ADD/ADHD

Attention deficit disorder (ADD), formerly known as attention deficit/hyper-activity disorder (ADHD), is one of the most common mental disorders among children today. It is estimated that approximately 3 percent to 5 percent of all children (two to three times as many boys are affected than girls) or nearly 2 million American children (which correlates to one child in each classroom in the United States) have ADHD according to the National Institute of Mental Health.¹ ADHD does not only affect children, as symptoms can progress into adulthood as well.

The specific causes of ADHD are currently unknown, with several factors being responsible in different people. No solitary causative factor has been identified as being responsible for the different behavior patterns observed in ADHD. ADHD is only diagnosed by certain characteristic behavior patterns that are observed over time; no other clear physical signs can be seen. Common behavioral pattern categories in ADHD include inattention, impulsivity, and hyper-activity.

• Inattention: This is marked by difficulty in keeping the mind focused on any one subject and a short attention span. People with ADHD often become bored after only a few minutes at work on a subject, and placing focused attention on new or unfamiliar topics can be challenging.

• Impulsivity: This is marked by an inability to refrain from immediate reactions, making it difficult to wait and first think before speaking or acting.

• Hyperactivity: This is marked by constant perpetual motion; staying in one place and sitting still can be difficult. Adults may feel quite restless and may start several projects and have a difficult time finishing them.

Diagnosis of ADHD is based upon an analysis of the person’s behavioral patterns, which are compared to established criteria. These criteria are defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The manual outlines the three previously mentioned behavior patterns, and people may display varying amounts of each pattern or only one. Because nearly everyone displays some of these symptoms at some time in their life, certain criteria, including age of onset (early in life, before age seven), duration of symptoms (continuous for at least six months), frequency (occurring more often in themselves than others of similar age), and most importantly, behavior(s), must occur in at least two different areas of the person’s life, namely, school, home, work, or social settings.

A recent report issued by the Centers for Disease Control and Prevention claimed that nearly 1.6 million elementary school–aged children have a diagnosis of ADHD, and a national survey revealed that the parents of 7 percent of children ages 6–11 years old were told by a healthcare professional that their child had ADHD.² The report also included the following demographic information: boys are nearly three times as likely to have ADHD than girls; white children are twice as likely than Hispanic and black children to have a diagnosis of ADHD; children with health insurance are diagnosed with ADHD more often than children without health insurance; and children with ADHD use more healthcare services, including mental health services, than those without ADHD. This report went on to propose that ADHD is probably overdiagnosed in those with regular access and may be underdiagnosed in those with limited healthcare access.

A common neurodevelopmental disorder, ADHD results in impaired educational processes, social growth, and adaptation that lead to increasing rates of behavioral difficulty, depression, school dropouts, and substance abuse,³ which have lead to the mass prescription of stimulant psychotropic medications in children affected with this disorder. With no fully established biological causes recognized, ADHD does display prominent heritability. Mainstream treatment focuses on the use of mainly stimulant drugs, and because of the perceived relative success of these drugs in alleviating ADHD symptoms, many studies have focused mainly on genes that are responsible for the development and regulation of brain neurotransmitter systems, specifically that of dopamine, wherein the physiologic basis for the action of these drugs exists.

Genetic factors do play a role in the genesis of ADHD; estimates of herita-bility are greater than those of nearly every other child and adolescent psychiatric disorder and first-degree relatives have increased rates of ADHD, including conduct and affective disorders as well as substance abuse and dependency. Additionally, the subtypes of ADHD (impulsivity, hyperactivity, inattention) do not correlate with that of additional family members, leading researchers to conclude that nongenetic factors are responsible for intrafamialial variability.⁴ Factors other than genetics have been implicated in the development of ADHD prior to birth. Prenatal exposure to nicotine and psychosocial adversity have been identified as risk factors for ADHD; a review of the studies in ADHD literature exploring the relationship between prenatal exposure to these factors and the risk of developing ADHD revealed that smoking (specifically nicotine exposure) and exposure to psychosocial stress during pregnancy indicated greater and modest risk, respectively, in contributing to the development of ADHD.⁵ Other causes/contributors of ADHD that have been implicated in the literature include food sensitivities and allergies, food additive intolerance, imbalance and deficiency of nutrients, environmental toxicity (including heavy metal poisoning, thyroid irregularities, and other toxic pollutants).

