Let’s learn some new acronyms and better understand what is desired in completing the nutritional status Care Area Assessment (CAA). First step is the completion of the MDS. The answers given in the MDS (Minimum Data Set) will trigger in different areas in section V. These are called Care Area Triggers (CATs), and they identify conditions that may require further evaluation because they may have an impact on specific issues or conditions. This more in-depth review of a triggered care area may identify causes, risk factors, and complications associated with the care area condition.
After completing the CAT, or section V, depending on MDS system used, it is helpful to work through the CAA (Care Area Assessment) worksheet for nutritional status. This documentation on the worksheet can be helpful to support how decisions were made in each step towards nutrition intervention and care plan. The beginning of the worksheet, in computer based MDS systems, the nutritional status CAA will list the “triggering conditions”. These triggers can come from other disciplines, even other sections of the MDS.
Next is analyzing these triggers. Take each triggered item and discuss it as it pertains to the specific resident. Discuss if this trigger is an issue at this time, or beneficial for management of the disease, such as a therapeutic diet can be beneficial for management of diabetes.
After reviewing the triggers, the current eating patterns of the resident are in question. There are several sections to this section that can be hidden in some computer layouts. Some of the questions are: does the resident complain about food quality? Or does the resident have a food allergy or intolerance? But issues regarding meal patterns, that may be resident’s normal habits, should be indicated here. Examples of these behaviors are: always refuses lunch as her habit from home, or avoids pork due to religious reasons. Document the reasons why items were marked, or make reference back to where this is noted in medical record.
On to “functional problems that affect ability to eat” review. These review items are a good head-to-toe list to assist while RD is completing a full assessment of the resident. Head to toes check list: Vision- can he see what he is eating? Swallowing- can he swallow what he’s eating? Arm/hand strength- can he feed himself or reach his own food? Mechanically-altered or therapeutic diet that he may not like to eat? Overall decline or change in ability for ADLs (Activities of Daily Living) – can he walk to get food for himself? Document in text box where this information is found and when documented if appropriate.
Cognitive issues can be a large factor in nutritional outcomes. Observing dining room behaviors can detect the need for frequent cues, anxiety around others, wandering, throwing food. Examine staff documentation since some of these diagnoses, or behaviors will be noted by the social worker, nursing staff, and even mental health care worker notes. Once again document in the text box where the information was found, example is “see electronic medical record”, “see clinical notes”.
If the resident is able to tell staff his food preferences, he is more likely to receive food he likes and willing to eat. Communication is a big part of meeting a resident’s needs nutritionally. It helps to know if he is tolerating the food or needs assist. Having a hard time making himself understood, or/and difficulty understanding others can be caused by several issues. This can be created by hearing difficulty, slurred speech, language barriers, or expressive/ receptive aphasia.
Having mouth pain, loose teeth, or even no teeth, can make a difference in someone’s meal intake. The dental section reviews condition teeth or dentures, if they are intact, fit well. Having sores in mouth from thrush or mucositis from chemotherapy would be indicated in this area as well. Having dry mouth can make swallowing food difficult.
To develop a full picture of the specific resident, the next review step of nutritional CAA is reviewing
“Diseases and conditions that can affect appetite”. This section is a past medical history review, and marking which disease category that is appropriate. The section does ask where this information is documented, and since these are diagnoses, referring to physician notes would be accurate.
Most recent available lab values are to be reviewed in the CAA review. If there are abnormal lab values in electrolytes, plasma transferrin, pre-albumin, mark those boxes. For other abnormal values, write in the abnormal labs in the other box. Reviewing labs is part of nutritional assessment to determine best nutritional care for the resident. In the text box, document the date of the lab values.
During assessment, medications are reviewed. Many medications can interact with nutrient absorption or affect appetite. If a resident’s disease is well-managed with medication, then that resident has increased longevity. Diuretics, cardiac medications, laxatives can effect electrolyte values. Some anti-Parkinson’s medications can interact with food or protein. These are items need to be analyzed as part of the nutritional evaluation. Then document where this information is found, usually found in MAR (Medication Administration Record).
Environmental Factors can make a difference in how well the resident eats at meals. Some items are hopefully automatically in place where the resident eats, like adequate lighting to see food, or the dining environment fosters nice social environment. If the resident is receiving cueing or assistance at meals, there is a place to mark it. This is also the section for noting the use of adaptive equipment, like scoop bowl, nosey cup, or large-handled silverware.
This brings you to the end of the Nutritional Status CAA worksheet. Will Nutritional Status be addressed in the care plan? Yes or No or Not Assessed? If care planning for this problem, what is the overall objective? Would the main goals be for improvement, maintaining current function, minimize decline or for palliative measures? It is helpful to discuss the initial CAT trigger points in relation to care plan goals. The care plan is the map guiding each aspect of care, and having resident determine his own goals is the best standard of care. Care plans made with the resident ensures personalized care plans, and buy-in by each resident. Let’s find our place in this team with our residents, supporting, encouraging, and empowering them with the best nutrition care available.