Sample Care Area Assessment (CAA) for Nutritional Status
Resident Information:
- Name: John Doe
- ID: 123456
- Date of Assessment: YYYY-MM-DD
- Room Number: 101
Assessment Team:
- Primary Nurse: Alice Martin
- MDS Coordinator: George Smith
- Registered Dietitian (RD): Emily Thompson
- Physician: Dr. Sarah Johnson
Care Area Assessed:
- Specify the care area: Nutritional Status
Step 1: Triggered Care Areas
- Triggered by John's recent unintentional weight loss and reported decrease in appetite. Lab values indicate potential nutritional deficiencies.
Step 2: Review of MDS 3.0 Findings
- John has a history of chronic conditions, including hypertension and type 2 diabetes, which require careful dietary management. Despite a generally balanced diet, he consumes less than 75% of most meals and has experienced a 5% weight loss over the last month.
Step 3: Detailed Assessment
- Clinical findings: Unintentional weight loss, reduced meal consumption, and potential nutritional deficiencies that could impact John's chronic conditions and overall health.
- Review of medical records: Notes on dietary preferences, recent lab results indicating possible deficiencies in vitamins and minerals, and historical weight trends.
- Consultations with interdisciplinary team members: Highlight the need for a personalized nutrition plan, possibly including dietary supplements, to address deficiencies and support John's health.
- Resident and family interviews: Reveal a lack of interest in meals, partly due to taste preferences and meal presentation.
Step 4: Problem Identification
- Risks include worsening of chronic conditions due to inadequate nutrition, further unintentional weight loss, and the potential for malnutrition.
Step 5: Care Planning
- Goal: To improve John's nutritional status through tailored dietary interventions, ensuring his needs are met in line with his chronic conditions and promoting overall health and well-being.
- Interventions:
-
- Consult with the RD to develop a personalized nutrition plan that accommodates John's taste preferences, dietary restrictions, and nutritional needs.
- Introduce dietary supplements as recommended by the RD to address specific deficiencies.
- Implement regular nutritional monitoring, including weight checks and lab tests, to assess the effectiveness of the nutrition plan and make adjustments as needed.
- Enhance meal presentation and variety to increase meal appeal and encourage greater consumption.
- Educate John and his family on the importance of nutrition in managing his chronic conditions and maintaining health.
- Responsible Staff: RD, Nursing Staff, Physician
- Timelines: Immediate implementation with ongoing monitoring and adjustments based on John's response and nutritional status assessments.
Step 6: Interdisciplinary Team Review
- The team collaborates on John's nutritional care plan, emphasizing the critical role of nutrition in managing his health conditions and enhancing his quality of life.
Step 7: Resident and Family Engagement
- Engaging John and his family in discussions about his nutrition care plan ensures they understand the rationale behind dietary interventions and supports their active participation in his care.
Step 8: Monitoring and Reassessment
- Short-Term: Weekly monitoring of meal consumption and monthly weight checks to gauge the initial impact of dietary changes.
- Long-Term: Ongoing assessment of John's nutritional status through regular lab tests and RD evaluations to ensure his nutritional needs continue to be met effectively.
Documentation and Signatures:
- Signature of MDS Coordinator: George Smith, Date: YYYY-MM-DD
- Signature of Primary Nurse: Alice Martin, Date: YYYY-MM-DD
- Signatures of other interdisciplinary team members involved.
IDT Meeting Follow-Up:
- Scheduled Date: YYYY-MM-DD to review John's progress, discuss any challenges in improving his nutritional status, and adjust the care plan as necessary to optimize his dietary intake and health outcomes.
Feedback Form