Assignment: Assessing and Treating Clients With ADHD NURS 6630

Assignment: Assessing and Treating Clients With ADHD NURS 6630

Assignment: Assessing and Treating Clients With ADHD  NURS6630

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.

Assignment: Assessing and Treating Clients With ADHD  NURS6630

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

Not only do children and adults have different presentations for ADHD, but males and females may also have vastly different clinical presentations. They 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 mental health nurse practitioner, you must perform careful assessments and weigh the risks and benefits of medication therapies for clients across the lifespan. For this Assignment, you consider how you might assess and treat clients presenting with ADHD.

Learning Objectives
Students will:
Assess client factors and history to develop personalized therapy plans for clients with ADHD
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for ADHD
Evaluate efficacy of treatment plans
Evaluate ethical and legal implications related to prescribing therapy for clients with ADHD
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Read Also: NURS 6630 Therapy for Patients With Impulsive Substance Use Disorders SUD Tasks

Assignment: Assessing and Treating Clients With ADHD NURS 6630

Required Readings
Note: Review all materials from the Discussion.

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.

Note: Retrieved from Walden Library databases.

Required Media
Laureate Education (2016d). Case study: A young Caucasian girl with ADHD [Interactive media file]. Baltimore, MD: Author

Note: This case study will serve as the foundation for this week’s Assignment.

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To prepare for this Assignment:

This case study will serve as the foundation for this week’s Assignment.
The Assignment
Examine Case Study: A Young Caucasian Girl With ADHD You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

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Making Connections
Now that you have:

Assessed clients presenting with ADHD
Developed personalized plans of therapy for clients with ADHD
Examined factors that influence pharma