Assignment; NUR 6630 Assessing and Treating Patients with ADHD

Assignment; NUR 6630 Assessing and Treating Patients with ADHD

Assignment; NUR 6630 Assessing and Treating Patients with ADHD

Attention deficit hyperactive disorder (ADHD) is a neurodevelopmental disorder that psychiatric mental health nurse practitioners (PMHNP) experience in their practice. The affected patients present with symptoms that include impulsive behaviors, inattention, and hyperactivity. Patients with ADHD have difficulties in engaging mentally tasking activities such as arithmetic and tend to focus on things that are of interest to them. PMHNP are responsible for developing effective care plans that improve the functioning and learning of the patients diagnosed with ADHD. Therefore, this essay examines a case study involving an 8-year-old child who has been diagnosed with ADHD. The paper develops a treatment plan and focuses on ethical considerations that would affect treatment decisions.

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The patient in the case study is Katie. She is an 8-year-old Caucasian female brought to the office by her parents after being referred by her primary care provider. Katie’s teacher thinks that Katie may have ADHD, hence, the need for psychiatric review. The report entitled Conner’s Teacher Rating Scale-Revised shows that Katie is inattentive, easily distracted, forgets things easily, poor in spelling, arithmetic, and reading. She also has short attention span, lacks interest in schoolwork, easily distracted, starts things and never finishes them, and rarely follows through instructions. She also fails to finish her schoolwork. Katie agrees with the report that some subjects are boring, feels lost at times, wanders, inattentive, and denies bullying or abuse. Mental status examination is unremarkable except her euthymic mood and grossly intact attention. She has been diagnosed with attention deficit hyperactive disorder, predominantly inattentive presentation. The patient factors that will influence treatment decisions include her age and presenting symptoms.

Decision 1

Selected Decision

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

Why the Decision was Selected

I selected the decision to start Katie on Ritalin because the Food Drug and Administration (FDA) have recommended it as the drug of choice for treating ADHD in children. Ritalin works by increasing the concentration of dopamine and norepinephrine neurotransmitters in the brain. These neurotransmitters regulate mood, attention, and behavior. As a result, an increase in their concentration would enhance Katie’s attention, learning, and behavior in school(Roche et al., 2021). Studies support that Ritalin improves core functioning in school activities, socialization, and retention of information among patients diagnosed with ADHD.

Why the Other Two Options Were not Selected

I did not select the decision to initiate the patient on Wellbutrin (bupropion) XL 150 mg orally daily. This is because bupropion is an antidepressant that is recommended for use by patients who intend to stop smoking. The existing guidelines also consider its use as an alternative treatment for ADHD when the first line options have been tried(Kweon& Kim, 2019). I did not start Katie on Intuniv extended release 1 mg orally at bedtime. This is because it is associated with considerable adverse effects that may affect treatment outcomes. Evidence has shown that Intuniv is a sedative, which may affect Katie’s learning and attention further. Besides, it increases the risk of hypotension, fatigue, and headache, which makes Ritalin the drug of choice(Yu et al., 2023).

What I was hoping to Achieve

Ritalin improves mood, attention, learning, and behavior. As a result, I was hoping to achieve an improvement in ADHD symptoms such as inattention and her school performance. I was also hoping that Katie’s social skills would improve with the administration of Ritalin(Roche et al., 2021).

Ethical Considerations

Children are considered a vulnerable population in health. They are increasingly predisposed to harm because of most drugs being off-label. They also have immature organs needed for drug absorption, metabolism, and elimination. Therefore, PMHNP should prioritize safety in the treatment of ADHD. The selected drug should be free of any potential harm while optimizing treatment benefits(Butts & Rich, 2019). The PMHNP should also rely on the sources of evidence-based data and clinical guidelines when making decisions to initiate Katie on Ritalin.

Decision 2

Selected Decision

Change to Ritalin LA 20 mg orally daily in the morning.

