Attention deficit hyperactivity disorder (ADHD) is a condition that affects mental functioning and behavior. Diagnostic criteria include symptoms of inattention, hyperactivity, and impulsivity.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Disturbed Thought Processes
- Imbalanced Nutrition: Less Than Body Requirements
- Risk for Delayed Development
- Risk for Injury
Overview
ADHD often becomes noticeable in childhood, usually when a child starts going to school and continues into adulthood. While waiting one’s turn, sitting still, and paying attention are common difficulties in children, for those with ADHD, symptoms are more severe and frequent and interfere with learning and relationships. Symptoms must have persisted for six months and must occur both at home and school.
Diagnosis is usually made through a physical exam to rule out other causes, questionnaires, and psychological testing. There is no cure for ADHD, but it is manageable with behavioral therapy and medications.
Nursing Process
Nurses may care for patients with ADHD in schools, public health settings, and when admitted for inpatient care. Nurses are involved with educating parents of children with ADHD and supporting them through pharmacological and behavioral health treatment. Nurses collaborate with mental health professionals, special education teachers, social workers, and more to care for patients with ADHD.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to ADHD.
Review of Health History
1. Identify symptoms of inattention, hyperactivity, and impulsivity.
Symptoms of ADHD may be predominately inattentive, predominately hyperactive/impulsive, or a combination of both.
Symptoms of inattention include:
- Making careless mistakes
- Difficulty maintaining concentration
- Appearing not to listen when spoken to
- Difficulty following instructions
- Poor organization skills
- Losing items necessary for completing tasks
- Forgetfulness
Symptoms of hyperactivity and impulsivity include:
- Fidgeting
- Inability to sit still
- Inability to work or play quietly
- Excessive talking
- Interrupting
- Difficulty waiting one’s turn
2. Assess for contributing factors.
Research shows that genetics play a significant role in ADHD, though the exact genes are unknown. Some other potential factors include:
- Premature birth
- Low birth weight
- Smoking, alcohol, or drug abuse during pregnancy
- Environmental factors (lead exposure)
- Low socioeconomic status
3. Determine the onset of symptoms.
For diagnosis, symptoms are present by 12 years of age but often become evident once the child enters school.
4. Consider gender differences.
ADHD is more common in males. Boys typically present with symptoms of hyperactivity/impulsivity, while girls display symptoms of inattention.
5. Ask about the patient’s behavior and social interactions.
Interview parents, caregivers, and teachers surrounding the patient. Let them describe the patient’s behaviors at home, school, or work. Symptoms interfere with relationships, daily functioning, and development.
6. Review the patient’s health record.
Consider other medical conditions that may cause symptoms similar to ADHD yet require different treatment, such as:
- Other learning disabilities (autism)
- Depression or anxiety
- Epilepsy
- Sleep disorders
Physical Assessment
1. Assess the mental status of the patient.
A mental status exam will include the following when assessing for ADHD:
- Appearance: children may present as fidgety, easily distracted, unable to sit still, or actively moving around the room. Adults may also fidget or appear distracted or forgetful.
- Affect: Mood may be elevated but stable. The patient may feel some instances of low mood if experiencing negative feelings related to ADHD, such as low self-esteem.
- Speech: The patient should speak at a normal rate but may be louder due to impulsiveness.
- Thought process: Thoughts may include some difficulty staying on topic.
- Cognition: The patient often has difficulty with concentration. Calculations and recent recall may be affected.
2. Monitor for issues with behavior, addiction, or self-injury.
Research found that over 50% of children with ADHD also had another mental disorder like antisocial personality disorder or bipolar disorder. Monitor for the following:
- Difficulty making friends
- Disobeying rules or laws
- Self-harming
- Addiction and drug use
Diagnostic Procedures
1. Perform thorough psychiatric testing.
A complete psychiatric assessment is necessary to diagnose ADHD. There are various rating scales that patients, parents, or teachers can self-administer, but a diagnosis by a doctor is still required. Some examples of these rating scales include:
- Conners-Wells’ Adolescent Self-Report Scale
- Brown Attention Deficit Disease Scale
- Vanderbilt Assessment scale
- Adult ADHD Self-Report Scale
Note: A physical examination is necessary to rule out other potential causes, but laboratory results do not confirm ADHD. Brain imaging results have found differences in specific brain regions in children with ADHD, but imaging is currently only used for research purposes.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to ADHD.
