Sample Answer for NURS 6630 Assessing and Treating Patients With ADHD Included After Question
Not only do children and adults have different presentations for ADHD, but males and females may also have vastly different clinical presentations. Different people may also respond to medication therapies differently. For example, some ADHD medications may cause children to experience stomach pain, while others can be highly addictive for adults. In your role, as a psychiatric nurse practitioner, you must perform careful assessments and weigh the risks and benefits of medication therapies for patients across the life span. For this Assignment, you consider how you might assess and treat patients presenting with ADHD.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
To prepare for this Assignment:
- Review this week’s Learning Resources, including the Medication Resources indicated for this week.
- Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with ADHD.
The Assignment: 5 pages
Examine Case Study: A Young Caucasian Girl with ADHD. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
- Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
- Which decision did you select?
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
- Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting
By Day 7
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Rubric
NURS_6630_Week9_Assignment_Rubric
| NURS_6630_Week9_Assignment_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning Outcome Introduction to the case (1 page)Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient. |
|
10 pts | ||||
| This criterion is linked to a Learning Outcome Decision #1 (1–2 pages)• Which decision did you select?• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Decision #2 (1–2 pages)• Which decision did you select?• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Decision #3 (1–2 pages)• Which decision did you select?• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Conclusion (1 page)• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature. |
|
15 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. |
|
5 pts | ||||
| Total Points: 100 | ||||||
A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Patients With ADHD
Title: NURS 6630 Assessing and Treating Patients With ADHD
The management of attention deficit hyperactivity disorder (ADHD) among the pediatric population is quite challenging due to the limited amount of evidence supporting the safety of several recommended drugs for this disorder. To illustrate further the management of ADHD, the case of an 8-year-old Caucasian female has been provided. The patient presents with symptoms of ADHD as suggested by her teacher who completed the Conner’s Teacher Rating Scale-Revised. Her teacher claims that the patient is forgetful most of the time, and easily distracted with a very short concentration time. The patient also displays poor language, spelling, and arithmetic skills, hurting her overall school performance. The teacher also reported that lately, the patient has been failing to follow instructions, leaving her homework incomplete. Despite the patient’s parents refusing their daughter has ADHD, the patient reports that she gets bored most of the time at school with a lack of interest in school work. She however denies bullying of any kind at school with a good home life experience. With the findings of the conducted mental status examination and the Conner’s Teacher Rating Scale-Revised, the patient has been diagnosed with Attention deficit hyperactivity disorder, predominantly inattentive presentation.
Several factors were considered when deciding on the specific pharmacological agent and the right dosage to prescribe in the management of the patient’s condition. Such factors include the young age of the patient, her Caucasian race, her ADHD diagnosis, and the reported symptoms. The completed Conner’s Teacher Rating Scale-Revised can also help determine the severity of the patient’s condition which is crucial in determining the dosage of the selected drug. As such, this discussion aims at developing the most effective treatment plan for the 8-year-old patient in the management of ADHD, with a rationale for each decision made.
Decision#1
Selected Decision and Rationale
Administering Methylphenidate 10mg chewable tablets once a day in the morning was selected as the initial intervention.
Methylphenidate is a stimulant to the central nervous system that acts via noncompetitive blockage of noradrenalin and dopamine reuptake into the terminals, by inhibiting the action of the dopamine and noradrenaline transporters thus raising dopamine and noradrenaline levels in the synaptic cleft (American Psychiatric Association, 2013; Cipriani et al., 2018). Previous evidence supports the substantial effectiveness of Methylphenidate in the management of children diagnosed with ADHD, with a great safety profile and high tolerability levels (Hodgkins et al., 2012). The drug is only recommended for children of age 6 and above (Grimmsmann & Himmel, 2021). Finally, with consideration of the patient’s Caucasian race, the drug is metabolized in the liver via the CYP3A4 pathway, which is predominant among this ethnic population, hence limiting the risks of toxicity (Bonati et al., 2018). The chewable tablet formulation is normally recommended for children to promote compliance (Kikuchi et al., 2021).
