Attention

Deficit/Hyperactivity
Disorder
Capstone
By. Hana Scully
Nursing 360 Mental Health
Kapiolani Community College
October 6, 2016

Do You Ever Feel.

You catch yourself fidgiting or squirming in your seat.
Your getting up when your expected to sit down.
Your loud and disruptive during quiet activites
You cannot maintain attention or focus for activities you
find boring or difficult.
You dont finish meals or activities you have begun.
You are constantly talking or making excessive noise
Restlessness
Acting impulsivley and blurting out the answer before
the question is complete.
Taking someone elses turn in a game or activity
Have tempermetnal outburst

Assesment Data
Patient Information :
Sex: F
Age: 17
Date of Admission: 07/08/2016

LOS: 64 days

Transferred ? No
Income Source: Hawaii Police Department
Legal status: MH5a
Finacial status/insurance: Under parents insurance HMSA,
no personal income due to inability to work
Religion: Catholic patient stated, I am not very religious.

What brought patient to the

hospital?
The patient was brought into the hospital by HPD
after the mother called the cops because the
patient and her mother got in a argument and the
patient anger escalated and had aggressive
outburst and physical assaulted the mother. On
admission patient stated, Something happened
online, my mom overreacted and I hit my mom.

DSM Diagnosis:
Axis I : ADHD, Major depression, anxiety,
severe ODD
Axis II: Mental Retardation (Asperger)
Axis III: Acne
Axis IV: Lives at home with mother, father and
sister. Patient has changed school seven times
due to conflict with teachers and learning
abilities.
Axis V: 40-31 Major impairment in several
areas, such as school, family relations,
judgment, thinking, and mood.

Patients Description of Problem.

The patient has frequent aggressive
outburst, depression, easily lashes out at
peers and family members, difficult time
sitting still and cooperating in group
activities, abruptly interrupts group
activities by talking aloud, does not
participate in school activities and has
high amount of absences. Patient has
been enrolled in seven different schools
due to conflicts with teachers, failing
classes, and inability to concentrate and
complete assignments.

Strengths & Limitations

Patients Strengths: Patient is dedicated to
work on her feelings and improve her behavior.
Patient has an interest in art. Patient stated, Im
really good at art, it was the only class I would go
to at school. It helps me feel better. Thought
content is goal oriented.
Patients Limitations:
Impaired social interactions, aggressive outburst,
difficulty concentrating in group activities and
school, poor self esteem, irritable, restlessness,
difficulty concentrating. Patient stated, I failed
school because I never went to class because it
was to long and hard so I couldnt concentrate.

Mental Status Exam

Behavior:

Grooming: Patient was well groomed and had good hygiene aeb
hair brushed hair, wearing clean green hospital scrubs, wearing
hospital slippers, and no foul odor.
Attitude: Patient was cooperative and calm during interaction and
open to discussing reasoning for admission and relationships with
family
Motor: Patient was drawing and fidgeting with markers during
interaction but was able to focus on questions being asked.
Speech was appropriate rate, rhythm, and volume.
Sleep pattern: Patient takes melatonin at 0800 and sleeps
throughout the night with minimal disturbances. Patient wakes up
most morning by 6:45 am.
Appetite: Patient eats 100% of meals and snacks.
Suicidal/homicidal ideation: Patient verbalized no Suicidal or
homicidal ideation.

Mood: Euthymic aeb by stating she is, feeling better and looking
forward to her mom visiting.
Affect: Congruent with mood, full range.
Sensorium: Recent: Appropriate. Patient was oriented to person,
place, time, and situation. Patient was able to state understanding
of current problems.
Remote: Intact aeb patient able to state where she was born and
date of birth, where she lives now, and reasoning for admission
that occurred 2 months ago.
Judgment: Patient had good insight on reasoning for admission
aeb verbalizing her understating for admission and stating coping
strategies for stressful events. Patient states, I am working on
controlling my feelings and not getting so upset with people.
Intellect: Below average for age aeb poor vocabulary and inability
to focus and concentrate on learning.
Imagery:
Delusions: No delusions

Cognition:
Form: Appropriate aeb patient able to form
complete and coherent sentences and hold
meaningful and appropriate conversations.
Flow: Patients replies are on topic. Occasionally
would pause and think before answering. Patient
answered all questions appropriately.
Content: Thought process was linear, thoughts were
goal orientated towards discharge and working on
improving family relationships.