1. Initiate pharmacological therapy as ordered.
For adults with ADHD, pharmacological therapy through the use of stimulants continues to be the cornerstone of treatment. The following stimulants are used to treat ADHD:
- Dextroamphetamine
- Amphetamine
- Lisdexamfetamine
- Methylphenidate
2. Consider other medications.
A selective norepinephrine reuptake inhibitor, atomoxetine, is a nonstimulant that may be used to treat ADHD in adults and children. The following medications may also be added to the patient’s treatment regimen:
- Antidepressants
- Clonidine
- Guanfacine
3. Monitor for side effects.
Healthcare providers and parents may be hesitant to prescribe stimulants for children. If prescribed, monitor for and educate on the following side effects:
- Delayed growth
- Decreased appetite
- Weight loss
- Headaches
- Changes in mood
4. Implement behavioral psychotherapy.
Behavioral psychotherapy is most effective when used in combination with pharmacological treatment. This type of therapy utilizes positive reinforcement in the form of rewards for desired behavior and consequences for inappropriate behavior. Parental training and classroom training may be all that is necessary for managing symptoms in younger children.
5. Consider trigeminal nerve stimulation.
The FDA approved the trigeminal nerve stimulation system for children ages 7-12 who are not taking ADHD medication. The device lowers hyperactivity by producing a low-level electrical pulse.
6. Encourage consistency at home.
The nurse can educate parents on strategies to build a consistent home routine that supports appropriate behavior. This includes:
- Showing physical and verbal affection
- Giving directions clearly and one at a time
- Limiting distractions and overstimulation
- Disciplining using time-outs to interrupt unwanted behavior
- Maintaining a consistent schedule for meals, naps, and bedtime
- Helping the child keep their environment organized
- Modeling patience and appropriate social interactions
7. Offer support to caregivers.
The parents or caregivers of children with ADHD may become overwhelmed with managing their child’s behavior. Offer resources such as support groups or books. Remind parents that they require breaks and to ask for help when needed. Discuss family or marriage counseling if relationships are affected.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for ADHD, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for ADHD.
Compromised Family Coping
Family members may have difficulty providing efficient support or guidance to the client with ADHD.
Nursing Diagnosis: Compromised Family Coping
Related to:
- Exhaustion of supportive system
- Incorrect understanding of ADHD
- Family disorganization or role changes
As evidenced by:
- Frequent arguing
- Defiance
- Relationship problems
- Increased conflict
Expected outcomes:
- Patient and their family will interact appropriately with each other, providing support and assistance as indicated.
- Patient and their family will verbalize knowledge and understanding of the condition.
- Patient’s family will verbalize resources available for the client and themselves.
Assessment:
1. Assess the family’s understanding of ADHD.
A lack of knowledge may be a barrier to coping and effective communication. Inquire about the family’s understanding of how to best support the client.
2. Assess coping methods currently being used.
Families with maladaptive coping skills may need additional instruction on effective coping strategies.
Interventions:
1. Encourage family and marital counseling.
Families may require counseling to learn to express themselves and work through conflicts. Parents of a child with ADHD may need marital counseling as the disorder can be stressful on their relationship.
2. Suggest parental training.
Parents can take classes to learn how to manage, discipline, and reward their child with ADHD.
3. Educate on stress management.
Family members need to take time for personal stress management. This can include exercise, adequate sleep, time with friends, and time alone.
4. Encourage support groups.
The family can be directed toward support groups to vent and learn from other families with similar concerns.
Disturbed Thought Processes
ADHD causes low levels of the neurotransmitter dopamine, which helps control movements and emotions, and can cause altered thinking.
