ADHD and nursing school please help

SheaTab · Nov 26, 2009

This is a great discussion! I am so glad you opened up some much needed dialogue about ADHD. There are a number of misconceptions about this disorder. I STRONGLY recommend that you purchase the book: Driven To Distraction : Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood; Hallowell. This book has really helped me to understand a lot of the issues that I've had as a student and in my personal life.

I was untreated up until recently and school was always a significant challenge. Since treatment, it has literally been like having a light switch flipped on in terms of my ability to comprehend and retain complex material. I remember struggling to a debilitating degree with reading and found myself self-medicating with another stimulant -- Caffeine. It worked well, actually. Are you being treated?

So, as an aside, I was a 4.0 nursing student all the way through my ADN, BSN, and MSN (except for one graduate-level nursing theory course)! I figured out how to learn in spite of my excessive distractibility and you can do the same. I'd love to give you some advice if I may. This strongly applies to all nursing students as well.

1. Always read for comprehension!! At the end of each paragraph you read, stop, cover your book and explain aloud/silently what you just read. If you can't, go back and reread. If you can't explain it, you probably don't really get it. Yes, this takes a lot of additional study time, but studying this way is worth its weight in gold. The time you do spend reading infinitely more productive. And, you have an obligation to your patients to really understand the pathophysiologic basis of all the nursing care you give.

2. Always read the chapters. You may distract more easily in class and will get less out of lectures than some of your peers. With this in mind, lecture only hits the highlights and there is SO MUCH MORE to know than the highlights. Also, you will have an easier time picking up on the important points during lecture if you have pre-read the chapters.

3. Remember, no cell is an island. One thing goes awry and the other systems will likely be affected. Understand the pathophysiology and you will have infinitely less to memorize! Here is an example I gave one of my students:

"Remember the examples I helped you work through with regard to the negative feedback mechanism of TSH & T3/T4. Also, how about the one where we talked about Aldosterone and the effects on the BP? This was an essential concept that all of you should have grasped from the renal lecture and also in fluid & electrolytes. Remember, if you can’t explain it, then you probably don’t really get it. Also, what happens when your patient asks you about their condition? I know you don’t want to be one of those nurses who tells them to wait until their physician rounds in the morning or one who gives the wrong information. The problem with memorizing is that you will do your best to get it for the test and then when it comes up in another system, you have no idea how to apply it. Remember, that any broken body system will have effects on all the others. Answering questions and taking care of these complex patients requires you to apply not just endo patients but also cardiac, renal, neuro,, pulmonary, etc. because one problem will affect other systems. Does that make sense? Take Hyperaldosteronism, for example. You have to understand that the aldosterone will cause you to retain sodium and excrete potassium. Now, if you don’t understand how this hormone is activated, you might get confused and think that this is just an endo problem. Aldosterone can be activated by anything that affects blood flow to the kidneys. So, consider the patient who is bleeding to death and has low flow to the kidneys. This will activate renin (needs conversion help from angiotensinogen from the liver!), then angiotensin I (AT I) (which requires angiotensin converting enzyme from the LUNGS & Kidneys) to convert to angiotensin II (AT II) which will ultimately result in renal tubular reabsorption of sodium, chloride, water and elimination of potassium. It will also activate Aldosterone which will also result in renal tubular reabsorption of sodium, chloride, water and elimination of potassium! Guess what else AT II does? It causes arterial constriction and stimulation of Antidiuretic Hormone (ADH) release from the posterior pituitary. This will result in increased BP from water reabsorption in the kidneys. All of these things result in increased blood flow to the kidneys which is why this started in the first place! In the case of hemorrhage, Aldosterone will help matters by causing sodium reabsorption, water will follow the sodium and result in increased blood volume! This is a good thing in this case. Imagine however that the kidneys were receiving low blood flow because the pump (heart) is diseased and not working properly as is the case with heart failure. This will also cause activation of RAAS cascade will further exacerbate the problem by causing increased fluid retention. Also, consider that AT II causes vasoconstriction (increased systemic vascular resistance) which will make the heart work harder to pump through constricted vessels. Aldosterone can cause potassium depletion which will put this patient at risk for a host of other problems related to hypokalemia. How about the patient who has diabetes and thus arteriosclerosis and thickening of the basement membrane of the renal vessels. Their kidneys will perceive that there is a low-output state and activate Renin Angiotensin Angiotensin II Aldosterone. Do these patients need increased blood volume? Not usually, but they will get it and it can have a devastating effect on the body. You will often see these patients on an Ace inhibitor because of this. Make sense? Aldosterone can also be activated by elevated levels of potassium which makes sense now that you understand the system. Activation will result in dumping of the potassium. Dig?