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Nursing Diagnoses Organized According to Diagnostic Divisions (continued)

Elimination—ability to excrete waste products
• Bowel Incontinence
• Constipation
• Constipation, perceived
• Constipation, risk for
• Diarrhea
• Motility, dysfunctional gastrointestinal
• Motility, risk for dysfunctional gastrointestinal
• Urinary Elimination, impaired
• Urinary Elimination, readiness for enhanced
• Urinary Incontinence, functional
• Urinary Incontinence, overflow
• Urinary Incontinence, reflex
• Urinary Incontinence, stress
• Urinary Incontinence, urge
• Urinary Incontinence, risk for urge
• Urinary Retention [acute/chronic]

Food/Fluid—ability to maintain intake of and utilize nutrients and liquids to meet physiological needs
• Breastfeeding, effective
• Breastfeeding, ineffective
• Breastfeeding, interrupted
• Dentition, impaired
• Electrolyte Imbalance, risk for
• Failure to Thrive, adult

• Feeding Pattern, ineffective infant
• Fluid Balance, readiness for enhanced
• [Fluid Volume, deficient hypertonic or hypotonic]
• Fluid Volume, deficient [isotonic]
• Fluid Volume excess
• Fluid Volume, risk for deficient
• Fluid Volume, risk for imbalanced
• Glucose Level, risk for unstable blood
• Liver Function, risk for impaired
• Nausea
• Nutrition: less than body requirements, imbalanced
• Nutrition: more than body requirements, imbalanced
• Nutrition: more than body requirements, risk for imbalanced
• Nutrition, readiness for enhanced
• Oral Mucous Membrane, impaired
• Swallowing, impaired

Hygiene—ability to perform activities of daily living
• Neglect, self
• Self-Care, readiness for enhanced
• Self-Care Deficit: bathing
• Self-Care Deficit: dressing
• Self-Care Deficit: feeding
• Self-Care Deficit: toileting

Neurosensory—ability to perceive, integrate, and respond to internal and external cues
• Confusion, acute
• Confusion, risk for acute
• Confusion, chronic
• Infant Behavior, disorganized
• Infant Behavior, risk for disorganized
• Infant Behavior, readiness for enhanced organized
• Memory, impaired
• Neglect, unilateral
• Peripheral Neurovascular Dysfunction, risk for
• Sensory Perception, disturbed (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory)
• Stress Overload
• [Thought Processes, disturbed]

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Nursing Diagnoses Organized According to Diagnostic Divisions

Activity/Rest—ability to engage in necessary or desired activities of life (work and leisure) and to obtain adequate sleep and rest

• Activity Intolerance
• Activity Intolerance, risk for
• Activity Planning, ineffective
• Disuse Syndrome, risk for
• Diversional Activity, deficient
• Fatigue
• Insomnia
• Lifestyle, sedentary
• Mobility, impaired bed
• Mobility, impaired wheelchair
• Sleep, readiness for enhanced
• Sleep Deprivation
• Sleep Pattern, disturbed
• Transfer Ability, impaired
• Walking, impaired

Circulation—ability to transport oxygen and nutrients necessary to meet cellular needs

• Autonomic Dysreflexia
• Autonomic Dysreflexia, risk for
• Bleeding, risk for
• Cardiac Output, decreased
• Intracranial Adaptive Capacity, decreased
• Perfusion, ineffective peripheral tissue
• Perfusion, risk for decreased cardiac tissue
• Perfusion, risk for ineffective cerebral tissue
• Perfusion, risk for ineffective gastrointestinal
• Perfusion, risk for ineffective renal
• Shock, risk for

Ego Integrity—ability to develop and use skills and behaviors to integrate and manage life experiences

• Anxiety [specify level]
• Anxiety, death
• Behavior, risk-prone health
• Body Image, disturbed
• Conflict, decisional (specify)
• Coping, defensive
• Coping, ineffective
• Coping, readiness for enhanced
• Decision Making, readiness for enhanced
• Denial, ineffective
• Dignity, risk for compromised human
• Distress, moral
• Energy Field, disturbed
• Fear
• Grieving
• Grieving, complicated
• Grieving, risk for complicated
• Hope, readiness for enhanced
• Hopelessness
• Identity, disturbed personal
• Post-Trauma Syndrome
• Post-Trauma Syndrome, risk for
• Power, readiness for enhanced
• Powerlessness
• Powerlessness, risk for
• Rape-Trauma Syndrome
• Relationships, readiness for enhanced
• Religiosity, impaired
• Religiosity, risk for impaired
• Religiosity, readiness for enhanced
• Relocation Stress Syndrome
• Relocation Stress Syndrome, risk for
• Resilience, impaired individual
• Resilience, readiness for enhanced
• Resilience, risk for compromised
• Self-Concept, readiness for enhanced
• Self-Esteem, chronic low
• Self-Esteem, situational low
• Self-Esteem, risk for situational low
• Sorrow, chronic
• Spiritual Distress
• Spiritual Distress, risk for
• Spiritual Well-Being, readiness for enhanced