Nursing Diagnosis: Disturbed Thought Processes
Related to:
- Neurological disorder
- Dopamine imbalance
As evidenced by:
- Inability to concentrate
- Poor decision-making skills
- Inability to follow instructions
- Forgetfulness
Expected outcomes:
- Patient will be able to complete a task without becoming distracted.
- Patient will display improved control of emotions, concentration, and hyperactivity.
- Patient will demonstrate appropriate decision-making.
Assessment:
1. Assess the patient’s attention span or distractibility.
This will help determine their level of decision-making and problem-solving to evaluate if they can participate in planning and carrying out interventions.
2. Review test results, questionnaires, and progress notes.
The nurse can review the results of physician progress notes or the evaluations of mental health professionals to determine how to handle further interactions.
Interventions:
1. Accept the patient as they are.
Considering their condition and communicating with them as an equal will boost their confidence and self-esteem.
2. Use simple and direct instructions.
Instructions should be clear and concise due to the patient’s short attention span. Visual aids or pictures may also be used for clarity.
3. Avoid stimulating, distracting surroundings.
Making sure that the environment is conducive to concentration will prevent the patient from becoming easily distracted and unable to concentrate.
4. Provide positive reinforcements.
Good deeds should be praised or rewarded. Positive feedback should be given immediately to encourage good behavior.
Imbalanced Nutrition: Less Than Body Requirements
Poor dietary habits have been linked to ADHD, and stimulant medications prescribed for the disorder can cause appetite suppression and weight loss.
Nursing Diagnosis: Imbalanced Nutrition
Related to:
- Unhealthy eating habits
- Food aversion
- Inadequate interest in food
- Medication side effects
As evidenced by:
- Expressed loss of appetite
- Food intake less than the recommended daily allowance
- Weight loss
Expected outcomes:
- Patient will maintain their body weight within acceptable limits for their age and height.
- Patient will verbalize an increase in appetite.
Assessment:
1. Conduct a nutritional evaluation.
Obtain information about the patient’s usual food preferences, family meal choices, and any difficulty affording healthier food options.
2. Assess the patient’s eating patterns.
Medications for ADHD can suppress the appetite, but then, as the medication wears off, the patient becomes hungry and may not make healthy dietary choices.
3. Assess for medication side effects.
Stimulants prescribed for ADHD are known to suppress the appetite.
Interventions:
1. Monitor nutritional status and weight.
Children should have their weight monitored when taking ADHD medications. If concerns arise, laboratory tests can determine nutritional gaps.
2. Debunk myths about diet.
It is false that sugar or artificial colors or additives cause ADHD. In some instances, sugar may seem to increase hyperactivity due to increased energy. Regardless, sugary or processed snacks should be avoided or limited to reduce other health risks.
3. Offer healthy snacks often.
Encourage high fiber and protein-rich snacks that can prevent glucose spikes and keep the patient fuller longer to prevent urges for processed foods.
4. Plan meals and maintain family meal times.
Parents should model healthy eating for their children. It’s also important for parents to monitor children with ADHD to ensure they are not skipping meals or forgetting to eat. Keep mealtimes consistent at home and, if possible, eat meals together as a family.
5. Discuss stimulant discontinuation.
If a loss of appetite becomes severe, causing malnutrition, discontinuing the medication may be necessary.
Risk for Delayed Development
Patients with ADHD are at risk for delayed development in behavior, social skills, and learning.
Nursing Diagnosis: Risk for Delayed Development
Related to:
- Delayed diagnosis
- Developmental lag
- Genetics
- Prematurity
- Lead exposure
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred, and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will be able to perform self-care and self-control activities appropriate for their age.
- Patient’s family will verbalize their understanding of the delay/deviation in development and plans for intervention.
- Patient will demonstrate behavior and social skills appropriate to their age group.
Assessment:
1. Identify additional factors affecting development.
Along with ADHD, additional factors may affect development, such as other mental or physical disabilities, poverty, poor nutrition, failure to thrive, and abuse or neglect.
2. Assess the patient’s developmental levels continuously.
Monitoring ongoing growth through improvements on tests, following instructions, organization, and more will provide supporting evidence to evaluate whether interventions are effective and if any additional actions are needed.
