Assignment: Assessing and Treating Patients With ADHD

Assessing and Treating Patients With ADHD

Introduction

This assignment involves a case study about a pediatric client who presented to the clinic accompanied by her parents. The teacher had filled the Conner’s Teacher Rating Scale-Revised” scale that suggested the patient diagnosis was Attention-Deficit/Hyperactivity Disorder (ADHD). ADHD is a common neuropsychiatric disorder among children and it is characterized by impulsivity, hyperactivity, and inattention (Layton et al., 2018). The Conner’s Teacher Rating Scale indicated that the client was forgetful, inattentive, poor in academics, and easily distracted. The scale also showed she was having a short attention span and would only show attention to the things that were interesting to her. It was difficult for her to follow instructions, did not complete tasks or schoolwork. during the interview, she reported that schoolwork was boring. According to the findings from the MSE, the client had attained the appropriate developmental milestones and her speech was clear, coherent, and logical. Her affect mood was bright, consistent with her euthymic mood. The client’s insight and judgment were suitable for her age. During the clinical interview, she was able to count backward from 100. However, her attention and concentration were grossly intact. The diagnosis for the client was thus confirmed as attention deficit hyperactivity disorder, predominantly inattentive presentation basing on her symptoms and the findings from the Conner’s Teacher Rating Scale. Accordingly, the purpose of this assignment is to choose the suitable medications for the client and discuss how ethical principles were applied when choosing the medications.

Decision Point One

The available treatment choices include Wellbutrin, Intuniv, and Ritalin 10 mg. Wellbutrin works by increasing the level of dopamine and norepinephrine to treat depressive symptoms (Nadar et al., 2018) while Intuniv is a non-stimulant used to treat ADH among children (Huss et al., 2018). Ritalin was selected for the client since it is a stimulant and hence a first-line treatment choice for ADHD (Iacobucci, 2018). Ritalin is well-tolerated in children due to minimal side effects. Intuniv was not selected since it is a second-line treatment, while Wellbutrin was not chosen because FDA has not approved the medication to treat ADHD.

The selection of Ritalin for the client expected that she will respond to treatment and manifest symptom improvement. This is because Ritalin is effective in treating ADHD. Ritalin also has few side effects and thus it is expected that the client will not report side effects (Iacobucci, 2018).

However, even though the client manifested symptom improvement through improved concentration and attention, she was only able to focus during morning hours. The symptom improvement in morning hours is due to Ritalin’s effectiveness in treating ADHD symptoms. She was not able to concentrate and be attentive in the afternoon because the efficacy of the medication faded away with time. Moreover, the client experienced increased heart rate, a common side effect of Ritalin.

The client’s parents were provided with adequate information about all medications to help them make an informed choice. This means the ethical principle of informed consent was applied in this decision. Moreover, the medication selected aimed to give the best treatment outcomes to the client and this means that the ethical principle of beneficence was applied (Teven & Gottlieb, 2018).

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Decision Point Two

For this decision, the medications included having the client continue with the same Ritalin dose, stopping taking Ritalin, and starting Addrellal or changing to Ritalin LA 20 mg. Adderall increases dopamine and norepinephrine levels to treat ADHD (Faraone, 2018), but other treatment choices including Ritalin. The decision to have Ritalin changed to LA 20 mg was selected since this is a long-lasting treatment and thus the efficacy of Ritalin LA could last the entire day. As a result, the symptoms of ADHD will be improved the entire day. It was not appropriate to maintain the same dose of Ritalin because the efficacy of this dose does not last the whole day. It was not appropriate to change to Adderall since the maximum efficacy of Ritalin has not been evaluated yet.

By selecting Ritalin LA 20 mg, the expectation was that the client would be attentive and concentrate the entire day. This is due to the ability of the effects of Ritalin LA to last longer, as it is a long-acting medication (McCarthy et al., 2018). It is also expected that she would tolerate Ritalin LA 20 mg and thus not have any side effects.

As expected, the client was able to maintain attention and concentrate from the morning and even in the afternoon, indicating the efficacy of Ritalin LA. Moreover, the client did not report any side effects, showing that she tolerated Ritalin LA 20 mg.

For this treatment decision, both beneficence and non-maleficence were used to ensure that the most effective treatment choice and with minimal side effects was selected for this client. This was to ensure that the client had the best treatment outcome, without adverse effects (Teven & Gottlieb, 2018). Moreover, informed consent was sought from the parents before changing to Ritalin LA 20 mg.

Decision Point Three

For this decision, the choices included maintaining the Ritalin LA 20 mg, increase Ritalin LA to 30 mg, and lastly have the client’s EKG obtained. The decision to have Ritalin LA 20 mg maintained was chosen. This decision was chosen because the client is responding well to Ritalin LA 20 mg as she is able to be attentive and concentrate the entire day. The effects of long-lasting medications last longer and hence the effects of Ritalin LA lasted the whole day. She also tolerated this medication and dose well. Increasing Ritalin LA to 30 mg was not considered because increasing the dose could lead to the client experiencing side effects. Obtaining EKG was not considered since the client’s pulse rate is stable and hence it was not important to have the EKG performed.

Deciding to have Ritalin LA 20 mg maintained expected that the client would continue responding to treatment and maintain attention and concentration even in the afternoon. This is because Ritalin is effective in treating ADHD (Dolu et al., 2019). Selection of Ritalin LA 20 mg also expected that she would continue tolerating this dose.

For this treatment decision (maintaining Ritalin LA 20 mg), both beneficence and non-maleficence were used to ensure that the most effective treatment choice and with minimal side effects was selected for this client (Teven & Gottlieb, 2018). This was to ensure that the client had the best treatment outcome, without adverse effects.

