NURS 6630 Assessing and Treating Patients With ADHD

NURS 6630 Assessing and Treating Patients With ADHD

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).

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).

Not only can children and adults present differently for ADHD, but males and females may also present in drastically different clinical ways. Different people may react differently to pharmacological therapy. Some ADHD drugs, for example, may induce stomach ache in youngsters, while others might be very addictive in adults. As a psychiatric nurse practitioner, you must conduct careful assessments and balance the risks and benefits of pharmacological therapy for patients throughout their lives. Consider how you may assess and treat patients who present with ADHD for this Assignment.

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.

By Day 7

Submit your Assignment.

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• Please save your Assignment using the naming convention “WK9Assgn+last name+first initial.(extension)” as the name.
• Click the Week 9 Assignment Rubric to review the Grading Criteria for the Assignment.
• Click the Week 9 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK9Assgn+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.

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Submit Your Assignment by Day 7 of Week 9

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Week 9 Assignment

 

Quiz: Assessing and Treating Patients With Psychopharmacology

Photo Credit: Getty Images

By Day 7

Complete the 20-question Quiz to gauge your understanding of this module’s content.

Submission Information

Submit Your Quiz by Day 7

To submit your Quiz :

Week 9 Quiz

 

What’s Coming Up in Module 3?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

In the next module, you will begin to apply your assessment and therapy skills in treating patients for disorders with behavioral components.

Diego, a ninth-grader, had always been an active child with a short attention span. For years, his mother blamed his behavior on him being “all boy,” assuming that it would improve as he grew older. Instead, Diego became increasingly overwhelmed by daily tasks such as chores and homework, resulting in disruptive behaviors at home and school. Diego was diagnosed with and treated for attention deficit hyperactivity disorder after being evaluated by his .

of all ages, with more than 6 million children diagnosed with the disorder (CDC, n.d.). Consider that approximately 60% of children with in the United States become adults with ADHD (ADAA, n.d.). Individuals of all ages, like Diego, find that ADHD symptoms make life difficult. Patients, on the other hand, often respond well to therapies and have positive health outcomes when properly diagnosed and treated.

This week, as you study ADHD therapies, you will look at the . You also investigate the ethical and legal implications of these treatments.

Learning Objectives

Students will:

• Assess patient factors and history to develop personalized
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for ADHD
• Synthesize knowledge of providing care to patients presenting for ADHD
• Analyze ethical and legal implications related to prescribing therapy for patients with ADHD
• Identify concepts related to psychopharmacologic treatments and therapy for patients across the lifespan

Learning Resources

Prince, J. B., Wilens, T. E., Spencer, T. J., & Biederman, J. (2016). Stimulants and other medications for ADHD. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 99–112). Elsevier.

 

 

 

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

armodafinil amphetamine (d) amphetamine (d,l) atomoxetine bupropion chlorpromazine clonidine	guanfacine haloperidol lisdexamfetamine methylphenidate (d) methylphenidate (d,l) modafinil reboxetine

 

 