Intuniv was an inappropriate choice for this patient given that previous studies report that the drug being a non-stimulant is more effective in the management of ADHD when used together with a stimulant (Pelham III et al., 2022). Wellbutrin on the other hand is a norepinephrine-dopamine reuptake inhibitor (NDRI) discouraged among children below the age of 9 years old due to its elevated risks of seizures (Kikuchi et al., 2021).
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Expected Outcome.
Up to 50% of the patient’s symptoms will be resolved within the following 4 weeks (Kikuchi et al., 2021). She will be able to concentrate for longer hours with increased attention and memory (Hodgkins et al., 2012). Her overall academic performance will also improve significantly.
Ethical Consideration
Based on the provisions of legal and ethical guidelines for nurses, the PMHNP is obliged to consider the patient ethnicity and race to promote culturally sensitive care (Bonati et al., 2018). The patient’s parents also have a legal right to information concerning the health of their child, for sound decision-making (American Psychiatric Association, 2013). Respecting the patient’s autonomy is key to promoting patient satisfaction.
Decision#2
Selected Decision and Rationale
Out of the options provided, the most effective second intervention was to change the treatment regimen to a long-acting Ritalin 20mg administered once daily in the morning. The patient has reported the potential effectiveness of the drug in managing ADHD symptoms (Hodgkins et al., 2012). However, since the dose is quite limited to resolving the patient’s symptoms all day, using a long-acting agent will help prolong the duration of action, improving the patient’s attention, concentration, and memory the entire day (Cipriani et al., 2018). Studies show that long-acting Methylphenidate lasts in the body system for up to 10 to 12 hours (American Psychiatric Association, 2013). The side effect reported of elevated heart rate is common among pediatric patients on methylphenidate which resolves as the patient continues taking the drug (Pelham III et al., 2022). Consequently, previous evidence confirms that using a long-acting agent, hence reduces the concentration of the drug at one point, reducing the risks of toxic doses, when used for a long time (Kikuchi et al., 2021).
Maintaining the dose of methylphenidate was not necessary as the patient will continue experiencing limited effectiveness of the drug later in the day (Grimmsmann & Himmel, 2021). Administering Adderall in place of Methylphenidate was also inappropriate at the moment given that the former is associated with increased risks of cardiovascular complications which would compromise the health of the patient (Bonati et al., 2018).
Expected Outcome
The patient will be able to attain full concentration and attention level with the use of the drug for 4 weeks (Pelham III et al., 2022). This should help promote her overall academic performance and interest in school activities. The side effect of increased heart rate is expected to return to normal within this period (Grimmsmann & Himmel, 2021).
Ethical Considerations
“Not harm” is one of the main ethical obligations of nurses, especially when taking care of children (Bonati et al., 2018). As such, the PMHNP needed to explain to the parents of the patient why the side effect occurred and the main cause of action to resolve the side effect and promote the health of their child (Kikuchi et al., 2021).
Decision#3
Selected Decision and Rationale
Advising the patient to continue taking the long-acting Methylphenidate 20mg once daily and report for reevaluation after 4 weeks was considered the final decision. The patient reported completely resolved side effects with improved effectiveness of the drug in the management of ADHD symptoms all day (Hodgkins et al., 2012). Previous evidence demonstrates that patients on Ritalin may exhibit maximum benefit within 8 to 12 weeks of treatment therapy (American Psychiatric Association, 2013; Cipriani et al., 2018). Most pediatric patient on Methylphenidate has reported great tolerance to the medication with a desirable safety profile in long-term use (Grimmsmann & Himmel, 2021). However, in rare cases, the patient may exhibit ineffectiveness to the medication which might call for the dose titration, hence the need for reevaluating the patient after four weeks (Kikuchi et al., 2021).
At this point, it was not appropriate to increase the dose of methylphenidate to 30mg as studies show that low effective doses are safer for use by children, with reduced risks of adverse effects (Pelham III et al., 2022). Consequently, based on the current patient heart rate, it is not necessary to obtain EKG, as her pulse is within the normal limits of a child of her age (Bonati et al., 2018).
Expected Outcome
For the next four weeks, the patient will report further improvement in ADHD symptoms all day (Grimmsmann & Himmel, 2021). She should display appropriate language, spelling, and arithmetic skills, with improved attention and concentration level (Hodgkins et al., 2012). No side effects are expected.
