◊
◊ PROBLEM STATEMENT
Statement of general problem
Example: Alteration in mood and behavior...
Relationship to specific diagnosis
Example: ...related to dementia with agitated features
...related to depression
...related to schizophrenia
List specific symptoms resident is experiencing
Example: ...as evidenced by striking out with contact resisting personal care and treatment throwing things verbally abusive comments “You stupid, fat pig!”
Note complicating factors, what exacerbates the basic problem
Example: ...complicated by pain, hearing deficit, adjustment to new environment, grief related to loss of home
◊
MEASURABLE GOALS
Example: Episodes of striking out with contact will decrease to zero by
three months
◊ APPROACHES AND INTERVENTIONS
What the entire team is doing to address the problem and achieve the goal(s)
Include interventions for
Licensed Staff, i.e. Rule out pain
NACs, i.e. Explain all care
Social Services
Activities
Mental Health
All Staff
Include the psychotropic medication(s) as intervention(s)
◊
◊
INDIVIDUALIZED APPROACHES that address specific interventions that are effective for the particular resident

◊ Consider information obtained from the following
Social history/ assessment
Family interview
NAC input
Mental Health/ Social Services recommendations
◊ Example: A resident who enjoyed cooking might be redirected by looking at
cookbooks or recipe cards
◊ HELPFUL SUGGESTIONS
◊ Utilize the MDS to help identify basic problem and build from there by specifying exact symptoms for the resident
Example: for “negative statements” on section E1a, specify what the
resident is saying that is negative:
...negative statements of wanting to die or “get away from it all”
◊ Utilize social history/ assessment , activity preferences (MDS section N), customary routine (MDS section AC) to enhance individuality of the care plan
◊ Integrate monitoring and quantifying of behavioral symptoms as required for psychotropic drug usage through the care plan via: goals reflect target behaviors psychotropic medication is intended to treat to limit number of goals, select the most problematic symptoms and address those
Monitor episodes of target behaviors as noted in goals
Example: A resident is receiving zyprexa 5.0 mg q HS for treatment of dementia with psychosis AEB visual hallucinations of bugs on the floor and in the bed
Goal: Episodes of visual hallucinations of bugs on the floor or in the bed will decrease to zero by 3 months
Monitor: Document episodes of visual hallucinations of bugs of bugs on the floor or in the bed

Example Care Plan
PROBLEM/NEED
Alteration in Mood and Behavior as evidenced by
 Comments re: wanting to die
 Persistent anger at staff and family with verbally abusive comments “You stupid idiotic bitch!”
 Verbalizations of fears related others plotting to harm her
 Tearfulness
 Striking out with contact during ADL care
 Refuses requested care then states staff did not provide
 Complicated by:
 Dementia with psychosis
 Adjustment to new environment
 COPD
 Family dynamics issues
 Pain
GOAL(S)
1. Comments re: wanting to die will decrease to zero by three months
2. Verbalization of fears re: others plotting to harm her will decrease to zero by three months
3. Will have no episodes of striking out with contact for three months
APPROACHES
 * Set limits on verbally abusive comments/ striking out; rule out pain
 Postpone care and reapproach if verbally abusive comments/ striking out persists
 Educate family re: limit setting
 Encourage resident to express feelings re: why she wants to die, validate
 Encourage resident to identify reasons to live
 Do not argue with resident re: her fearful delusions, validate& remind her this is a safe place
 Encourage verbal expression of feelings when tearful, validate
 Redirect with conversation re: past and current interests
 cats
 embroidery
 I Love Lucy
 Bible verses
 Document episodes of refusing requested care
 Memory book at bedside to remind of care delivery, initial with date and time at each visit
 Mental health evaluation and treatment per MD order, see treatment plan and progress notes
 Meds for treatment of dementia with psychosis per MD order, monitor SE and effectiveness per goals # 2 and #3: ZYPREXA

 AIMS testing every 6 mos
 Monitor level of depression via GDS administration q 90 days
 Set limits on verbally abusive comments/ striking out; rule out pain