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ELECTROPHYSIOLOGY

Depolarization of the heart is the initiating event for cardiac contraction. The electric currents that spread through the heart are produced by three components: cardiac pacemaker cells, specialized conduction tissue, and the heart muscle itself.The ECG,however, records only the depolarization (stimulation) and repolarization (recovery) potentials generated by the atrial and ventricular myocardium.

The depolarization stimulus for the normal heartbeat originates in the sinoatrial (SA) node, or sinus node, a collection of pacemaker cells.These cells fire spontaneously; that is, they exhibit automaticity. The first phase of cardiac electrical activation is the spread of the depolarization wave through the right and left atria, followed by atrial contraction. Next, the impulse stimulates pacemaker and specialized conduction tissues in the atrioventricular (AV) nodal and His-bundle areas; together, these two regions constitute the AV junction. The bundle of His bifurcates into two main branches, the right and left bundles, which rapidly transmit depolarization wavefronts to the right and left ventricular myocardium by way of Purkinje fibers. The main left bundle bifurcates into two primary subdivisions, a left anterior fascicle and a left posterior fascicle. The depolarization wavefronts then spread through the ventricular wall, from endocardium to epicardium, triggering ventricular contraction.

Since the cardiac depolarization and repolarization waves have direction and magnitude, they can be represented by vectors. Vectorcardiograms that measure and display these instantaneous potentials are no longer used much in clinical practice.However, the general principles of vector analysis remain fundamental to understanding the genesis of normal and pathologic ECG waveforms.Vector analysis illustrates a central concept of electrocardiography—that the ECG records the complex spatial and temporal summation of electrical potentials from multiple myocardial fibers conducted to the surface of the body.This principle accounts for inherent limitations in both ECG sensitivity (activity from certain cardiac regions may be canceled out or may be too weak to be recorded) and specificity (the same vectorial sum can result from either a selective gain or a loss of forces in opposite directions).

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Reference Ranges—Hematology and Coagulation

