NURS 6541 Pediatrics Midterm Study Guide - Walden University ( A grade / School graded)

NURS 6541 Pediatrics Midterm Study Guide - Walden University ( A grade / School graded) Peds Midterm Study Guide Section 1 Emily Turner 1. Children are able to sit without extra support at what age?  6-8 month olds ...

NURS 6541 Pediatrics Midterm Study Guide - Walden University ( A grade / School graded) Peds Midterm Study Guide Section 1 Emily Turner 1. Children are able to sit without extra support at what age?  6-8 month olds should be able to sit briefly without extra support, 7-9 months old sit well independently. 2. Types of car seats (see also #60): Appropriate ages and weights for forward and rear facing seats.  When can kids ride in the front seat of the car?  13 years old. When should they use booster seat? 4-8 years old The AAP recommends: • Infants and toddlers should ride in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by their seat. Most convertible seats have limits that will allow children to ride rear-facing for 2 years or more. • Once they are facing forward, children should use a forward-facing car safety seat with a harness for as long as possible, until they reach the height and weight limits for their seats. Many seats can accommodate children up to 65 pounds or more. • When children exceed these limits, they should use a belt-positioning booster seat until the vehicle’s lap and shoulder seat belt fits properly. This is often when they have reached at least 4 feet 9 inches in height and are 8 to 12 years old. • When children are old enough and large enough to use the vehicle seat belt alone, they should always use lap and shoulder seat belts for optimal protection. • All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection. 3. Recommended vaccine schedule (many questions): https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html (Items 3, 6, 46, and 85 in this study guide address vaccines) 4. Child abuse questions: • What age is it appropriate to have certain types of fractures?  Metaphyseal fractures, multiple differently aged posterior rib fractures, complex or multiple skull fractures, spinous process or scapular fractures are suspicious in children. • When should you be concerned about a young infant with tons of bruises (eg - if they are not walking yet would be unusual)?  Long bone fx are unusual in young infants.   • When is it necessary for you to report? Anytime you suspect any sort of abuse.   • Who do you report to? CPS.   • Do you face any repercussions?  Should not. • Any fracture in a non-ambulatory infant without clear accidental and consistent mechanism should raise a red flag.   (items 4, 5 and 29 in this guide address child abuse) 5. Toddler abuse: There will be a list of injuries. Which would be caused by abuse? • Bruises TEN4 by AAP 1. T- torso; E- ear; N- neck; 4- in children less than or equal to 4 years and ANY bruise in children less than 4 months • Injuries tend to occur away from bony prominences (neck, head, buttocks, trunk, hands, and upper arms) 6. Contraindications of vaccinating children.  Who should not receive a live vaccine? Immunocompromised, allergic reaction to a previous dose or component of vaccine, history of intussusception for Rotavirus  See CDC sheet “vaccines by medical indication” https://www.cdc.gov/vaccines/schedules/hcp/imz/child-indications.html Immunocompromised should not receive: Rotavirus, MMR, influenza (LAIV) or varicella HIV infection should not receive: Influenza (LAIV), MMR or varicella Kidney disease should only cautiously receive influenza (LAIV) Asthma: No influenza (LAIV) CSF leaks: No influenza (LAIV) (Items 3, 6, 46, and 85 in this study guide address vaccines) 7. Young boy with mental retardation.  He was a premie.  They give a scenario.  What caused his mental retardation? eg - understand congenital abnormalities, infections, preemie complications, chromosomal aberrations, brain tumor, serum blood levels • Important risk factors for intellectual disability (ID) include low level of maternal education, advanced maternal age, and poverty. • The causes of ID are extensive and include conditions that interfere with brain development and functioning. Among the known causes of ID, the majority are genetic abnormalities. 1. A genetic cause can be identified in >50 percent of cases of ID in populations referred for specialty evaluation. Down syndrome is the single most common genetic cause of ID. X-linked disorders (including fragile X syndrome) account for approximately 5 to 10 percent of ID in males. De novo dominant mutations are an important cause of severe ID. • Metabolic disorders can cause ID or may be comorbid. ID can present alone or with neurologic abnormalities such as epilepsy or structural brain defects, or with other congenital anomalies. • Nongenetic prenatal causes of ID include congenital infections, and teratogens such as alcohol, lead, and valproate. Perinatal abnormalities account for up to 5 percent of ID and include preterm birth, hypoxia, infection, trauma, and intracranial hemorrhage. Postnatal and acquired causes of ID include accidental or nonaccidental trauma, central nervous system (CNS) hemorrhage, congenital hypothyroidism, hypoxia (eg, near-drowning), environmental toxins, psychosocial deprivation, malnutrition, intracranial infection, and CNS malignancy. 