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

STEP 5: CARE PLANNING DECISIONState whether you will be care planning this problem or not.If yes..• What is the goal of the plan of care?If not to care plan..• State the reason whyRemember…Do not write the plan of care interventions in this step.Save these for the plan of care.EXAMPLES:Current plan of care will be updated with the goal of increasing caloric intake and preventing further skinbreakdown.No plan of care is required because resident has no evidence of dehydration.EXAMPLE OF COMBINED RAPSCombined RAPs: Nutritional Status & Dental CareNutritional Status Triggers:• K5c = Checked (Mechanically altered diet)• K4a = checked (Complains about taste of many foods)• K4c = Checked (Leaves 25% or more food uneaten at most meals)Dehydration Trigger:• J1d = Checked (Insufficient fluid/did not consume all liquids provided)Dental Care Triggers:• K1c = checked (mouth pain)• L1e = checked (oral abscess)COMBINED NEW RAPS: NUTRITIONAL STATUS, DEHYDRATION AND DENTAL CARE1New RAPs. 2Mr. Wiley has a tooth abscess and is experiencing pain when eating or drinking.He has been limiting fluid intake, eating less than 50% of the food at his meals and complainingthat everything tastes bad when eating. 3The mouth pain is impacting his ADL functioning andlimiting his participation in activities. The mechanically altered diet to reduce chewing pain is nolonger effective. 4Referral will be made to MD to discuss antibiotic therapy, and pain medicationand the dentist for possible tooth extraction. 5This RAP will be care planned with the goal ofeliminating the resident’s mouth pain and avoiding dehydration resulting from a reduction in fluidintake.For Information: 416.327.7625 8ltchrai@ontario.ca8