Nursing Interventions ^*denotes collaborative interventions

Rationale

Do not assume that the client knows proper or expected behavior. State expectations for behavior in clear terms.

Developmentally, the client may be unable to process social cues to guide reasonable behavior choices.

Assess the frequency and severity of accidents.

It is necessary to establish a baseline before planning interventions.

Provide supervision for potentially dangerous situations. Limit the client’s participation in activities when safety cannot be ensured.

The client’s ability to perceive harmful consequences of a behavior is impaired.

Talk with the client about safe and unsafe behavior. Explain that accidents will result in increased supervision and that purposeful unsafe behavior will have consequences.

This provides the client with clear expectations.

Attempt to distinguish between accidents and behaviors that are deliberate.

Physical safety is a priority. Accidents will require increased supervision, but deliberate actions can be altered with behavioral techniques.

If the situation is determined to be accidental, institute safeguards or limitations as appropriate.

Different interventions are instituted for accidents than for deliberate actions.

If the situation is determined to be deliberate, institute consequences in a nonpunitive manner.

Logical consequences for an undesirable behavior can diminish the occurrence of the behavior.

Make corrective feedback as specific as possible, for example, “Do not jump down the stairs. Walk down one step at a time.”

Specific information will help the client understand expectations.

Provide consequences that are directly related to the undesirable behavior. Institute consequences as soon as possible after the occurrence of the behavior.

The client will be better able to draw the correlation between undesirable behavior and consequences if the two are related to each other.

^*Teach the client’s parents or caregivers about ADHD and the client’s treatment plan and medication, if any.

The client’s parents or caregivers may lack knowledge about ADHD and treatment.

^*Assist the client’s parents or caregivers to make the distinction between accidental and purposeful incidents.

This will enable them to deal with behaviors at home more effectively.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Identify the factors that aggravate the client’s behavior and those that help the client’s performance.

The external stimuli that exacerbate the client’s problems can be identified and minimized. Likewise, factors that positively influence the client can be effectively used.

Provide an environment as free from distractions as possible. Institute interventions on a one-to-one basis. Gradually increase the amount of environmental stimuli.

The client’s ability to deal with external stimulation is impaired.

Engage the client’s attention before giving instructions (i.e., call the client’s name and establish eye contact).

The client must hear the instructions as a first step toward compliance. He or she may not comprehend instructions if his or her attention is distracted by something else.

Give instructions slowly, using simple language and concrete directions.

The client’s ability to comprehend instructions (especially if they are complex or abstract) is impaired.

Ask the client to repeat instructions before beginning tasks.

Repetition demonstrates that the client has accurately received the information.

Separate complex tasks into small steps.

The likelihood of success is enhanced with less complicated components of a task.

Provide positive feedback for completion of each step.

The client’s opportunity for successful experiences is increased by treating each step as an opportunity for success.

Allow breaks, during which the client can move around.

The client’s restless energy can be given an acceptable outlet, so he or she can attend to future tasks more effectively.

State expectations for task completion clearly.

The client must understand the request before he or she can attempt task completion.

Initially, assist the client to complete tasks.

If the client is unable to complete a task independently, having assistance will allow success and will demonstrate how to complete the task.

Progress to prompting or reminding the client to perform tasks or assignments.

The amount of intervention gradually is decreased to increase client independence as the client’s abilities increase.

Give the client positive feedback for performing behaviors that come close to task achievement.

This approach, called shaping, is a behavioral procedure in which successive approximations of a desired behavior are positively reinforced. It allows rewards to occur as the client gradually masters the actual expectation.

Gradually decrease reminders.

Client independence is promoted as staff participation is decreased.

Assist the client to verbalize by asking sequencing questions to keep on the topic (“Then what happens?” and “What happens next?”).

Sequencing questions provide a structure for discussions to increase logical thought and decrease tangentiality.

^*Teach the client’s family or caregivers to use the same procedures for the client’s tasks and interactions at home.

Successful interventions can be instituted by the client’s family or caregivers by using this process. This will promote consistency and enhance the client’s chances for success.

^*Explain and demonstrate “positive parenting” techniques to family or caregivers such as time-in for good behavior, or being vigilant in identifying and responding positively to the child’s first bid for attention; special time, or guaranteed time spent daily with the child with no interruptions and no discussion of problem-related topics; ignoring minor transgressions by immediate withdrawal of eye contact or physical contact and cessation of discussion with the child to avoid secondary gains.

It is important for parents or caregivers to engage in techniques that will maintain their loving relationship with the child while promoting, or at least not interfering with, therapeutic goals. Children need to have a sense of being lovable to their significant others that is not crucial to the nurse-client therapeutic relationship.