1. Blood lead testing should be performed if the child has not had prior lead screening and/or risk factors for exposure are present (eg, persistent mouthing behavior, pica, living in a house or child care facility built before 1950, recent immigration or home renovation, ethnic remedies, and some parental occupations [smelting, soldering, and auto body repair]). Section 2 Melissa Burris 8. Newborns: What type of vitamin deficienc\ies cause problems? eg - vitamin A, B1, C, D and K Vitamin A Deficiency: Anorexia, dry skin, increased risk for infection, keratinization of epithelial cells of the respiratory tract,night blindness, corneal lesions. Vitamin B1 Deficiency: Beriberi: Muscle weakness, ataxia, confusion, anorexia, tachycardia, heart failure in infants. Vitamin C Deficiency: Scurvy, cracked lips, bleeding gums, slow wound healing, easily bruises. Vitamin D Deficiency: Inadequate bone mineralization, rickets or skeletal malformations, delayed dentition Vitamin K Deficiency: Defective coagulation of blood, hemorrhages, liver injury. - - - - - - - - - - - - - - 37. Teething toddler recommendations p 891 Cold teething ring, wet, chilled washcloth, massaging the guns, for older children, may use chilled hard food. Tylenol Ok. Do not use frozen anything or orajel. 38. More questions about language development issues Section 8 Danielle LeBlanc 39. Sleep patterns in young children (this image is bigger on #47) 40. Refusal bowel patterns on toilet Two behaviors associated with stool toileting refusal may require the intervention of the pediatrician. The first is stool withholding causing constipation which can result in rectal impaction and primary encopresis. The second is lack of successful toilet training by 42 months of age. 41. 2 year-old breath holding spells A spell typically lasts less than a minute before a child starts breathing normally again. Breath-holding spells can happen in healthy children between 6 months and 6 years old, but are most common during the second year of life. They can be more common in kids with a family history of them. -not voluntary or intentional, not harmful, worst case seizure with no lasting effects, two types: cyanotic (usually doesn’t breath during a crying fit and passes out) and pallid (scared, turns white and passes out), should only last one minute at the longest 42. Bilingual child advice It preserves culture, increases mental flexibility, increases employment and lifestyle opportunities, suggest one-parent use one language, language milestones met in primary language, but secondary language lags, if significant delays then evaluation similar as with monolingual children 43. Walking around with object at what age - 18 months. Section 9 Shana Light What are some common features of 12 mo old, 2yo, 5yo behavior? 44. Stranger anxiety - Fearfulness in the presence of strangers is thought to emerge around 6 months of age and extends through about 36 months of age.  At 12 month WCC, warn parents that stranger anxiety reaches a peak in the next few months.  The onset of stranger fear is believed to be adaptive, offering balance to infants’ propensities for approach and exploration.  Some fear is normal, excessive fear can be a predictor for social anxiety later in life.  Some experts suggest that Infants who develop Autism Spectrum Disorder have an absent, delayed, or modified Stranger Anxiety Response. 45. Parallel play - From the age of two to three, children move to playing alongside other children without much interaction with each other. They may be engaged in similar activities or totally different activities but they like being around others their own age. Non-parallel play - Negativism - to increase independence- 18-30 months (lots of saying “no”) 46. Catch up vaccines - https://www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html (Items 3, 6, 46, and 85 in this study guide address vaccines) 47. Normal sleep pattern for infants - As compared with older children and adults, newborns have longer sleep duration, an increased proportion of REM sleep, and shorter REM-NREM cycles. Sleep-wake patterns become more diurnal and sleep times gradually decrease from infancy through adolescence.  Identification of sleep problems in children is important because a growing body of evidence suggests that sleep disorders may interfere with physical, cognitive, emotional, and social development. Conversely, children with neurodevelopmental problems, learning differences, or behavior problems may be at heightened risk for sleep problems compared with the general pediatric population.  