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NURS 6630 Assignment Assessing and Treating Patients With ADHD

NURS 6630 Assignment Assessing and Treating Patients With ADHD

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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.

Katie, an 8-year-old female whose parents brought her to the clinic today, is the subject of this assignment’s case study. Katie’s instructor suspected she had ADHD, so the primary care physician referred her to the clinic for testing. Katie is inattentive, forgets things easily, is inattentive, and difficulties with spelling, reading, and mathematics, according to the teacher’s report on the Conner’s Teacher Rating Scale-Revised. Katie’s attention span is short, she pays attention to what she is interested in, and she is uninterested in school activities, according to the teacher. Katie’s parents have strongly denied the report. Katie describes school as “excellent,” admits to finding subjects dull, and admits that her mind wanders during class time. Katie was appropriately attired for the occasion, had euthymic mood, bright affect, and grossly intact concentration and attention, and denies any visual or aural hallucinations, as well as suicidal or homicidal thoughts. Based on the data, Katie was diagnosed with attention deficit hyperactivity disorder, particularly inattentive presentation. As a result, the symptoms listed above will influence the patient’s treatment method.

Decision Point One

Selected Decision

The selected decision is beginning Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning.

Reason for the Selection

Ritalin was selected for the patient because it is a drug that is commonly used in the treatment of children suffering from ADHD. Ritalin works by managing the symptoms of ADHD such as lack of attention and learning deficits (Ruuskanen et al., 2019). Ritalin works by improving the cognitive function of the affected children. The improvement in cognitive functioning is attributable to the ability of the drug to raise the levels of norepinephrine and dopamine in the brain. Accumulation of dopamine and norepinephrine causes an improvement in the cognitive functioning of the patient (Feldman et al., 2018). Ritalin also has a quicker peak performance in ADHD when compared to the other alternatives (J. Bachmann et al., 2017).

NURS 6630 Assignment Assessing and Treating Patients With ADHD

Why the Other Options were not Selected

The decision to administer Wellbutrin (bupropion) or Intuniv extended release was not selected because of the low peak performance level when compared to Ritalin. In addition, Wellbutrin was not selected, as it is the drug of choice for adults with ADHD. The use of Wellbutrin in children may result in side effects such as suicidal ideations and attempts (Hile, 2020). Intuniv was also not selected because of its side effects such as sedation that will affect the attention span of the children (Verbeeck et al., 2017). NURS 6630 Assignment Assessing and Treating Patients With ADHD

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What I was Hoping to Achieve

Ritalin improves the cognitive functioning in children with ADHD (Pakdaman et al., 2018). Therefore, I was hoping to witness an

NURS 6630 Assignment Assessing and Treating Patients With ADHD

NURS 6630 Assignment Assessing and Treating Patients With ADHD

improvement in the client’s attention span. I was also expecting an improvement in Katie’s academic performance. I also expected to witness improvement in memory since the client does not have a history of sleep deprivation.

How Ethical Considerations May Impact Treatment Plan and Communication with Patients

The ethical consideration of informed assent may influence the treatment plan for the client since Katie’s parents may decline the selected treatment. The ethical consideration of non-maleficence and benevolence may also influence the selection of treatment since options with minimal harm must be selected. Lastly, the PMHNP must ensure privacy and confidentiality of the client’s data (Buka, 2020).

NURS 6630 Assignment Assessing and Treating Patients With ADHD

Decision Point Two

Selected Decision

Change to Ritalin LA 20 mg orally daily in the morning.

Reason for the Selection

Ritalin LA is the long-acting type of Ritalin that provides prolonged therapeutic effect to children with ADHD. The prolonged therapeutic effect implies that the client will remain attentive throughout the day in the school and at home (Ruuskanen et al., 2019). The administration of Ritalin chewable tablets 10 mg orally in the morning was effective. However, the teacher reported that Katie began staring off into space and daydreaming by afternoon. The implication of the symptoms is that the peak performance of Ritalin chewable was reached by afternoon, hence, the client experiencing symptoms of ADHD. The client however experienced the side effect of tachycardia that is associated with Ritalin chewable tablets. The administration of the long-acting form of Ritalin is therefore safe since it is associated with minimal side effects (Schwarz, 2017). NURS 6630 Assignment Assessing and Treating Patients With ADHD

Why the Other Options were not Selected

The decision to continue with the same dose of Ritalin and re-evaluate in 4 weeks was not selected because the desired therapeutic effect of Ritalin had not been achieved. Katie will relapse to the previous symptoms of ADHD. The decision to discontinue Ritalin and begin Adderall RX 15 mg orally daily was not chosen because Ritalin had resulted in moderate improvement in symptoms. Changing to Adderall was likely to increase the side effects of the drug, hence, safety issues in treatment (Schwarz, 2017).

What I was Hoping to Achieve

Ritalin LA has long-lasting therapeutic effects. As a result, it was expected that the client will remain attentive throughout the day. It was also expected that the client’s experiences of side effects of Ritalin would be minimal. Lastly, the cognitive skills of the client were expected to improve (Schwarz, 2017).

