively address Daniel's needs, reducing frustration and behavioral outbursts.
  • Employ positive reinforcement techniques by the social worker and nursing staff to encourage Daniel to communicate his needs in a more appropriate manner.
  • Regular consultations with a neurologist to monitor TBI symptoms and adjust care as needed.
  • Provide Daniel and his family with education on managing TBI symptoms and support for adjusting to changes in his behavior and independence.

• Responsible Staff: Nursing staff, Social Worker, Neurologist, Gastroenterologist
• Timelines: Immediate implementation with ongoing monitoring and adjustments based on effectiveness and Daniel's feedback.

Step 6: Interdisciplinary Team Review

• The team supports the integrated care plan, recognizing the importance of addressing both medical and behavioral symptoms to improve Daniel's well-being.

Step 7: Resident and Family Engagement

• Engaging Daniel and his family in the care planning process ensures that interventions are aligned with his personal preferences and comfort, fostering a collaborative approach to care.

Step 8: Monitoring and Reassessment

• Short-Term: Daily assessment of bowel regimen effectiveness and behavioral responses to the toileting plan.
• Long-Term: Monthly evaluations of the overall care strategy's impact on Daniel's behavior and quality of life, with adjustments as necessary.

Documentation and Signatures:

• Signature of MDS Coordinator: Greg Allen, Date: YYYY-MM-DD
• Signature of Primary Nurse: Lisa Thompson, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to review progress, discuss any challenges, and refine the care plan to continue supporting Daniel's needs effectively.