Assignment: Assessing and Treating Patients With ADHD NURS 6630
A Sample Answer For the Assignment: Assignment: Assessing and Treating Patients With ADHD NURS 6630
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.
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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.
The patient is an 8-year-old Caucasian girl who was referred by a primary care physician and was brought in by her parents. The patient’s primary care provider assessed the patient after the teacher raised the possibility that she might have ADHD.”Corners Teacher Rating Scale -Revised” is presented by the parents. Katie exhibits inattentive, easily distracted, forgetful, poor spelling, poor reading, and poor arithmetic behaviors, per the teacher’s evaluations.
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Katie has a limited attention span, focuses on what interests her, and shows little enthusiasm for her homework. Katie is known for starting things but not finishing them and for not doing as she is told. Parents believe Katie would exhibit behavioral outbursts and be perpetually hyperactive if she had ADHD. Katie acknowledges having a restless mind in class and finding most courses to be dull. Katie rejects any claims of bullying at school.
She speaks clearly and coherently, and she is suitably matured. She is dressed appropriately for the place and the weather and is aware of place, time, and other person. She doesn’t exhibit any notable tics, gestures, or mannerisms. A euthymic mood is self-reported. No delusions, paranoia, or hallucinations.
Can count from 100 by 2s and 5s and has mostly intact attention and concentration, insight and sound judgment, denying SI and HI. Intuniv ER 1mg at bedtime, bupropion XL 150mg PO daily, or 10mg chewable methylphenidate in the morning are the three options for Katie after her ADHD diagnosis.
Decision One: Begin Ritalin (methylphenidate) Chewable Tablets 10 Mg Orally in the Morning
The initial choice was to take 10mg of oral methylphenidate chewable tablets in the morning. The family reported that the patient does not look hyper at home and that the most of the attention problems arise in school, which was the impetus for the decision. Psychostimulants have a solid track record of short-term efficacy and have been shown to be both secure and reliable.
This prescription is beneficial because it can be used for a short, medium, or long period of time, providing the patient with coverage during school and other associated activities while letting the drug to wear off and not be in the system for a longer period of time during the day (Mühlberger et al . ,2020).
Because bupropion XL is not regarded as a first-line therapy and can cause suicidal thoughts in children, it was a poor choice. Additionally, bupropion has a half-life of up to 21 days, so adverse effects might not manifest right away. Additionally, bupropion takes time to take effect.
Her symptoms were noted at school, and Intuniv XL was not chosen because it is not regarded as a first-line treatment, has side effects like hypotension, bradycardia, and sedation, and takes time to take effect. The dosage is appropriate and is still a possibility. If the patient is not having any issues with sleeplessness or hyperactivity at home, the medication’s sedative effect may not be good (Huecker et al, 2017).
Decision Two: Change to Ritalin LA 20mg Orally Daily in the Morning
Results reveal that after four weeks, teachers are aware that the patient loses focus in the afternoon but that her symptoms are improved in the morning. The complaints of “feeling heart funny” and a heart rate of 130 beats per minute worry the parents.
Continue and reevaluate in four weeks, switch to Ritalin 20mg taken orally in the morning, or stop Ritalin and start Adderall XR 15 PO are the alternatives on the table. Making the right choice with Ritalin LA 20mg PO in the morning was crucial. Ritalin affects cognition, motivation, and action by increasing the amount of dopamine produced in the striatum (Smith, 2017).
Due to the patient’s cardiac complaints while using Adderall and the fact that they were losing concentration in the middle of the day, altering the drug was a critical step in preventing future effects. Because the medication has a long half-life, it won’t lose its effectiveness in the middle of the day. Since Adderall was one of two options, it was not chosen.
There was a need to increase the amount because the first dose was ineffective and had negative side effects. The fact that Adderall increases dopamine, serotonin, and norepinephrine levels can increase heart rate or cause a fluttering sensation and should thus not be prolonged or increased (Wolraich et al., 2019).
Decision Three: Maintain Current Dose of Ritalin LA and Reevaluate in 4 Weeks
Academic performance increased and persisted as a result of this choice after four weeks, and her chest felt better with a heart rate of 92 beats per minutes during the clinic appointment. There are three options: stick with the existing course of treatment with a follow-up evaluation in four weeks, up the dosage of Ritalin LA to 30 mg PO, or get an EKG based on Katie’s heart rate. The decision is to stick with the existing course of treatment and reevaluate after 4 weeks.
This choice was taken because there are now no side effects or adverse events documented and the patient’s symptoms seem to be under control. Since the patient is feeling better and the higher dose could result in side effects or symptoms, it is not necessary to increase the medication to 30 mg PO. Since the patient’s heart rate is within normal ranges and they are not currently complaining of chest pain, heart palpitations, or tachycardia, an EKG is not required (Ghanaatgar et al., 2022).