How Ethical Considerations May Impact Treatment Plan and Communication with Patients

The ethical aspect of safety in patient care influences the selection of the above treatment option. Ritalin was safer when compared to the alternatives that were presented in the case study. The ethical aspect of informed consent would have impacted the treatment since the parents should assent the treatment. Lastly, promotion of patient autonomy should be considered by educating the patient and the family about the benefits and risks of the different treatment options (Buka, 2020). NURS 6630 Assignment Assessing and Treating Patients With ADHD

Decision Point Three

Selected Decision

The selected decision is maintaining the current dose of Ritalin LA and re-evaluate after 4 weeks.

Reason for the Selection

The above decision was made because the optimum therapeutic effect of Ritalin LA has been reached. The symptoms of ADHD that the client experienced earlier have been managed. The client also did not experience any side effects of Ritalin LA (Pakdaman et al., 2018). Therefore, continuing with the current dose of Ritalin LA is the most effective solution to consider in the treatment process.

Why the Other Options were not Selected

The decision to increase the dose of Ritalin LA to 30 mg orally daily was not selected because the desired therapeutic effect of Ritalin had been achieved. Increasing the dosage would have also predisposed the patient to side effects such as tachycardia and suicidal ideations. Obtaining EKG based on the current heart rate was not selected because the pulse rate is normal. Therefore, there is no indication for EKG (Schwarz, 2017).

What I was Hoping to Achieve

I was hoping to achieve sustained therapeutic effect of Ritalin LA by making the above decision. I was also hoping to eliminate any side effects that the patient could have experienced by using Ritalin. I was also hoping to witness sustained improvement in the client’s cognitive functioning due to the effects of Ritalin LA (Schwarz, 2017).

How Ethical Considerations May Impact Treatment Plan and Communication with Patients

The ethical consideration of benevolence and non-maleficence would affect the treatment of the patient in the case study. The PMHNP is expected to prioritize the safety of the selected treatment interventions. The PMHNP also has the responsibility of ensuring data integrity. The data of the patient should be kept private and confidential (Buka, 2020).

Conclusion

This case study has explored the treatment of ADHD in children. The case study showed that Ritalin is the most effective drug of choice for children with ADHD. Ritalin produces its effect by increasing the levels of norepinephrine and dopamine in the brain. Since ADHD is associated with cognitive deficits, the improvement in the levels of dopamine and norepinephrine result in the improvement of the cognitive skills of the patient. The chewable forms of Ritalin was found to be associated with the side effect of tachycardia and reduced period of therapeutic effect. The teacher of the client reported that the symptoms of ADHD relapsed by afternoon following the depletion of Ritalin in the system. As a result, the decision to administered Ritalin LA was made. Ritalin LA proved effective in improving the attention span of the client throughout the day. The client also improved her cognitive skills as seen in the enhanced academic involvement and achievement. The administration of Ritalin LA also led to the reduction in the side effects that the client experienced with Ritalin (Pakdaman et al., 2018). Ethical considerations had an influence on the treatment decisions that were made in the case study. For example, the PMHNP aimed at ensuring that safety in the care given to the patient was promoted. The PMHNP selected the treatment options that were associated with optimum therapeutic effect and minimal harm to the patient. In addition, the PMHNP had the professional responsibility of ensuring that data privacy and confidentiality was promoted alongside seeking informed assent from the parents of the client (Buka, 2020). Therefore, PMHNP should be aware of the ethical considerations that influence the decisions that they make in practice.

References

Buka, P. (2020). Essential Law and Ethics in Nursing: Patients, Rights and Decision-Making. Taylor & Francis.

Feldman, M. E., Charach, A., & Bélanger, S. A. (2018). ADHD in children and youth: Part 2—treatment. Paediatrics & Child Health, 23(7), 462–472. https://doi.org/10.1093/pch/pxy113

Hile, A. (2020). Bupropion for the treatment of ADHD. Lynchburg Journal of Medical Science, 2(1). https://digitalshowcase.lynchburg.edu/dmscjournal/vol2/iss1/15

  1. Bachmann, C., Philipsen, A., & Hoffmann, F. (2017). ADHD in Germany: Trends in diagnosis and pharmacotherapy. Deutsches Ärzteblatt International, 114(9), 141–148. https://doi.org/10.3238/arztebl.2017.0141

Pakdaman, F., Irani, F., Tajikzadeh, F., & Jabalkandi, S. A. (2018). The efficacy of Ritalin in ADHD children under neurofeedback training. Neurological Sciences, 39(12), 2071–2078. https://doi.org/10.1007/s10072-018-3539-3

Ruuskanen, E., Leitch, S., Sciberras, E., & Evans, S. (2019). “Eat, pray, love. Ritalin”: A qualitative investigation into the perceived barriers and enablers to parents of children with ADHD undertaking a mindful parenting intervention. Complementary Therapies in Clinical Practice, 37, 39–46. https://doi.org/10.1016/j.ctcp.2019.08.005

Schwarz, A. (2017). ADHD Nation: Children, Doctors, Big Pharma, and the Making of an American Epidemic. Simon and Schuster.