The most common causes of daytime sleepiness include insufficient nocturnal sleep compared with the average sleep requirements for the age group, poor sleep hygiene, and medication side effects. Less common but important causes include narcolepsy, obstructive sleep apnea (OSA), idiopathic hypersomnia, and periodic limb movement disorder (PLMD) 48. Order of food introduction - The AAP recommends introduction of foods other than breast milk or infant formula at about 6 months old. Signs that a child is developmentally ready: 1) can sit with little or no support, 2) has good head control, 3) opens his or her mouth and leans forward when food is offered.  The AAP says that for most children, you do not need to give foods in a certain order. Let your child try one food at a time at first to see if your child has any problems with that food, such as food allergies. Wait 3 to 5 days between each new food. The 8 most common allergenic foods are milk, eggs, fish, shellfish, tree nuts, peanuts, wheat, and soybeans. Generally, it is not recommended to delay introducing these foods.  By 7 or 8 months old, the child can eat a variety of foods including infant cereals, meat or other proteins, fruits, vegetables, grains, yogurts and cheeses.  If providing cereal, offer a variety of fortified infant cereals such as oat, barley, and multi-grain instead of only rice cereal, due to risk of exposure to arsenic. Section 10 Setoria James 49. TB tests (what could a positive result indicate?) Mantoux skin test is an intradermal injection of 0.5-5ml tuberculin units that should produce a palpable wheal of 6-10mm induration. Read the test at 48-72 hours, measuring induration not erythema. The following are considered positive for latent infection or active TB: -induration of 5mm or greater in children who are in close contact with a patient who is in active or previously active TB, have HIV, immunosuppression or are recieveing immunosuppressive drugs. - Induration of 10mm or greater in children younger than 4 with any of the above higher risk factors - Induration of 15mm or greater in children 4 and older with no other risk factors - If the skin test shows any induration after 72 hours it should be considered positive   Interferon Gamma release assay is a screening that rests for t-cell response to the specific M. Tuberculosis antigens. They have an advantage over the Mantoux in that they are not affected by prior BCG vaccine. positive result is indicative of TB infection. This is the recommended test for those 3 and older who received the BCG vaccine, or who are unlikely to RTC for TST reading 50. Breastfeeding and what we should tell breastfeeding moms for reassurance 51. Screening refugee children for TB.  What other types of screening are required for refugee children?tuberculosis-guidelines.html 52. Adolescent patient labs: fasting and postprandial glucose  FBG 126 or greater, Hgb AIC of 6.5% or greater, post prandial glucose of 200 or greater is indicative of diabetes 53. Regular screening tests for patients with a history of hyperlipidemia and obesity S99ection 11 Beth Lax 54. Well child check-ups help track growth and development, prevention by administering vaccines, time to discuss concerns, and builds a team approach to care. Schedule per Bright Futures Newborn, First week (3-5 days), 1 month, 2 month, 4 month, 6 month, 9 month, 12 month, 15 month, 18 month, 2 year-18 years. 55. Drug screen of children and STIs         All children over 14 can request STI testing and treatment confidentially without parent approval.         Children under 13 will need to have parent approval or child protective services involved.         High risk individuals: youth in detention centers, male homosexuals, and IV drug users.         Highest rates in 15-24 yo. 56. Anticipatory guidance for 5 year old and 8 year old 5 yr olds Social determinants of health:  Risks (neighborhood and family violence, food security, family substance use), strengths and protective factors (emotional security and self-esteem, connectedness with family)         Teach your child nonviolent conflict-resolution techniques         Talk with parents/trusted adult if you are bullied         Contact community resources, like SNAP, for help with food assistance Don’t use tobacco/e-cigarettes.  Call 800-QUIT-NOW for help to quit smoking.  Talk with me if you are worried about family member drug/alcohol use.         Encourage independence, self-responsibility; show affection; praise appropriately         Spend time with your child.  Make time to talk Development and mental health:  Family rules and routines, concern for others, respect for others; patience and control over anger.         