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Assessing and Treating Patients With ADHD Not only do children and adults have d

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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, you must perform careful assessments and weigh the risks and benefits of medication therapies for patients across the life span. For this paper, you consider how you might assess and treat patients presenting with ADHD.
To prepare for this Assignment:
• Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with ADHD.
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
• 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
• 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
• 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
• 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.
• 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.
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.
CASE STUDY
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 you 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 you should do: Select one of these decisions.
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.
*Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING. This is the best options to choose.
*Decision Point One
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better in the morning, which has resulted in improvement in her overall academic performance. However, by the afternoon, Katie is “staring off into space” and “daydreaming” again
Katie’s parents are very concerned, however, because Katie reported that her “heart felt funny.” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute
*Decision Point Two
Continue same dose of Ritalin and re-evaluate in 4 weeks
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s academic performance is still improved, but her attention continues to worsen throughout the school day
Katie is still reporting that her heart feels “funny.” Today’s pulse rate is 122 beats per minute, regular rhythm
Decision Point Three
Change to Ritalin LA 20 mg orally daily in the morning
Guidance to Student
Ritalin LA would be a good choice in this case as the side effect of tachycardia could be related to the immediate release Ritalin. There is no indication for a STAT EKG unless Katie’s pulse were irregular or there were other signs of cardiac abnormality noted. Discontinuation of immediate release Ritalin in favor of immediate release Adderall would be of questionable benefit, and may be associated with the same side effect. Additionally, immediate release preparations will not last throughout the school day to maintain Katie’s attention.
*Decision Point One
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better in the morning, which has resulted in improvement in her overall academic performance. However, by the afternoon, Katie is “staring off into space” and “daydreaming” again
Katie’s parents are very concerned, however, because Katie reported that her “heart felt funny.” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute
*Decision Point Two
Discontinue Ritalin and begin Adderall XR 15 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s academic performance is still improved, and the XR preparation has helped sustain her attention throughout the school day, however, you also learn that Katie is having tachycardia with this medication, too
*Decision Point Three
Maintain current dose of medication and re-evaluate in 4 weeks
Guidance to Student
Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. You should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.
Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.
There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.
*Decision Point One
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better in the morning, which has resulted in improvement in her overall academic performance. However, by the afternoon, Katie is “staring off into space” and “daydreaming” again
Katie’s parents are very concerned, however, because Katie reported that her “heart felt funny.” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute
*Decision Point Two
Discontinue Ritalin and begin Adderall XR 15 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s academic performance is still improved, and the XR preparation has helped sustain her attention throughout the school day, however, you also learn that Katie is having tachycardia with this medication, too
*Decision Point Three
Decrease to Adderall XR 10 mg orally daily
Guidance to Student
Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. You should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.
Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.
There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.

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