Attention Deficit Hyperactivity Disorder

Subjective Objective Assessment Planning Interventions Evaluation

“ TJ has been VS: T 36.9 C, RR 16, Differential diagnoses:  Refer to weekly  Ensuring safety  Referred to weekly
all over the HR 92, BP 120/80,
 Hyperthyroidism behavioural  Improving Role behavioural therapy
place and Ht 125cm, Wt 55lb performance
 Mood disorder therapy at local at local outpatient
cannot General: Well  Simplify instructions
 Anxiety outpatient clinic.
concentrate nourished, well  Promoting a
in class or developed. Alert and Common Co-morbidites clinic. Structured Daily
complete oriented to time,  Learning routine  Established
tasks at place and person.  Establish  Providing client and educational plan with
Disabilities
home.” Skin: Warm, dry, no family education and
rashes  Depression educational plan teachers, guidance
support
HEENT: Head  Anxiety with teachers, office, pediatric
midline. Ears: Clean  Oppositional guidance office, provider and parent
canals bilaterally, Defiant Disorder pediatric to ensure optimal
TMs visualized,  Conduct provider and supports are
+light reflex, no Disorder
erythema or edema parent to provided to minimize
bilaterally. Eyes: ensure optimal disruptions and
PERRLA, EOM intact, supports are distractions in the
20/20 vision provided to classroom.
bilaterally without
correction. No minimize
strabismus, no disruptions and
nystagmus. distractions in
Fundoscopic exam the classroom.
normal, vessels
intact, optic disc
with clear margins.
Nares patent with
no edema or
erythema. No
thyromegaly.
CV: RRR, S1 and S2
present. No
murmurs, clicks, or
gallops
Lungs: Clear to
auscultation
bilaterally, no
wheezing, rhonchi
or rales
Abdomen: Soft,
nontender,
nondistended.
Bowel sounds
present in all 4
quadrants, no
hepatosplenomegaly
Neuro: CN II-XII
grossly intact.
Musculoskeletal: 5/5
strength and ROM in
all extremities. No
scoliosis or kyphosis.
Psychiatric:
Hyperactive
 Date and Time Focus
1/1/19 Impaired Social Interaction Data: Received lying on bed awake. Short
11:00 am attention span noted. High level of distractibility.
Inability to complete tasks. Inability to sit still and
excessive talking was observed.

Action: Identified the factors that aggravate and

alleviate the client’s performance. Provided an
environment as free from distractions as
possible. Engaged the client’s attention before
giving instructions. Asked the client to repeat
instructions before beginning tasks. Separated
complex tasks into small steps. Provided positive
feedback for complain of each step.

Response: Able to exacerbate the client’s

problems that can be identified and minimized
and able to comprehend instructions