Ethical Consideration
In the final decision, the PHMNP had to consider several ethical principles including nonmaleficence, beneficence, and justice (American Psychiatric Association, 2013). Since the patient was fully satisfied with the treatment outcome, the clinician needed to utilize his/her clinical judgment to advise the patient to continue using the medication for optimal benefits (Pelham III et al., 2022).
NURS 6630 Assessing and Treating Patients With ADHD Conclusion
The pediatric patient described in the case study provided presents with symptoms of ADHD as reported by her teacher. In the development of the treatment plan for this patient, her young age, Caucasian gender, ADHD diagnosis, and presenting symptoms were considered in the selection of the safest and most effective drug. As such, the initial decision was to administer methylphenidate 10mg once daily in the morning (American Psychiatric Association, 2013). Methylphenidate is a stimulant medication that has been proven to be safe and effective in managing ADHD symptoms in both children and adults. Wellbutrin and Intuniv were not considered in this decision as a result of safety issues among children associated with increased risks of side effects (Hodgkins et al., 2012). After 4 weeks, the patient reported significantly improved ADHD symptoms earlier in the day, with minimal effect of the medication later in the day, in addition to side effects of elevated heart rate (Pelham III et al., 2022). It was thus necessary to administer long-acting Methylphenidate 20mg once daily to promote management of the patient’s symptoms the entire day. The long-acting formulation has a longer duration of action (Bonati et al., 2018). Maintaining the dose of Methylphenidate or switching the drug with Adderall was not appropriate at this point (Kikuchi et al., 2021).
The patient reported resolved side effects with well-managed ADHD symptoms the entire day after 4 weeks. This shows that she was tolerant to the drug with great safety and effectiveness hence the need to continue the same medication at the same dose for another 4 weeks before the reevaluation (Grimmsmann & Himmel, 2021). Increasing the dose of Methylphenidate or obtaining an EKG was not appropriate at this point. The PMHNP also encountered several ethical considerations when taking care of the patient with the main one being “no harm.” Additional ethical principles observed include justice, nonmaleficence, and beneficence (Cipriani et al., 2018).
NURS 6630 Assessing and Treating Patients With ADHD References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Bonati, M., Reale, L., Zanetti, M., Cartabia, M., Fortinguerra, F., Capovilla, G., … & Lombardy ADHD Group. (2018). A regional ADHD centre-based network project for the diagnosis and treatment of children and adolescents with ADHD. Journal of attention disorders, 22(12), 1173-1184. https://doi.org/10.1177/1087054715599573
Cipriani, A., Adamo, N., Del Giovane, C., Coghill, D., Banaschewski, T., Hollis, C., … & Cortese, S. (2018). Unbalanced risk-benefit analysis of ADHD drugs–Authors’ reply. The Lancet Psychiatry, 5(11), 871-873. https://doi.org/10.1016/S2215-0366(18)30396-1
Grimmsmann, T., & Himmel, W. (2021). The 10-year trend in drug prescriptions for attention-deficit/hyperactivity disorder (ADHD) in Germany. European journal of clinical pharmacology, 77(1), 107-115. https://doi.org/10.1007/s00228-020-02948-3
Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245–268. https://doi.org/10.2165/11599630-000000000-00000
Kikuchi, D., Obara, T., Tokunaga, M., Shiozawa, M., Takahashi, A., Ito, M., … & Watanabe, Y. (2021). Drug prescription for attention deficit hyperactivity disorder drugs in pediatric outpatients: A retrospective survey of Japanese Administrative Data (2012–2018). Asian Journal of Psychiatry, 57, 102512. https://doi.org/10.1016/j.ajp.2020.102512
Pelham III, W. E., Altszuler, A. R., Merrill, B. M., Raiker, J. S., Macphee, F. L., Ramos, M., … & Pelham Jr, W. E. (2022). The effect of stimulant medication on the learning of academic curricula in children with ADHD: A randomized crossover study. Journal of consulting and clinical psychology, 90(5), 367. https://doi.org/10.1037/ccp0000725
A Sample Answer 2 For the Assignment: NURS 6630 Assessing and Treating Patients With ADHD
Title: NURS 6630 Assessing and Treating Patients With ADHD
Attention Deficit Hyperactivity Disorder (ADHD) is one of the most prevalent disorders in child psychiatry with the prevalence increasing over the years. It is characterized by inattention, hyperactivity, and impulsivity. It has a male predilection with a male to female ratio of 2:1. The hyperactive and impulsive subtype is the most prevalent. The inattentive subtype occurs in 18.3% of the condition and mostly affects females (Magnus et al., 2020). ADHD is diagnosed before the age of 12 years. It affects an individual’s ability to form and maintain close social ties.
