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A. INTRODUCTION

Background of the Study

ADHD (attention deficit hyperactivity disorder) is the most common behavioral

disorder that starts during childhood. However, it does not only affect children - people

of all ages can suffer from ADHD. Psychiatrists say ADHD is a neurobehavioral

developmental disorder.

An individual with ADHD finds it much more difficult to focus on something

without being distracted. He has greater difficulty in controlling what he is doing or

saying and is less able to control how much physical activity is appropriate for a

particular situation compared to somebody without ADHD. In other words, a person with

ADHD is much more impulsive and restless.

Health care professionals may use any of the following terms when describing a

child (or an older person) who is overactive and has difficulty concentrating - attention

deficit, attention deficit hyperactivity disorder, hyperkinetic disorder, hyperactivity.

North Americans commonly use the terms ADD (attention deficit disorder) or ADHD

(attention deficit hyperactivity disorder). In the UK hyperkinetic disorder is the official

term - however, ADD and ADHD have become widely used.

ADHD in children is completely different from normal childhood excited and

boisterous behavior. Many children, especially very young ones, are inattentive and

restless without necessarily being affected by ADHD.

The Centers for Disease Control and Prevention (CDC) estimates that approximately

4.4 million children aged 4 to 17 have been diagnosed with ADHD in the USA by a


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healthcare professional. As of 2003 two-and-a-half million American children aged 4 to

17 are being treated for ADHD with medicines. The CDC adds that in 2003 7.8% of all

school-aged American children were reported to have an ADHD diagnosis by their

parent.

Three types of ADHD

According to the CDC, there are three types of ADHD. They are defined according to

which symptoms stand out the most.

1. Predominantly Inattentive Type

The person finds it very difficult to organize or finish a task. They find it hard to pay

attention to details and find it difficult to follow instructions or conversations.

2. Predominantly Hyperactive-Impulsive Type

The person finds it hard to keep still - they fidget and talk a lot. A smaller child may be

continually jumping, running or climbing. They are restless and impulsive - interrupting

others, grabbing things and speaking at inappropriate times. They have difficulty

waiting their turn and find it hard to listen to directions. A person with this type of

ADHD will have more injuries and/or accidents than others.

3. Combined Type

A person whose symptoms include all those of 1 and 2, and whose symptoms are

equally predominant. In other words, all the symptoms in 1 and 2 stand out equally.


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Travelbee began her career as a nursing educator in 1952, teaching psychiatric

nursing at Depaul Hospital Affiliate School, New Orleans, while working on her

baccalaureate degree. She also taught psychiatric nursing at Charity Hospital School of

Nursing, Louisiana State University, New York University in New York City, and the

University of Mississippi in Jackson. In 1970, she was named Project Director at Hotel

Dieu School ofNursing in New Orleans. At the time of her death, Travelbee was the

director of graduate educate at Lousiana State University School ofNursing.

Travelbee began publishing articles in nursing journals in 1963. Her first book,

Interpersonal Aspects of Nursing, was published in 1966 and 1971, a second book,

Intervention in Psychiatric Nursin: Process in the the One-to-One Relationship, was

published in 1969. It was edited by Doona and published in 1979 as Travelbee

Intervention in Psychiatric Nursing.

HUMAN-TO-HUMAN RELATIONSHIP

A human-to-human relationship is primarily an experience or series of

experiences between a nurse and the recipient of her care. The major characteristic of

these experiences is that the nursing needs of the individual (or family) are met. The

human-to-human relationship, in nursing situations, is the means through which the

purpose of nursing is accomplished. The human-to-human relationship is established

when the nurse and the recipient of his or her care attain a rapport after having

progressed through the stages of the original encounter, emerging identities, empathy,

and sympathy.


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The human-to-human relationship model, shown in figure 1.1, represents the

interaction between the nurse and the patient. The first circles on the bottom at the point

of the original encounter indicates possibility of and need for developing the encounter

into a therapeutic relationship. As the interaction process progresses toward rapport,

the circles join into one full circles, representing that the potential for a therapeutic

relationship has been attained.

Original encounter. The original encounter is characterized by the first

impression by the nurse of the ill person and by the ill person of the nurse. The nurse

and patient perceive each other in stereotype roles.


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Emerging identities. The emerging identities phase is characterized by the

nurse and patient perceiving each other as unique individuals. The bond of a

relationship is beginning to form.

Empathy. The empathy phase is characterized by the ability to share in the other

persons experience. The result of the empathic process is the ability to predict the

behavior of the individual with whom he or she has empathized . Travelbee believed

that two qualities that enhanced the empathy process were similarities of experience

and the desire to understand another person.

