NURS 6630 WEEK 9 Assignment: Assessing and Treating Patients With ADHD

NURS 6630 WEEK 9 Assignment: Assessing and Treating Patients With ADHD

Assignment: Assessing and Treating Patients With ADHD

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.

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.

 

 

ORDER AN ORIGINAL NURS 6630 WEEK 9 ASSIGNMENT

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.

Attention Deficit Hyperactivity Disorder. A Young Girl With ADHD

BACKGROUND

Katie is an 8 year old Caucasian female who is brought to your office today by her mother & father. They report that they were referred to you by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have ADHD. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine whether or not she has this condition.
The parents give the PMHNP a copy of a form titled “Conner’s Teacher Rating Scale-Revised”. This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.
Katie’s parents actively deny that Katie has ADHD. “She would be running around like a wild person if she had ADHD” reports her mother. “She is never defiant or has temper outburst” adds her father.

SUBJECTIVE

Katie reports that she doesn’t know what the “big deal” is. She states that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds her other subjects boring, and sometimes hard because she feels “lost”. She admits that her mind does wander during class to things that she thinks of as more fun. “Sometimes” Katie reports “I will just be thinking about nothing and the teacher will call my name and I don’t know what they were talking about.”
Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. Offers no other concerns at this time.

MENTAL STATUS EXAM

The client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2’s and 5’s. Insight and judgment appear age appropriate. Katie denies any suicidal or homicidal ideation.
Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation

RESOURCES

§ Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein, J. N. (1998). Revision and restandardization of the Conners’ Teacher Rating Scale (CTRS-R): Factors, structure, reliability, and criterion validity. Journal of Abnormal Child Psychology, 26, 279-291.

Decision Point One

Select what the PMHNP should do:

• Begin Wellbutrin (bupropion) XL 150 mg orally daily
• Begin Intuniv extended release 1 mg orally at BEDTIME
• Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING

Learning Resources

Required Readings (click to expand/reduce)

Prince, J. B., Wilens, T. E., Spencer, T. J., & Biederman, J. (2016). Stimulants and other medications for ADHD. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 99–112). Elsevier.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

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

Martin, L. (2020). A 5-question quiz on ADHD. Psychiatric Times.
https://www.psychiatrictimes.com/view/5-question-quiz-adhd

Medication Resources (click to expand/reduce)

U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

 

Note:

To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

• armodafinil
• amphetamine (d)
• amphetamine (d,l)
• atomoxetine
• bupropion
• chlorpromazine
• clonidine
• guanfacine
• haloperidol
• lisdexamfetamine
• methylphenidate (d)
• methylphenidate (d,l)
• modafinil
• reboxetine

 

ORDER AN ORIGINAL NURS 6630 WEEK 9 ASSIGNMENT

 Solution to : Assessing and Treating Patients with ADHD

Attention deficit hyperactivity disorder (ADHD) is one of the most typical pediatric neurodevelopmental diseases. It is generally diagnosed in childhood and might persist into maturity (Shu-Cheng et al., 2020). ADHD is defined by a persistent cycle of inattention and hyperactivity-impulsivity that impairs performance or development. Although the etiology is uncertain, genetic and environmental factors are thought to have a role. ADHD is more common in males than in females, and females frequently report signs of inattention. There is no treatment for ADHD, but its symptoms can be managed with medication, psychotherapy, and education (Sumathi et al., 2019). This paper is based on the case study of a young Caucasian girl diagnosed with ADHD. It explores several treatment approaches taking into account pharmacokinetic and pharmacodynamics aspects. It also demonstrates how ethical concerns may impact the treatment strategy.

Case Scenario

The study involved Katie, an eight-year-old Caucasian female who arrived at the clinic with her parents, who claim that their PCP referred to them after seeking her advice after Katie’s teacher hinted that she could be having ADHD. According to the corners teachers rating scale-revised, Katie is inattentive, easily distracted, forgets what she has already learned, and poorly in spelling, reading, and arithmetic. Furthermore, her attention span is limited, and she only pays attention to things that pique her interest. According to the teacher, she seems uninterested in schoolwork and is often sidetracked. Katie is also known for starting things but never finishing them, seldom following through on directions, and failing to complete her schoolwork.

