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.

3 MAIN FEATURES
• Inattention
• Hyperactivity
• Impulsiveness

DIAGNOSTIC CRITERIA
• 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
• #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
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

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

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

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 Alzheimers
• Benzodiapezepines
o Valium, Diazepam
o Decreased amount can cause agitation
• Antianxiety
o These drugs can be addictive and cause increased agitation

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