NURS 6630 Assessing and Treating Patients With ADHD

Sample Answer for NURS 6630 Assessing and Treating Patients With ADHD Included After Question

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.

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).

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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).

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).

NURS 6630 Assessing and Treating Patients With ADHD
NURS 6630 Assessing and Treating Patients With ADHD

            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).

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).

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 disorders22(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 Psychiatry5(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 pharmacology77(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 Psychiatry57, 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 psychology90(5), 367. https://doi.org/10.1037/ccp0000725

NURS 6630 Assessing and Treating Patients with ADHD

Attention Deficit/Hyperactivity Disorder (ADHD) is a developmental disorde, mostly diagnosed in children. The hallmark clinical features of ADHD are problems with executive functions. Children with ADHD exhibit difficulties in paying attention, inhibiting impulses, restraining movements, and regulating behavior (Drechsler et al., 2020). This adversely affects their communication, daily living, and socialization. The purpose of this assignment is to describe the case of a young girl with ADHD and discuss the treatment interventions appropriate for the patient.

Introduction to the Case

The case scenario concerns Katie, an 8-year-old girl who comes to the alongside her mother and father. They were referred to the psychiatric office by their PCP after they sought advice since Katie’s teacher states that she could have ADHD. The PCP referred Katie for psychiatric evaluation to establish whether she has ADHD. Katie’s parents have brought a copy of Conner’s Teacher Rating Scale-Revised questionnaire completed by the teacher.  The questionnaire responses reveal that Katie has problems with attention, memory, spelling, reading, and arithmetic and she gets easily distracted. Besides, she has a short attention span and mostly pays attention to what interests her. According to Katie’s teacher, she is disinterested in school work; she never completes what she initiates, including school work, and has problems following instructions. Katie states that her mind shifts when in class to things that she perceives as fun.

The patient factors that can affect decision-making when prescribing treatment include age, medication adverse effects, and parents’ treatment preferences. The prescriber must prescribe a medication approved for the patient’s age and diagnosis (Wolraich et al., 2019). Besides, the drug’s potential side effects should be considered to avoid causing more harm and promote compliance.  

Decision #1

Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING.

Why Did You Select This Decision?

In school-aged patients, 6 years and older, amphetamine and methylphenidate stimulants are the recommended first-line agents for ADHD (Wolraich et al., 2019). Ritalin was selected because approximately 75% of ADHD patients respond to the initial stimulant (Jerome & Jerome, 2020). Thus, there is a high chance that Katie will respond to the initial treatment with Ritalin.

Why Did You Not Select The Other Two Options Provided In The Exercise?

Wellbutrin was not selected because of its slow onset of action. Deang et al. (2019) explain that Wellbutrin takes some time before its full benefit is realized. Compared to the quick onset of stimulants, it can take 3-7 days to see any benefits of Wellbutrin. Intuniv was not also selected because it is recommended as a second-line agent for ADHD, and should only be considered when first-line agents are ineffective or not tolerated (Jerome & Jerome, 2020).

What I Was Hoping To Achieve By Making This Decision

The PMHNP hoped that Ritalin would significantly alleviate Katie’s ADHD symptoms, thus increasing her attentiveness in class and reducing distractibility without adverse effects. According to Drechsler et al. (2020), Ritalin is one of the most effective medications in treating ADHD symptoms, and it has a good efficacy and side effect profile.

Ethical Considerations Impact on Treatment Plan and Communication

The ethical principle of beneficence may affect treatment since the prescriber is required to identify and prescribe a drug associated with the best outcomes for 8-year-olds with ADHD. Informed consent may affect communication since the clinician will be expected to seek consent from Katie’s parents before starting treatment.