On the other hand, Katie’s parents deny that she has ADHD, claiming that she would have been running about like a wild person and that she is never disrespectful or has temper tantrums. She describes the school as “OK,” with art and recess being her favorite subjects. Other classes, she claims, are dull and sometimes challenging to complete since she is “lost.” The patient agrees that her attention does stray during class to topics she considers more enjoyable. Katie denies any abuse and school bullying. The patient looks to be developed for her age. Her words are clear, concise, and reasonable. She has no notable mannerisms, gestures, or tics. Euthymic is the self-reported mood. She denies any visual or auditory hallucinations, and no delusory or paranoid thoughts are tolerated. Her attention and attentiveness are both excellent. She has been diagnosed with ADHD, predominantly inattentive presentation.

Decision #1

To begin therapy, the PMHNP may prescribe Wellbutrin XL 150mg, Intuniv extended-release 1mg bedtime, or Ritalin chewable pills to the patient. As PMHNP caring for this patient, Ritalin chewable tablets of 10mg in the morning would be my first choice. This decision was made because Ritalin, a first-line pharmaceutical therapy for ADHD, provides the best mix of efficacy and side effects in children and adolescents with attention deficit hyperactivity disorder (Camp et al., 2021). Ritalin functions as a stimulant by inhibiting DA and NE reuptake, allowing these neurotransmitters to reach peak levels in the presynaptic cleft. The positive effects of Ritalin on attention maintenance have also been facilitated via alpha-1 adrenergic receptor activation. Clinical studies have revealed that children with ADHD had a mutation in the dopamine transporter, DRD-4, and D2 receptor genes, which may be partially compensated for by the dopaminergic actions of Ritalin.

Wellbutrin is another viable choice for ADHD management, but it takes more than four weeks to demonstrate the therapeutic effect, making it unsuitable as a first-line treatment. Furthermore, Wellbutrin is not generally suggested for children since its safety and efficacy have not been established (Camp et al., 2021). Intuniv, on the other hand, is often used as a supplementary treatment for ADHD to combat behavioral symptoms like social aggressiveness, hyperarousal, and emotional sensitivity rather than the core inattentive symptoms of ADHD.

I anticipate that Katie’s overall condition will improve after making this decision. After four weeks of therapy, Katie’s parents reported communicating with her teacher, who confirmed that Katie’s symptoms had significantly improved in the morning, resulting in improved performance. However, in the afternoon, she “stares off into space” and “daydreams” again. Her parents are also concerned about Katie’s allegation that her “heart felt funny.” Her heart rate was 130 bpm when she was examined. The outcomes are as predicted because Ritalin’s pharmacological impact is as limited as its duration of action, and this medicine raises peripheral norepinephrine levels, resulting in sympathetic side effects such as tachycardia and tremors.

Decision #2

At this decision point, I would switch the client’s prescription to Ritalin LA 20 mg PO OD to be taken in the morning. This choice was made considering that long-acting stimulant preparations are equally effective as short-acting ones and are more efficient due to improved compliance, a lower risk for addiction, and more extended coverage throughout the day (Zuddas et al., 2018).

Keeping the client on the same dose of Ritalin and re-evaluating in four weeks is not a practical option because the patient’s symptoms may persist. Discontinuing Ritalin and beginning the patient on Adderall XR 15 mg orally daily was not an appealing alternative in this scenario because the client responded positively to the previous prescription despite the considerable adverse effects. Furthermore, Adderall may create undesirable effects such as aggressiveness, psychosis, hallucination, anger, and seizures, making it unsuitable for the patient (Kerna et al., 2020).

