CAA Documentation - Nursing Home Help

Respiratory: asthma, emphysema, COPD,shortness of breath,Infectious: Infections, wound infectionother than foot or lower extremity,Isolation - activeMetabolic: diabetes, thyroid,hyponatremiaGastrointestinal bleedRenal disease, dialysisHospice CareCancerDehydrationSigns of Infection (fromobservation, clinical recordFeverCloudy or foul smelling urineCongested lungs or coughDyspneaDiarrheaAbdominal painPurulent wound drainageErythema around an incisionIndicators of DehydrationDehydration care area triggered,indicating s/s of dehydration arepresentRecent decrease in urine volume ormore concentrated urine than usualRecent decrease in eating habits –skipping meals or leaving food uneaten,weight lossNausea, vomiting, diarrhea or blood lossReceiving IV medsReceiving diuretics or drugs that maycause electrolyte imbalanceFunctional StatusRecent decline in ADL statusIncreased risk for fallsMedications (that may contribute todelirium)New med or dosage increaseDrugs w/anticholinergic properties(antipsychotics, antidepressants,antiparkinsonian, antihistamines)OpioidsBenzodiazepines, especially long actingAnalgesics, cardiac and GI meds, antiinflammatorydrugsRecent abrupt discontinuation,omission, or decrease in dose of ashort/long acting benzodiazepineDrug interactionsResident taking more than one drugfrom a particular class of drugsPossible drug toxicity, esp. if the personSOB if lies flatRecent hospital stay with foley catheter that has now been removedOn thyroid replacementDX GI Bleed and UlcerDaily afternoon elevated temperaturesSOB if lies flatNo S/S but did have IV fluids in hospital for hydration after surgeryDecrease appetite with recent weight lossHistory of GI Bleed. Recent blood transfusion post surgery.Bumex dailyRequires more assist since hip fxFell causing fx hipProzac was just increased but symptoms were noted before increaseOn both cardiac, GI meds, and analgesicsMU MDS and Quality Research Team, Sinclair School of Nursing, University of Missouri (revised 03/11) 2