Psychiatric-Mental Health Nursing Paper

Psychiatric-Mental Health Nursing Paper

Assignment 1: Practicum: Decision Tree

Introduction

The focus of the assignment is on making three decisions regarding the diagnosis and treatment of a client, 8-year-old Caucasian female with school difficulties. The first decision will involve making a differential diagnosis for the client and providing a rationale for selecting the decision. The second decision will involve making a decision about the treatment pan psychotherapy and providing a rationale for the decision. The last decision will be about treatment plan psychopharmacology and justifying the decision. In addition, the co-morbid physical and mental factors that may affect the diagnosis and treatment of the client will be considered. Finally, the paper will discuss the ethical considerations that may influence the treatment plan and communication with the client and her family. Psychiatric-Mental Health Nursing Paper

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Decision #1: Differential Diagnosis

The selected decision for the differential diagnosis of the client is 314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation. This decision was selected because the client meets the criterion for A1 (inattention) for ADHD.  According to American Psychiatric Association (2013) the DSM-5 criteria confirming diagnosis of ADHD inattention include: the person fails to be attentive to details or makes mistakes in work, classwork, and other activities; difficulties in maintaining attention in tasks or play activities; often seems like one is not listening when spoken to directly; fails to follow through on instructions, does not finish classwork, chore or workplace duties; experiences difficulties in tasks and activities organization; normally avoids, does not like or is unwilling to take part in activities or tasks that need sustained mental efforts such as classwork or homework; regularly misplaces things essential for activities or tasks such as pens, books, toys; gets easily diverted and distracted by unnecessary stimuli and is often forgetful in daily activities (Volkmar et al, 2014). The client meets most of the above symptoms as indicated by the scoring of the Conner’s Teacher Rating Scale, subjective data and mental status exam. The Conner’s Teacher Rating Scale indicated that the client is inattentive, gets distracted easily, makes careless mistakes in her classwork, forgetful about the already learned content, poor in arithmetic, spelling and reading, short attention span and has difficulties in peer interactions. Subjective data indicated that the client could not sit still during the interview, was interruptive and reported that her mind wanders during class. The mental status exam revealed that the client’s attention and concentration were somehow limited.  Other standardized assessment instruments that might be essential in identifying symptoms of ADHD include ACTeRS and the Vanderbilt Assessment Scale. In addition, the Child Behavior Checklist can be used to further assess the behavior of the client (Sadock et al, 2014).

By selecting this decision, the expectation was that the correct diagnosis for the client would facilitate appropriate prescribing of the treatment regimen for the client.

Decision #2: Treatment Plan for Psychotherapy

The selected decision is to begin Adderall XR 10 mg orally daily. Adderall is a branded combination of (75%) dextroamphetamine along with (25%) levoamphetamine salts. This decision was selected because Adderall is FDA approved for the treatment of ADHD. In addition, evidence shows that Adderall is a stimulant that is effective in improving and balancing neurotransmitters level within the brain. Adderall also has minimal side effects and has fewer rebound symptoms because the medication wears off gradually and it is typically a long-lasting medication (Lakhan & Kirchgessner, 2013). According to Lakhan & Kirchgessner (2013), Adderall is an extended-release formulation that has a duration action of about 10-12 hours. This is a notably longer duration of action when compared to the majority of other methylphenidate formulations whose duration of action is a maximum of 6 hours. In addition, studies show that Adderall is a neuro-enhancement medication that is effective in memory improvement, improving focus and attention span (Lakhan & Kirchgessner, 2013). Accordingly, Adderall would be effective in treating the symptoms and signs of ADHD for the client.

By choosing this decision, it was expected that symptoms and signs of ADHD for the client would improve since Adderall has been shown to be effective in improving symptoms such as attention span. Specifically, it was hoped that the client’s disruptive behavior would reduce as well as her ability to focus and pay attention. It was also hoped that the medication would improve the client’s episodic memory and hence reduce her forgetfulness. This is because a study conducted by Advokat & Mindy (2013) demonstrated that Adderall is a stimulant that has the ability to improve episodic memory in individuals with ADHD and also has some cognitive benefit.

