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:
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- 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.
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