C H A P T E R 2 2
Psychotherapeutic agents
349
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An attention-deficit disorder is a behavioural
syndrome characterised by hyperactivity and a short
attention span.
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Narcolepsy is a disorder characterised by daytime
sleepiness and sudden loss of wakefulness.
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CNS stimulants, which stimulate cortical levels and
the RAS to increase RAS activity, are used to treat
attention-deficit disorders and narcolepsy. These
drugs improve concentration and the ability to filter
and focus incoming stimuli.
KEY POINTS
to determine baseline status before beginning
therapy and for any potential adverse effects.
Also obtain a FBC.
Implementation with rationale
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Ensure proper diagnosis of behavioural syndromes
and narcolepsy
because these drugs should not
be used until underlying medical causes of the
problem are ruled out.
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Arrange to interrupt the drug periodically in
children who are receiving the drug for behavioural
syndromes
to determine whether symptoms recur
and therapy should be continued.
■
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Arrange to dispense the least amount of drug
possible
to minimise the risk of overdose and
abuse.
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Administer drug before 6 p.m.
to reduce the
incidence of insomnia.
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Monitor weight, FBC and ECG
to ensure
early detection of adverse effects and proper
interventions.
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Consult with the school nurse or counsellor
to
ensure comprehensive care of school-aged children
receiving CNS stimulants
(Box 22.7).
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Provide safety measures such as side rails and
assistance with ambulation if CNS effects occur
to prevent injury.
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Provide thorough teaching, including drug name,
prescribed dosage, the need to secure the drug as
a controlled substance, measures for avoidance of
adverse effects, warning signs that may indicate
possible problems and the need for monitoring
and evaluation
to enhance knowledge about drug
therapy and to promote compliance.
Offer support
and encouragement to help the person to cope with
the drug regimen.
Evaluation
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Monitor response to the drug (decrease in
manifestations of behavioural syndromes, decrease
in daytime sleep and narcolepsy).
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Monitor for adverse effects (CNS stimulation,
CV effects, rash, physical or psychological
dependence, GI dysfunction).
■
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Evaluate effectiveness of the teaching plan (person
can give the drug name and dosage, name possible
adverse effects to watch for and specific measures
to help avoid adverse effects and describe the need
for follow-up and evaluation).
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Monitor effectiveness of comfort measures and
compliance with the regimen.
School nursing and Ritalin administration
In the last several years, the number of school children
receiving diagnoses of attention-deficit disorder or
minimal brain dysfunction and being prescribed
methylphenidate (Ritalin) has increased dramatically.
Because this drug needs to be given two or three times
each day, it has become the responsibility of the school
nurse to dispense the drug during the day. Some school
nurses reportedly spend between 50% and 70% of their
time administering these drugs and completing the
necessary paperwork. In 2000–2001, several long-acting
formulations of methylphenidate became available.
Concerta, previously available in an extended-
release tablet in 18- and 36-mg strengths, is now also
available in a 54-mg strength.This form is suggested for
every-12-hours dosing.The advantage of these extended-
release forms is expected to be a decrease in the number
of students who must see the nurse for medication during
the school day and, perhaps, a decrease in the stigma that
may be associated with needing this drug.
The school nurse has additional responsibilities besides
administering the drug.The school nurse is responsible
for assessing children’s response to the drug and for
coordinating the teacher’s and healthcare providers’
input into each individual case, including the incidence
of adverse effects and the appropriateness of the drug
therapy.The nurse should:
• Ensure that the proper diagnosis is made before
supporting the use of the drug.
• Constantly evaluate and work with the primary
healthcare provider to regularly challenge children
without the drug to see whether the drug is doing what is
expected or whether the child is maturing and no longer
needs the drug therapy.
The school nurse needs to be prepared to be an
advocate for the best therapeutic intervention for a
particular child. Because long-term methylphenidate
therapy is associated with many adverse effects, use of the
drug should not be taken lightly.
The evidence
BOX 22.7