Continue family routines; assign household chores         Use discipline for teaching, not punishment         Model anger management/self-discipline         Solve conflict/anger by talking, going outside and playing, walking away School:  Readiness, established routines, school attendance, friends; after-school care and activities, parent-teacher communication.         Ensure child is ready to learn (regular bedtime routine, healthy breakfast)         Tour school; attend back-to-school events.         Be sure after-school care is safe, positive         Talk with child about school experiences         If child has special health care needs, be active in IEP process Physical growth and development:  Oral health (regular visits with dentist, daily brushing and flossing, adequate fluoride, limits on sugar-sweetened beverages and snacks), nutrition (healthy weight; increased vegetable, fruit, whole-grain consumption; adequate calcium and vitamin D intake; healthy foods at school), physical activity (60 minutes of physical activity a day)         Help child with brushing teeth if needed.         Visit dentist twice a year         Brush teeth twice a day; floss once Help child choose healthy eating (provide healthy foods, eat together as a family, be a role model)         Eat breakfast; eat vegetables/fruits         Eat when you’re hungry; stop when you’re satisfied         Drink milk 2 to 3 times per day         Limit sugary drinks/foods Consider making family media use plan (www.helathychildren.org/MediaUsePlan), which can help balance child’s needs for physical activity, sleep, school activities, and unplugged time; decide on rules for media time in time left over after all other activities; take into account quantity, quality, location of media use.         Be physically active often during the day Safety:  Car safety (also see #2 and #60), outdoor safety, water safety, sun protection, harm from adults, home fire safety, firearm safety.         Use properly positioned belt-positioning booster seat in backseat         Teach safe street habits (crossing/riding school bus)         Ensure child uses safety equipment (helmet, pads)         Teach child to swim; supervise around water Use sunscreen; wear hat; avoid prolonged exposure when sun is strongest, between 11:00 am and 3:00 pm Teach rules for how to be safe with adults: (1) no adult should tell a child to keep secrets from parents; (2) no adult should express interest in private parts; (3) no adult should ask a child for help with his/her private parts; explain “privates”         Install smoke detectors and carbon monoxide detector/alarms; make fire escape plan Remove firearms from home; if firearm necessary, store unloaded and locked, with ammunition locked separately 8 year olds Social determinants of health:  Risks (neighborhood and family violence, food security, family substance use, harm from the internet), strengths and protective factors (emotional security and self-esteem, connectedness with family and peers)         Teach your child nonviolent conflict-resolution techniques         Talk with parents/trusted adult if you are bullied         Contact community resources, like SNAP, for help with food assistance Don’t use tobacco/e-cigarettes.  Call 800-QUIT-NOW for help to quit smoking.  Talk with me if you are worried about family member drug/alcohol use.         Put family computer in easily seen place, monitor computer use; install safety filter       Don’t give out personal information online Encourage independence, self-responsibility; show affection; praise appropriately         Spend time with your child.  Make time to talk. Know child’s friends. Development and mental health:  Independence, rules and consequences, temper problems and conflict resolution; puberty and pubertal development         Encourage competence/independence/self-responsibility         Discuss rules, consequences         Be positive role model; do not hit or let others hit         Talk about worries         Be aware of pubertal changes; answer questions simply School:  Adaptation to school, school problems (behavior or learning issues), school performance and progress, school attendance, IEP or special education services, involvement in school activities and after-school programs, parental involvement         Ensure child is ready to learn (regular bedtime routine, healthy breakfast)         Show interest in school and activities         If concerns, ask teacher about evaluation for special help/tutoring; help with bullying         If child has special health care needs, be active in IEP process Physical growth and development:  Oral health (regular visits with dentist, daily brushing and flossing, adequate fluoride, avoidance sugar-sweetened beverages and snacks), nutrition (healthy weight; adequate calcium and vitamin D intake; limiting added sugar intake), physical activity (60 minutes of physical activity a day, screen time)         Take child to dentist twice a year         Give fluoride supplement if dentist recommends         Limit sweetened drinks/snacks         Brush teeth twice a day; floss