This week’s case study focuses on Katie an 8-year-old Caucasian female brought into the office by her parents following a referral. She is referred for a psychiatry assessment to determine if she has ADHD. From the Conner’s Teacher Rating Scale-Revised, Katie is inattentive, easily distracted, forgets things already learned, and poor in spelling, reading, and arithmetic. Of note is that she has a short attention span, lacks interest in school work, is easily distracted, starts things but never finishes them, seldom follows through on instructions, and fails to finish her school work. She has no open defiance or temper outbursts. In subjective history, her favorite subjects are art and recess. She finds other subjects hard and boring. She admits her mind wanders off from class most of the time. There is no history of abuse or bullying at school. She reports that her home life is fine and her parents are good to her. The Mental State Exam is normal. She is appropriately developed for her age. She has a clear, coherent, and logical speech. She is oriented to time, place, person, and event. She has no mannerisms or tics. Her subjective mood is euthymic with a bright affect. She has no hallucinations, delusions, or abnormalities of thought. Attention and concentration are intact. Insight and judgment are age appropriate. Her diagnosis is ADHD, predominantly inattentive presentation. Decision-making in the prescription of ADHD medication is influenced by the patient’s gender, the subtype of ADHD displayed, level of academic impairment, age, and the parent’s socioeconomic status (Kamimura-Nishimura et al., 2019). These factors act together to influence the drug to be used, the dosage, and the duration of therapy. The purpose of this paper is to discuss the decision points on the treatment of this patient in regards to the choice of drug, the expectations post initiation of therapy, and the ethical considerations.
Decision 1
Chewable Methylphenidate tablets 10mg orally in the morning
Reason for Selection
Methylphenidate is considered the first-line drug therapy for childhood, adolescent, and adult ADHD (Cortese et al., 2021). The American Academy of Pediatrics recommends parent training in behavior management, and classroom training, along with medications. Methylphenidate is highly efficacious in the resolution of emotional dysregulation, and propensity to violent behavior and increases susceptibility to learning and rehabilitation of social skills (Asherson et al., 2019). The availability of methylphenidate also influences its wide use.
The few Randomized Control Studies done show that Bupropion is considered as effective as Methylphenidate in the treatment of ADHD. It also has fewer adverse symptoms compared to methylphenidate. For therapy, several trials agree that there is still a need for a further trial of the medication. Some serious adverse effects like paresthesia, agitation, and palpitations were marked in bupropion (Pozzi et al., 2020). For this reason, its suitability for treatment is reduced especially in children and adolescents.
In trials of Intuniv, there was significant symptomatology improvement in inattention, hyperactivity, and impulsivity. Intuniv is however associated with severe side effects such as polydipsia, hypotension, nasopharyngitis, and hypersomnolence (Iwanami et al., 2020). This limits its use despite having a decent efficacy.
Expectation
There is an expected beginning of the resolution of symptomatology within a few days of therapy. These changes include an enhanced concentration with a slightly increased concentration span, improved attention, reduced distractibility, and a reduction in antisocial behaviors like violence and breaking of school rules (Jaeschke et al., 2021). These changes must be supported by both classroom and parent training.
Ethical Considerations
The ethical considerations are hinged on the four principles of justice, do no harm, beneficence, and respect for autonomy. Considering the best treatment for the child’s condition is approved through research findings. The autonomy of children is an important factor. A child’s flexibility in preference is important in character development. A small room for guided autonomy is associated with better outcomes. For this reason, the parents act in the best interest of the child. Informed consent is key. Informed consent in children is proven to strengthen the morals and structure of the child by improving esteem and social interactions (Díaz-Pérez et al., 2020). Providing adequate information and education regarding the condition is n important tenet. Providing top-notch care in the best interest of the child through offering follow-up is vital.