Conclusion
Stimulant medication classes are one of the most well-known ways to treat ADHD, which is a frequent diagnosis and has many treatment options. Stimulants have a short half-life, are effective, and operate quickly. They have their drawbacks, yet they can be useful at work and at school without having sedative or suicidal effects. Children who use drugs that influence serotonin are more likely to have suicide thoughts. When giving a child medication, it’s crucial to keep an eye out for any side effects and changes (Rajeh et al, 2017).
Katie began to get better, but stimulants can make your heart race and make your chest flutter. Because Adderall affects serotonin, dopamine, and norepinephrine, it is more likely to result in those side effects. Therefore, switching the patient to a stimulant that only affects dopamine can lessen the symptoms. It’s also critical that the medication be long-lasting rather than short-lasting, which would wear off in the middle of the class (Harris & Green 2019)
References
Ghanaatgar, M., Taherzadeh, S., Ariyanfar, S., Jahromi, S. R., Martami, F., Gharaei, J. M., … & Shahrivar, Z. (2022). Probiotic supplement as an adjunctive therapy with Ritalin for treatment of attention-deficit hyperactivity disorder symptoms in children: A double- blind placebo-controlled randomized clinical trial. Nutrition & Food Science, 53(1), 19- 34. Doi: 10.1108/NFS-12-2021-0388/full/html
Harris, S., & Green, S. (2019). Role of Cortical Catecholamines in the Paradoxical Action of Psychostimulants. The FASEB Journal, 33(S1), lb90-lb90. Doi: 10.1038/s41598-022- 07029-2.
Huecker, M. R., Smiley, A., & Saadabadi, A. (2017). Bupropion. https://pubmed.ncbi.nlm.nih.gov/29262173/
Mühlberger, A., Jekel, K., Probst, T., Schecklmann, M., Conzelmann, A., Andreatta, M., … & Romanos, M. (2020). The influence of methylphenidate on hyperactivity and attention deficits in children with ADHD: a virtual classroom test. Journal of Attention Disorders, 24(2), 277-289. Doi: 10.1177/1087054716647480.
Rajeh, A. Amanullah, S., Shivakumar, K., & Cole, J. (2017). Interventions in ADHD: A comparative review of stimulant medications and behavioral therapies. Asian Journal of Psychiatry, 25, 131-135. Doi: 10.1016/j.ajp.2016.09.005.
Smith, M. (2017). Hyperactive around the world? The history of ADHD in global perspective. Social History of Medicine, 30(4), 767-787. Doi: 10.1093/shm/hkw127
Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., & Zurhellen, W. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4). Doi: 10.1542/peds.2019-2528
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.
Attention-deficit/hyperactivity disorder (ADHD) is a mental condition that is mostly common among children. The condition is associated with various behavioral symptoms including issues with maintaining good attention, excessive motor activities, and impulsiveness during the subsistence of the condition. The symptoms of ADHD in children include challenges in socializing with peers, poor grades in class, and excitability. The diagnosis of ADHD is challenging because it is problematic to determine the precise setting where the victims can demonstrate the symptoms. However, if some of the above mentioned symptoms endure for more than six months, it is can result in diagnosis of the conditioned and consequently pave way for an effective therapy (Ahmann et al., 2017). The aim of this paper is to delve into the management of ADHD on an 8-year-old Caucasian girl. In particular, a therapy will be developed based on pharmacokinetics and pharmacodynamics. Moreover, ethical considerations of the therapy will be examined.
Summary of the Case
The present case involves is about an 8-year old Caucasian female named Katie. She was brought to the clinic by her parents after receiving a referral from the primary care provider (PCP) after an evaluation by her teacher and a perception that she might be having ADHD. Parents wanted their daughter to be evaluated by a psychiatrist to affirm or rule out ADHD as reported by Katie’s teacher. In addition, the parents handed over a Corner’s Teacher Rating Scale-Revised form to the psychiatric-mental health nurse practitioner (PMHNP) which was filled by Katie’s teacher to report about the patient’s symptoms. According to the report, Katie is easily distracted, inattentive, forgetful in addition to having challenges with spelling, arithmetic, and reading. She also has a short attention span and mostly attends to activities that are of interest to her. According to the teacher, Katie is not interested in classwork, and that she gets easily distracted with non-academic things. She can also start activities and fails to finish them and rarely follows instructions required to accomplish schoolwork. Katie’s parents, however, deny the teacher’s assertion about the condition of their daughter arguing that she could manifest psychotic symptoms that they have not yet seen in their child. In using the DMS-IV rating scale, Katie’s condition points to ADHD. She has difficulty in paying attention and is also hyperactive when informed about her mental condition. Besides, Katie acts without thought especially when she affirms that she likes art and recess but finds other school subjects boring. She, therefore, misses the details as to why she has been enrolled in a school and is likely not to apply mental effort required in learning if not treated on time.
