RAI-MDS 2.0 Nutritional Care Resource Guide April 2011 - CCIM

What have you read to support evidence of this problem? (consultations, interdisciplinarynotes, lab reports, vital signs, weights, intake and output records, flow sheets)EXAMPLES:Example 1Nutritional Status RAPTrigger: K4c = leaves 25% or more food uneaten at most mealsResident (Mr.T.) refuses to eat and needs cueing at most meals. He has been leaving 25% ofhis pureed food at lunch and dinner, stating food has no taste.Example 2Dehydration RAPTriggers: J1c = dehydrated; O4e = taking diureticMrs. S. has dry mouth and mucous membrane. She appears lethargic. She consumes lessthan 500cc/day. Staff indicates that Mrs. S. chokes on liquid and coughs more frequently.STEP 3: KEY ISSUES THAT CONTRIBUTE TO THE RAP OR NON-TRIGGERED CLINICAL PROBLEMWhat is the cause of this problem? Are there any complications or changes as a result of thisproblem?How is this RAP or non-triggered clinical problem affecting the day-to-day functioning or wellbeing of the resident?What interventions have you tried?Are they effective?EXAMPLE:The decrease in intake has caused Mr. T. to lose 2.8 kg in the last quarter. The stage onepressure ulcer is now a stage two ulcer and his CHESS score has increased from 1 to 3. He hasnot been taking his evening supplement because he likes to go to bed early. The supplement hasbeen changed to high calorie and recently added to his dinner and he is tolerating well.STEP 4: NEED FOR REFERRALState whether you are making a referral or not.If yes… Which discipline do you need to refer to? Why are you making the referral? For example, a referral will be sent to the speech language pathologist for swallowingassessment.For Information: 416.327.7625 7ltchrai@ontario.ca7