Decision 2
Change to Ritalin LA 20mg orally daily in the morning
Reason for Selection
The slow-release long-acting Ritalin is considered effective in controlling symptoms of inattention and hyperactivity (Karahmadi et al., 2020). The long-acting Ritalin has increased compliance with medication. Although the adverse effects of the long-acting and short-acting Ritalin are comparatively the same, Ritalin LA could be responsible for a reduction in side effects as it causes a maintained plasma concentration of the drug over time.
Arrhythmias and increased systolic blood pressure are common adverse effects of Ritalin (Liang et al., 2018). Continuation with the same dose of Ritalin could cause further development in other side effects of cardiovascular disease such as stroke which would be detrimental (Nauman et al., 2021). Adderall has a very high potential for abuse and dependence. In women, Adderall can cause infertility. Sudden stoppage of the drug also comes with severe withdrawal effects such as suicidal ideas, delusions, and psychosis. These side effects occur in both the short term and the long term.
Expectations
Due to a change to Ritalin LA, there is expected maintenance in improved concentration and consequently a good performance. Resolution of the daydreaming in the afternoon. There is also an expected decrease in the presenting side effects like high heart rate; there is an expected reduction in heart rate.
Ethical Considerations.
Informed consent to the change of drug is important with adequate education on the dosage. Autonomy of the child should be guided by the parents as at the same time the child is allowed to express their preference (Díaz-Pérez et al., 2020). Continuous counseling of the family on how best to handle and train the child. A cordial patient-doctor relationship is very vital for this particular case as it eases subsequent clinic visits for follow-up.
Decision 3
Maintain current dose of Ritalin LA and reevaluate in 4 weeks
Reason for Selection
At this point, the current dose is effective in perfectly controlling the symptoms and the side effects have vanished. It is advised that in drug usage, the lowest effective dose is indicated. Here heart rate of 92 beats per minute falls in the range appropriate for her age. For this reason, maintaining the current dosage is the most plausible option. Increasing Ritalin LA to higher doses is not advisable firstly because the symptoms are well controlled without any adverse effects. Secondly higher doses are associated with increased side effects (Karahmadi et al., 2020). Obtaining an EKG based on her heart rate is futile. The heart rate of 92 beats per minute is normal for her age.
Expectations
The current dose of Ritalin in conjunction with the psychosocial treatments should be able to abate the symptoms. There should be a net effect of improved concentration and learning. The girl should be able to get better grades. There will be improved interest in school work and not easily distractible. There will be minimal side effects of the drug as it is set at the lowest effective dose.
Ethical Considerations
The mere fact of not doing any harm and providing recommended drug treatment at the minimal effective dose is not enough. Respectful handling of the patient in a child-friendly manner and her parents by the healthcare provider is an essential part of treatment as it builds patient confidentiality and trust (Díaz-Pérez et al., 2020). The success of long-term follow-up is also greatly dependent on this relationship. Sound patient education on the side effects and dosage of the drug is key.