once         Wear mouth guard during sports Help child choose healthy eating (provide healthy foods, eat together as a family, be a role model)         Eat breakfast; eat vegetables/fruits         Eat when you’re hungry; stop when you’re satisfied         Drink milk 3 or more times a day         Limit sugary drinks/foods         Be physically active often during the day Consider making family media use plan (www.healthychildren.org/MediaUsePlan), which can help balance child’s needs for physical activity, sleep, school activities, and unplugged time;  decide on rules for media time in time left over after all other activities; take into account quantity, quality, location of media use. Safety:  Car safety (also see #2 and #60), safety during physical activity, water safety, sun protection, harm from adults, firearm safety         Use belt-positioning booster seat in the backseat Ensure child uses safety equipment (helmet, pads).  Be a role model and always wear a helmet         Teach child to swim; supervise around water Use sunscreen; wear hat; avoid prolonged exposure when sun is at its strongest, between 11:00 am and 3:00 pm Know child’s friends; teach home safety rules for fire/emergencies; teach rules for how to be safe with adults: (1) no adult should tell a child to keep secrets from parents; (2) no adult should express interest in private parts; (3) no adult should ask a child for help with his/her private parts. Remove firearms from the home; if firearm necessary, store unloaded and locked, with ammunition locked separately 57. A mother states her daughter cheats when playing certain games.  What is your best response? 58. 7 year old accidents at night and bedwetting Nocturnal enuresis-monosymptomatic nocturnal enuresis (no problems during the day just at night)-non-monosymptomatic nocturnal enuresis (bowel, bladder symptoms during the day as well as problems at night).                                 Diagnosing         1)        Determine if the child is constipated or impacted.   2)        Neurological developmental delay. 3)        Behavioral comorbidities.  Link to ADHD and enuresis (especially daytime enuresis) 4)        Functional small bladder capacity.  Seems normal but at night functionality is reduced. 5)        Sleep disorders-obstructive sleep apnea. 6)        Stress and family issues.  Divorce, move, new family member. 7)        Polyuria-drinking through the night or too much caffeine intake. 8)        Inappropriate toilet training.                         Gather information History Voiding characteristics (urgency, dysuria, dribbling), cluster voiding (waiting till after school), bowel and bladder postponing behavior, number of voids per day, frequency of wetting (day or night). Pediatric urology referral (weak or interrupted urinary stream, need to use abdominal pressure to urinate, Both daytime incontinence and nocturnal enuresis combined. How much fluid intake and when. UTI Family history-treatment, age of resolution Toilet training history-age, how, did child ever remain dry and for how long What happens when enuresis occurs, punishment, who changes bed, what previous tx Sleep patterns-does child have obstructive sleep disordered breathing or apnea General health Behavior issues Have there been any changes in the home, was enuresis present before Physical exam Assess external genitalia checking for irritation, infection, labial fusion, and or meatal stenosis. Check for fecal impaction-looking for masses at the suprapubic midline and LLQ Check lower back for dimples and hair tufts Assess for neurologic function and deep tendon reflexes Diagnostics UA with culture if warranted Management Urotherapy-voiding schedule and regulate fluid intake, using appropriate posture when urinating, voiding before bed and immediately upon waking.  Aggressive treatment of constipation. Enuresis alarm-an alarm sounds when it is getting wet.  It is first-line therapy when kidney disease, diabetes, or urogenital malformations have been ruled out. Drug therapy-not a curative, but helps when used in conjunction with other interventions.  Desmopressin is most effective in children with large nocturnal urine production and normal nocturnal bladder capacity.  Short term 4-8 weeks. (Often used for sleepovers) Must awaken children 10 hours after taking to urinate.  Take on an empty stomach avoid caffeine, chocolate, NutraSweet and carbonated beverages. 59. Erickson’s stages of development Erickson expanded on Freud’s theories-each stage presents problems that an individual seeks to master.  He believed if problems were not resolved, they would be revisited again at future stages.                         