Sympathy. Sympathy goes beyond empathy and occurs when the nurse desires

to alleviate the cause of the patients illness and suffering. When one sympathizes, one

is involved but not incapacitated by the involvement. The nurse is to create helpful

nursing action as a result of reaching the phase of sympathy. This helpful nursing

action requires a combination of the disciplined intellectual approach combined with the

therapeutic use of self

Rapport. Rapport is characterized by nursing actions that alleviate a patients

distress. The nurse and ill person are relating as human being. The ill person exhibits

both trust and confidence in the nurse. A nurse is able to establish rapport because she

possesses the necessary knowledge and skills required to assists ill persons, and

because she is able to perceive, respond to, and appreciate the uniqueness of the ill

human being.


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y Social History

Patient Lu is a grade 3 student. He likes to play basketball with his friends. He

drinks alcoholic beverages like matador and he started smoking when he was 10 years

old. He usually goes to Albay with his family every summer.

y Environmental Histor

They live in a depressed area near the highway. Thier house is made up of

stones. There is a small canal beside their kitchen. Their street is full of bystanders that

was always fighting and arguing. His parents are always fighting because of financial

problem.


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PHYSICAL ASSESSMENT

Physical examination follows a methodical head to toe format in the

Cephalocaudal assessment. This is done systematically using the techniques of

inspection, palpation, percussion and auscultation with the use of materials and

investments such as the penlight, and stethoscope and also the senses.

During the procedure, I made every effort to recognize and respect the patients

feelings as well as to provide comfort measures and follow appropriate safety

precautions.

This was taken on March 4, 2011

General Appearance and Mental Status: He wears a polo shirt and a khaki pants as

school uniform with black undershirt and a black shoes. He takes a bath before going to

school and there is the presence of curiosity.

Body Part Techniques

used

Normal Findings Actual Findings Interpretation

A.HEAD

Skull y Inspection

y

Palpation

Proportional to the

body size of the

body, round with

prominence in the

frontal area

The skull is

proportion on the

body size. The

skull is tilted to

the left for about

The depression

is due to breech

presentation

with forcep

delivery.


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There is slighty

presence of lice

in other part.

Face Inspection

Palpation

Oblong or oval or

square or heart-

shaped,

symmetrical facial

expression that is

dependent on the

mood or true

feelings smooth

and free from

wrinkles, in

involuntary muscle

movement

The face is

assymmetrical,

but free from

wrinkles and in

any involuntary

muscle.

Due to his head

deformities.

Eyes and

Eyebrows

Inspection Parallel and

evenly placed

symmetrical.Non-

protruding with

scant amount of

secretion. Both

eyes black and

clear

The eyes and

eyebrows are

not evenly

placed

symmetrically.

The left eye is

much smaller

than the right

Due to his head

deformities


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eye. There is no

drooping or

tumors. Both

eyes are black

and clear.

Eye lashes Inspection Black evenly

distributed and

turned outward

Long and black

evenly

distributed

Normal

Eye lids Inspection Upper lids cover a

small portion of

the iris and the

cornea and the

sclera when the

eyes are closed

the lids meet

completely.

Symmetrical color

is the same the

surrounding skin.

Covers a small

portion of the iris

and the cornea

and the sclera

when the eyes

are closed the

lids meet

completely

Normal

Sclera Inspection White and clear White and clear.

No presence of

dark spot.

Normal

Iris and Pupil Inspection Proportional to the Dark brown color Normal


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size of the eye

round.

Black/brown and

symmetrical.

Constrict with

increasing light

and

accommodation

when the light

closely constrict

the size of the

pupil it get smaller

than the normal

size

and both

symmetrical.

Constricting

effect when

there is

increasing light

and

accommodation

when the light

closely constricts

the size of the

pupil it gets

smaller than the

normal size.

Ears Inspection Parallel

symmetrically

proportion to the

size of the head.

Bean-shaped,

helix is in line with

the outer canthus

of the eye, skin is

the same color as

Bean-shaped,

unsymmetrically

proportion to the

size of head.

The ears are not

centrally

positioned to the

head but the

ears have same

Due to head

deformities


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the surrounding

area, clean

color with the

skin.

Ear canal Inspection Pinkish clean with

scant amount of

cerumen and a

few cilia.

Presence of

cilia, slightly

pinkish and

scant amount of

cerumen.

Normal

Hearing acuity Senses Able to hear

whisper spoken 2

feet away.

Able to hear

whisper

Normal

Nose Inspection Midline,

symmetrical and

patent

Midline,

symmetrical and

patent. Same

color and tender.

normal

Mouth Inspection Pinkish

symmetrical Lip

margin well

defined, smooth

and moist

Dark color lip Due to smoking

Gums Inspection Pinkish. Smooth.

