Adhd

ADHD • •

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In order to be diagnosed with ADHD you have to be evaluated by a Psychologist (not Pediatrician) Persistent pattern of inattention, hyperactivity, or impulsivity Seen mostly in boys and is a Lifelong Disorder A behavioral disorder usually manifested before the age of 7 that includes over activity, chronic inattention, and difficulty dealing with multiple stimuli.

3 MAIN FEATURES • • •

Inattention Hyperactivity Impulsiveness

DIAGNOSTIC CRITERIA • • •

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Symptoms of : Inattention Hyperactivity Impulsiveness Symptoms need to be present before age 7 Causes impairment in 2 or more settings: o Home and School; Social situation; Job situation You will see impairment in social functioning and their academic performance Inattention o Fail to give close attention to details or makes careless mistakes o Has difficulty sustaining attention in tasks or play o Does not seem to listen when spoken to directly o Does not follow through and fails to finish tasks o Has difficulty organizing tasks and activities  Book bag is a wreck  Parents should help to get organized; request a teacher that is organized o Avoids or dislikes tasks requiring sustained attention o Loses things necessary for tasks or activities  If cant remember to bring a book home; have the child bring home all books. o Is easily distracted by extraneous stimuli o Is forgetful in daily activities Hyperactivity o Fidgets with hands or feet, or squirms in seat o Leaves seat in classroom when expected to remain seated o Runs and climbs excessively in inappropriate situations o Has difficulty in playing or engaging in leisure activities quietly  Want to be the first; interrupt others; talks excessively o Acts as if “driven by a motor” constantly “on the go” Impulsivity o Blurts our answers before question is completed o Has difficulty waiting for turn o Interrupts and intrudes on others conversation and games.

SUBTYPES • • •

ADHA Predominantly Inattention o Symptoms of inattention – At least 6 symptoms of inattention and fewer than 6 of the others ADHD Predominantly Hyperactivity and Impulsive type ADHD Combined type most common o Include symptoms of inattention, hyperactivity and impulsivity o When they are diagnosed they have had the symptoms for at least 6 months

Remember: They have to have the symptoms at least 6 months before they are diagnosed

PREDISPOSING FACTORS • • • • • • •

Biological Influences Genetics o Tends to run in families Chemical Theory Prenatal o Maternal Smoking has been linked to impulsive behavior o Fetal Alcohol syndrome Environmental Influences o Lead in paint Diet factors Psychosocial Influences o Some have been from disorganized chaotic environment o May have a family hx of alcohol

NURSING DIAGNOSIS •

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#1 R/F Injury R/T Impulsive and Accident prone behavior o Inability to perceive self harm o If they are playing ball and the ball goes in the street; this child would just run out there and get it. o Make sure they have a safe environment o Talk to them about different activities o SUPERVISION o Need to use Behavior Therapy – Negative Enforcement  If you run in the street you will have to come in the house for 3 hours Impaired Social Interaction o Develop a reputation because of being intrusive and hyperactive o Let them know that you accept them as a person but cannot accept their behavior o Talk with the child about their behaviors when they occur o If they are Intrusive you need to say “This is not appropriate, you need to wait until I finish this conversation and then I’ll give you a turn” o TOKEN Therapy – A form of behavior modification Social isolation Growth and development altered Noncompliance with task exceptions o They just don’t do what they are suppose to do o That is related to low frustration tolerance and short attention span o They need STRUCTURE every day.  Every day you come home and do homework; go to bed and get up at same time.  No distractions – Does not need TV to do homework o Complete a task in parts  Study in parts – work project in parts  Reward completion of each Part Self esteem disturbance o They realize they are not like everyone else; it will gradually begin to bother them o Set realistic goals – Give them something to do they can be successful at

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Give immediate feedback for positive behavior Set limits Impose consequences Safe environment Accident prone

MEDICATIONS • •

Remember: Medication is important but they still need Structure and Organization Central Nervous System Stimulants o Dexedrine, Cylert  Delayed affect; usually 2-3 weeks to work  Used with older children o Ritalin o Cylert o Adderol ACTIONS: o Increase attention span o Control the hyperactivity o Improve the childs ability to learn SIDE EFFECTS: o Insomnia o Mood changes  Be sure to ASSESS MOOD CHANGES AND CHANGES IN PERSONALITY  If changes are noted they will change medication o Weight loss, Anorexia o Tachycardia o Decrease in growth and development o Physical tolerance can occur  Need higher doses to achieve therapeutic behavior

