Indications for Hospitalization or Discharge
ADHD is a condition that affects behavior, cognition, academic, emotional and social functioning. When a patient is experiencing extreme behaviors that interferes with normal activities of daily living. This is a medical emergency and requires hospitalization. ADHD can make a patient have suicidal tendencies.
Patients who feel they want to hurt themselves or someone else is a medical emergency and requires immediate hospitalization.
Upon discharge it is important for the patient to understand and adhere to all provider discharge instructions. Patients on stimulants and antidepressants need to take their medications as directed and with supervision of a family member or caregiver. Family, friends and caregivers need to understand that these medications can lead to suicidal tendencies. Any signs or red flags, the patient must seek care immediately.
For any reasons, if the medicine that was prescribed is not helping or have side effects or more importantly if the patient is having an allergic reaction, patients must see the provider right away.
It is important for patients and families to keep a medical health record and a list of patient medications at all times.
Following up with a healthcare provider regularly is key.
Medications upon discharge
According to UptoDate, “medications combined with behavioral/psychological interventions for most school aged children (6 years) and adolescents who meet diagnostic criteria for ADHD as an adjunct to behavioral interventions for preschool children who meet diagnostic criteria for ADHD and fail to respond to behavioral interventions alone. However, the values and preferences of the patient and family are critical factors in deciding whether or not to initiate medication. The decision of families who choose to decline medication must be respected”. It is important to take into account the patient and family’s wishes and the patient’s comorbid conditions. Stimulants are the first line agents preferred to other medications because stimulants have a rapid onset of action and long record of safety and efficacy.
Amphetamines are used to treat ADHD.
Atomoxetine is an alternative to stimulants and may be more appropriate for patients with a history of illicit substance use or family members with a history of illicit substance use, concern about abuse or diversion, or a strong family preference against stimulant medication.
Apha-2-adrenergic agonists (guanfacine, clonidine) usually are used when children respond poorly to a trail of stimulants or atomoxetine, have unacceptable side effects. As a class, they are less effective than stimulants.
Patient and family need to understand that stress make ADHD worse. The importance of learning how to calm the body and mind is detrimental such as deep breathing, muscle relaxation, music and biofeedback. Talking to a friend, spouse or family member is encouraged. Patients are encouraged to learn more about ADHD. Drinking alcohol is prohibited, eating a healthy diet and having a regular sleep schedule is vital to optimum health with ADHD.
Pharmacotherapy for ADHD has three stages: titration, maintenance, and termination.
During the titration stage, the optimal dose and frequency of the medication is determined from one to three months. During this time requires close monitoring (usually weekly) by the clinician, some of which can be done by phone.
The dose reponse relationship for stimulant medication varies by child. When children and adolescents who are being treated with stimulant medications develop side effets, it’s important to determine the timing of the effect of the medication and determine whether the effect is related to a coexisting disorder or environmental stressor.
Clinicals must take into a account the client’s decreased appetite, poor growth, dizziness, insomnia/nightmares, mood lability, rebound, tics, pyschosis, diversion and misuse. Patient teaching is crucial when it comes to taking the medication exactly as prescribed for dose and frequency or whether it is working. Alcohol must be avoided along with other illegal substance. Patient’s must know where to administer the medication in a safe location and not to be coerced or tempted to sell the medication.
There must be a plan for transition of responsibility, from child to adolescent. The adolescent must fully be responsible for managing his or her medication regimen before leaving home, at school or at work.
Treatment failure is part of the process. The patient and the family’s wishes must be taken into consideration.
In Maintenance therapy begins once the optimal dose and frequency of the medication has been determined. During the maintenance stage, regular monitoring is necessary to review the process and adjust doses if necessary. A review of the child and adolescent’s medication their understanding and compliance must be reviewed.
The termination stage is individualized. After several years of medication, it is reasonable to offer children and adolescents who have stable improvement in ADHD symptoms and target behaviors to have a trial off of the medication to determine whether the medication is still necessary.
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