Video Case Study - Attention-Deficit/Hyperactivity Disorder

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Introduction0:00–0:33

Nurse Sienna works in a family practice clinic and is caring for Paul, an 11-year-old who was brought in by his caregiver, Erin, for poor school performance over the past year.
After settling Paul in his room, Nurse Sienna goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Paul’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

Recognizing and Analyzing Cues0:33–2:51

First, Nurse Sienna recognizes important cues, including Paul’s vital signs which are temperature 98.6 F or 37 C, heart rate 88 beats per minute, respiratory rate 14 breaths per minute, and blood pressure 105/66 mmHg.
She notices that Paul is restless and regularly stands up to look at and touch objects in the examination room. Nurse Sienna gathers more information from Erin and Paul.
Nurse Sienna: Hi Paul, how are you doing today? Paul: Okay, I guess.
I don’t know why I have to be here. Erin: Paul’s been having trouble in school.
His grades have been getting worse over the past few months. He's also been turning in his assignments late or not at all, and when he does turn them in, they’re incomplete.
Paul: (shrugs) It's hard to pay attention. Erin also reports that Paul’s teachers say he often disrupts class by standing up and blurting out answers to questions instead of raising his hand; and that he has difficulty following rules and waiting for his turn during group activities.
When asked about the home environment, Erin reports that when Paul is asked to perform a household chore, he either forgets to do the chore or doesn't finish it once he starts it.
Nurse Sienna then analyzes these cues. She reviews Paul’s electronic health record, or EHR, and notes that he’s been to the clinic twice in the past year for similar behavioral difficulties and tested negative for underlying vision, hearing, or cognitive disorders.
Nurse Sienna confers with the health care provider, who diagnoses Paul with attention-deficit/hyperactivity disorder, or ADHD.
Nurse Sienna knows that ADHD is likely a group of disorders thought to be caused by abnormalities in the function of the central nervous system, which regulates concentration, attention, focus, and impulse control.
As a result, patients can experience inattention, hyperactivity, and impulsivity, which may lead to disrupted learning, school performance, and difficulty completing tasks.
Nurse Sienna recognizes that Paul needs effective management of his ADHD symptoms. Now, using the information she’s gathered, Nurse Sienna develops a priority hypothesis of ineffective impulse control.

Prioritizing Hypotheses, Generating Solutions, and Taking Action2:51–4:51

Then, Nurse Sienna generates solutions to address Paul’s impulse control, and she establishes the expected outcome that after intervening, Paul will demonstrate improved ability to focus on tasks at school and at home by his follow-up appointment.
Nurse Sienna then takes action to implement these solutions. She reviews the EHR and notes that the health care provider prescribed methylphenidate and outpatient behavioral therapy.
Nurse Sienna explains to Erin that methylphenidate is a stimulant that works in the brain to improve focus and attention and decrease impulsivity.
Then Nurse Sienna teaches Paul and Erin about additional ways to manage ADHD symptoms. Nurse Sienna: Paul, do you enjoy playing any sports?
Paul: I love basketball! Gym class is my favorite.
Nurse Sienna: Great! Playing sports can help use up your energy so you can focus more during your classes.
Erin: Actually, Paul’s school has a basketball league starting soon. I can sign him up for it.
Nurse Sienna: Good idea. Now, you’ll also need to tell Paul’s teachers about his diagnosis to make sure that he has regular, scheduled breaks during class.
You should also speak to them about Paul receiving certain accommodations, like extra time for exams and assignments as well as a distraction-free area to test in.
Our clinic will provide you with the paperwork to give to his school. Erin: Okay.
But what can I do at home to help him focus? Nurse Sienna: Great question.
One strategy is to make a weekly schedule of his chores and school assignments that he can check off each day. Does that sound like something you could do, Paul?
Paul: I think so. Nurse Sienna then informs Erin that Paul is scheduled to begin outpatient behavioral therapy the following week, which will help him develop daily routines and build organization and communication skills.
After one month, Paul returns to the clinic for his follow-up appointment and Nurse Sienna evaluates the outcomes of her actions.

Evaluating Outcomes4:51–5:47

His vital signs are temperature 98.6 F or 37 C, heart rate 81 beats per minute, respiratory rate 14 breaths per minute, and blood pressure 101/65 mmHg.
Erin reports that Paul’s been taking his methylphenidate as prescribed and is regularly attending behavioral therapy. Additionally, Paul’s teachers report that he’s been less distracted in class and outbursts have decreased.
Paul tells Nurse Sienna that he still has trouble sitting still during the entirety of class, but he thinks taking tests in a separate, quiet space helps him concentrate.
Erin also reports that using a weekly checklist has helped him finish chores at home. Alright, as a quick recap… Nurse Sienna recognized and analyzed cues related to Paul’s ineffective impulse control, and prioritized hypotheses and generated solutions to address this problem.

Review5:47–6:13

Nurse Sienna then took action and evaluated Paul’s outcomes, comparing them to the expected outcome. Since Paul reported improved ability to focus on tasks at school and home, Nurse Sienna determined that the plan