Sample Care Area Assessment (CAA) for Pressure Ulcer Management

Resident Information:

• Name: James Anderson
• ID: 348762
• Date of Assessment: YYYY-MM-DD
• Room Number: 156

Assessment Team:

• Primary Nurse: Sarah Lee
• MDS Coordinator: Gregory Chen
• Wound Care Specialist: Dr. Helen Rodriguez
• Registered Dietitian (RD): Michael Brown
• Physical Therapist (PT): Anna White

Care Area Assessed:     

• Specify the care area: Pressure Ulcer Management

Step 1: Triggered Care Areas

• Triggered by the identification of a Stage II pressure ulcer on James's sacral area during routine skin integrity checks, highlighting the need for immediate intervention and reassessment of preventive measures.

Step 2: Review of MDS 3.0 Findings

• James has limited mobility due to advanced Parkinson's disease, making him highly susceptible to pressure ulcers. He has a history of diabetes, contributing to slower wound healing rates.

Step 3: Detailed Assessment

• Clinical findings: Stage II pressure ulcer on the sacral area, indicating partial-thickness skin loss. James also shows signs of nutritional deficiencies that may impede wound healing.
• Review of medical records: Documents James's mobility issues, previous pressure ulcer history, and diabetes management plan.
• Consultations with interdisciplinary team members: Emphasize the importance of a tailored care plan involving nutritional support, regular repositioning, and wound care management.
• Resident and family interviews: Reveal concerns about James's skin health and request for thorough communication regarding care plans and prevention strategies.

Step 4: Problem Identification

• Identified risks include the potential for the current pressure ulcer to progress to a more severe stage, development of additional pressure ulcers, and prolonged wound healing due to nutritional deficiencies and diabetes.

Step 5: Care Planning

• Goal: To heal the existing pressure ulcer, prevent the development of new ulcers, and address underlying risk factors such as immobility and nutritional deficiencies.
• Interventions:

• • Implement a specialized wound care regimen as prescribed by Dr. Rodriguez, including appropriate dressing changes and monitoring for signs of infection.
  • Develop a repositioning schedule to relieve pressure on the affected area, facilitated by nursing staff and reinforced through PT consultations.
  • RD to assess and optimize James's dietary intake, ensuring adequate protein and micronutrients to support wound healing.
  • Utilize pressure-relieving devices (e.g., specialized mattresses or cushions) to reduce the risk of ulcer development in high-risk areas.
  • Educate James and his family on pressure ulcer prevention and management strategies, fostering an environment of open communication and collaborative care.

• Responsible Staff: Wound Care Specialist, Nursing Staff, RD, PT
• Timelines: Immediate initiation of wound care and preventive measures, with ongoing monitoring and adjustments based on wound healing progress and James's overall condition.

Step 6: Interdisciplinary Team Review

• The team collaborates on James's care plan, ensuring a comprehensive approach to managing his pressure ulcer and preventing further skin integrity issues.

Step 7: Resident and Family Engagement

• Engaging James and his family in the care planning process ensures they understand the importance of each intervention and feel supported in managing James's condition effectively.

Step 8: Monitoring and Reassessment

• Short-Term: Weekly assessments of the pressure ulcer's healing progress and daily monitoring of repositioning effectiveness.
• Long-Term: Monthly evaluations of James's overall skin integrity, nutritional status, and mobility to adjust care plans as necessary and prevent recurrence.

Documentation and Signatures:

• Signature of MDS Coordinator: Gregory Chen, Date: YYYY-MM-DD
• Signature of Primary Nurse: Sarah Lee, Date: YYYY-MM-DD
• Signatures of other interdisciplinary team members involved.

IDT Meeting Follow-Up:

• Scheduled Date: YYYY-MM-DD to review James's progress, address any challenges in ulcer management and prevention, and refine the care plan to continue supporting his skin integrity and overall health effectively.