Why the Decision was Selected

I selected the decision to change to Ritalin LA 20 mg orally daily in the morning because of the symptom changes reported after four weeks. Katie returned to the office after four weeks with evidence of improved symptoms of ADHD. The parents report that there has been an overall improvement in her academic performance. The teacher reports that the symptom improvements are evident in the morning. However, Katie begins to stares off into space and daydreams by the afternoon session. Katie’s parents were also concerned about her heart feeling funny. They reported a pulse rate of 130 beats per minute. The report demonstrates that Ritalin had mild effect on ADHD symptoms. The therapeutic dosage of Ritalin has not been achieved leading to her starring off and daydreaming in the afternoon. The parents’ concern about the pulse rate is expected because of side effect of Ritalin. The side effects improve with time(Sibeoni et al., 2023; Sun et al., 2019). Therefore, an appropriate decision is to change to long acting form of Ritalin to ensure its effects last throughout the day for sustained and improved ADHD symptoms.

Why the Other Two Options Were not Selected

I did not select the decision to continue with the same dose of Ritalin and re-evaluate after 4 weeks. This is because the optimum therapeutic effect of Ritalin has not been reached. The client reports only mild improvement in symptoms. Maintaining the current dose will not lead to the desired improvement in ADHD symptoms and functioning. I did not select the decision to discontinue Ritalin and begin Aderral XR 15 mg orally. Katie tolerated the initial dose of Ritalin. There were also mild to moderate improvement in ADHD symptoms. As a result, it does not warrant a change in treatment (Roche et al., 2021). Changing the treatment may result in symptom worsening and development of adverse reactions.

What I was hoping to Achieve

The long acting form of Ritalin would result in sustained symptom management throughout the day. As a result, I was hoping Katie’s teacher would report that her attention span is sustained throughout the day. I was also hoping that Katie’s class performance would improve. I was also hoping that she would tolerate the current dosage of Ritalin(Roche et al., 2021).

Ethical Considerations

The promotion of patient’s autonomy in psychiatric practice is important, as it influences treatment choices and outcomes. PMHNP should inform and involve patients and their significant others in decision-making. They should also make decisions that prioritize their values, needs, and preferences. This implies that PMHNP should involve Katie and her parents in the treatment by seeking informed consent before initiating any treatments(Butts & Rich, 2019). The provision of autonomous care results in outcomes such as enhanced patient satisfaction, empowerment, and treatment adherence.

Decision 3

Selected Decision

Maintain the current dose of Ritalin LA and re-evaluate in 4 weeks.

Why the Decision was Selected

I chose the decision to maintain the current dose of Ritalin LA and re-evaluate in 4 weeks. This was because the desired improvements in ADHD symptoms had been achieved. Katie returned to the clinic in four weeks. Her academic performance is still improved. The switch to the LA preparation is lasting Katie throughout the school day. Katie’s reports of her heart feeling funny have also gone away. Her pulse rate today was 92 beats per minute. The report implies that the desired therapeutic dose and effectiveness of Ritalin LA has been achieved(Roche et al., 2021). The dosage should be maintained to sustain the symptom improvements and minimize the risk of adverse reactions to Ritalin.

Why the Other Two Options Were not Selected

I did not choose the decision to increase Ritalin LA to 30 mg orally daily. There was no indication to increase Ritalin LA dosage. The desired outcomes have been achieved. A further increase in Ritalin LA dosage may result in unwanted side and adverse effects(Sibeoni et al., 2023). I did not choose the decision to obtain EKG based on current heart rate. This is because Katie’s pulse rate is within the normal range for her age.

What I was hoping to Achieve

I was hoping to sustain symptom improvements with the selected decision. I was also hoping continued improvement in Katie’s academic performance. I was also hoping that Katie would continue to tolerate the current dose of Ritalin LA(Sun et al., 2019).

Ethical Considerations

A breach of Katie’s right to privacy and confidentiality would affect the treatment decisions. The PMHNP has the professional responsibility of ensuring the protection of Katie’s data integrity. Her personal data should not be shared or accessed by unauthorized persons without seeking assent from her and consent from her parents(Butts & Rich, 2019). Unauthorized access would raise ethical and legal issues in her care process, hence, the need for the promotion of data integrity.