NURS 6630 Assessing and Treating Patients With ADHD Conclusion
ADHD is a common encounter in child psychiatry. It is mostly overdiagnosed even in patients who show a few symptoms but don’t meet the diagnostic criteria (Magnus et al., 2020). It is characterized by reduced attention, hyperactivity, and impulsivity. These symptoms have to occur for no less than 6 months and the patient less than 12 years for a primary diagnosis to be made. Although ADHD is more common in boys, the inattention subtype is common in girls. This case study provides a perfect example of the inattention subtype. It involves an 8-years-old Caucasian girl who displays markedly reduced attention in class, easy distractibility, and poor academic performance but does not have violent properties. There is no demarcated precipitating factor for her condition. Methylphenidate is the first-line drug used in the management of ADHD in all age groups (Cortese et al., 2021). Methylphenidate is highly efficacious in the resolution of emotional dysregulation, and violent behavior and increases susceptibility to learning and rehabilitation of social skills (Asherson et al., 2019). The availability of methylphenidate also influences its wide use. Studies show that Bupropion is as effective as Methylphenidate in the treatment of ADHD. For therapy, several trials agree that there is still a need for a further trial of the medication. Intuniv use is marred by adverse effects such as increased thirst, nasopharyngitis, and somnolence which makes its use unpopular (Iwanami et al., 2020). Studies comparing the efficacies of Ritalin LA and the short-acting Ritalin show only a minimal difference in their profiles. The slow release of Ritalin reduces the dosing interval hence improving medication adherence. In the dissolution of symptoms, there is no major difference although clinically, Ritalin LA is associated with reduced side effects (Karahmadi et al., 2020). The principle of monotherapy and usage of the lowest effective dose is a key facet in the treatment of ADHD. The drug choice is influenced by the pharmacokinetic profile of the drug, availability, age of the patient, symptomatology, level of academic and social impairment, subtype of ADHD, gender, and the socio-economic status of the patient (Kamimura-Nishimura et al., 2019). Ethical considerations include informed consent, guided autonomy, providing the best treatment possible, formation of meaningful patient and healthcare provider relationships that improve treatment, and constant counseling and education of the patient concerning the different aspects of management.
NURS 6630 Assessing and Treating Patients With ADHD References
Asherson, P., Johansson, L., Holland, R., Fahy, T., Forester, A., Howitt, S., Lawrie, S., Strang, J., Young, S., Landau, S., & Thomson, L. (2019). Randomised controlled trial of the short-term effects of OROS-methylphenidate on ADHD symptoms and behavioural outcomes in young male prisoners with attention-deficit/hyperactivity disorder (CIAO-II). Trials, 20(1). https://doi.org/10.1186/s13063-019-3705-9
Cortese, S., Newcorn, J. H., & Coghill, D. (2021). A Practical, Evidence-informed Approach to Managing Stimulant-Refractory Attention Deficit Hyperactivity Disorder (ADHD). CNS Drugs, 35(10), 1035–1051. https://doi.org/10.1007/s40263-021-00848-3
Díaz-Pérez, A., Navarro Quiroz, E., & Aparicio Marenco, D. E. (2020). Moral structuring of children during the process of obtaining informed consent in clinical and research settings. BMC Medical Ethics, 21(1). https://doi.org/10.1186/s12910-020-00540-z
Iwanami, A., Saito, K., Fujiwara, M., Okutsu, D., & Ichikawa, H. (2020). Efficacy and Safety of Guanfacine Extended-Release in the Treatment of Attention-Deficit/Hyperactivity Disorder in Adults. The Journal of Clinical Psychiatry, 81(3). https://doi.org/10.4088/jcp.19m12979
Jaeschke, R. R., Sujkowska, E., & Sowa-Kućma, M. (2021). Methylphenidate for attention-deficit/hyperactivity disorder in adults: a narrative review. Psychopharmacology, 238(10), 2667–2691. https://doi.org/10.1007/s00213-021-05946-0
Kamimura-Nishimura, K. I., Epstein, J. N., Froehlich, T. E., Peugh, J., Brinkman, W. B., Baum, R., Gardner, W., Langberg, J. M., Lichtenstein, P., Chen, D., & Kelleher, K. J. (2019). Factors Associated with Attention Deficit Hyperactivity Disorder Medication Use in Community Care Settings. The Journal of Pediatrics, 213, 155-162.e1. https://doi.org/10.1016/j.jpeds.2019.06.025
Karahmadi, M., Saadatmand, S., & Tarahi, M. J. (2020). Investigation of Efficacy of Short-Acting Methylphenidate (Ritalin) and Long-Acting (Matoride) on Symptoms of Attention Deficit Hyperactivity Disorder in Children Aged 6–18 Years: A Single-Blind, Randomized Clinical Trial. Advanced Biomedical Research, 9. https://doi.org/10.4103/abr.abr_9_20
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A Sample Answer 3 For the Assignment: NURS 6630 Assessing and Treating Patients With ADHD
Title: NURS 6630 Assessing and Treating Patients With ADHD
Attention-deficit/hyperactivity disorder (ADHD) is a developmental psychiatric condition common in pediatric populations, although it also diagnosed in the adult population. It is diagnosed based on features attention deficits, hyperactivity, or impulsivity. The symptoms affect a patient’s level of functioning and cognitive ability (Cabral et al., 2020). The purpose of this assignment is to discuss the case of a child with ADHD, propose treatment interventions, and explain how ethical considerations impacted the patient’s treatment plan.