Rubric Detail

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Content

Name: NURS_6630_Week9_Assignment_Rubric

		Excellent Point range: 90–100	Good Point range: 80–89	Fair Point range: 70–79	Poor Point range: 0–69
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.		Points Range: 9 (9%) – 10 (10%) The response accurately, clearly, and fully summarizes in detail the case for the Assignment. The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient.	Points Range: 8 (8%) – 8 (8%) The response accurately summarizes the case for the Assignment. The response accurately explains the specific patient factors that impact decision making with prescribing medication for this patient.	Points Range: 7 (7%) – 7 (7%) The response inaccurately or vaguely summarizes the case for the Assignment. The response inaccurately or vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.	Points Range: 0 (0%) – 6 (6%) The response inaccurately and vaguely summarizes the case for the Assignment, or is missing. The response inaccurately and vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.
Decision #1 (1–2 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. • 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.		Points Range: 18 (18%) – 20 (20%) The response accurately and clearly explains in detail the decision selected. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients. Examples provided fully support the decisions and responses provided.	Points Range: 16 (16%) – 17 (17%) The response accurately explains the decision selected. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response. The response accurately explains how ethical considerations impact the treatment plan and communication with patients. Examples provided support the decisions and responses provided.	Points Range: 14 (14%) – 15 (15%) The response inaccurately or vaguely explains the decision selected. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients. Examples provided may support the decisions and responses provided.	Points Range: 0 (0%) – 13 (13%) The response inaccurately and vaguely explains the decision selected. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing. Examples provided do not support the decisions and responses provided, or is missing.
Decision #2 (1–2 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. • 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.		Points Range: 18 (18%) – 20 (20%) The response accurately and clearly explains in detail the decision selected. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients. Examples provided fully support the decisions and responses provided.	Points Range: 16 (16%) – 17 (17%) The response accurately explains the decision selected. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response. The response accurately explains how ethical considerations impact the treatment plan and communication with patients. Examples provided support the decisions and responses provided.	Points Range: 14 (14%) – 15 (15%) The response inaccurately or vaguely explains the decision selected. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients. Examples provided may support the decisions and responses provided.	Points Range: 0 (0%) – 13 (13%) The response inaccurately and vaguely explains in detail the decision selected. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing. Examples provided do not support the decisions and responses provided, or is missing.
Decision #3 (1–2 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. • 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.		Points Range: 18 (18%) – 20 (20%) The response accurately and clearly explains in detail the decision selected. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients. Examples provided fully support the decisions and responses provided.	Points Range: 16 (16%) – 17 (17%) The response accurately explains the decision selected. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response. The response accurately explains how ethical considerations impact the treatment plan and communication with patients. Examples provided support the decisions and responses provided.	Points Range: 14 (14%) – 15 (15%) The response inaccurately or vaguely explains the decision selected. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients. Examples provided may support the decisions and responses provided.	Points Range: 0 (0%) – 13 (13%) The response inaccurately and vaguely explains in detail the decision selected. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing. Examples provided do not support the decisions and responses provided, or is missing.
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.		Points Range: 14 (14%) – 15 (15%) The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient. The response accurately and clearly explains a justification for the recommendations provided, including clinically relevant resources that fully support the recommendations provided.	Points Range: 12 (12%) – 13 (13%) The response accurately summarizes the recommendations on the treatment options selected for this patient. The response accurately explains a justification for the recommendation provided, including clinically relevant resources that support the recommendations provided.	Points Range: 11 (11%) – 11 (11%) The response inaccurately or vaguely summarizes the recommendations on the treatment options selected for this patient. The response inaccurately or vaguely explains a justification for the recommendations provided, including clinically relevant resources that inaccurately or vaguely support the recommendations provided.	Points Range: 0 (0%) – 10 (10%) The response inaccurately and vaguely summarizes the recommendations on the treatment options selected for this patient, or is missing. The response inaccurately and vaguely explains a justification for the recommendations provided, including clinically relevant resources that do not support the recommendations provided, or is missing.
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.		Points Range: 5 (5%) – 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.	Points Range: 4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive.	Points Range: 3.5 (3.5%) – 3.5 (3.5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment is vague or off topic.	Points Range: 0 (0%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation		Points Range: 5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors.	Points Range: 4 (4%) – 4 (4%) Contains a few (1 or 2) grammar, spelling, and punctuation errors.	Points Range: 3.5 (3.5%) – 3.5 (3.5%) Contains several (3 or 4) grammar, spelling, and punctuation errors.	Points Range: 0 (0%) – 3 (3%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.		Points Range: 5 (5%) – 5 (5%) Uses correct APA format with no errors.	Points Range: 4 (4%) – 4 (4%) Contains a few (1 or 2) APA format errors.	Points Range: 3.5 (3.5%) – 3.5 (3.5%) Contains several (3 or 4) APA format errors.	Points Range: 0 (0%) – 3 (3%) Contains many (≥ 5) APA format errors.
Total Points: 100

Name: NURS_6630_Week9_Assignment_Rubric

Assessing and Treating Patients with Attention Deficit Hyperactivity Disorder

(ADHD)

The assigned case demonstrates an 8-year-old Caucasian female patient who presented to the clinic following her class teacher’s suggestion that she might have ADHD. The patient was brought to the psychiatric unit by bothering her parents who were not convinced that their child needed medical attention. Their family physician also reviewed the patient and recommended psychiatric evolution. Based on the completed “Conner’s Teacher Rating Scale-Revised” form, the child presents with symptoms of forgetfulness, inattentiveness, and being easily distracted in addition to poor arithmetic, reading, and spelling skills. The patient also reported having no interest in schoolwork and a short concentration span. She claims to be absent-minded most of the time, with most of the subjects being boring. Mental status examination results showed that other than the ADHD symptoms, the patient displayed no sign of any other comorbidity. She has thus been diagnosed with ADHD, predominantly inattentive presentation.