Interventions:
1. Encourage psychological counseling.
Counseling can help the child learn time management skills, control impulsive behavior, improve self-esteem, and develop friendships.
2. Incorporate learning accommodations.
The child with ADHD should be given accommodations to meet their learning needs. This may include extended testing times, 1:1 tutoring, and reduced classwork loads.
3. Approach the patient according to their level of functioning.
Conversing with the patient appropriately will help promote intellectual conversations, encouraging them to feel capable of their own thoughts.
4. Do not place blame.
A child with ADHD may be unable to control their hyperactivity, outbursts, interruptions, and frustrations. Remain calm and patient when interacting with them to prevent feelings of inadequacy or shame.
Risk for Injury
The core characteristics of attention deficit hyperactivity disorder include hyperactivity and impulsivity, which can increase the patient’s risk for injuries such as fractures, burns, head injuries, occupational injuries, and more.
Nursing Diagnosis: Risk for Injury
Related to:
- Altered psychomotor performance
- Poor impulse control
- Hyperactive behavior
- Poor decision-making
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain free from injuries.
- Patient will demonstrate interventions that will help reduce the risk of injuries.
Assessment:
1. Assess the patient’s age, developmental stage, and health and behavioral status.
The degree of risk for injury is dependent on the patient’s age, developmental status, and current health and behavioral issues. Younger children are at risk for different injuries than teenagers or adults.
2. Assess the patient’s home or work environment.
The nurse can conduct a review of the patient’s home or work environment to identify areas that may contribute to injuries.
Interventions:
1. Urge supervision during playtime and activities.
Insist on close supervision of children with activities that could lead to injury, such as swimming, using motorized toys, climbing, or certain sports.
2. Set realistic goals and provide a structured environment.
Providing the patient with a structured environment with set expectations can help patients with ADHD feel more in control and focused, reducing risky or careless behaviors.
3. Encourage the use of safety devices.
Children should wear helmets and elbow/knee pads when riding bikes or participating in certain sports. Adults should consider hard hats, protective eye wear, harnesses, special gloves, and more depending on occupational work hazards.
4. Remove potential hazards from the home.
Weapons, including knives, should not be accessible to children. Ensure any guns are unloaded and kept in a locked safe.
References
- Adult attention-deficit/hyperactivity disorder (ADHD) – Diagnosis and treatment – Mayo Clinic. (2023, January 25). Top-ranked Hospital in the Nation – Mayo Clinic. Retrieved January 2024, from https://www.mayoclinic.org/diseases-conditions/adult-adhd/diagnosis-treatment/drc-20350883
- Attention deficit hyperactivity disorder. NHS. https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/. Accessed Dec. 4, 2022
- Attention-deficit/Hyperactivity disorder (ADHD). (2023, February 22). Cleveland Clinic. Retrieved January 2024, from https://my.clevelandclinic.org/health/diseases/4784-attention-deficithyperactivity-disorder-adhd
- ADHD. Nemours Kids Health. https://kidshealth.org/en/parents/adhd.html. Accessed Dec. 4, 2022
- Doenges, M. E., Moorhouse, M. F. (1993). Nurses’s Pocket Guide: Nursing Diagnoses with Interventions (4th Ed.). F.A. Davis Company.
- Attention Deficit Hyperactivity Disorder (ADHD): The Role of Dopamine. Healthline. https://www.healthline.com/health/adhd/adhd-dopamine#takeaway. Accessed Dec. 8, 2022
- Family Functioning, Psychological Distress, and Well-Being in Parents with a Child Having ADHD. Sage Journals. https://journals.sagepub.com/doi/10.1177/2158244015626767. Accessed Dec 8, 2022
- Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2023, August 8). Attention deficit hyperactivity disorder – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved January 2024, from https://www.ncbi.nlm.nih.gov/books/NBK441838/
- Soreff, S. (2023, March 24). Attention deficit hyperactivity disorder (ADHD) clinical presentation: Physical, causes. Diseases & Conditions – Medscape Reference. Retrieved January 2024, from https://emedicine.medscape.com/article/289350-clinical#b4