Conclusion

From the provided data and the findings from the Conner’s teacher rating scale, the client was diagnosed with ADHD, predominantly inattentive presentation. ADHD is characterized by symptoms such as forgetfulness, inattention, inability to concentrate, carelessness, among other symptoms. Following the diagnosis, the first decision included prescribing her Ritalin 10 mg because this is the appropriate and first-line medication for ADHD. The medication also has minimal side effects. However, even though the client showed significant improvement with this decision, he would only remain attentive and concentrate during morning hours, but the inattentiveness and lack of concentration would resurface in the afternoon. Therefore, the second decision to change to Ritalin LA 20 mg in order to increase the medication’s efficacy and make the effects last the whole day. This would enable the client to concentrate and be attentive all day long. With Ritalin LA 20 mg, the client concentrated and focused the entire day, indicating the improved efficacy of the medication. The third decision was to have the Ritalin LA 20 mg maintained because this dose of Ritalin was effective and also the client did not have any adverse effects. When selecting the medications for the client, it was ensured that informed consent was sought from parents, and also the decisions likely to have minimal side effects and best treatment outcomes were applied by using the ethical principles of beneficence and non-maleficence.

References

Dolu, N., Altınkaynak, M., Güven, A., Özmen, S., Demirci, E., İzzetoğlu, M., & Pektaş, F. (2019). Effects of methylphenidate treatment in children with ADHD: a multimodal EEG/fNIRS approach. Psychiatry and Clinical Psychopharmacology, 29(3), 285-292.

Faraone, S. V. (2018). The pharmacology of amphetamine and methylphenidate: relevance to the neurobiology of attention-deficit/hyperactivity disorder and other psychiatric comorbidities. Neuroscience & Biobehavioral Reviews, 87, 255-270.

Huss, M., Dirks, B., Gu, J., Robertson, B., Newcorn, J. H., & Ramos-Quiroga, J. A. (2018). Long-term safety and efficacy of guanfacine extended-release in children and adolescents with ADHD. European child & adolescent psychiatry, 27(10), 1283-1294.

Iacobucci, G. (2018). ADHD: methylphenidate should be first-line drug treatment in children, review confirms.

Layton, T. J., Barnett, M. L., Hicks, T. R., & Jena, A. B. (2018). Attention deficit–hyperactivity disorder and month of school enrollment. New England Journal of Medicine, 379(22), 2122-2130.

McCarthy, S., Neubert, A., Man, K. K., Banaschewski, T., Buitelaar, J., Carucci, S., … & Wong, I. C. (2018). Effects of long-term methylphenidate use on growth and blood pressure: results of the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). BMC psychiatry, 18(1), 1-10.

Nadar, J. S., Kale, P. P., Kadu, P. K., Prabhavalkar, K., & Dhangar, R. (2018). Potentiation of Antidepressant Effects of Agomelatine and Bupropion by Hesperidin in Mice. Neurology research international, 2018, 9828639. https://doi.org/10.1155/2018/9828639

Teven, C. M., & Gottlieb, L. J. (2018). The four-quadrant approach to ethical issues in burn care. AMA journal of ethics, 20(6), 595-601.

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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.

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.

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.

 

USE THE BELOW CLARIFIED INSTRUCTIONS FROM THE LECTURER, THEY DEFINE EXACTLY WHAT NEEDS TO BE DONE TO GET FULL MARKS

The Assignment

Examine Case Study: A Young Caucasian Girl With ADHD(https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_09/index.html)  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.

I want you to answer the questions given to you (decision points one, two, and three) before you click on the option. The answers will be based on your decisions made and patient outcomes during the decision tree. I am looking for an essay that is long enough to cover the topic BUT short enough to keep my interest.  The course page suggests writing 1 page per decision – my opinion is that it will be very difficult to justify your treatment decisions and provide scientific evidence in 1 page (especially for decision #1). I do not need you to tell me about the patient or the treatment options available to you – I am very familiar with the cases.  Your introductory page should be an overview of the disease state you are treating along with a purpose statement for the assignment.  Remember this is a Pharmacology class that incorporates Pharmacotherapy and not a class on diagnosing disease. I want you to tell me why you selected an option (why is it the best option- using clinically relevant and patient specific data) AND why you did not choose the other options (with clinically relevant and patient specific data).

Introduction to the case (1 page)

Briefly explain and summarize the disease state you are treating this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1.5+ pages)

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. Again, provide STRONG scientific evidence.  Clinical studies or treatment guidelines are a good place to start!

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. You should provide me with a clear understanding of the stimulant vs. non-stimulant clinical decision you’ve made.  Be sure to cite specific guidelines for pediatric ADHD.

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. Again, provide STRONG scientific evidence.  Clinical studies or treatment guidelines are a good place to start!

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)

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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. Again, provide STRONG scientific evidence.  Clinical studies or treatment guidelines are a good place to start!

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.

After writing up your rationale at each decision point, I would ask yourself the following questions:

Have I provided clinical data from a meta-analysis, case report or clinical trial to support the drug I picked being safe, efficacious and the best choice for this patient?

Have I provided clinical data, etc. to support a clear rationale as to why the other treatment options are NOT optimal?

Is the focus of my discussion on mechanism of action and receptors/neurotransmitters that the drug acts on? If the answer is YES, you should consider doing additional research to address the above two questions

Also include how ethical considerations might impact your treatment plan and communication with clients.

The rubric, as I interpret it, suggests 5 references cited with every assignment for full credit on this portion (20 points).  References used for your introductory paragraph, ethical considerations or conclusion do not count towards the 5 references required.  As a general rule of thumb, I would encourage you to reference AT LEAST two sources (not including the textbook) for each decision point – this will result in 6 references total for your clinical decision making.

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