The care plan for this patient will mainly focus on pharmacological interventions. Before deciding on which drug to prescribe, it was necessary to evaluate the patient factors which impact pharmacokinetic and pharmacodynamic processes. For instance, the patient being of young age limits the available treatment options dues to safety issues. Consequently, dosing adult patients and pediatric patients is not done similarly as children are not just considered small adults. Other factors which will impact the decision-making process include her Caucasian race, diagnosis of ADHD, and all the presenting symptoms. The purpose of this discussion is thus to describe the decisions made in prescribing medication to an 8-year-old with symptoms of ADHD, in addition to the legal and ethical considerations encountered when developing the treatment plan for this patient.

Decision #1

Selected Decision and Rationale

The initial decision was to administer Ritalin 10mg chewable tablet once a day. Ritalin is a stimulant that has been recommended as a first-line medication for pediatric and adult patients with ADHD in most clinical guidelines (American Psychiatric Association, 2013). Previous evidence demonstrates a desirable safety profile with great effectiveness of the drug in managing hyperactivity, inattentiveness, and impulsivity in children from the age of 6 years onwards (Cortese, 2020). Short-acting tablets are suggested as the first option when using the drug at a starting dose of 5 to 10mg depending on the age of the child and the severity of the symptoms (Hodgkins et al., 2012). Dose titration by 5mg per week is however recommended to obtain an optimal dose for a positive outcome (Boland et al., 2020). Chewable tablets are recommended for this age group as most children normally have problems with swallowing (Ross et al., 2020).

Bupropion is a stimulant that is greatly discouraged from use among the pediatric population due to the increased incidence of seizures for children below the age of 12 years (Brikell et al., 2021). Intuniv has also displayed increased risks of cardiovascular events such as low blood pressure or syncope, hence not appropriate at this moment (Mechler et al., 2021).

Expected Outcome

            With great compliance to the recommended drug at the right dosage and frequency, the patient will exhibit improved symptoms within 2 to 4 weeks (American Psychiatric Association, 2013). Her interest in schoolwork is expected to improve along with her concentration level, attention, and memory (Cortese, 2020). She should be able to achieve better grades at school.

 

 

Ethical Considerations

            When developing a treatment plan for pediatric patients, clinicians are normally obliged to protect the child from harm, while promoting their health (Mechler et al., 2021). Ethical principles such as clinical judgment, nonmaleficence, justice, beneficence, and respect for the patient’s autonomy were also observed when making this decision (Cortese, 2020).

Decision #2

Selected Decision and Rationale

The second intervention was to administer 20 mg of long-acting Ritalin orally in the morning. The patient reported improved symptoms only during the morning hours and not later in the day, which led to increasing the dose from 10mg to 20mg and considering a long-acting formulation to prolong the duration of action (Brikell et al., 2021). Studies show that upon oral administration of Ritalin, its effectiveness begins appearing after 30 to 45 minutes and lasts in the patient’s body for up to 10 to 12 hours (American Psychiatric Association, 2013; Ross et al., 2020). The patient also reported that her “heartfelt funny,” with an increased heart rate of up to 130 bpm, which is a common side effect of Ritalin (Hodgkins et al., 2012). Evidence demonstrates that most of the common side effects of Ritalin such as increased heartbeat are usually self-limiting and resolve with time (Mechler et al., 2021). As such the benefits of the drug outweighed the side effects, hence the need to continue with the same treatment regimen, and alter the dose for the optimum level (Boland et al., 2020).

Maintaining the present dose of Ritalin was unnecessary as the patient will experience a similar outcome with a lack of effectiveness of the drug later in the day (Brikell et al., 2021). Consequently, Adderall was also not considered as an option as the medication is associated with increased risks of cardiovascular side effects such as tachycardia, which the patient was already experiencing from the previous intervention (Cortese, 2020).

Expected Outcome

            A long-acting formulation is expected to manage the patient’s symptoms of ADHD from morning to late in the evening (Mechler et al., 2021). The patient’s attentiveness, interest in school work, concentration level, and overall performance are all expected to improve within 4 weeks. The patient heart rate is also expected to normalize (Cortese, 2020).

Ethical Consideration

            With the reported side effect, the PMHNP had to observe ethical principles such as beneficence and nonmaleficence and utilize their clinical judgment in preventing further harm to the patient (Hodgkins et al., 2012). Consequently, it was necessary to inform the patient’s parents of the reason behind the side effect to promote their trust in the treatment process (American Psychiatric Association, 2013).