Understanding the effects of Aldosterone, will also help you understand how and why ACE inhibitors work. They prevent the conversion of Angiotensin I to Angiotensin II which will result in preventing the stimulation of the adrenal cortex which will release aldosterone. You can also see then how Angiotensin Receptor Blockers (ARBs) and Renin Blockers (RBs) work to help patients with hypertension. They ultimately prevent the release of Aldosterone!  Anything that results in increased circulating blood volume will raise the BP. Sometimes this is a good thing, like in the case that you are severely dehydrated or hemorrhaging. It can be a terrible thing for the patient who has heart failure, is already hypertensive, or who is in renal failure!"

Do you see how understanding a very important "little" thing like the function of aldosterone helps you to grasp endo, cardiac, and renal issues?

4. Sit at the front of the class during lecture and tests. This will help with distractibility. Also, wear ear plugs during tests. No exceptions.

5. Read up on the stress response as well. Understanding cortisol will help you immensely in terms of anticipating the effects of nearly every disease process and its effects on the body. Additionally, psychological stressors have the same effect!

I'm proud of you for coming forward and talking about your ADHD. You have nothing to be ashamed of. This is a very real condition that improves dramatically with treatment and lifestyle modifications. Many nurses and doctors have ADHD and thrive very well in the profession. Many also choose high-intensity areas like Emergency Medicine/Nursing because the environment is very stimulating. No shame! We are humans just like our patients; and as such, we will experience alterations in our physical and mental health from time-to-time.

Keep Rocking!

Tabitha

ashleyisawesome, BSN, RN · Nov 26, 2009

my clinical instructor is a clinical psych mental health specialist, so she picked up that i had ADD right away. she asked me about it and i admitted that i used to take aderall, but its adverse effects outweigh the benefits for me and i prefer not to take medications..

well ever since then, i feel as though i have become the joke of our clinical group. shes constantly making jokes about me and my ADD, and its embarassing... she even critiques my papers in front of the whole group and says things like "we can clearly see Ashley's ADD shining through here, she starts out great and then takes a sharp left turn and i dont know what shes talking about!" then everyone laughs.. except me..

SheaTab · Nov 26, 2009

my clinical instructor is a clinical psych mental health specialist, so she picked up that i had ADD right away. she asked me about it and i admitted that i used to take aderall, but its adverse effects outweigh the benefits for me and i prefer not to take medications..
well ever since then, i feel as though i have become the joke of our clinical group. shes constantly making jokes about me and my ADD, and its embarassing... she even critiques my papers in front of the whole group and says things like "we can clearly see Ashley's ADD shining through here, she starts out great and then takes a sharp left turn and i dont know what shes talking about!" then everyone laughs.. except me..

Houston, we have a problem!

Ashley, I am horrified that you have felt made fun of and publicly critiqued. This is absolutely unacceptable in my estimation. I'd like to make a suggestion to you, if I may.

I'd suggest that you request a formal meeting with this instructor during non-class/clinical time. This will provide for limited distractions and also indicate to her that you care strongly about your concerns. You might have a conversation that goes something like this ...

"Dr./Ms. Doe, I wanted to discuss something with you that has concerned me with regard to my mental health clinical experience. There have been a few times when my diagnosis was referenced publicly that have resulted in a great deal of embarrassment to me. I am hoping that we can talk about this and perhaps come to a better understanding."

Just like our vulnerable patients, students are also very vulnerable. Ashley, try to stick to "I" statements to keep the conversation heading in a productive direction. Try to organize your thoughts beforehand and make sure you are able to give a few examples of specific incidences where these things have occurred. You don't want to attack your instructor, but you are actually doing her a favor by letting her know how inappropriate her actions are. She might easily make this mistake again. Also, there might be a possibility that you have laughed along with the group at times which may have resulted in her and the class thinking it doesn't bother you much. I can easily see how this might happen as a way to protect yourself from feeling made fun of. You know the old saying, "I'm not laughing at you, I'm laughing with you." Or, "if you can't beat them, join them?" Certainly a nursing student wouldn't try "beating" her professor, so it is better to join in the fun, even if it is aimed at you. Hopefully, just by telling her that your feelings have been hurt will result in a heartfelt apology. I suspect they will. However, if that isn't her response, I'd suggest you take your concerns to your course coordinator and then follow the command all the way up. Be kind, informed, and assertive. Your health history is not up for public discussion unless you choose to make it so. Even if you have discussed your diagnosis among your peers and instructors, you may reserve the right to take it off the table as available to discuss in the future. If this has something to do with it, then perhaps you simply need to tell the instructor that moving forward, you'd prefer it if your diagnosis not be discussed publicly.

Please let me know if I can help.

Keep Rocking!

Tabitha