ADHD

• 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.

DIAGNOSTIC CRITERIA
• Symptoms of
o Inattention
o Hyperactivity
o Impulsiveness
• Symptoms need to be present before age 7
• Causes impairment in 2 or more settings for at least 6 months
o Home and School; Social situation; Job situation
• You will see impairment in social functioning and their academic performance
• Symptoms aren’t better accounted for by another mental disorder
• 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.
ASSESSMENT GUIDELINES
Performance with age appropriate tasks
Social interaction- disruptive, intrusive
Level of physical activity- boundless energy
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
• Anatomical- part of brain not developing correctly
• Genetics
o Tends to run in families
• Chemical Theory- abnormal levels of dopamine
• Prenatal, Perinatal, Postnatal
o Maternal Smoking has been linked to impulsive behavior
o Fetal Alcohol syndrome
• Environmental Influences
o Lead in paint- must have lead testing to approve for medicaid
• Diet factors
• Psychosocial Influences
o Some have been from disorganized chaotic environment
o May have a family hx of alcohol
o Disruptions in family
o Harsh discipline adds to behavior
NURSING DIAGNOSIS
• #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
o Give immediate feedback for positive behavior
o Set limits
 o Impose consequences
o Safe environment
o Accident prone
Assist with attaining socially acceptable behavior
Assist with increasing self-worth
Assist with completing assigned tasks- might need radio on, may have to sit with them
MEDICATIONS
• Remember: Medication is important but they still need Structure and Organization
• Methylphenidate (MPH)- amphetamines
o Ritalin
o Adderal
o Metadata er/cd
o Concerta
o Focalin
o Methylin/er
o Dexedrine/spansule
o Dextrostat
ACTIONS:
o Increase attention span
o Control the hyperactivity
o Improve the child’s 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, stomach ache
o Irritability
o headache
o Increased anxiety
o Tachycardia
o Decrease in growth and development
o Physical tolerance can occur
 Need higher doses to achieve therapeutic behavior
Strattera
Non stimulating
Acts on norepinephrine
Can be given later in the day
Side effects similar to cns stiumulant but less common
Monitor for urinary retention
May be abruptly withdrawn
4-6 wks to begin working
• Antidepressants
o To help with side effects
o Wellbutrin
o Prozac
Alpha-adrenergic
o Tenex
o Catapres
NURSING IMPLICATIONS R/T DRUGS
• 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 To allow rest from side effects
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
• 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
• Manifested 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, fire setting
• Deceitfulness and theft
• Serious violation of rules- stay out at night, runs away
• 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
o Genetic
 May be heredity
o Temperament
 Aggressive personality
o Biochemical Factor
 Increase in testosterone
• Psychosocial
• 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
 Bad peer groups- peer rejection
NURSING ASSESSMENTS CHARACTERISTICS
• Physical aggression is #1 Problem- bullies, threatens, intimidates
• Moral development issues- understanding impacts of behavior
• Seen in all areas of child’s 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 Punching bag to work out aggression
o If they have already started throwing things and breaking windows you are past the Redirect
Phase -- Put in time out
o Show of strength
o When calm talk about anger
o Help to deal with anger appropriately
o The least restrictive that would be affective
o Have plenty of staff on hand
• 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
 Is a defensive coping mechanism
 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, Depakote, or lithium
o Depends on severity of symptoms
• Antidepressant
o Zoloft, Celexa, & Lexapro
o If they are depressed
• Ativan PRN
• Antipsychotics
o to control aggression
o Risperdal, Abilify, Zyprexa
• May need Haldol but it depends on symptoms
• Prevent harm to control aggression
• Assist with
o Attaining socially acceptable behavior
o Accepting responsibility
 OPPOSITIONAL DEFIANT DISORDER
• 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- mutism
• Enuresis/encopresis- voiding & stooling on self
• 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
• Behavior therapy
• Group therapy
• 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
  Is a defensive coping mechanism
 Make sure they understand and accept responsibility***
 Point out their behavior and their role in behavior
 Point our they are being defensive
• Noncompliance with therapy
• Defensive coping
• Low self esteen
 DELIRIUM & DEMENTIA

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 Stuporous
• 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
ASSESS
Acuity of onset
Orientation
Attention span
Memory impairment
Thought process
Sensory/perceptual change
Mood & affect
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 Encephalopathy, Kidney failure
o Endocrine Disorders, Hypothermia, Hypothermia
• Sleep Deprivation
• Sensory deprivation or Sensory Overload
o Sometimes seen in patients in ICU
Substance abuse
Toxins
Infections
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
• 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
o Something may be given at night – low dose of Haldol
• If an alcoholic they may be given: Librium or Tranxene on a regular basis

DEMENTIA
• Progressive and Irreversible brain syndrome
 • Develops slowly
• 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
ETIOLOGY
Acetycholine alteration
Aluminum
Alteration in immune system
Head trauma
Genetic factor
Brain pathologh
CLINICAL MANIFESTATIONS
• Apraxia
o Inability to carry out motor activity even though motor is intact
o Continues until bedbound
Aphasia
Agnosia
• 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
• 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
• Exact cause unknown maybe due to acetycholine alterations enzyme required to produce
acetycholine
• Accumulation of aluminum
• Head trauma
COMMON CAUSES OF DEMENTIA
• Primary Dementia
o Progressive and not reversible
 Alzheimer’s Dementia
 Multiinfarct dementia or Vascular Dementia
 Picks Disease
• Secondary Dementia
o May be reversible
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- aluminum
 Carbon Dioxide and some drugs
TYPES OF DEMENTIA
• Alzheimer’s Type
o Neurofibrillary Tangles – Tangles in the brain
o Senile Plaque
o 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
• Genetic Theory
o In the Family
• Vascular Dementia
o Vascular dementia can be from a stroke is directly caused by an interruption of blood flow to
the brain
 Directly due to Cerebral vascular Disease
 Several small strokes that destroy many parts of the brain
o Arterial HTN
o Cerebral Emboli or Edema
• Multifarct Dementia
STAGES
No apparent symptoms
Forgetfulness
Early confusion
Late confusion
Early dementia
Middle dementia
Late dementia
ASSESSMENTS
• Get good history from family
o Mood swings, personality, behavior, cognitive, language
• Good physical assessment
o Neuro status, mental status, psychological tests
• 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
• EEG
MEDICATIONS
• Antipsychotic
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 Xanax for a brief period of time
• DO NOT GIVE Barbiturates
o These can cause excitement, agitation, and confusion
• Meds that Improve Cognition
o Cyclan, Aricept, Exelon, Reminyl
o Mild to moderate
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
These drugs may cause a lot of gastric irritation, n/v
They are also Liver toxic
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
• Vitamin E
o To preserve brain functioning and delay Alzheimer’s
• Benzodiapezepines
o Valium, Diazepam
o Decreased amount can cause agitation
• Antianxiety
o These drugs can be addictive and cause increased agitation
Namenda
o Targets the neuro transmitter glutamate
o Moderate to severe
TREATMENT
• 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)
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
o Group and Family Therapy
o Safe environment
o Reality Orientation
o May put signs on door to recognize it is their room
o Listen – As long as they are not getting agitated
o Nursing homes will let them bring something from home
o Provide schedule
o Consistency
Impaired verbal communication
Impaired environmental interpretation syndrome
Impaired memory