Assignment
Jack Crackers, 83 years old male resident is admitted at Centennial Community Long-term care (LTC) facility from the local hospital. He is admitted to the locked unit due to his constant wandering behaviour.
Diagnosis - CVA with aphasia, left side weakness, Alzheimer's disease.
Swallowing difficulty noted. Vision is acceptable. Poor hearing requiring hearing aide.
Anthropometric Data: 177.8 cm, 70 kg, ABW (acceptable body weight) 64 - 92 kg.
Estimated requirements as calculated by the RD: 1800 - 2500 kcal/day; 70 g protein/day; 1800-2500 mL fluids/day. Weight history: weight loss gradual over the past 4 years per his son and daughter, they are unable to provide the exact amount of weight change and they do not remember what his usual weight was.
Nutrition related History as per Daughter (Substitute Decision Maker/ Power of Attorney)
1) Regular diet, regular texture, regular fluids before his CVA.
2) NKFA or intolerances.
3) Intakes at home were 60% to 100%. He required supervision and some assistance with his activities of daily living.
4) Fluid hx average 2 L/day with encouragement and supervision, otherwise he will not know to drink on his own.
5) Dislikes coffee. Not fond of water, desserts such as pudding.
6) Likes tea, juices, water, soups, fruit, cakes, pies. He generally consumes meat, rice, vegetables. He is able to eat on his own with supervision when the foods are given to him.
Your observation:
1) He moves in his wheelchair within the unit hallway.
2) Staff reports he tries to get up from his wheelchair after his care is completed and he does this until his bedtime.
3) In the dining room he will start to eat and then he stops. Staff are trying to encourage him to eat. He currently receives set up assistance and direction, staff only provide him with one-on-one assistance for his fluids. Average intake at meals 25% to 50 % of meals. Snack intake is variable depending on whether staff can get him to focus on consuming his foods and fluids. Average fluid intake 1800 mL/day.
Additional information: Regular diet, minced texture, regular consistency fluid menu provides average 2600 kcal, 85 g protein, Fiber 30 g. This includes main meals and snacks.
A SOAP note based on the case information provided. For your plan develop 1 SMART goal and resident focused specific interventions.
Based on your SOAP note
A. Identify what and how you plan to monitor this residents' progress.
B. Identify what outcome you plan to measure.
C. Identify how you intend to evaluate outcome.