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.