Resident Information:

• Name: Dorothy Miller
• ID: 789456
• Date of Assessment: YYYY-MM-DD
• Room Number: 102

Assessment Team:

• Primary Nurse: Janet Simmons
• MDS Coordinator: Brian O'Neill
• Physician: Dr. Susan Park
• Physical Therapist (PT): Kevin Lopez
• Occupational Therapist (OT): Rachel Green

Care Area Assessed:      

• Specify the care area: Pain

Step 1: Triggered Care Areas

• Triggered by Dorothy's reports of persistent lower back pain and discomfort during mobility and rest, affecting her daily activities and overall quality of life.

Step 2: Review of MDS 3.0 Findings

• Dorothy has a history of osteoarthritis and has recently undergone hip replacement surgery, contributing to her current pain levels.

Step 3: Detailed Assessment

• Clinical findings: Documented complaints of lower back pain, with pain scale ratings consistently between 4 and 6 out of 10. Observations of pain behaviors during mobility and ADL assistance.
• Review of medical records: Notes on osteoarthritis management, surgical history, and previous pain management strategies, including medication and physical therapy.
• Consultations with interdisciplinary team members: Discussions on the effectiveness of current pain management strategies and potential for non-pharmacological interventions.
• Resident and family interviews: Express concerns about the impact of pain on Dorothy's mood, mobility, and participation in social activities.

Step 4: Problem Identification

• Identified risks include chronic pain leading to decreased mobility, potential for depression, and reduced engagement in rehabilitation and social activities.

Step 5: Care Planning

• Goal: To effectively manage Dorothy's pain through tailored pharmacological and non-pharmacological strategies, enhancing her mobility, mood, and overall engagement in daily life.
• Interventions:

• • Comprehensive pain assessment by the physician to review and adjust medication regimens as needed, considering potential side effects and interactions.
  • Implementation of a personalized physical therapy program focusing on pain relief and improving mobility.
  • Incorporation of non-pharmacological pain management techniques, such as heat therapy, massage, and relaxation exercises, led by the OT.
  • Education for Dorothy and her family on pain management strategies and safe medication use.
  • Regular pain assessments using standardized tools to monitor pain levels and adjust care strategies accordingly.

• Responsible Staff: Physician, PT, OT, Nursing Staff
• Timelines: Immediate initiation of revised pain management strategies with ongoing monitoring and evaluation at weekly interdisciplinary team meetings.

Step 6: Interdisciplinary Team Review

• The team collaborates on Dorothy's care plan, ensuring a holistic approach to pain management that addresses her specific needs and preferences.

Step 7: Resident and Family Engagement

• Engaging Dorothy and her family in the care planning process ensures they are informed and involved in decision-making, promoting adherence to pain management interventions.

Step 8: Monitoring and Reassessment

• Short-Term: Daily monitoring of pain levels post-intervention and weekly assessments to evaluate the effectiveness of pain management strategies.
• Long-Term: Monthly reviews of Dorothy's overall pain management plan to ensure continued effectiveness and adjust as necessary based on her evolving needs.

Documentation and Signatures:

• Signature of MDS Coordinator: Brian O'Neill, Date: YYYY-MM-DD
• Signature of Primary Nurse: Janet Simmons, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to review Dorothy's progress in pain management, discuss any challenges, and refine the care plan to optimize her comfort and quality of life.Top of Form