Psychiatric Mental Health Nursing by Videbeck

488 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS

PSYCHOPHARMACOLOGY

Medications often are effective in decreasing hyper-
activity and impulsiveness and improving atten-
tion; this enables the child to participate in school
and family life. The most common medications are
methylphenidate (Ritalin) and an amphetamine com-
pound (Adderall) (Lehne, 2001; McCracken, 2000a).
Methylphenidate is effective in 70% to 80% of chil-
dren with ADHD; it reduces hyperactivity, impul-
sivity, and mood lability and helps the child to pay
attention more appropriately. Dextroamphetamine
(Dexedrine) and pemoline (Cylert) are other stimu-
lants used to treat ADHD. The most common side
effects of these drugs are insomnia, loss of appetite,
and weight loss or failure to gain weight. Methyl-
phenidate, dextroamphetamine, and amphetamine
compound are also available in sustained-release
form taken once daily; this eliminates the need for
additional doses when the child is at school. Because
pemoline can cause liver damage, it is the last of these
drugs to be prescribed. Table 20-1 lists drugs, dosages,
and nursing considerations.
Giving stimulants during daytime hours usually
effectively combats insomnia. Eating a good break-
fast with the morning dose and substantial, nutritious
snacks late in the day and at bedtime will help the
child to maintain an adequate dietary intake. When
stimulant medications are not effective or their side
effects are intolerable, antidepressants are the second
choice for treatment(see Chapter 2). Atomoxetine
(Strattera) is a nonstimulant drug approved in 2002
by the Food and Drug Administration for treatment
of ADHD. It is an antidepressant, specifically a se-
lective norepinephrine reuptake inhibitor. The most

common side effects in children during clinical trials

were decreased appetite, nausea, vomiting, tiredness,

and upset stomach. In adults, side effects were sim-

ilar to other antidepressants including insomnia,

dry mouth, urinary retention, decreased appetite,

nausea, vomiting, dizziness, and sexual side effects

(Eli Lilly, 2002)

STRATEGIES FOR HOME AND SCHOOL

Medications do not automatically improve the child’s

academic performance or ensure that he or she makes

friends. Behavioral strategies are necessary to help

the child to master appropriate behaviors. Environ-

mental strategies at school and home can help the

child to succeed in those settings. Educating parents

and helping them with parenting strategies are crucial

components of effective treatment of ADHD. Effective

approaches include providing consistent rewards and

consequences for behavior, offering consistent praise,

using time-out, and giving verbal reprimands. Addi-

tionalstrategies are issuing daily report cards for

behavior and using point systems for positive and

negative behavior (McCracken, 2000a).

In therapeutic play,play techniques are used

to understand the child’s thoughts and feelings and

to promote communication. This should not be con-

fused with play therapy, a psychoanalytic technique

used by psychiatrists. Dramatic play is acting out an

anxiety-producing situation such as allowing the child

to be a doctor or use a stethoscope or other equipment

to take care of a patient (a doll). Play techniques to

release energy could include pounding pegs, running,

or working with modeling clay. Creative play tech-

Table 20-1

STIMULANTDRUGSUSED TOTREATADHD

Generic (Trade) Name Dosage (mg/day) Nursing Considerations

Adapted from Lehne, R. A. (2001) and Drug Facts and Comparisons (2002).

methylphenidate (Ritalin)

sustained release(Ritalin-SR,

Concerta, Metadate-CD)

dextroamphetamine (Dexedrine)

sustained release(Dexedrine-SR)

amphetamine (Adderall)

sustained release(Adderall-XR)

pemoline (Cylert)

10–60 in 3–4 divided doses

20–60 in the morning

5–40 in 2–3 divided doses

10–30 in the morning

5–40 in 2–3 divided doses

10–30 in the morning

37.5–112.5 in the morning

Monitor for appetite suppression

or growth delays.

Give regular tablets after meals.

Alert client that full drug effect

takes 2 days.

Monitor for insomnia.

Give last dose in early afternoon.

Monitor for appetite suppression.

Alert client that full drug effect

takes 2 days.

See dextroamphetamine.

Monitor for elevated liver function

tests and appetite suppression.

Alert client that drug may take

2 weeks for full effect.