Sample Care Area Assessment (CAA) for Psycho/Social Well-Being After Loss
Resident Information:
- Name: Edward Jenkins
- ID: 852963
- Date of Assessment: YYYY-MM-DD
- Room Number: 412
Assessment Team:
- Primary Nurse: Patricia Wilson
- MDS Coordinator: Derek Simmons
- Social Worker (SW): Michelle Nguyen
- Bereavement Counselor: Olivia Roberts
- Psychologist: Dr. Karen Lopez
Care Area Assessed:
- Specify the care area: Psycho/Social Well-Being
Step 1: Triggered Care Areas
- Triggered following the resident expressing feelings of sadness, lack of interest in previously enjoyed activities, and a sense of hopelessness, especially significant after losing a lifelong friend and companion three months ago.
Step 2: Review of MDS 3.0 Findings
- Edward has been diagnosed with situational depression. His mood and engagement levels have notably declined since the loss, impacting his overall well-being and participation in nursing home activities.
Step 3: Detailed Assessment
- Clinical findings: Persistent symptoms of depression, including withdrawal from social interactions and expressed feelings of loneliness.
- Review of medical records: Notes on the recent loss, initiation of antidepressant medication, and referral to bereavement counseling.
- Consultations with interdisciplinary team members: Highlighted the need for a personalized approach to support Edward's emotional and social needs, incorporating his interests and available social support systems.
- Resident and family interviews: Revealed Edward's passion for gardening and painting, which he has neglected recently. His family, particularly his grandchildren, have expressed a desire to be more involved in his care and activities.
Step 4: Problem Identification
- Identified risks include prolonged depression, social withdrawal, and the neglect of personal interests and hobbies that previously provided a sense of joy and purpose.
Step 5: Care Planning
- Goal: To foster Edward's emotional healing, reconnect him with his interests, and encourage social interaction to combat isolation.
- Interventions:
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- Introduce a tailored gardening project as a therapeutic activity, allowing Edward to nurture plants in the nursing home's garden.
- Schedule regular painting sessions to rekindle his passion for art, potentially leading group activities to inspire other residents.
- Organize weekly visits from family, especially his grandchildren, to strengthen his social support network.
- Continue with bereavement counseling and psychologist evaluations to monitor and support his mental health recovery.
- Facilitate participation in spiritual services or gatherings that align with Edward's beliefs and provide additional emotional support.
- Responsible Staff: Social Worker, Bereavement Counselor, Recreational Therapist, Family Liaison
- Timelines: Begin interventions immediately, with weekly progress reviews and adjustments based on Edward's feedback and engagement levels.
Step 6: Interdisciplinary Team Review
- The team supports the comprehensive care plan, emphasizing the importance of Edward's active participation in his recovery process and the potential positive impact of reintegrating his hobbies and interests.
Step 7: Resident and Family Engagement
- Engaging Edward and his family in the care planning process has been crucial, ensuring the plan reflects his personal preferences, interests, and the support network available through his family.
Step 8: Monitoring and Reassessment
- Short-Term: Monitor Edward's engagement with the gardening and painting activities, as well as his response to family visits and counseling sessions.
- Long-Term: Evaluate the overall impact of the interventions on his psycho/social well-being, making necessary adjustments to support ongoing recovery and engagement.
Documentation and Signatures:
- Signature of MDS Coordinator: Derek Simmons, Date: YYYY-MM-DD
- Signature of Primary Nurse: Patricia Wilson, Date: YYYY-MM-DD
- Signatures of other interdisciplinary team members involved.
IDT Meeting Follow-Up:
Scheduled Date: YYYY-MM-DD to review Edward's progress and adapt the care plan as needed to ensure it continues to meet his psycho/social needs effectively.