First Decision Point
Chosen Decision
Begin the patient on Ritalin 10 mg tablets PO in their chewable form in the mornings.
Reasons for the Selecting this Decision
Ritalin (methylphenidate) is approved by the FDA as the first line medication in the ADHD management. Ritalin is also ideal compared to other non-stimulant agents ion relation to the effect size. While effect size of Ritalin is 0.5, other non-stimulant agents such as Intuniv has effect size of 0.9. Mechanically, Ritalin operates by inhibiting the dopamine and neurotransmitters norepinephrine reuptake. In addition, the medication contains a concentration of a plasma bi-modial when administered to children orrally. Moreover, the medication contains plasma binding in low capacity and a bioavailability of 22±8%, which is an indication of a marked presystemic metabolism. The adverse effects of the medication in children is relatively low given that it has a rapid half-life of about 3.5 hours (Brown et al., 2018). Other medications such as Wellbutrin was not considered in this case because of minimal safety profile especially in children. It also has many side effects including seizures, making it unfit for children. Therefore, this drug was not used because it is considered as an alternative non-stimulant agent that is not FDA authorized.
Expected Results in this Decision
Ritalin has been demonstarted to generate the desired effects 2 weeks following adminstration. Therefore, the PMNHP anticipates that the girl would demonstrate high concentration, interpersonal relationships, and improved focus (Brown et al., 2018). The rationale for opting for lower dose daily is informed by a precautionary measure not to affect the girl by the medication.
Differences between Anticipated and Real Results
The patient was presented back to the facility after two weeks. After assessment and data collection, the PMNHP realized that the girl did not demonstrate signs of being inattentive in school during morning hours. Consequently, the secondary data identified that the girl had improved in her academic performance. This is essentially in line with what the PMNHP expected. However, the improvements were shown to deterioriate during the afternoon hours due to the reduction in the therapeutic effect of the Ritalin. As a result, the girl starts wandering into space and daydreaming in the afternoon hours. The Tachycardia, which is a side-effect commonly associated with Ritalin was also reported in patient.
How Ethical Considerations May Impact the Treatment Plan
There is need for ethical considerations in the treatment plan such as autonomy to help in engaging the patient and her family in the treatment process. Beneficence and nonmaleficence considerations are also necessary in ensuring that the identified plan results in the best care outcomes without the risk of harm to the patients (Slade, 2017). For example, the medication chosen in this case is effective in treating ADHD with least side effects that cannot cause harm to the girl.
Second Decision Point
Chosen Decision
Shift to 20 mg of Ritalin LA once daily in the morning.
Reason for Selecting this Decision
The ratiobnale of increasing the dosage is to help in managing the elevated hearts which emanated as a consequence of the initail decision. Increasing the Ritalin dosage is essential for long action, thus, making it have extended therapeutic effect on the patient, which can last for about 12 hours unlike the initial dosage which had half-life of 3.5 hours. Also, it is likely to be controlled and demonstrate reduced release nature, which is crucial in minimizing the peak plasma concentration of the medication, thus, dealing with the cardiovascular side effects that the patient experienced after the initial intervention (Ching et al., 2019). There was no any drug compliance issues reported in patient and so, it is not neccesary to opt for other agents such as Adderal. In fact, Adderal is likely to result in increased heart beats as side effects similar to what was reported in the initial intervention.
Expected Results in this Decision
The expectation by the PMHP is that the girl would demonstrate controlled symptoms the whole day for the duration of four weeks that she would be on the long acting medication. She is also expected to have better concentration both in the morning and evening hours. The improved concentration should in turn help her to improve in her academic performance at school. Moreover, the PMNHP anticipates that the girl’s heart rate activities will be restored back to normal within the medication period (Konrad-Bindl et al., 2016).
Differences between Expected Results and Real Results
When the patient visited after four weeks, the assessment and data gathered through secondary sources indicated that her concentration at school improved after effecting the adjustments to the original therapy. As a result, their was outstanding improvement in her academic performances. Moreover, the patient’s heart rate stabilized as a result of using the Ritalin LA. This improvement in the patient outcomes is attributed to consistent compliance to the therapy as anticipated by the PMNHP.
How Ethical Considerations May Impact the Treatment Plan
Ethical principles of beneficence and nonmaleficence can possibly impact treatment plan by determining how the medication can help patient and the possible side effects of the treatment choice (Slade, 2017). For instance, in the present case, Ritalin was opted for due to its potential in ensuring beneficence and other medications such as Wellbutrin avoided due to their dire side effects that may cause harm to the patient.