The result for this decision was that there was an improvement in signs and symptoms of ADHD for the client as manifested by the ability of the client to be more attentive at school and the ability to maintain attention throughout the morning classes. This outcome was consistent with the expected outcome. However, during the afternoon the client would “daydream” which means she was not able to maintain attention in the afternoon. The reason for the client being not able to maintain attention in the afternoon was that the medication dose administered had worn off and therefore the inattentive symptoms would begin manifesting again prior to the administration of the subsequent dose of Adderall (Advokat & Mindy, 2013).  It was also reported that the client started losing appetite after she started taking Adderall. The loss of appetite for the client can be attributed to the medication’s side effects. Appetite loss is a common side effect with this medication because it suppresses appetite (Sallee, 2015).Psychiatric-Mental Health Nursing Paper

Decision #3: Treatment Plan for Psychopharmacology

The selected decision for the client’s treatment plan for psychopharmacology is the addition of a small dose of immediate release of Adderall in the early afternoon. This decision was selected because the client has been showing inattentiveness during the afternoon because by afternoon the medication wears off. Therefore, the addition of a small dose of Adderall in the afternoon for the client will ensure that the client will maintain attention in the afternoon as well. In addition, the addition of a small dose of immediate release of Adderall would help the client to maintain attention during early evening and hence she will be able to do any homework given at school (Heal et al, 2013).

The reason why the decision to assure the parents that weight loss is a common side effect with Adderall was not chosen is because this option will not assist the client in maintaining attention in the afternoon classes. Secondly, the option of augmenting the Adderall treatment with family therapy was not selected because the family therapy would not solve the issue of return of the return of inattentive symptoms during the afternoon classes (Heal et al, 2013). Accordingly, this justifies the decision to add a small dose of immediate release of Adderall in the early afternoon in order to enable the client to maintain attention even during the afternoon.

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Ethical Considerations in Treatment Plan

It will be important to ensure that the professional legal obligations of ensuring optimal treatment for the client are met. Therefore, it should be ensured that the assessment and treatment of Katie is I accordance with the current professional guidelines (American Nurses Association, 2014). Informed consent should be sought from the parents of Katie while Katie should also be allowed to assent to the treatment. This is because any assessment or treatment without seeking informed consent involves a legal misdemeanor of battery. Accordingly, in this case, it will be important to seek consent from the client’s parents but at the same time try to take into account the views and wishes of Katie (Merman et al, 2017). The treatment process for the client will also involve respect for autonomy by obtaining suitable consent. Moreover, the hyperactivity presents an ethical conflict between justice and beneficence/non‐maleficence. Other ethical aspects include the addictive effects of ADHD treatments and also evidence shows that ADHD treatment may have irreversible effects on the central nervous system. Accordingly, the healthcare practitioner should educate the client’s parents regarding the potential side effects of the proposed treatment to ensure the parents are fully informed before they consent into the treatment (Merman et al, 2017).

Conclusion

The selected decision for the differential diagnosis of the client is 314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation. This is because the client meets the criterion for A1 (inattention) for ADHD as per DSM-5. The selected decision for decision point two is to begin Adderall XR 10 mg orally daily. The rationale for selecting this decision is because Adderall has been shown to be effective in improving signs and symptoms of ADHD by improving and balancing neurotransmitters level within the brain. The selected decision for decision point three is to add a small dose of immediate release of Adderall in the early afternoon. The rationale for selecting this decision is to ensure that the client will be able to maintain attention even during the afternoon.  Finally, it will be important to seek consent from the parents of Katie and also integrate wishes and views of Katie in the treatment plan. It is also important to educate the parents about the possible side effects of the proposed treatment regimen. Psychiatric-Mental Health Nursing Paper

References

Advokat C & Mindy S. (2013). Attention-deficit hyperactivity disorder (ADHD) stimulant medications as cognitive enhancers. Front Neurosci. 7(82).

American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Heal D, Smith S, Gosden  & Nutt D. (2013). Amphetamine, past and present – a pharmacological and clinical perspective. J Psychopharmacology. 27(6), 479–496.

Lakhan S & Kirchgessner A. (2013). Prescription stimulants in individuals with and without attention deficit hyperactivity disorder: misuse, cognitive impact, and adverse effects. Brain Behav. 2(5), 661–677.

Merman S, Laura B, Hans G & Frances A. (2017). ADHD: a critical update for educational professionals. Int J Qual Stud Health Well-being. 12(1): 1298267.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwe

Sallee F. (2015). Early Morning Functioning in Stimulant-Treated Children and Adolescents with Attention-Deficit/Hyperactivity Disorder, and its Impact on Caregivers. J Child Adolesc Psychopharmacol. 25(7): 558–565.

Volkmar, F., Siegel, M., Woodbury-Smith, M., King, B., McCracken, J., & State, M. (2014). Practice parameter for the assessment and treatment of children and adolescents with autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 53(2), 237–257. Psychiatric-Mental Health Nursing Paper

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