Care plan help

[calmone]

I work LTC and am working on a care plan. I have it almost completed but am stumped on one problem. The resident is on Psychotropic meds and it must be included on the plan of care. I am having problems coming up with a goal and at least 3 approaches (or actions) for this problem.

I have this for the diagnosis:

Psychotropic drug us R/t insomnia, S/P CVA depression

Now I need the goal and approaches. Any ideas PLEASE???!!!!

(the resident receives Trazodone Q HS)

[bookwormom]

I don't think the med itself is the problem; it's the insomnia, or behavior problem, etc. The meds are part of the nursing interventions. Now if there are side effects that are a big problem, you could build the Ns dx around that.

[Jolie, BSN]

How about:

Altered Sleep Pattern (Insomnia) R/T Physical Inactivity, Depression, etc.

A possbile goal would be: Resident will get at least 6 un-interrupted hours of sleep each night.

Nursing interventions could include: Physical activity during the day, daytime activities to prevent cat-napping, establishing a bedtime routine to include pm care, back-rub, light snack, etc., administration of prescribed meds prior to bedtime, a notation to not disturb resident during the night, call light within reach so resident can call for help if s/he awakens during the night.

[mandana]

I agree with the two posters before me.

Additional diagnoses related to the meds that you could consider (and I think the insomnia one is particularly good) could be

Risk for injury (falls) r/t orthostatic hypotension s/t medication regimen - interventions - keep walkways clear, keep bathroom light on, bed low, call light within reach, change positions slowly, teach pt importance of calling for help getting OOB....

Then you should also address the depression - is there a risk for self-directed violence here? Is it causing eating problems? Self-care deficit?

Good luck,

Amanda

[calmone]

Thank you everyone! I used ideas from each of your posts. I'm so glad this site is here. I went through my care plan books, wracked my brain and still couldn't get it. I knew I could count on you! Thanks again, I appreciate your help.:1luvu:

Linda