No swelling no

retraction, no

discharge

dark color,

smooth and no

swelling.

Due to smoking


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Teeth Inspection 32 permanent

teeth aligned free

from caries or

feeling.

No halitosis

Yellowish teeth

with dental

carries. 32

Permanent teeth

are aligned..

Due to smoking

Tongue Inspection

Palpation

Large medium red

or pink slightly

rough on top

smooth along the

lateral margins,

moist, shiny, and

free movable

Medium sized

white color on

top and freely

movable.

Normal

Frenulum Inspection Midline. Straight.

and moist

Midline, straight

and moist

Normal

Cheeks Inspection

Palpation

Pinkish, smooth

and moist

Pinkish, smooth

and moist

Normal

Soft palate Inspection

Palpation

Pinkish, smooth,

and moist

Pinkish, smooth,

and moist

Normal

Voice Senses No hoarseness

and well modulate

well modulated. Normal

Neck Inspection

Palpation

Proportional to the

size of the body

and head,

Proportion and

symmetrical to

the head and

Due to breech

position forcep

delivery


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Slender- thin and

small. In young

client firms,

Elastic in

consistence.

Cone-shaped,

symmetrical skin

surface smooth.

In older women,

breast sag, nipples

lower, stringy and

nodular.

Warm to touch

and smooth

lumps and

masses.

Areola/Nipples Inspection

Palpation

Round or oval

color darker than

surrounding skin,

symmetrical for

dark skinned client

color is darker that

other skin

surfaces.

No masses and

Small, round

darker than

surrounding

skin,

symmetrical.

No masses,

tenderness and

discharges.

Normal


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area of tenderness

Abdomen Inspection

Palpation

Auscultation

Percussion

Skin is

unblemished, no

scar, color is

uniform or

scaphoid,

symmetrical

movement caused

by respiration. The

umbilicus is flat or

concave. Color is

the same as the

surrounding skin.

Skin is

unblemished, no

scar and lesions.

Color is uniform,

symmetrical

movement due

to respiration.

Umbilicus is flat,

no bulging,

masses.

Presence of

bowel sounds

and distention.

normal

Arm Inspection

Palpation

Skin color varies

Symmetrical fine

evenly distributed

presence/absence

of visible veins.

Warm dry and

elastic no areas of

tenderness.

Same color with

the body.

Symmetrical and

moves freely.

Absence of scar.

Warm and

tender.

normal.


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Hands and

Palm

Inspection

Palpation

Palm pinkish warm Small, soft and

pinkish palm. No

presence of

callus. Presence

of 5 fingers on

each hand.

Normal

Nails Inspection

Palpation

Nails are

transparent

smooth and

convex with pink

nail beds and

white translucent

As pressure

applied to the nail

bed, appears

white or balance

and pink color

returns

immediately as

pressure is

released.

Nails are

transparent and

smooth.N

o

presence of nail

polish. Pinkish

white translucent

tips. When

pressured is

applied the color

is white and

when released it

returns to normal

color.

Normal

Shoulder,

Arms, Elbows,

Inspection

Palpation

Perform on ease Moves freely

without difficulty.

Normal


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Hand and

wrists

Uniform color.

Legs Inspection

Palpation

skin is smooth fine

hair evenly

distributed

absence of

varicose vein

muscle

symmetrical length

Muscle appear

equal warm and

with good muscle

tone.

Skin color is

uniform.

Symmetrical and

muscles are

tender and

warm. No

presence of

edema. Moves

freely without

difficulty.

Normal

Ankles, toes

and nails

Inspection

Palpation

Five toes in each

foot sole and

dorsal surface is

smooth with pink

nailbeds and white

translucent tips.

Range of motion

Pinkish white

color of nails

with translucent

tips. No

presence of nail

polish. Five toes

in each foot.

Moves freely

without any

discomforts.

Normal


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GORDONS PATTERN OF FUNCTIONING

Patterns of

Functioning

Before Diagnosis After Diagnosis Analysis/

Interpretation

Health perception

management pattern

Lu takes a

multivitamins which

is prescribed by the

health center.

He takes a bath

once a day.

He already

completed his EPI

vaccines.

He takes a same

vitamins that his

cousin takes.

He takes a bath

twice a day.

It shows a small

difference in his

personal hygiene.

Nutritional/Metabolic

pattern

He drinks coffee

before going to

school.

He likes to eat fruits

and vegetables

especially

ampalaya.

He is not a picky

eater.

There is no

significant changes

was shown before

and after diagnosis.


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He eat 4 times a

day.

He has no allergies

on all foods.

He drinks 8-10

glasses of boiled

water everyday

Elimination pattern He usually urinate

7 times a day.

