Care Plan for Managing Psychotropic Medication

Care Plan for Managing Psychotropic Medication

Category / Primary Body System

• Psychosocial and Mental Health

Problem

• Resident is receiving psychotropic medication.

Goals

1. Resident will have no side effects from the given medication.
2. Resident will have no falls for the next 90 days.
3. Resident will be maintained on and tolerate the lowest effective medication dose for the next 90 days.

Plan/Approach

1. Monitoring and Assessment

   • Assess and document mood and behavior regularly to monitor the effectiveness of the medication and identify any changes.
   • Monitor for side effects of psychotropic medications, including dizziness, drowsiness, orthostasis, nausea/vomiting, dry mouth, constipation, anorexia, and increased confusion.
   • Notify the attending physician and psych team if any limiting side effects are observed.

2. Medication Administration

   • Administer medications as ordered and monitor their effectiveness. Notify the physician if symptoms do not improve or abate.
   • Engage the psych team for medication monitoring and therapy as needed.
   • Pharmacy consultant to review medications as needed to ensure optimal dosing and minimize side effects.

3. Patient and Family Involvement

   • Involve the resident and their family in all appointments, tests, and testing results to ensure they are informed and involved in the care plan.
   • Provide frequent reassurance and intervene per the behavior care plan for any signs of anger, aggression, or depression.

4. Fall Prevention

   • Check on the resident frequently to decrease anxiety and prevent falls, ensuring not to intrude on their privacy.
   • Respect resident privacy and dignity, always addressing them as an adult.

5. Appetite and Nutritional Monitoring

   • Monitor for possible effects of medications on appetite and adjust dietary plans as needed.

6. Behavior Tracking

   • Track and document behavior using a behavioral monitoring record to identify any patterns or concerns.
   • Reassure and intervene per behavior care plan for any anger, aggression, and depression.

7. Monitoring for Extrapyramidal Symptoms (EPS)

   • Monitor for signs of EPS, such as restlessness, muscle rigidity, tremor, and excessive salivation. Notify the MD if these symptoms are noted.

Rationale

1. Monitoring and Assessment

   • Regular monitoring helps detect early signs of side effects or medication ineffectiveness, allowing for prompt intervention.

2. Medication Administration

   • Ensuring medications are given as prescribed and monitored for effectiveness and side effects maintains therapeutic efficacy and minimizes adverse effects.

3. Patient and Family Involvement

   • Involving the patient and family in the care plan promotes understanding, compliance, and emotional support.

4. Fall Prevention

   • Frequent checks and respect for privacy help prevent falls while maintaining the resident’s dignity.

5. Appetite and Nutritional Monitoring

   • Monitoring appetite helps ensure the resident maintains proper nutrition, which can be affected by psychotropic medications.

6. Behavior Tracking

   • Documenting behavior provides data to adjust the care plan as needed and address any emerging issues promptly.

7. Monitoring for Extrapyramidal Symptoms (EPS)

   • Early detection of EPS allows for timely intervention to prevent severe complications.

Actions

1. Monitoring and Assessment

   • Document mood and behavior regularly, noting any changes or side effects.
   • Notify the physician of any limiting side effects promptly.

2. Medication Administration

   • Administer medications as prescribed, observing for side effects and effectiveness.
   • Engage the psych team for ongoing monitoring and adjustment of the medication regimen.
   • Consult the pharmacy as needed for medication reviews.

3. Patient and Family Involvement

   • Communicate with the resident and family about appointments, tests, and results.
   • Reassure the resident frequently and provide interventions as per the behavior care plan.

4. Fall Prevention

   • Check on the resident regularly while respecting their privacy and dignity.

5. Appetite and Nutritional Monitoring

   • Monitor the resident’s appetite and adjust dietary plans as needed.

6. Behavior Tracking

   • Document behaviors using a monitoring record, noting any patterns or changes.

7. Monitoring for Extrapyramidal Symptoms (EPS)

   • Observe for signs of EPS and report any findings to the MD promptly.