Case Overview
The case depicts an 8-year-old child, Katie, referred for psychiatric assessment of ADHD. Her teacher expressed concerns that she could have ADHD based on her behavior. Results from the ADHD assessment questionnaire filled by her teacher, shows that she has attention deficits, distracted, memory deficits, and has challenges in spelling, reading, and calculation. Besides, the child has a limited attention span, which is only better when doing things that she likes. Katie has less interest in school, fails to complete tasks, hardly adheres to instructions, and does not do her assignments. However, her parents do not believe that she has ADHD because she is not defiant or have temper outbursts. Katie admits that her mind wanders in class and she often feels lost in her schoolwork. She is diagnosed with ADHD, inattentive presentation.
ADHD treatment comprises both pharmacological and psychotherapy interventions. However, various actors in this patient may impact treatment decisions, including her age, severity of ADHD symptoms, presence of other psychiatric comorbidities, drug allergies, and the parents’ treatment preferences (Childress, 2021).
Decision #1
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING.
Why This Decision was Selected
The patient was initiated on Ritalin because it is recommended as a first-line agent in treating ADHD in children older than six years. Ritalin is a psychostimulant and acts by increasing the activity of central dopamine and norepinephrine, the neurotransmitters involved in attention and executive function (Childress, 2021). Besides, Ritalin has tolerable side effects, which will promote medication compliance.
Bupropion was not selected since it is not approved by the FDA for ADHD in chuldren. It is usually prescribed off-label when stimulants are unsuccessful in treating ADHD and patients with comorbid conditions (Brown et al., 2018). Intuniv was not initiated because it is recommended as a second-line agent due to a lower efficacy than stimulants. The drug causes rebound hypertension if stopped abruptly and is thus a less ideal choice (Brown et al., 2018).
What I Hoped To Achieve
I hoped that Ritalin would alleviate ADHD symptoms within four weeks and that Katie’s teacher would report improved concentration and attention span in class. Feldman et al. (2018) explain that stimulants such as Ritalin improve academic performance in children with ADHD and their overall quality of life and lower the risk of children developing anxiety and depressive disorders later in life.
Ethical Considerations That May Affect the Treatment Plan
Ethical principles of nonmaleficence and beneficence influenced treatment decisions because the provider was obligated to select a treatment that would promote the best possible outcomes while promoting patient safety (Bipeta, 2019). Ritalin was selected because the evidence supports its efficacy in treating ADHD and its safety profile.
Decision #2
Switch to Ritalin LA 20 mg orally daily in the morning.
Why This Decision was Selected
Ritalin was changed to a long-acting formulation since the effects of the immediate-release preparation were only sustained for a limited duration. The half-life of immediate-release preparation is about four hours and should be administered 2-3 times per day to sustain the effects (Steingard et al., 2019). However, the long-acting preparation has a longer half-life of 10–12 hours, and its effects are sustained a whole day. Therefore, a long-acting formulation was the ideal choice for this patient so that she could concentrate in class the entire day.
The choice to continue the same Ritalin dose and reassess after four weeks was not appropriate because the patient had low concentration levels and was daydreaming in the afternoon. The symptoms would have persisted or worsened if the dose was not adjusted to either a long-acting formulation or 2-3 times daily dosing (Steingard et al., 2019). Besides, stopping Ritalin and starting Adderall XR was not ideal because stimulants should only be stopped if the maximum dose is not effective.
What I Hoped To Achieve
I expected that switching to a long-acting formulation would maintain the Ritalin’s effects for longer period. Katie’s teacher would report that she had adequate attention and concentration levels throughout the day. Long-acting stimulants act in phases to suppress ADHD symptoms throughout the day. A fraction of the dose is released immediately, while the rest goes into effect hours later (Steingard et al., 2019). Long-acting stimulants usually wear off in 12 to 16 hours.
