Sample Care Area Assessment (CAA) for Mood State in Terminal Illness
Resident Information:
- Name: Charles Anderson
- ID: 334455
- Date of Assessment: YYYY-MM-DD
- Room Number: 510
Assessment Team:
- Primary Nurse: Helen Ramirez
- MDS Coordinator: Mark Johnson
- Social Worker (SW): Emily Clark
- Psychologist: Dr. Sarah Bennett
- Hospice Care Consultant: Dr. Lisa Moreno
Care Area Assessed:
- Specify the care area: Mood State
Step 1: Triggered Care Areas
- Triggered by a PHQ-9 score of 15, indicating significant depression in the context of a terminal cancer diagnosis. Charles's transition from independence to requiring assistance with ADLs and experiencing regular urinary incontinence has contributed to his current mood state.
Step 2: Review of MDS 3.0 Findings
- Charles, a new resident, faces challenges adjusting to life in the Living Center due to his terminal illness and consequent loss of independence. His emotional well-being is further compromised by feelings of embarrassment related to urinary incontinence.
Step 3: Detailed Assessment
- Clinical findings: Depression linked to terminal illness diagnosis, significant changes in lifestyle, and physical health concerns.
- Review of medical records: Documented diagnosis of terminal cancer and depression, initiation of antidepressant medication, and discussions about hospice care.
- Consultations with interdisciplinary team members: Emphasized the need for personalized care planning, incorporating psychological support, hospice care guidance, and strategies to maintain dignity and independence.
- Resident and family interviews: Highlighted the importance of Charles's personal belongings and the comfort derived from his family's support.
Step 4: Problem Identification
- Identified risks include further mood deterioration, potential for weight loss due to depression, and increased agitation stemming from his illness and environmental changes.
Step 5: Care Planning
- Goal: To improve Charles's mood state, facilitate his adaptation to the Living Center, and ensure a dignified, comfortable environment that acknowledges his terminal condition.
- Interventions:
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- Regular 1-2 weekly visits by the SW to provide emotional support and facilitate hospice care discussions.
- Engage a psychologist to assess and adjust antidepressant therapy as needed, ensuring optimal management of depression symptoms.
- Implement personalized strategies to manage urinary incontinence, enhancing Charles's comfort and reducing feelings of embarrassment.
- Involve Charles and his family in personalizing his living space with meaningful items from home to foster a sense of belonging and continuity.
- Coordinate with hospice care services to align Charles's care with his and his family's wishes, focusing on quality of life and symptom management.
- Responsible Staff: Social Worker, Psychologist, Nursing Staff, Hospice Care Consultant
- Timelines: Immediate implementation with ongoing evaluation and adjustment based on Charles's needs and preferences.
Step 6: Interdisciplinary Team Review
- The team agrees on the comprehensive approach to address Charles's mood state and overall well-being, emphasizing the importance of coordinated care and family involvement.
Step 7: Resident and Family Engagement
- Active involvement of Charles and his family in developing the care plan ensures that interventions are aligned with his values, preferences, and comfort.
Step 8: Monitoring and Reassessment
- Short-Term: Monitor Charles's response to antidepressant adjustments and the effectiveness of incontinence management strategies.
- Long-Term: Evaluate the impact of social work and psychological interventions on Charles's mood and quality of life, adjusting the care plan as necessary.
Documentation and Signatures:
- Signature of MDS Coordinator: Mark Johnson, Date: YYYY-MM-DD
- Signature of Primary Nurse: Helen Ramirez, Date: YYYY-MM-DD
- Signatures of other interdisciplinary team members involved.
IDT Meeting Follow-Up:
- Scheduled Date: YYYY-MM-DD to review Charles's progress, discuss any new challenges, and refine the care plan to continue supporting his psycho-social and physical needs effectively.
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