NURSING IMPLICATIONS R/T DRUGS • •

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Assess mental status o Looking for changes in mood o Reported when noted Protect from injury o Prone to accidents; they are impulsive o Keep stimuli low o Teach parents they need a quiet environment “Drug Holiday” o To determine the effectiveness of the drugs o Usually don’t take on weekends or summer holidays Avoid OTC medications especially cold medications o Can interact with drug and cause toxic effect o Need to let doctor know that child is on Ritalin before he prescribes any medications Weigh regularly o Monitor for anorexia o Weighed on weekly basis Give after meals o Decreases their appetite Teach parents about Cylert o May take 2-3 weeks to take affect

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Don’t withdraw abruptly Do not give at hour of sleep o Stimulant – can cause insomnia o Sustained Release can be given early in the morning

CONDUCT DISORDERS • • • •

A repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate societal norms or rules are violated. These children will Violate the Rights of Others Mini Antisocial Manifestated by 3 or more behaviors in the past 3 months or one behavior in the past 6 months

DIAGNOSTIC p.910 • • • • • • • • • • • •

Physical Aggression o Toward people and animals Destructive to property o Break into houses Deceitfulness and theft Serious violation of rules Causes impairment in social, academic, or occupational functioning Lie Very Manipulative Runaway from home Truant from school May stay out all night without parents permission Usually begins before they are 13 years old A young Antisocial

2 SUBTYPES • •

Childhood onset before age of 10 Adolescent onset after age of 10

PREDISPOSING FACTORS • • • • •

Biological influences Genetic o May be heredity Temperament o Aggressive personality Biochemical Factor o Increase in testosterone Family Influences o Parents rejected child o Inconsistently managed child o Harsh or no discipline o Lived in institution at an early age o Absence of father o Parents antisocial modeling this behavior o Associated with delinquent subgroup  Get involved with gangs  Crime

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Bad peer groups

NURSING ASSESSMENTS CHARACTERISTICS • • • • • • • • • • • •

Physical aggression is #1 Problem Seen in all areas of childs life Sealing, lying, truancy common No guilt or remorse Use of tobacco, drugs, drinking, at an early age - Sex at an early age Projection “my family hates me” really they hate their family Do not take responsibility for actions Decreased self esteem but it is manifested as “tough guy” appearance Poor frustration tolerance; If things don’t go their way they get very upset Irritability, Temper outbursts Anxiety / depression Low academic achievement / adhd common

NURSING DIAGNOSIS •

#1 is R/F Violence directed at others o Intervene before become violent - Redirect o o o o o o o

Punching bag to work out aggression If they have already started throwing things and breaking windows you are past the Redirect Phase -- Put in time out Show of strength When calm talk about anger Help to deal with anger appropriately The least restrictive that would be affective Have plenty of staff on hand

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Impaired Social Interactions o Develop trusting relationship 1to1 o I Accept and care about you as a person but not what you are doing o Impose consequences o Reward for positive behavior o Consequences for negative behavior o They will want to blame others  Make sure they understand and accept responsibility***  Point out their behavior and their role in behavior  Point our they are being defensive Tokens for adolescents • Self Esteem Disturbance o Show interest o Spend time o Develop 1 to 1 o Point out positive but also point out manipulation

TREATMENT • •

Medication may be ordered for these kids Mood stabilizers o For problems controlling anger  Tegretol or Depakote o Depends on severity of symptoms

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Antidepressant o If they are depressed Ativan PRN May need Haldol but it depends on symptoms

OPPOSITIONAL DEFIANT DISORDER • • • • •

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Mainly they do not violate rights of others – No violence They are acting out 24-7 Mainly towards authority figures Must have behavior for at least 6 months 4 or more of the symptoms – o Client loses temper o Argue with adults o Refuse to comply with rules o Deliberately annoy people o Blame others o DO NOT want to take responsibility Not physically aggressive Impairment in social, academic, or occupational functioning This is a recurrent pattern of negativistic, disobedient, hostile, defiant behavior towards authority figures without the violation of the basic rights of others.

