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Multidisciplinary Care Plans to Support Unpreventable Outcomes in Four Geriatric Syndromes


Jacqueline Vance, RNC, BSN, CDONA/LTC, FACDONA; Jean E. Cefalu, MSN, APRN, CWOCN, CNE; Charles A. Cefalu, MD, MS

Long-term care residents commonly experience pressure ulcers, falls, dehydration, and altered nutritional status contributing to undesired weight loss. The occurrence of these events is not always a result of poor care; in some cases, these events may not be preventable due to numerous other medical factors at play. To determine whether an outcome is unavoidable, long-term care staff must commit to identifying risk and implementing the appropriate interventions, a process that should be repeated throughout the course of a resident’s stay and documented thoroughly. A multidisciplinary care plan should be tailored to meet individual residents’ needs and risk factors, and reviewed and updated frequently. This tip sheet outlines the essential components of an interdisciplinary care plan to prevent pressure ulcers, fall, dehydration, and malnutrition/weight loss. 

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