Ethical Considerations That May Affect the Treatment Plan
Beneficence impacted the treatment plan since the clinician had to change the Ritalin dose to a formulation with better treatment outcomes than the initial one (Bipeta, 2019). The decision was selected with the patient’s well-being in mind, which means that beneficence was upheld.
Decision #3
Maintain the current Ritalin LA dose and reevaluate in 4 weeks.
Why This Decision was Selected
This was an ideal decision since the patient responded adequately to the Ritalin LA 20 mg. The patient had an improved academic performance and the effects of LA Ritalin lasted the entire day. The dose was also maintained since there were no reported side effects of the drug, and it was thus safe to continue. Brown et al. (2018) explain that pharmacologic treatment of ADHD in children and adolescents should start with long-acting stimulant drugs in most cases.
It was not ideal for increasing Ritalin LA to 30 mg since the initial 20 mg dose worked effectively and lasted the whole day with a single dose. Besides, a higher dose may result in side effects, which would be undesirable. An EKG was not also requested since the palpitations had diminished and the heart rate was normal. Advanced cardiac exams such as EKG are recommended if a patient presents with side effects of chest pain, loss of consciousness, and symptoms suggestive of heart disease (Brown et al., 2018).
What I Hoped To Achieve
I expected that maintaining Ritalin LA would continue to alleviate the patient’s ADHD and improve her school grades. Childress (2021) explains that daytime functioning and evening commitments should influence the chosen stimulant formulation. A long-acting formulation should be chosen as an alternative to an immediate release to improve adherence and lower the risk of misuse.
Ethical Considerations That May Affect the Treatment Plan
Nonmaleficence impacted the treatment plan since the clinician had to choose the safest treatment intervention with a lower risk of harming the patient (Bipeta, 2019). Interventions that pose a risk to the patient were not selected, such as increasing the dose or changing the drug.
NURS 6630 Assessing and Treating Patients With ADHD Conclusion
Katie presented with symptoms of distractibility and inattention mainly observed in school. The patient factors that would impact prescribing decisions include age, the severity of symptoms, the presence of other psychiatric comorbidities, drug allergies, and the parents’ treatment preferences (Childress, 2021). The patient was initiated with Ritalin chewable tablets 10 mg since it is an FDA-approved drug for treating ADHD in children from six years. The drug also has a tolerable safety profile (Childress, 2021). Although the patient’s concentration and attention improved, the drug did not sustain the effects the whole day, and the symptoms recurred in the afternoon. As a result, immediate release Ritalin was switched to a LA formulation to maintain its effects for longer.
The long-acting formulation adequately sustained the drug’s desired effects the whole school day. As a result, the patient’s academic performance improved, and she reported the palpitations had abated. The patient was maintained on the Ritalin LA 20 mg dose since there were no reported side effects and the desired treatment outcomes were attained (Steingard et al., 2019). Increasing the dose might have resulted in side effects and was thus not recommended. Beneficence and nonmaleficence impacted the treatment plan. The clinician had to select treatment interventions associated with the best outcomes and least side effects to promote the best treatment outcomes without compromising the patient’s safety.
NURS 6630 Assessing and Treating Patients With ADHD References
Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19
Brown, K. A., Samuel, S., & Patel, D. R. (2018). Pharmacologic management of attention deficit hyperactivity disorder in children and adolescents: a review for practitioners. Translational Pediatrics, 7(1), 36–47. https://doi.org/10.21037/tp.2017.08.02
Cabral, M. D. I., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational Pediatrics, 9(Suppl 1), S104. https://doi.org/10.21037/tp.2019.09.08
Childress, A. C. (2021). Novel Formulations of ADHD Medications: Stimulant Selection and Management. Focus (American Psychiatric Publishing), 19(1), 31–38. https://doi.org/10.1176/appi.focus.20200032
Steingard, R., Taskiran, S., Connor, D. F., Markowitz, J. S., & Stein, M. A. (2019). New Formulations of Stimulants: An Update for Clinicians. Journal of child and adolescent psychopharmacology, 29(5), 324–339. https://doi.org/10.1089/cap.2019.0043