PREDISPOSING FACTORS • •

Biological factors Family influences o Inconsistent discipline o Parents may have disorder themselves o Maybe no parents around

NURSING ASSESSMENTS AND CHARACTERISTICS • • • • • • • • • • • • •

Passive aggressive behavior o Expressing aggression in passive way, procrastinate, careless, disobedient, and negative, violate minor rules around home, and resist authority. May be directed only at Parents Running away from home May develop Conduct disorder Not talking School avoidance / underachievement o They do go to school but they do not do anything while they are there Eating and sleeping problems Temper tantrums Fighting / Argumentative Oppositional attitude directed toward adults, mainly parents Behavior may or may not be arising from others “It’s your fault” Problem with interpersonal relationships Few Friends

NURSING DIAGNOSIS • • •

Same as for conduct except NO Risk for Violence Behavior therapy Group therapy

DELIRIUM DELIRIUM AND DEMENTIA • •

Clinically significant deficit in cognitive or memory exists representing a change from a previous level of functioning. Causes may be form a substance or combination of things May be Medical cause

DELIRIUM • • • • • • •

A disturbance of consciousness and a change in cognition that develops rapidly over a short period of time. ALWAYS Secondary to some other condition Can occur after hours to days abruptly the duration is usually brief o May have metabolic imbalance; Liver or Kidney failure Can Begin abruptly o Falling; head injury; after a seizure Duration is usually brief; Person is able to recover once the underlying cause is determined If persists can develop into dementia they can progress to coma and wake up in a vegetative state or even die. FIND OUT WHAT IS THE CAUSE

CLINICAL MANIFESTATIONS • • • • • • • • • • • • • • • • •

Difficulty sustaining attention Distractible o Have to be reminded to pay attention Disorganized thinking Rambling speech Impaired reasoning Disorientated to time and place Recent memory impairment Illusions and hallucinations are common LOC affected o Might go from Hyper to Stuporis Sleep fluctuations Dreams nightmares Activity varies Agitated or stuporous state Tremors Emotional instability o Anxious or Depressed May act on emotions o If Depressed may begin to cry Autonomic manifestations o Tachycardia o Sweating flushed face o Dilated pupils o Increased BP

TREATMENT • • • • • • •

#1 find out what is causing and treat if not treated permanent brain damage may occur Then pay attention to fluid and electrolyte status, hypoxia and diabetic problems Constant monitoring do not leave alone Low level of stimulate so as not to agitate No visitors No TV Generally not a lot of medications Low dose Haldol or Librium to alcoholic patient

CAUSES • • • • • • • • • • • • • • • • •

Psychosocial stressors Sleep deprivation Tumors Anticholinergerics Neuro disease Seizures High temp Drugs o Digoxin, Steroids, or CNS depressants Problem with liver or kidney failure Post op states Drug intoxication and withdrawal from alcohol intoxication Antianxiety drugs Cocaine – Crack Infections - High Fever - Elderly UTI Metabolic Disorders o Hypoxia, Hypoglycemia, Liver Failure, Hepatic Encaphalopathy, Kidney failure o Endocrine Disorders, Hypothermia, Hypothermia Sleep Deprivation Sensory deprivation or Sensory Overload o Sometimes seen in patients in ICU

TREATMENT • • • • • • • •

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Determine the cause and correct it Give close attention to Fluid and Electrolyte status of client If Hypoxic for any reason REMEMBER: Someone has to be with these patients, needs to be staff, may have family sit with client Make sure there is a low level of stimuli in the environment Patients can have changes in their mood and can act on those changes They need a calm, quiet environment May require Chemical or Mechanical Restraints o Generally medication is not ordered - not a routine thing o Possible may have to be restrained o The least restrictive thing you can do May get more confused at night – “Sundown” Syndrome

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o Something may be given at night – low dose of Haldol If an alcoholic they may be given: Librium or Tranziene on a regular basis

DEMENTIA Progressive and Irreversible brain syndrome Syndrome of acquired persistent intellectual impairment with complex functioning in multiple spheres of mental activity such as memory, language, visual, spatial, emotional, or personality and cognition.

AREAS OF CHANGE • • • • • • •

Abstract thinking judgment and impulse control Behavior o Inappropriate for the situation Personal appearance neglect hygiene Language may not talk at all may ramble Personality changes o Different form personality they had before o Hard for the family to understand Progressive irreversible course Lose recent memory o Hide things and forget where they put things o If they have to take medication  May take several times b/c could not remember

CLINICAL MANIFESTATIONS • • • • • • • • • • • • • • • • •

Apraxia o Inability to carry out motor activity even though motor is intact Personality changes, irritability Unable to care for self Cannot be left alone o At risk for accidents o Leave things cooking Wandering o Wrist bands to help keep from walking outside building Later stages things get worse Apraxia continues until bed bound They can become mute or scream Need complete care with ADL’s Seizures common Refusal to eat or difficulty swallowing r/f aspiration - PNEUMONIA At risk for decubti, infection Pneumonia which is the #1 cause of death Symptoms will vary from person to person and will go through stages in different times Incidence very common Alzheimer’s type May be divided into 3-4 stages

