Assignment Task: Follow up case study, write an IER note
The RD has asked for your assistance to complete follow up quarterly assessment on the resident. Intake records: In the first month after admission and after implementing your interventions resident intake improved towards 70 % at all meals with fluid intake between 1875 mL - 2000 mL/day. Bowel movement: normal since admission. Weight data: Weight this month - 67.0 kg; 1 month ago - 67.8 kg; Weight 2 months ago 69 kg. Weight at admission/3 months ago 70 kg. Meal time observation:
He is having more difficulty consuming his food and is now observed to be holding food in his cheeks (pocketing food). When the utensil is placed in his hand, he holds it and will play with it or drop it on the ground.
He is pouring the fluids from the cup, instead of drinking the fluids from it. He is coughing when fluids are consumed. Staff report:
He is more aggressive in his behavior yelling in the dining room when being fed. Staff try to calm him down by talking to him but this is not effective.
Staff have noticed that he is consuming more of the sweeter menu items such as soft cream pies and ice creams. He no longer enjoys the vegetables as much as he used to and will often spit it out.
The nurse is concerned about his increased coughing when eating and drinking. Staff has trialed pureed fruits for dessert and this was consumed. You contact her daughter to discuss her care plan. Daughter tells you:
She noticed her dad almost choking on diced fruit she brought in as snack for him the other day.
She observes her dad is not consuming as much as he used to but continues to use up a lot of energy trying to get up from his wheelchair throughout the day. She also noticed that he is coughing more when drinking his fluids. She feels she has to force her dad to eat and drink when she visits.
During some of her visits her dad did not have his hearing aid on. She feels his inability to hear the staff is resulting in his aggressive behavior.
Write follow up note using the IER format. For your plan develop 1 SMART goal & resident focused specific interventions.
Based on your IER note
1. Identify what and how you plan to monitor resident progress
2. Identify what outcome you plan to measure
3. Identify how you intend to evaluate the outcome