By making this choice, I expect the client to report a considerable improvement in her symptoms throughout the day, academic performance, and a drop in her pulse rate. After four weeks of therapy, Katie reported an improvement in her academic performance and the fact that the shift to LA preparation spanned her the entire school day, and her “funny” heart sensation had vanished entirely. Katie’s pulse rate was 92 beats per minute after she was assessed.

Decision #3

      I would keep the client on his current Ritalin LA dose for the time being and reassess her in four weeks. This choice was selected since the client reported a satisfactory response to the dosage with no evident side effects. A heart rate of 92 beats per minute is typical for children aged 7 to 9 years old and does not necessitate an EKG. Furthermore, subjecting the youngster to intrusive diagnostic instruments when there is no justification to do so is not excellent patient care. Boosting the Ritalin LA dosage from 20mg to 30 mg orally once daily would not be a realistic choice because the existing dosage seemed helpful to the client, so there is no need for a quantity increment.

Ethical Consideration

Attention deficit–hyperactivity disorder, the most common neuropsychiatric ailment in children, is marked by inattention, impulsivity, and, in some cases, hyperactivity. Fundamental ethical considerations, such as the notion of autonomy, must be addressed in the provision of care. Before commencing treatment, PMHNP must get consent from the patient’s parents, considering the child’s opinions and wishes (Lundin, 2020). Because children are unreliable historians, PMHNP must acquire additional insight from their parents and teachers. Since most ADHD medications can become addictive if abused, it’s vital to evaluate for abuse because it might affect the clinical condition. Additionally, educating the patient and her caregivers about the symptoms and treatment options for this disease is crucial in ensuring that the illness does not persist into adulthood.

Conclusion

ADHD is a chronic neurodevelopmental disorder that primarily impacts children and adolescents and can impact adults in rare situations. This disease is only diagnosed once the client’s clinical symptoms have lasted for at least six months. ADHD is genetically determined. Environmental risk factors abound, with several prenatal events linked to an increased risk of ADHD. Management differs depending on the individual’s age, and medication must be used with caution in children owing to the unknown long-term effect on development. The ideals of autonomy, informed consent, and respect must all be honored when giving care.

 

References

Camp, A., Pastrano, A., Gomez, V., Stephenson, K., Delatte, W., Perez, B., . . . Guiseppi-Elie, A. (2021). Understanding ADHD: Toward an innovative therapeutic intervention. Bioengineering, 8(5), 56. doi:http://dx.doi.org/10.3390/bioengineering8050056

Kerna, N. A., Flores, J. V., Holets, H. M., Nwokorie, U., Pruitt, K. D., Solomon, E., & Kadivi, K. (2020). Adderall: On the Razor’s Edge of ADHD Treatment, Enhanced Academic and Physical Performance, Addiction, Psychosis, and Death. EC Psychology and Psychiatry, 9, 65-71.

Lundin, L. (2020). Parental narratives online about ADHD. Social Work in Mental Health, 18(6), 684-703.s

Shu-Cheng, C., Yu, J., Suen, L. K., Sun, Y., Ya-Zheng, P., Dong-Dong, W., . . . Wing-Fai Yeung. (2020). Pediatric 0RW1S34RfeSDcfkexd09rT2tuina1RW1S34RfeSDcfkexd09rT2 to treat attention deficit hyperactivity disorder (ADHD) symptoms in preschool children: Study protocol for a pilot randomized controlled trial. Pilot and Feasibility Studies, 6, 1-13. doi:http://dx.doi.org/10.1186/s40814-020-00704-z

Sumathi, M., Cholli, N. G., & Nayak, S. (2019). Classification of attention deficit hyperactivity disorder (ADHD) considering diagnosis and treatment. International Journal of Modern Education and Computer Science, 10(6), 26. doi:http://dx.doi.org/10.5815/ijmecs.2019.06.04

Zuddas, A., Banaschewski, T., Coghill, D., & Stein, M. A. (2018). ADHD treatment. Oxford textbook of attention deficit hyperactivity disorder, 379.