Interpersonal relationships:
Peers: Patient had appropriate special boundaries with peers.
Staff: patient seeks attention by staff aeb by constantly
asking for hugs and asking to have time alone to talk with the
nurse.
Gender Preferences: Observed patient interacted more
frequently with male peers.
Developmental level: Adolescents. Identity vs. role
confusion. Adolescents who experience difficulties fitting in
with their peers and who suffer from low self-esteem may
suffer from role confusion. (Fortinash) The patient did meet
varies aspects of this developmental stage, due to the patient
impaired social interactions she does not have very much
friends and during this stage peer validation is very
important. Due to the patient disregard for school and
inability to focus and complete assignments she is failing
academily. The patient has chronic low self-esteem and may
suffer from role confusion.

Medical Issues & Labs

BMI:20.78 Category:normal weight Height: 165.1 (55) Weight:65.862 kg
(145lb)
Axis III: Acne

Date/Panels in which all values were normal:

7/9/2016: TSH 1.76 (normal range: 0.27-4.20)
7/9/2106: Glucose 98 (normal range: 70-99)
7/9/2016 comprehensive metabolic panel- normal
8/1/2016: Group A strep- negative
Date/Any abnormal labs: 7/9/2016 :
7/8/2016: CBC normal other than platelet count was slightly decreased at
143 normal
Labs you would expect but were not ordered: Pregnancy test due to
age/sexually active, Lipid profile, liver function test (atypical antipsychotic
medication
Glucose readings x 24h for all diabetic pts: n/a patient is not
diabetic. Glucose reading done on 7/9/2106: Glucose 98 (normal range:
70-99)
All drug screen findings: Positive amphetamine in urine possibly related
to currently medications for ADHD. Patient stated no substance abuse but
has recently used Adderall.

Medications
Order: Guanfacine (Tenex) 1mg PO BID 0800, 2100. Drug class:
alpha 2A adrenergic receptor agonist. Pts target sx: ADHD. Total
24h dose:2mg. Recommended: range:0.5-2 mg/day Current
Side effects: Patient stated she is tired a lot, Fatigue, headache
Order: Sertraline (Zoloft) 150 mg tab PO daily 0800. Drug class:SSRI.
Pts target sx: Depression. Total 24h dose:150 mg
Recommended range:Do not exceed 200 mg per day. Current Side
effects: Fatigue
Order: Ziprasidone (Geodon) capsule 40 mg PO with breakfast. Drug
class: Atypical antipsychotic. Pts target sx: Bipolar, outburs. Total
24h dose:40 mg. Recommended range:40-80 mg q12h2 Current
Side effects: Patient stated no side effects from the mediation.
Order: eythromycin/benzoyl peroxide topical PRN. Drug
class:Topical antibiotics. Pts target sx: Acne. Total 24h dose:
apply BID as needed in the morning and evening. Current Side
effects: Dry skin, redness.

Hospital Treatment Plan

Safety: Patient will be free of self harm or harm
towards others aeb no assultive behavior
towards others.
Symptoms management: Patient will decrease
feelings of anger and anxiety aeb patient
report and documentation of no anxiousness,
outburst, anger for two consectutive days.
Patient will gain control over her feelings and
actions.
Discharge

Discharge Plan
Discharge date uncertain. Mother
expressed concern about patient returning
home due to past history and behavioral/
physical abusive outburst. Family
discouraged the idea of Ka Pa Ola, which
was discussed, with department of health.
Social worker plans to discuss discharge
issues with mother and patient in next
family meeting.

Assesment tools
Coppersmith Self-esteem Inventory

Nursing Priorites
1.Risk for harm/violence towards others.

2.Impaired social interactions

3.Difficulty in performing age appropriate task

and complying with social norms.

Nursing Care plan

Nursing Diagnosis: Risk for harm towards
others aeb Irritability, anger, and history of
previous aggressiveness, impulsive, explosive
outburst and physically assaulting peers.
LT goal: Within two months patient will be able to
identify triggers and rise in feelings such as
anger, frustration, and irritability and demonstrate
appropriate behavior to prevent outburst or being
physical and verbal abusive towards others.
ST goal: Patient will be able to recognize feelings of
anger and report to the nurse to be given
interventions as needed. Patient will refrain from
verbal and physical outburst and have no aggressive
outburst during my 8-hour shift.

The Big Picture

Behavioral
improvements