NURS 6630 Week 9 Assignment: Decision Tree on the Pharmacological Management of a Young Caucasian Girl with Attention-Deficit/ Hyperactivity Disorder or ADHD

NURS 6630 Week 9 Assignment: Decision Tree on the Pharmacological Management of a Young Caucasian Girl with Attention-Deficit/ Hyperactivity Disorder or ADHD

NURS 6630 Week 9 Assignment: Decision Tree on the Pharmacological Management of a Young Caucasian Girl with Attention-Deficit/ Hyperactivity Disorder or ADHD

Examine Case Study: A Young Caucasian Girl with ADHD. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

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Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

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Decision Tree on the Pharmacological Management of a Young Caucasian Girl with Attention-Deficit/ Hyperactivity Disorder or ADHD

            Attention-deficit/ hyperactivity disorder is one of the recognized neurodevelopmental disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5. This is the current and latest authoritative text with the diagnostic criteria that must be met for a psychiatric diagnosis to be made. The presentation may be predominantly inattentive, predominantly hyperactive, or both. The American Psychiatric Association (APA) places the prevalence of the condition in children at 8.6 percent (APA, 2013; Sadock et al., 2015). This particular 8 year-old fulfils the diagnostic criteria of ADHD in the DSM-5 in that she is inattentive, hyperactive, and presents with characteristic learning difficulties as opposed to her peers at school. She has problems with reading, memory, and arithmetic according to her teachers who have filled the revised “Connor’s Teacher Rating Scale” form that her parents have brought her to then clinic with. The purpose of this decision tree paper is to show which medications amongst a given range of choices fits to treat her of her symptoms.

The First Decision Point

            At this first decision point there are three medications that are presented as possible evidence-based solutions to her symptoms. They are bupropion (Wellbutrin) XL 150 mg by mouth every day; guanfacine (Intuniv) 1 mg extended release tablet to be taken at bedtime; or methylphenidate (Ritalin) 10 mg to be chewed every morning (Walden University, n.d.). The third option of methylphenidate is chosen here because there is sufficient evidence from current peer-reviewed literature that supports its efficacy in treating ADHD. This evidence is found in Childress (2016). Furthermore, the medication is approved by the US Food and Drug Administration (FDA) for the treatment of ADHD in both children and adults (Stahl, 2017). These were enough reasons for the choice.

            The remaining two options were not considered because even though guanfacine is FDA-approved for the treatment of ADHD in children and adolescents; its efficacy and the evidence supporting it is not superior to that of methylphenidate. Bupropion is not FDA-approved for ADHD in children and would only have been used off-label. It also has the disadvantage of eliciting suicidal ideation when used in children (Stahl, 2017). Avoidance of the other two options because of the side effect of suicidality and lack of evidence were motivated by beneficence and nonmaleficence as bioethical principles (Haswell, 2019). Methylphenidate (Ritalin) is the choice that ensured efficacy and safety in this case.

The Second Decision Point

            The child is seen again and assessed after treatment with the methylphenidate for four weeks. The teachers who had filled the assessment form for the girl stated during this period that she had began showing improvement in concentration and other areas at school. They however claimed that the symptoms were re-emerging in the afternoons, probably after the medication wore off. There was also a report of palpitations and taking the girl’s pulse revealed that she had a pulse rate of 130 beats per minute. As a child this would not be a major concern though. The second decision had to be made and the options were:

1. To continue with the current methylphenidate dose and reassess again after another 4 weeks.
2. To change the formulation of the methylphenidate (Ritalin) to long-acting (LA) and increase the dose to 20 mg chewable every morning. Or

• To discontinue methylphenidate (Ritalin) and start amphetamine (Adderall) XR 15 mg orally every day (Walden University, n.d.).

            The choice is made to change the formulation of the methylphenidate (Ritalin) to a long-acting (LA) preparation and increase the dose to 20 mg chewable every morning. This decision was taken because the Ritalin was already showing its therapeutic effect on the girl. The only thing was that its effect was waning too fast before the day was over. This was solved by giving a LA preparation and doubling the dose to 20 mg. The other two choices were shunned because continuing with the current dose would have been clinically imprudent and against nonmaleficence (the child would still suffer symptoms in the afternoons). Also, even though amphetamine (Adderall) XR is FDA-approved for treating ADHD in this age group (Stahl, 2017) it would have been unnecessary as the Ritalin was already working. Giving the patient the most benefit (beneficence) from the therapeutic effects of methylphenidate (Ritalin) is what inspired the choice.

The Third Decision Point

            After another four weeks the girl is brought back for reassessment and the report is encouraging. Symptoms are now under control for the whole day and the girl no longer feels that the heart is racing abnormally. This time she has a pulse rate of 92 beats per minute. Her performance at school is also reported to have improved. The options to choose from at this last decision point are to increase methylphenidate to 30 mg daily; to do an electrocardiogram (EKG) because of the girl’s heart rate; or to continue the current methylphenidate dose and review again after another four weeks (Walden University, n.d.). The decision is made t continue the current dose of Ritalin and reassess again in another 4 weeks. The reason for this is that the patient is tolerating the Ritalin and it is also showing maximum therapeutic effect. There is therefore no indication to sop it or to increase the dose. The need for an EKG is also not there as the heart rate of 92 beats per minute is appropriate for her age. Increasing the dose of Ritalin would have violated nonmaleficence and probably caused side effects.

Conclusion

            The decision tree above has been taken with great consideration for evidence-based practice or EBP. The choices made are backed by scholarly evidence and facts drawn from practice. Ethical considerations are also given prominence and in this case beneficence and nonmaleficence prevailed. In the case of this 8 year-old with ADHD, methylphenidate (Ritalin) LA at the maximum dose of 20 mg orally daily proved sufficient. 

References

American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Childress, A.C. (2016). Methylphenidate HCL for the treatment of ADHD in children and adolescents. Expert Opinion on Pharmacotherapy, 17(8), 1171-8. https://doi.org/10.1080/14656566.2016.1182986

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.

Walden University (n.d.). Attention-deficit/ hyperactivity disorder: A young girl with ADHD. https://cdn-media.waldenu.edu/2dett4d/Walden/NURS/6630/DT/week_09/index.html