Case study - Attention-deficit hyperactivity disorder: Nursing

Nurse Sienna works in a family practice clinic and is caring for Paul, a 10-year-old who was brought in by his caregiver, Erin, for poor school performance over the past year. In collaboration with the registered nurse, RN Joy, 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.

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 RN Joy, and they speak to the healthcare 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, along with Paul’s medical history, Nurse Sienna reports her findings to RN Joy and together they develop a priority hypothesis of ineffective impulse control.

Then, they generate solutions to address Paul’s impulse control, and establish 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 and RN Joy then take action to implement these solutions. RN Joy notes that the healthcare provider prescribed methylphenidate and outpatient behavioral therapy for Paul. Then, RN Joy teaches Erin and Paul about medication. She explains that methylphenidate is a stimulant that works in the brain to improve focus and attention and decrease impulsivity. She also teaches them about management of Paul’s ADHD symptoms. Then, when RN Joy leaves the room, Nurse Sienna reinforces the teaching.

Nurse Sienna: Erin and Paul, do you have any questions about what Nurse Joy talked with you about?