Attention Deficit Hyperactivity Disorder.docx

Attention Deficit Hyperactivity Disorder Subjective “ TJ has been all over the place and cannot concentrate in class or complete tasks at home.”

Objective Assessment VS: T 36.9 C, RR 16, Differential diagnoses: HR 92, BP 120/80,  Hyperthyroidism Ht 125cm, Wt 55lb  Mood disorder General: Well  Anxiety nourished, well developed. Alert and Common Co-morbidites oriented to time,  Learning place and person. Disabilities Skin: Warm, dry, no  Depression rashes  Anxiety HEENT: Head midline. Ears: Clean  Oppositional canals bilaterally, Defiant Disorder TMs visualized,  Conduct +light reflex, no Disorder erythema or edema bilaterally. Eyes: PERRLA, EOM intact, 20/20 vision bilaterally without correction. No strabismus, no nystagmus. Fundoscopic exam normal, vessels intact, optic disc with clear margins. Nares patent with

Planning 

Refer to weekly behavioural therapy at local outpatient clinic.

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Establish educational plan with teachers, guidance office, pediatric provider and parent to ensure optimal supports are provided to minimize disruptions and distractions in the classroom.

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Interventions Ensuring safety Improving Role performance Simplify instructions Promoting a Structured Daily routine Providing client and family education and support

Evaluation 

Referred to weekly behavioural therapy at local outpatient clinic.

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Established educational plan with teachers, guidance office, pediatric provider and parent to ensure optimal supports are provided to minimize disruptions and distractions in the classroom.

no edema or erythema. No thyromegaly. CV: RRR, S1 and S2 present. No murmurs, clicks, or gallops Lungs: Clear to auscultation bilaterally, no wheezing, rhonchi or rales Abdomen: Soft, nontender, nondistended. Bowel sounds present in all 4 quadrants, no hepatosplenomegaly Neuro: CN II-XII grossly intact. Musculoskeletal: 5/5 strength and ROM in all extremities. No scoliosis or kyphosis. Psychiatric: Hyperactive

Date and Time 1/1/19 11:00 am

Focus Impaired Social Interaction

Data: Received lying on bed awake. Short attention span noted. High level of distractibility. Inability to complete tasks. Inability to sit still and excessive talking was observed. Action: Identified the factors that aggravate and alleviate the client’s performance. Provided an environment as free from distractions as possible. Engaged the client’s attention before giving instructions. Asked the client to repeat instructions before beginning tasks. Separated complex tasks into small steps. Provided positive feedback for complain of each step. Response: Able to exacerbate the client’s problems that can be identified and minimized and able to comprehend instructions