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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