Decision #3

Selected Decision and Rationale

            The last intervention was to advise the patient to continue with the same treatment regimen and report for reevaluation in 4 weeks. The decision was based on the patient’s reported outcome of great effectiveness and tolerance to the long-acting Ritalin all day long (Brikell et al., 2021). The patient side effects had also gone away given that the long-acting preparation reduces the peak plasma concentration hence reducing the risks associated with toxic levels in the blood (Mechler et al., 2021). Consequently, evidence suggests that at low optimal doses, patients with ADHD on long-acting Ritalin may take up to 9 to 12 weeks to exhibit maximum potential in the management of symptoms (American Psychiatric Association, 2013; Ross et al., 2020). Long-term use of the drug among children has been reported to be safe, with further effectiveness in managing the patient’s symptoms (Boland et al., 2020). However, some patients normally display diminished effectiveness of the medication upon using it for a longer time, which might require further dose adjustment, hence the need to reevaluate the patient after 4 weeks (Cortese, 2020).

Increasing the dose to 30mg was unnecessary at this point, as this would only lead to previously resolved side effects of increased heart rate (Hodgkins et al., 2012). The patient’s recorded heart rate during the present visit was also within normal limits appropriate for her age, hence disqualifying the need of obtaining an EKG (Brikell et al., 2021).

Expected Outcome

            The patient will experience further remission of ADHD symptoms before the next appointment in four weeks (American Psychiatric Association, 2013). Her school performance will improve over time, with good arithmetic, reading, and spelling skills. No side effects will be reported during this time (Mechler et al., 2021).

Ethical Considerations

Nurses are required to attend to the needs of the patient aiming at optimum outcomes and striving at attaining patient satisfaction (Hodgkins et al., 2012). With the patient being comfortable with the outcome of the initial intervention, the PMHNP needed to educate them adequately on the need for their child to continue taking the medication for another four weeks to promote positive outcomes (Brikell et al., 2021).

Conclusion

Management of mental disorders is normally quite challenging for most clinicians given the limited evidence supporting the safety of psychotropic agents. In the management of the pediatric patient diagnosed with ADHD as reported in the provided case study, several factors were considered in promoting appropriate decision-making on which drug to prescribe. The patient was first prescribed Ritalin 10mg chewable tablet to be taken orally every morning. Ritalin is the most recommend stimulant medication as the first line for the management of ADHD in children and adults in most national clinical practice guidelines (Brikell et al., 2021). Bupropion and Intuniv were not selected because of their increased risks of side effects that would undermine the health of the patient (Hodgkins et al., 2012). During the following appointment four weeks later, the patient reported improved symptoms only during the morning hours, with the side effect of increased heart rate (Ross et al., 2020). This led to the second decision, which was to use a long-acting preparation of 20mg of Ritalin to promote the management of ADHD symptoms the entire day (Cortese, 2020). Continuing the same intervention would have led to similar outcomes, while the use of Adderall would have worsened the side effects of elevated heart rate (Boland et al., 2020).

In the following appointment, the patient reported that her blood pressure had normalized, with further management of ADHD symptoms throughout the day. The final decision was thus to continue using the same treatment regimen for another four weeks, and come back for reevaluation (Mechler et al., 2021). Increasing the dose further would have led to side effects, while EKG was not necessary as the patient’s heart rate was normal. The PMHNP observed several ethical considerations in making decisions concerning the medication to administer including justice, autonomy, beneficence, and nonmaleficence (American Psychiatric Association, 2013).

 

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Boland, H., DiSalvo, M., Fried, R., Woodworth, K. Y., Wilens, T., Faraone, S. V., & Biederman, J. (2020). A literature review and meta-analysis on the effects of ADHD medications on functional outcomes. Journal of Psychiatric Research, 123, 21-30.

Brikell, I., Wimberley, T., Albiñana, C., Pedersen, E. M., Vilhjálmsson, B. J., Agerbo, E., … & Dalsgaard, S. (2021). Genetic, clinical, and sociodemographic factors associated with stimulant treatment outcomes in ADHD. American Journal of Psychiatry, 178(9), 854-864.

Cortese, S. (2020). Pharmacologic treatment of attention deficit–hyperactivity disorder. New England Journal of Medicine, 383(11), 1050-1056. DOI: 10.1056/NEJMra1917069

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