Verbeeck, W., Bekkering, G. E., Noortgate, W. V. den, & Kramers, C. (2017). Bupropion for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database of Systematic Reviews, 10. https://doi.org/10.1002/14651858.CD009504.pub2

Assessing and Treating Clients 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.

Case: An elderly widow who just lost her spouse.

Three questions to ask the patient and a rationale for asking these questions.

  1. Who do you live with now?

I would like to know if she lives by herself, or if she is having company during this time when she is feeling depressed and unable to sleep.  I would be concerned for her if she wakes up in the middle of the night due to Insomnia, is probably tired or confused, and falls.  In addition, if someone helps her monitor her medication and make sure that she is taking it correctly.

  1. Could you tell me your medications, and how are you taking them?

 In this way, I will know if she really knows each medication, dosage, and frequency or if she is forgetting any of them.  Maybe she is not taking sertraline correctly or forgetting to take it and therefore she is feeling depressed again.

  1. Are you having negative thoughts or suicidal ideation?

It is important to know how severe her depression is and if she needs to be monitored 24 hrs in a mental health facility to prevent any event until the medication works.

 

People in the patient’s life to speak to or get feedback from to further assess the patient

I would like to know if she has any children, caregivers, or any support system that she usually goes to (such as a Pastor, church, friend, etc)  I would like to know her living situation, socio-economic status, if she does her ADLs or if she needs help, if she is having company during the day and at night, how many hours she is sleeping, if her house is safe for her (no cables or rugs on the floor), and if she normally does any activity that she is not doing anymore.

Physical and diagnostic tests

CBC, CMP, HGA1C, EKG, hepatic function panel, and Polysomnography. I will know her renal function (GFR), electrolytes, B12, if she has any QT interval or any heart dysrhythmia, thyroid function, etc. before I start any medication. According to Gerstenslager & Slowik (2021), stated “Polysomnography is a sleep study to diagnose any sleep disorder and in addition may be used to help initiate or adjust treatment plan”.  Psychiatrists frequently prescribe psychotropic drugs that may prolong cardiac repolarization, thereby increasing the risk for torsade de pointes (Funk ET al., 2018).

Differential diagnoses for the patient

1) Major depressive disorder (MDD)

2) Sleep Apnea

3) DM

My first differential is MDD- according to Otte et al., (2016) “MDD is a debilitating disease that is characterized by depressed mood, diminished interests, impaired cognitive function, and vegetative symptoms, such as disturbed sleep and appetite. Occurs about twice as often in women than it does in men”.

Pharmacologic agents and their dosing

Trazodone- FDA approved for depression and insomnia.  I will use this medication for an add augmentation with Sertraline 100 mg.  I will start low and slow 25 mg first 2 -4 weeks, especially for her age.  This medication is metabolized CYP450, half-life.  The first phase is approximately 3-6 hours and the second phase is approximately 5-9 hours.  Blocks serotonin 2 A receptors potently, blocks serotonin reuptake pump.  Onset therapeutic actions in Insomnia are immediate if dosing is correct.  The onset of therapeutic actions in depression is usually not immediate, often delayed 2-4 weeks whether given as an adjunct to another anti-depressant or as a monotherapy (Stahl, 2017).

Lunesta- metabolized by CYP 450 3A4 and 2E1, terminal elimination half-life approximately 6 hours, heavy high fat meal slow absorption, which could reduce the effect on sleep latency.  FDA approved for insomnia.  May bind selectively, a subtype of the benzodiazepine receptor.  May enhance GABA inhibitory actions that provide sedative-hypnotic effects more selectively than other actions of GABA.  Inhibitory actions in sleep centers may provide sedative-hypnotic effects and generally takes less than an hour (Stahl, 2017).

Drug therapy contraindications

One of the contradictions of using Trazodone– Do not take it with MAOI, caution for patients with a history of seizures, and reports of increased and decreased prothrombin time in patients taking warfarin (Stahl, 2017).

Checkpoints

Initial dosage 25-50 for 4 weeks.  If the symptoms are not improved, then I will increase the dosage as usually tolerated by 50-100 mg/day, but some patients may require up to the full antidepressant dose range.  However, I prefer to go low and slow due to her age (Stahl, 2017).

References

Funk, M. C.., Beach, S. R., Bostwick, J. R., Celano, C. M., Hasnain, M., Pandurangi, A., Khandai, A., Taylor, A., Levenson, J. L., Riba, M., & Kovacs, R. J. (2018).  Resources Document on QTc prolongation and psychotropic medications.  American Psychiatric Association.  https://content.waldenu.edu/content/dam/laureate/laureate-academics/wal/ms-nurs/nurs-6630/week-07/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med.pdf

Gerstenslager B, Slowik JM. Sleep Study. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563147/

Stahl S. (2017).  Essential psychopharmacology prescribers guide. (6th eds).  Cambridge, United Kingdom.

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