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Exact cause unknown maybe due to acetycholine alterations enzyme required to produce acetycholine Accumulation of aluminum Head trauma

COMMON CAUSES OF DEMENTIA •

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Primary Dementia o Progressive and not reversible  Alzheimer’s Dementia  Multiinfarct dementia or Vascular Dementia  Picks Disease Secondary Dementia o A result from some other pathological process  TB  Tertiary neurosyphilis  Infection of brain or trauma  Toxic metabolic disturbance  Neoplasm’s  Other neurological disease  Normal pressure hydrocephalus  Aids related dementia  Alzheimer’s pathological changes  Pernicious anemia – Vitamin B12 deficiency  Folic acid deficiency  Thyroid, parathyroid, or adrenal gland dysfunction  Liver or Kidney dysfunction  Metal poisoning  Carbon Dioxide and some drugs

TYPES OF DEMENTIA •

Alzheimer’s Type Neurofibrillary Tangles – Tangles in the brain Senile Plaque Granulovascular Degeneration  Brain cells fill with granular material o Brain Atrophy o Enlarged Ventricles o Divided into stages  First stage OK and Last stage is the Worst  Progressive Cause of Alzheimer’s o Cause is unknown o Alterations in immune system o Accumulation of aluminum o Alterations of Immune system o o o

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Genetic Theory o In the Family

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Vascular Dementia o

Vascular dementia can be from a stroke is directly caused by an interruption of blood flow to the brain

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 Directly due to Cerebral vascular Disease  Several small strokes that destroy many parts of the brain Arterial HTN Cerebral Emboli or Edema

Multifarct Dementia

ASSESSMENTS • • •

Get good history from family Good physical assessment Dementia versus depression o The physician must differentiate between these two

DIAGNOSTIC TESTS • • •

Test blood and urine Pet Scans and Cat Scans; MRI Lumbar Punctures to r/o other conditions

MEDICATIONS • • • • •

Antipshycotic o Used to control aggression and agitated o WATCH DOSES in the elderly Antidepressants o Given in early stages when they realize what is going on with them o That dose has to be decreased in the elderly May get Ativan or Zanax for a brief period of time DO NOT GIVE Barbiturates o These can cause excitement, agitation, and confusion Meds that Improve Cognition o Increase the acetycholine level in the cerebral cortex o They will not alter the course of the disease but it may slow it down a little o Used in mild to moderate dementia o Cyclan for Vascular dementia o Cognex Cholinesterase inhibitor

These drugs may cause a lot of gastric irritation, n/v They are also Liver toxic

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o Weekly blood tests initially to monitor liver functions o Diarrhea and vomiting side effects gastric irritation N/V, liver toxic for Cognex Mood Enhancers o Works on Vascular Dementia o Can improve orientation o Cyclan  For Vascular Dementia o Hydergine  Vasodilator  Enhance brain cell metabolism mild mental improvement increased alertness

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Vitamin E o To preserve brain functioning and delay Alzheimers Benzodiapezepines o Valium, Diazepam o Decreased amount can cause agitation Antianxiety o These drugs can be addictive and cause increased agitation

TREATMENT • •

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Group Therapy o Reality orientation o Getting them involved with socialization Family Therapy o If the patient lives at home the family needs to know how to create a safe environment o Families need support Milieu Therapy o Safe environment o If in nursing home – Bracelet – o It is OK for the patient to wonder in the building – as long as they are not going to hurt themselves. o No throw rugs o Not waxed floors o Make sure they have things in the environment to orient client  Calendars, Clocks, Newspapers, Magazines o Make sure they have good lighting o Need caring staff OT/RT o Used to help people useful o Keep involved o You cannot introduce any new activities o SINGING

NURSING DIAGNOSIS • #1 R/F Injury (Trauma)

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o Very important to provide safety locks on doors armbands on, no throw rugs o Not a lot of stress in environment o Clocks and radios, television, music therapy, hymns, Good caring staff that likes working with them. Have familiar things in room, good lighting, do not treat like a child. Self Care Deficit o Provide help at first o In later stages all care to maintain dignity o Provide schedule of activities but do not force them to go Altered Thought Process o Orientation: Clocks, calendar o Talk slowly and do not shout

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Group and Family Therapy Safe environment Reality Orientation May put signs on door to recognize it is their room Listen – As long as they are not getting agitated Nursing homes will let them bring something from home Provide schedule Consistency