The Intent of section D is to assess the resident’s perception of his/her mood and psychosocial well-being, to record staff observations of indicators of the resident’s mood and psychosocial well-being, and to identify and immediately protect residents who may be at risk for self-harm.

Resident interview is included in the section.

Social Service care plans and Nursing care plans that might be triggered from section D are:

Depression

Anger

Anxiety

Depression

Fear

Insomnia

Paranoia

Social Isolation

Suicidal Ideation

Withdrawal from Care / Activities

Read more about coding this part of the MDS 3.0, and significant change in condition, quality indicators and measures, RUG IV categories, and skilled charting.

Coding Section D Mood of MDS 3.0

Read more about coding the MDS 3.0 in the book MDS Coordinator Book.

Many more resources and nursing care plans for geriatric residents can be found in the books Nursing Care Plans for Long Term Care, Social Service Care Plans, Restorative Nursing Care Plans, and Activities Care Plans, and on the page Care Plan Samples.

ASA, founded in 1954, originally as the as the Western Gerontological Society, is a good resource for articles and information on aging issues. The website has resources on ageism, caregiving, multicultural aging, policy and healthcare advocacy, and many other topics useful to providers of long term care.

The MindAlert Program “trains members on the newest findings in cognitive fitness, and disseminates information on current research and innovative programs that help older adults maintain and improve cognitive and mental function in their later years.”

ASA American Society on Aging

Many more resources and nursing care plans for geriatric residents can be found in the books Nursing Care Plans for Long Term Care, Social Service Care Plans, Restorative Nursing Care Plans, and Activities Care Plans, and on the page Care Plan Samples.

Pain assessments for nursing care plans should be done at admission, with each MDS assessment, and after any change in the resident’s condition, level or frequency of pain, and/or any change in the resident’s response to pain medications.

Assessment tools may use a combination of checklists and interview questions. It is best to get descriptions of pain from the resident in his or her own words. Using scales and graphs will help to get more detailed descriptions about levels of pain. Specialized assessment tools should be used to assess the pain of residents who have cognitive and/or communication deficits. Important components of screening for pain are observations at rest, during movement, and during activities that may increase pain, such as dressing changes, bathing, and ambulation.

Guidelines for facility pain assessment protocols:

Policy and procedure states when pain assessments and reassessments are to be done

Policy and procedure specifies what assessment tools are to be used

Comprehensive pain assessments for nursing care plans are completed at admission

Pain assessments are completed quarterly

Pain scales and measurements are used in pain assessments

Pain is rated by residents’ descriptions

Specialized pain assessment is used for residents with cognitive and/or communication deficits

Assessing Pain for Nursing Care Plans

Many more resources and nursing care plans for geriatric residents can be found in the books Nursing Care Plans for Long Term Care, Social Service Care Plans, Restorative Nursing Care Plans, and Activities Care Plans, and on the page Care Plan Samples.

The intent of section C is to determine the resident’s ability to remember, think coherently, and organize daily self-care activities. The focus is on resident performance, including a demonstrated ability to remember recent and long-past events and to perform key decision-making skills.

The section includes the Brief Interview for Mental Status, and examines short term and long term memory and the resident’s ability to make decisions.

Whether or not the resident shows signs of delirium is examined in this section.

Nursing care plans that might be generated from section C are:

Cognitive Deficit, Decision-Making Impaired

Cognitive Deficit, Disordered Thinking

Cognitive Deficit, Memory Problem

Read the complete guide to coding section C of the MDS 3.0, including information on care area assessment triggers and RUG IV categories.

Coding Section C Cognitive Patterns of the MDS 3.0

Read more about coding the MDS 3.0 in the book MDS Coordinator Book.