Third Decision Point
Chosen Decision
The Ritalin dosage will be maintained. However, the girl will have to be re-evaluated after four weeks following the administration of medication.
Reason for Selecting this Decision
As shown above, the girl positively responded to the second dosage. The dosage proved effective in managing the symptoms and addressing the Tachycardia, which is an indication that it is necessary for the nurse to maintain this therapy. The idea of increasing the dosage of Ritalin LA to 30 mg was ruled out on the ground that it is likely to lead to negative events as a result of increased plasma concentration which can lead to another incidences of reccurance of increased heart rate (Huss et al., 2017). The current heart rate of the girl is 92, which is in the ordinary heart rate range for children and young people between the ages 6-12. Imperatively, the impacts of extended use of Ritalin in children have not been systematically assessed and established. As such, it is vital to conduct the re-assessment after four weeks.
Expected Results in this Decision
The expectation is that the girl will consistently demonstrate improvements in concentration, which would in turn ensure better improvement in her academic performances. It is also expectation of the PMNHP that heart rate of the girl will return to the normal range for young children which is between 75-118. Regarding the side efefcts, it is the expectation of the PMNHP that no side effects will be manifested in patient again.
Differences between Expected Results and Real Results
The restraint of the symptom in the patient is anticipated to persist. As a result, the expectation is that the patient would improve in her concentration in class the entire day without any distractions. Moreover, it is expected that the heart rate will continue to be about 92 and no severe side effect wiil manifest. To achieve these expectations, the patient should strictly adhere to the medications to benefit from the long-term positive impacts.
How Ethical Considerations May Impact the Treatment Plan
Ethical considerations such as nonmaleficence and beneficence can potentially impact the treatment plan by ensuring that the identified medication fosters desired outcomes. The benefits of the medication should also offset the risk (Slade, 2017). Upholding these considerations can be demonstrated in efforts to reduce side effects of medication by reducing the dosage in case of side effect or opting for a drug with insignificant or no side effects.
Conclusion
ADHD as a mental condition that is assocaited with many dire consequences in young children. The disgnosis of the ADHD is chalenging due to several symptomatology similarities it has with other mental health conditions. However, stimulants such as Ritalin have proven valuable in managing this condition. The first decision entailed the use of ritalin 10 mg in its chewable form to ensure compliance. The client’s parents and teachers repoerted improved symptomatology by the patient. Her concentration and attention to things improved significantly. However, the intervention also produced a side effect of increased heart beat rate, which is common in the drug in some cases (Brown et al., 2018). As such, I was compelled to ensure that the next decision would address the side effect. As such, I chose to use 20 mg of the same medication but in its longacting form. The longacting nature of the drug was effective in managing both the high heart rate side effect. In addition, the long acting capacity improved the therapeutic effect of the drug. The client was able to concentrate on activities throughout the day.
The improved therapeutic impact of the second choice meant that it was unnecessary to interfere with the therapy. As such, the Ritalin dosage and nature were maintained. However, I choose to recommend another assessment within 4 weeks to monitor the progress of the therapy. The other reason for conducting the assessment after four weeks is based in the fact that the effect of the long acting nature of the drug has not been established (Konrad-Bindl et al., 2016). As such, I chose the decision deliberately for those reasons. Therefore, Ritalin is an effective drug in the management of the ADHD in the patient.
References
Ahmann, E., Saviet, M., & Tuttle, L. J. (2017). Interventions for ADHD in children and teens: A focus on ADHD coaching. Pediatric Nursing, 43(3), 121. https://search.proquest.com/openview/e957b43bd0b75aec19bee528ffece353/1?pq-origsite=gscholar&cbl=47659
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. doi: 10.21037/tp.2017.08.02
Ching, C., Eslick, G. D., & Poulton, A. S. (2019). Evaluation of methylphenidate safety and maximum-dose titration rationale in attention-deficit/hyperactivity disorder: a meta-analysis. JAMA pediatrics, 173(7), 630-639. doi:10.1001/jamapediatrics.2019.0905
Huss, M., Duhan, P., Gandhi, P., Chen, C. W., Spannhuth, C., & Kumar, V. (2017). Methylphenidate dose optimization for ADHD treatment: review of safety, efficacy, and clinical necessity. Neuropsychiatric disease and treatment. https://psycnet.apa.org/record/2017-30608-001
Konrad-Bindl, D. S., Gresser, U., & Richartz, B. M. (2016). Changes in behavior as side effects in methylphenidate treatment: review of the literature. Neuropsychiatric disease and treatment. https://psycnet.apa.org/record/2016-51190-001
Slade, M. (2017). Implementing shared decision making in routine mental health care. World psychiatry, 16(2), 146-153. https://doi.org/10.1002/wps.20412
To prepare for this Assignment:
- Review this week’s Learning Resources, including the Medic