Attention deficit hyperactivity disorder

Overview-Incidence

ADHD is most commonly diagnosed in children, although diagnosis before age 4 or 5 is difficult. Some patients aren't diagnosed until adulthood. About 30% to 70% of children diagnosed with ADHD continue to show symptoms into adulthood. The disorder affects more adult males than adult females. Estimates suggest that anywhere from 1% to 7% of adults exhibit ADHD symptoms.

Treatment-Diet

As tolerated

Nursing Considerations-Monitoring

Behavior and activity level Nutritional status Ability to sleep Compliance with medication regimen Adverse drug reactions Response to treatment Complications Suicidal ideation

Overview

Behavioral problem characterized by difficulty with inattention, impulsivity, hyperactivity, and boredom Also called ADHD Without impulsivity and hyperactivity, known as attention deficit disorder (ADD)

Assessment-History

Characterization as a fidgeter and a daydreamer Appearance of being inattentive and lazy Sporadic performance at school or work

Diagnostic Test Results

Complete psychological, medical, and neurologic evaluations rule out other problems; specific tests include continuous performance test, behavior rating scales, and learning disability.

Treatment-General

Education about the nature and effect of the disorder Behavior modification; cognitive therapy, metacognitive therapy External structure Supportive psychotherapy; individual and marital therapy

Overview-Complications

Emotional and social isolation Poor nutrition

Overview-Pathophysiology

Exact mechanism is unknown. Alleles of dopamine genes may alter dopamine transmission in the neural networks. During fetal development, bouts of hypoxia and hypotension could selectively damage neurons located in some of the critical regions of the anatomical networks.

Overview-Risk Factors

Family history Comorbid conditions, such as learning disabilities, mood disorders, oppositional defiant disorder, or conduct disorder

Nursing Considerations-Associated Nursing Procedures

Family therapy Nutritional screening Oral drug administration

Nursing Considerations-Nursing Diagnoses

Ineffective coping Impaired social interaction Ineffective family therapeutic regimen management Risk for injury

Assessment-Symptoms of impulsivity

Interrupting Inability to wait patiently Socially inappropriate behavior; rude or insulting remarks Difficulties with executive functioning

Assessment-Physical Findings

Making careless mistakes Struggling to sustain attention Appearing as not listening Failing to follow through or finish activities Difficulty with organization Avoiding tasks that require sustained mental effort Distractedness Forgetfulness Misplacing of work Forgetfulness associated with appointments, social commitments, work deadlines; difficulty setting priorities

Assessment-Symptoms of Inattention

Making careless mistakes Struggling to sustain attention Appearing as not listening Failing to follow through or finish activities Difficulty with organization Avoiding tasks that require sustained mental effort Distractedness Forgetfulness Misplacing of work Forgetfulness associated with appointments, social commitments, work deadlines; difficulty setting priorities

Treatment-Activity

Monitoring (for safety purposes)

Patient Teaching-Discharge Planning

Refer the patient to family therapy. Refer the patient and family to social services to assist with necessary community resources.

Assessment-Symptoms of Hyperactivity

Restlesness Difficulty relaxing Feeling "on edge" Excessive talking

Nursing Considerations-Nursing Interventions

Set realistic expectations and limits to avoid frustrating the patient. Maintain a calm, consistent manner. Ensure a safe environment. Assess for signs of depression and suicidal ideation. Keep all instructions short and simple; make one-step requests. Provide praise, rewards, and positive feedback whenever possible. Provide diversional activities suited to a short attention span. Administer medications as prescribed; give short-acting methylphenidate in the morning, at noon, and at 4 p.m.; give long-acting forms once daily in the morning; give dextroamphetamine and amphetamine extended-release once daily in the morning; give atomoxetine in the morning. Apply a methylphenidate patch to the hip 2 hours before the intended effect and remove 9 hours later; anticipate the dosage to be titrated upward every week as needed. Assist with time management skills, planning, and organizational skills as well as ways to reduce distractions. Reinforce behavior modification and behavior therapy plans of care.

Treatment-Medications

Stimulants, such as methylphenidate hydrochloride (Ritalin, Concerta) or methylphenidate patch (Daytrana) Amphetamines, such as dextroamphetamine sulfate and amphetamine (Adderall) or lisdexamfetamine dimesylate (Vyvanse) Nonstimulants, such as atomoxetine hydrochloride (Strattera) Tricyclic antidepressants, such as desipramine hydrochloride (Norpramin) and nortriptyline hydrochloride (Aventyl) BuPROPion (Wellbutrin)

Overview-Causes

Underlying cause unknown Possible genetic link Hypothesis related to intrauterine exposure to toxic substances, exposure to food additives or colorings, or allergies

Patient Teaching-General

importance of behavior therapy and use of limits and positive feedback examples of rewards and positive reinforcements of good behavior need to develop realistic expectations medication regimen, including drugs, dosages, frequency, schedule for administration, and proper technique for applying a patch, if ordered intended effects of medication therapy and possible adverse reactions, including signs and symptoms that warrant notification of a practitioner, such as depression and suicidal ideation possible periodic drug cessation to determine continued need for medication effects of medications on sleeping and measures to promote sleep effects of medications on appetite and appropriate suggestions for sound nutritional choices, including small, frequent meals time management skills; organizational skills ways to reduce distractions increased risk for drug and alcohol dependence; need to drink in moderation or abstain from alcohol importance of continued follow-up and ongoing evaluation to determine the effectiveness of therapy and evaluate growth and development.

Nursing Considerations-Expected Outcomes

seek support systems and exhibit adequate coping behaviors demonstrate effective social interaction skills in one-on-one and group settings report improvement in family and social interactions remain free from injury.

Assessment-DSM-IV-TR Criteria

six symptoms or more from the inattention or hyperactivity-impulsivity categories symptoms present for at least 6 months symptoms evident before age 7 impairment present in two or more settings symptoms aren't accounted for by another mental disorder.