Conclusion

The decision to start Katie on Ritalin was effective. The FDA has approved the use of Ritalin in treating ADHD in children. The first decision led to mild improvement in ADHD symptoms. This prompted a change of treatment to Ritalin LA, which was effective in producing lasting improvement in ADHD symptoms. I selected Ritalin with the aim of improving her academic performance, attention, social skills, and functioning. These objectives were achieved by the time the third decision was made (Roche et al., 2021; Shellenberg et al., 2020). The decisions not to select the given alternatives were based mainly on the weighing of benefits and risks of their use in ADHD. It also entailed the consideration of the best practice evidence and clinical guidelines. It was imperative to select a drug that had minimal risk of harm to Katie and optimum potential of improving her ADHD symptoms.

Ethical considerations influenced Katie’s treatment decisions. One of them was the need for the promotion of data integrity. It is the PMHNP’s professional responsibility to ensure that Katie’s data is kept private and confidential. This would ensure the provision of care that aligns with the different legal requirements of safety, efficiency, and quality of psychiatric care. The other ethical consideration that influenced Katie’s treatment is the need for the promotion of safety in the treatment process. PMHNP have the professional responsibility of selecting treatments that are not associated with the risk of patient harm(Butts & Rich, 2019). As a result, Ritalin was selected since the FDA and clinical guidelines recommend its use based on its high safety index. Lastly, it was important to promote autonomous care in Katie’s case. Katie’s family input and decisions must be prioritized in the disease management process.

References

Butts, J. B., & Rich, K. L. (2019).Nursing Ethics: Across the Curriculum and Into Practice. Jones & Bartlett Learning.

Kweon, K., & Kim, H.-W. (2019). Effectiveness and Safety of Bupropion in Children and Adolescents with Depressive Disorders: A Retrospective Chart Review. Clinical Psychopharmacology and Neuroscience, 17(4), 537–541. https://doi.org/10.9758/cpn.2019.17.4.537

Roche, M., Mircher, C., Toulas, J., Prioux, E., Conte, M., Ravel, A., Falquero, S., Labidi, A., Stora, S., Durand, S., Mégarbané, A., &Cieuta-Walti, C. (2021). Efficacy and safety of methylphenidate on attention deficit hyperactivity disorder in children with Down syndrome. Journal of Intellectual Disability Research, 65(8), 795–800. https://doi.org/10.1111/jir.12832

Shellenberg, T. P., Stoops, W. W., Lile, J. A., & Rush, C. R. (2020). An update on the clinical pharmacology of methylphenidate: Therapeutic efficacy, abuse potential and future considerations. Expert Review of Clinical Pharmacology, 13(8), 825–833. https://doi.org/10.1080/17512433.2020.1796636

Sibeoni, J., Manolios, E., Hausser, C., Delage, R., Baylé, F., Speranza, M., Verneuil, L., &Revah-Levy, A. (2023).Perspectives of French adolescents with ADHD and child and adolescent psychiatrists regarding methylphenidate use.Scientific Reports, 13(1), Article 1. https://doi.org/10.1038/s41598-023-30921-4

Sun, C.-K., Tseng, P.-T., Wu, C.-K., Li, D.-J., Chen, T.-Y., Stubbs, B., Carvalho, A. F., Chen, Y.-W., Lin, P.-Y., Cheng, Y.-S., & Wu, M.-K. (2019). Therapeutic effects of methylphenidate for attention-deficit/hyperactivity disorder in children with borderline intellectual functioning or intellectual disability: A systematic review and meta-analysis. Scientific Reports, 9(1), Article 1. https://doi.org/10.1038/s41598-019-52205-6

Yu, S., Shen, S., & Tao, M. (2023).Guanfacine for the Treatment of Attention-Deficit Hyperactivity Disorder: An Updated Systematic Review and Meta-Analysis. Journal of Child and Adolescent Psychopharmacology, 33(2), 40–50. https://doi.org/10.1089/cap.2022.0038

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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.

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.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. 

Resources:

• Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th Ed.) Cambridge University Press.
  • Chapter 11, “Attention Deficit Hyperactivity Disorder and Its Treatment” (pp. 449-485)
• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787

• 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