He usually

defecates twice a

day and the color is

brown

He use the public

toilet when every

he needs to urinate

and defecate.

He still urinate and

defecate at the

same rate

The frequency of

patients elimination

is just the same

Activity-Exercise

pattern

He wakes up

around 5:00 to 7:00

in the morning.

He always want to

play and go outside

the house.

There is no

significant changes.


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on her physical

image

disabilities.

He always wear

short and sando.

Role-relationship

pattern

He is the youngest

in the family

He is the one who

always wash the

dishes.

He is aware that he

also needs to work

for the family

Theres no change

in her relationship

to his family.

Coping stress

tolerance pattern

He go back home

whenever people

starts to make fun

of him.

He go to his

friends house

when he was

bored.

He ignore those

people who tease

him.

There is no

significant changes

shown

Value-belief pattern He pray to God

when he feels he

was alone.

He pray to thank

God for the life he

gave.

He became more

religious when he

found out about his


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He go to church

alone .

condition


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C. CLINICAL DISCUSSION

Anatomy and Physiology

Central Nervous System

Spinal Cord

The spinal cord is a long bundle of neural tissue continuous with the brain that occupies

the interior canal of the spinal column and functions as the primary communication link

between the brain and the rest of the body. The spinal cord receives signals from the

peripheral senses and relays them to the brain.


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Brain Stem

The brain stem is the part of the brain that connects the cerebrum and diencephalons

with the spinal cord.

Medulla Oblongata

The medulla oblongata is located just above the spinal cord. This part of the brain is

responsible for several vital autonomic centers including:

4. the respiratory center, which regulates breathing.

5. the cardiac center that regulates the rate and force of the heartbeat.

6. the vasomotor center, which regulates the contraction of smooth muscle in the

blood vessel, thus controlling blood pressure.

The medulla also controls other reflex actions including vomiting, sneezing, coughing

and swallowing.

Pons

Continuing up the brain stem, one reaches the Pons. The pons lie just above the

medulla and acts as a link between various parts of the brain. The pons connect the two

halves of the cerebellum with the brainstem, as well as the cerebrum with the spinal

cord. The pons, like the medulla oblongata, contain certain reflex actions, such as some

of the respiratory responses.

Midbrain

The midbrain extends from the pons to the diecephalon. The midbrain acts as a relay

center for certain head and eye reflexes in response to visual stimuli. The midbrain is

also a major relay center for auditory information.


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Diencephalon

The diencephalons is located between the cerebrum and the mid brain. The

diencephalons houses important structures including the thalamus, the hypothalamus

and the pineal gland.

Thalamus

The thalamus is responsible for "sorting out" sensory impulses and directing them to a

particular area of the brain. Nearly all sensory impulses travel through the thalamus.

Hypothalamus

The hypothalamus is the great controller of body regulation and plays an important role

in the connection between mind and body, where it serves as the primary link between

the nervous and endocrine systems. The hypothalamus produces hormones that

regulate the secretion of specific hormones from the pituitary. The hypothalamus also

maintains water balance, appetite, sexual behavior, and some emotions, including fear,

pleasure and pain.

Cerebellum

The functions of the cerebellum include the coordination of voluntary muscles, the

maintenance of balance when standing, walking and sitting, and the maintenance of

muscle tone ensuring that the body can adapt to changes in position quickly.

Cerebrum

The largest and most prominent part of the brain, the cerebrum governs higher mental

processes including intellect, reason, memory and language skills. The cerebrum can

be divided into 3 major functions:


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Sensory Functions - the cerebrum receives information from a sense organ; i.e.,

eyes, ears, taste, smell, feelings, and translates this information into a form that

can be understood.

Motor Functions - all voluntary movement and some involuntary movement.

Intellectual Functions - responsible for learning, memory and recall.

Meninges

The meninges are made up of three layers of connective tissue that surround and

protect both the brain and spinal cord. The layers include the dura mater, the arachnoid

and the pia matter.

Cerebrospinal-Fluid

The cerebrospinal fluid is a clear liquid that circulates in and around the brain and spinal

cord. Its function is to cushion the brain and spinal cord, carry nutrients to the cells and

remove waste products from these tissues.


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Pathophysiology

Predisposing factors:-Age: 14-Gender: Male-Genetics

Precipitating factors:-Environment-Depression

Defect in dopamine receptors d4 (DRD4)

Uses (DA) dopamine (NE) norepineprine

neuro transmitter

To modulate attention and response to

ones environment

Dopamine transporter 1 (DAT1)

Pre synaptic to post synaptic receptors with

action potential

INATTENTION COMBINEDTYPE HYPERACTIVE

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