Reference Ranges—Hematology and Coagulation

LABORATORY TEST NORMAL ADULT REFERENCE RANGE CLINICAL SIGNIFICANCE Conventional Units SI Units Bleeding Time 3-10 minutes 3-10 minutes ▪ Prolonged in thrombocytopenia, defective platelet function, and aspirin therapy D-dimer <250 mg/mL <250 mg/mL ▪ Increased in disseminated intravascular coagulation, malignancy, and arterial and venous thrombosis Erythrocyte Count Males 4,600,000-6,200,000/mm3 4.6-6.2 × 1012/L ▪ Increased in severe diarrhea and dehydration, polycythemia, acute poisoning, and pulmonary fibrosis ▪ Decreased in all anemias in leukemia and after hemorrhage, when blood volume has been restored Females 4,200,000- 5,400,000/mm3 4.2-5.4 × 1012/L Erythrocyte Indices Mean corpuscular volume (MCV) 84-96 µ3 84-96 Fl ▪ Increased in macrocytic anemia; decreased in microcytic anemia Mean corpuscular hemoglobin (MCH) 28-34 µµg/ cell 28-34 pg ▪ Increased in macrocytic anemia; decreased in microcytic anemia Mean corpuscular hemoglobin concentration (MCHC) 32%-36% Concentration fraction: 0.32-0.36 ▪ Decreased in severe hypochromic anemia Erythrocyte Sedimentation Rate (ESR)-Westergren Method ▪ Increased in tissue destruction, whether inflammatory or degenerative; during menstruation and pregnancy; and in acute febrile diseases Males younger than age 50 <15 mm/hour <15 mm/hour Males older than age 50 <20 mm/hour <20 mm/hour Females younger than 50 <20 mm/hour <20 mm/hour Females older than age 50 <30 mm/hour <30 mm/hour Fibrinogen 200-400 mg/ dL 2-4 g/dL ▪ Increased in pregnancy, cancer, inflammation, and nephrosis ▪ Decreased in severe liver disease and abruptio placentae Fibrin Split (Degradation) Products < mg/L < mg/L ▪ Increased in disseminated intravascular coagulation, myocardial infarction, and pulmonary embolism Fibrinolysis (Whole Blood Clot Lysis Time) No lysis in 24 hours - ▪ Increased activity associated with massive hemorrhage, extensive surgery, transfusion reactions, and liver disease Hematocrit Males 42%-52% Volume fraction: 0.42-0.52 ▪ Decreased in severe anemia, anemia of pregnancy, and acute massive blood loss ▪ Increased in erythrocytosis of any cause, and in dehydration or hemoconcentration associated with shok Females 37%-47% Volume fraction: 0.37-0.47 Hemoglobin Males 13-18 g/ dL 2.02-2.79 mmol/L ▪ Decreased in various anemias, pregnancy, severe or prolonged hemorrhage, and with excessive fluid intake ▪ Increased in polycythemia, chronic obstructive pulmonary disease, failure of oxygenation due to heart failure, and normally in people living at high altitudes Females 12-16 g/dL 1.86-2.48 mmol/L International Normalized Ratio (INR) 1.0 - ▪ INR used to standardize the prothrombin time and anticoagulation therapy 2-3 for therapy in atrial fibrillation, deep vein thrombosis, and pulmonary embolism 2.5-3.5 for therapy in prosthetic heart valves Leukocyte Count Total 5,000-10,000/mm3 5-10 × 109/L ▪ Total is elevated in acute infectious diseases, predominantly in the neutrophilic fraction with bacterial diseases, and in the lymphocytic and monocytic fractions in viral diseases ▪ Elevated in acute leukemia, following menstruation, and following surgery or trauma ▪ Eosinophils elevated in collagen disease, allergy, and intestinal parasitosis ▪ Depressed in aplastic anemia, agranulocytosis, and by toxic chemotherapeutic agents used in treating malignancy Basophils 0%-0.5% Number fraction: 0.6-0.7 Eosinophils 1%-4% Number fraction: 0.01-0.04 Lymphocytes 20%-30% Number fraction: 0.00-0.05 Monocytes 2%-6% Number fraction: 0.2-0.3 Neutrophils 60%-70% Number fraction: 0.02-0.06 Partial Thromboplastin Time (Activated) 20-35 seconds - ▪ Prolonged in deficiency of fibrinogen, factors II, V, VIII, IX, X, XI, and XII, and in heparin therapy Platelet Count 140,000-400,000/mm3 0.140-0.4 × 1012/L ▪ Increased in malignancy, myeloproliferative disease, rheumatoid arthritis, and postoperatively; about 50% of patients with unexpected increase of platelet count will be found to have a malignancy ▪ Decreased in thrombocytopenic purpura, acute leukemia, aplastic anemia, and during cancer chemotherapy Prothrombin Time 9.5-12 seconds - ▪ Prolonged by deficiency of factors I, II, V, VII, and X, for malabsorption, severe liver disease, and coumarin anticoagulant therapy Reticulocytes 0.5%-1.5% of red cells Number fraction: 0.005-0.015 ▪ Increased with any condition stimulating increase in bone marrow activity (infection, blood loss ‘pacute and chronically following iron therapy in iron deficiency anemia’, and polycythemia vera) ▪ Decreased with any condition depressing bone marrow activity, acute leukemia, and late stage of severe anemias *Laboratory values may vary according to the techniques used in different laboratories.

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Ethical Core Concepts of Nursing Practice

Professional nurses occupy the frontlines of the health care arena. So, it is no surprise that they are the part of the health care team patients trust most with their health and welfare. Along with this privilege, nurses carry equal duties of responsibility and accountability to follow ethical principles and standards of care integral to the profession. Greater efforts must be made from within the profession to apply evidence-based research data to daily practice systematically and deliberately, thereby increasing patient safety, improving outcomes, and reducing risk and adverse events. Transformation of the professional culture within the health care system itself would give nurses at the bedside the incentive to join in these efforts as full partners with leaders in health care. Additional measures might include protocol implementation, preceptor performance review, peer review, continuing education, patient satisfaction surveys, and the implementation of risk management techniques. However, in certain instances, either despite or in the absence of such internal mechanisms, claims are made for an alleged injury or alleged malpractice liability. Although the vast majority of claims may be without merit, many professional nurses will have to deal with the unfamiliar legal system. A system of ethical principles and standards of care will be beneficial in such situations. Therefore, it is preferable for the nursing profession to incorporate certain ethical and legal principles and protocols into practice to make sure that the patient receives only safe and appropriate care.

