Care Plan for Psychotropic Drug Use

Category / Primary Body System

• Mental Health / Nervous System

Problem

• Patient is at risk for complications due to psychotropic drug use.

Goal

• Patient will be maintained on the least possible effective dose of psychotropic medication without experiencing side effects for 90 days.

Plan/Approach

1. Medication Management

   • Administer psychotropic medications as ordered
   • Monitor patient for the effectiveness of psychotropic medications
   • Monitor patient for side effects of psychotropic medications
   • Check lab values as ordered

2. Consultations and Evaluations

   • Provide psych consult as ordered
   • Conduct pharmacy evaluation of medications as needed
   • Perform AIMS (Abnormal Involuntary Movement Scale) assessments per protocol if antipsychotic medications are used

3. Behavioral Monitoring

   • Monitor for behavior changes that are not baseline for the patient and notify MD/RNP if any

Rationale

1. Medication Management

   • Administering medications as prescribed ensures the patient receives the appropriate treatment for their condition.
   • Regular monitoring of medication effectiveness helps in adjusting the dosage to the minimum effective level, reducing the risk of side effects.
   • Monitoring for side effects is crucial to identify and address adverse reactions promptly, ensuring patient safety.
   • Regular lab tests help monitor the patient’s physiological response to the medication and detect any potential complications early.

2. Consultations and Evaluations

   • Psych consultations provide additional insights and recommendations for managing the patient’s condition effectively.
   • Pharmacy evaluations ensure that the medication regimen is optimal and that drug interactions or contraindications are identified and managed.
   • AIMS assessments help in detecting early signs of tardive dyskinesia, a potential side effect of antipsychotic medications.

3. Behavioral Monitoring

   • Monitoring for behavioral changes helps in identifying early signs of adverse effects or worsening of the patient’s condition, enabling timely intervention.

Actions

1. Medication Management

   • Administer psychotropic medications according to the prescribed schedule and dosage.
   • Monitor and document the effectiveness of the medications, using standardized scales if applicable.
   • Observe for and document any side effects, reporting them to the prescribing physician promptly.
   • Conduct regular lab tests as ordered, reviewing and acting on the results to ensure safe medication use.

2. Consultations and Evaluations

   • Arrange for psych consultations as ordered to provide comprehensive care.
   • Facilitate pharmacy evaluations to review and optimize the medication regimen.
   • Perform AIMS assessments regularly if the patient is on antipsychotic medications, documenting findings and reporting any concerns.

3. Behavioral Monitoring

   • Monitor the patient’s behavior for any changes from their baseline, noting any new or worsening symptoms.
   • Notify the MD/RNP immediately of any significant behavioral changes or concerns.