Updated Care Plan for Psychotropic Use

Category / Primary Body System:

Mental Health / Psychopharmacology

Problem:

The patient is at risk for complications due to psychotropic drug use.

Goal:

The patient will have the least possible effective dose of psychotropic medication without side effects for 90 days.

Plan/Approach:

1. Medication Administration:

   • Step: Administer psychotropic medications as ordered.
   • Rationale: Ensuring the correct administration of medications maximizes their efficacy and minimizes the risk of complications.
   • Actions: Follow the prescribed dosage and schedule precisely, document each administration, and ensure the patient takes the medication as directed.

2. Effectiveness Monitoring:

   • Step: Monitor the patient for the effectiveness of psychotropic medications.
   • Rationale: Regular assessment of medication effectiveness ensures that the treatment is beneficial and adjustments can be made if necessary.
   • Actions: Conduct regular evaluations using standardized tools to assess symptom improvement and overall mental health status. Document findings and report to the healthcare provider.

3. Side Effect Monitoring:

   • Step: Monitor the patient for side effects of psychotropic medications.
   • Rationale: Early detection of side effects allows for prompt intervention and adjustment of the treatment plan.
   • Actions: Regularly assess the patient for common side effects such as drowsiness, weight gain, gastrointestinal issues, and movement disorders. Document and report any side effects to the healthcare provider.

4. Laboratory Monitoring:

   • Step: Check lab values as ordered.
   • Rationale: Regular lab monitoring helps identify potential adverse effects on the body and ensures safe medication use.
   • Actions: Schedule and conduct lab tests as prescribed, review results promptly, and adjust medication as necessary in consultation with the healthcare provider.

5. Psychiatric Consultations:

   • Step: Arrange for psych consults as ordered.
   • Rationale: Regular psychiatric evaluations ensure the patient's mental health treatment is optimized and adjusted as needed.
   • Actions: Schedule appointments with a psychiatrist as prescribed, ensure the patient attends, and follow up on recommendations.

6. Pharmacy Evaluation:

   • Step: Facilitate pharmacy evaluation of medications as needed.
   • Rationale: Pharmacy evaluations provide an additional layer of review for medication interactions, dosages, and efficacy.
   • Actions: Coordinate with the pharmacy to review the patient’s medication regimen, especially when changes are made or new medications are added.

7. AIMS Testing:

   • Step: Conduct AIMS (Abnormal Involuntary Movement Scale) test per protocol if the medication being used is an antipsychotic.
   • Rationale: Regular AIMS testing helps detect early signs of tardive dyskinesia and other movement disorders.
   • Actions: Perform AIMS testing at baseline and periodically as per protocol, document findings, and report any abnormalities to the healthcare provider.

8. Behavior Monitoring:

   • Step: Monitor for behavior changes that are not baseline for the patient and notify the MD/RNP if any are observed.
   • Rationale: Monitoring for atypical behavior changes helps detect potential adverse effects or the need for treatment adjustments.
   • Actions: Observe the patient’s behavior regularly, document any significant changes, and communicate concerns to the MD/RNP promptly.