Sample Care Area Assessment (CAA) for Nutritional Status
Resident Information:
- Name: Margaret Stevens
- ID: 569874
- Date of Assessment: YYYY-MM-DD
- Room Number: 212
Assessment Team:
- Primary Nurse: Sarah Johnson
- MDS Coordinator: David Lee
- Registered Dietitian (RD): Emily Clark
- Physical Therapist (PT): Alex Gomez
- Geriatrician: Dr. Nathanial Smith
Care Area Assessed:
- Specify the care area: Nutritional Status and Skin Integrity
Step 1: Triggered Care Areas
- Triggered by the presence of a pressure ulcer on Margaret's left ankle, following her admission after a fall that resulted in multiple bruises, a skin tear on her right elbow, and a large laceration across her right knee.
Step 2: Review of MDS 3.0 Findings
- Margaret, 85 years old, admitted post-fall with significant skin injuries. Consumes 75% of her meals, with regular diet, and possesses her own teeth in good condition. Weighs 178.2 pounds. Recent labs indicate potential nutritional deficiencies. She has a history of osteoarthritis, moderate dementia, and falls, placing her at risk for further physical decline, depression, and impaired skin integrity.
Step 3: Detailed Assessment
- Clinical findings: Current wounds including a pressure ulcer that necessitates enhanced nutritional support for healing.
- Review of medical records: Documents her fall, the extent of her injuries, and her medical history.
- Consultations with interdisciplinary team members: Emphasizes the need for a tailored nutritional plan to support wound healing and skin integrity.
- Resident and family interviews: Highlight Margaret's previous active lifestyle and her family's concern for her current condition and desire for her to regain her health and independence.
Step 4: Problem Identification
- Identified risks include delayed wound healing due to potential nutritional deficiencies, risk of further skin injuries, and the impact of her physical condition on her overall well-being.
Step 5: Care Planning
- Goal: To improve Margaret's skin integrity and promote wound healing through optimized nutritional status and targeted dietary interventions.
- Interventions:
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- Implement a dietary supplement regimen (House Supplement TID) as advised by the RD to address and prevent nutritional deficiencies.
- Regular RD consultations to adjust Margaret's diet and supplement plan based on her healing progress and nutritional needs.
- Coordinate with the PT for gentle, regular exercises to improve circulation and promote overall well-being, considering her osteoarthritis and dementia.
- Monitor Margaret's weight and nutritional intake closely, aiming to maintain her current weight and support tissue repair.
- Engage nursing staff in implementing a comprehensive skin care routine to prevent new pressure ulcers and monitor existing wound healing.
- Responsible Staff: RD, PT, Nursing Staff, MDS Coordinator
- Timelines: Immediate start with weekly RD reviews, daily nursing observations, and monthly PT evaluations to adjust care as needed.
Step 6: Interdisciplinary Team Review
- The team collaborates on Margaret's care plan, ensuring all aspects of her nutritional needs and skin integrity are addressed comprehensively.
Step 7: Resident and Family Engagement
- Engaging Margaret and her family in the care planning process ensures they are informed and supportive of the interventions, aligning with Margaret's preferences and health goals.
Step 8: Monitoring and Reassessment
- Short-Term: Daily monitoring of skin integrity and response to the dietary supplement regimen.
- Long-Term: Ongoing assessment of Margaret's nutritional status, weight maintenance, and overall well-being to ensure continuous improvement and adjustment of care strategies.
Documentation and Signatures:
- Signature of MDS Coordinator: David Lee, Date: YYYY-MM-DD
- Signature of Primary Nurse: Sarah Johnson, Date: YYYY-MM-DD
- Signatures of other interdisciplinary team members involved.
IDT Meeting Follow-Up:
- Scheduled Date: YYYY-MM-DD to review Margaret's progress, discuss any challenges in her nutritional and skin care management, and refine the care plan to further support her recovery and quality of life.