 

Clinical ethics literature identifies four principles and values that are integral to the professional nurse's practice: the nurse's ethical duty to respect the patient's autonomy and to act with beneficence, nonmaleficence, and justice.

 

RESPECT FOR THE INDIVIDUAL AND HIS AUTONOMY

• Respect for the individual's autonomy incorporates principles of freedom of choice, self-determination, and privacy.
• The professional nurse's duty is to view and treat each individual as an autonomous, self-determining person with the freedom to act in accordance with self-chosen, informed goals, as long as the action does not interfere or infringe on the autonomous action of another.
• See the National League of Nursing Statement on Patients' Rights (see Box 2-1).
• The Joint Commission has established National Patient Safety Goals based on such settings as ambulatory care, assisted living, and the facility. See www.jointcommission.org/patientsafety/nationalpatientsafetygoals for more information.

BENEFICENCE

The principle of beneficence affirms the inherent professional aspiration and duty to help promote the well-being of others and, often, is the primary motivating factor for those who choose a career in the health care profession. Health care professionals aspire to help people achieve a better life through an improved state of health.

 

NONMALEFICENCE

• The principle of nonmaleficence complements beneficence and obligates the professional nurse not to harm the patient directly or with intent.
• In the health care profession, this principle is actualized only with the complementary principle of beneficence because it is common for the nurse to cause pain or expose the patient to risk of harm when such actions are justified by the benefits of the procedures or treatments.
• It is best to seek to promote a balance of potential riskinduced harms with benefits, with the basic guideline being to strive to maximize expected benefits and minimize possible harms. Therefore, nonmaleficence should be balanced with beneficence.

 

JUSTICE

• Justice, or fairness, relates to the distribution of services and resources.
• As the health care dollar becomes increasingly more scarce, justice seeks to allocate resources fairly and treat patients equally.
• Dilemmas arise when resources are scarce and insufficient to meet the needs of everyone. How do we decide fairly who gets what in such situations?
• One might consider whether it is just or fair for many people not to have funding or access to the most basic preventive care, whereas others have insurance coverage for expensive and long-term hospitalizations.
• Along with respect for people and their autonomy, the complex principle of justice is a culturally comfortable principle in countries such as the United States. Nonetheless, the application of justice is complex and often challenging.

 

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Preventing Patient Falls

Falls are a major cause of injury and death among elderly people. In fact, the older the person, the more likely he is to die of a fall or its complications. 

Factors that contribute to falls among elderly patients include lengthy convalescent periods, a greater risk of incomplete recovery, medications, increasing physical disability, and impaired vision or hearing.

If you're helping a fallen patient, send an assistant to collect the assessment or resuscitation equipment you need.

Preventing 

Assess your patient's risk of falling at least once each shift (or at least every 3 months if the patient is in a long-term care facility). Your facility may require more frequent assessments. Note any changes in his condition -such as decreased mental status- that increase his chances of falling. If you decide that he's at risk, take steps to reduce the danger.

Correct potential dangers in the patient's room. Position the call light so that he can reach it. Provide adequate nighttime lighting.

Place the patient's personal belongings and aids (purse, wallet, books, tissues, urinal, commode, cane or walker) within easy reach.

Instruct him to rise slowly from a supine position to avoid possible dizziness and loss of balance.

Keep the bed in its lowest position so the patient can easily reach the floor when he gets out of bed. This also reduces the distance to the floor in case he falls. Lock the bed's wheels. If side rails are to be raised, observe the patient frequently.

Advise the patient to wear nonskid footwear.

Respond promptly to the patient's call light to help limit the number of times he gets out of bed without help.

Check the patient at least every 2 hours. Check a high-risk patient every 30 minutes.

Alert other caregivers to the patient's risk of falling and to the interventions you've implemented.

Consider other precautions, such as placing two high-risk patients in the same room and having someone with them at all times.

Encourage the patient to perform active range-of-motion (ROM) exercises to improve flexibility and coordination.

 

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