Psychological Crisis                Themes 0-12 mo                Trust vs Mistrust                To get; to give in return 12-18 mo                Autonomy vs Shame                To hold on; to let go 18-36 mo                                                                                                 3-6 yr                        Initiative vs Guilt                To make things; to play 6-11 yr                        Industry vs Inferiority                To make things; to complete 12-17 yr                Identity vs Role Confusion        To be oneself; to share being oneself or not                                                                 being oneself. 17-30 yr                Intimacy vs Isolation                To lose and find oneself in another Section 12 Lizzie Yager 60. Car safety (also see #2) • All infants and toddlers should ride in a rear-facing seat until they reach the highest weight or height allowed by their car seat manufacturer. Most convertible seats have limits that will allow children to ride rear facing for 2 years or more. • Children who have outgrown the rear-facing weight or height limit for their convertible seat should use a forward-facing seat with a harness for as long as possible, up to the highest weight or height allowed by their car seat manufacturer. Many seats can accommodate children up to 65 pounds or more. • All children whose weight or height exceeds the forward-facing limit for their car safety seat should use a belt-positioning booster seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are 8 through 12 years of age. All children younger than 13 years should ride in the back seat.​ ​ ​ 61. Bullying - Ultimate goal is to stop bullying before it starts through prevention programs in schools and community resources. • Defined by CDC as unwanted aggressive behaviors by another youth or group of youths-- very common in school setting (higher in middle than in high schoolI • Involves an observed or perceived power imbalance and behaviors are likely to be repeated multiple times • Can include physical, verbal or relation/social (i.e. rumors, isolation) 1. Cyber bullying now included with the recent advent of social media 1. Girls more often than boys • Bullying behaviors can cause harm and distress both physically and psychologically 1. Can cause social isolation and academic decline 2. Stress of bullying can increase risk of suicide • Bullies can be considered perpetrator and/or victim: multiple factors can increase the risk of engaging in bullying 1. Intolerance of violence 2. Externalizing behaviors 3. Low self-esteem 4. Poor peer relationships 5. Perception of being different 6. Can include siblings and relationship partners • PCP should treat and manage any injuries and refer to mental health and social work for continued followup 1. Report to CPS and law enforcement when necessary. 2. Interview child separately from parent: determine if bully, victim, or both 3. Use HEEADSSS assessment 1. Assess for drug/alcohol use 2. Assess for weapon use 4. Open ended questions 62. Puberty in Males • Initial sign is testicular enlargement (avg of 11 years old) 1. This happens about 6 months before pubic hair development 2. Left testis hangs lower than right • First release of spermatozoa (spermarche) generally at mean of 13.5 to 14.5 yrs • Rapid growth in height, peak height late in puberty 1. Generally lag 2 years behind girls 2. Growth spurts usually between 12 and 16 years 3. Change in voice coincides with peak height • Development of axillary, facial and body hair • 65% of males experience gynecomastia, enlargement of breast tissue, within a year of PHV. Generally lasts 12 to 18 months. • Acne early in puberty 63. Role of the NP in helping children and adolescents have healthy sexual development   provides an opportunity for the teen to ask questions to explore their sexuality -APRN ROLE:                 ensure confidential environment where each can freely exchange information                 providing guidance toward sexual, moral, social, physical development                 responsible sexual behavior teaching                 educate about use of condoms                 appropriate methods of BC and how to use                 annually interviewing about sex, alcohol and drug use asking questions about sexual orientation, number of partners, exchanging sex for drugs and unintentional pregnancies assessing sexual maturity phases for normal progression screening sexually active use for STIs (gonorrhea and chlamydia), and providing pregnancy and partner notification for referral and treatment Providing confidential HIV and syphilis screening for at risk youth Initiating routine cervical cytology at 21 y/o initiating Hep B series for those 11 and older recommending HPV vaccinations to 11-12 y/o 64. Adolescent substance abuse, what is true and not true pgs 383-385 *s/sx: decreased school performance, lethargy, hyperactivity or agitation, decreased attention, disinhibition, acting out, sleep changes, mood swings, change in appetite   weight loss, red eyes, chronic cough, frequent cold or allergy sx, accidents, trauma or injuries, intoxication, amnesia, dilated or constricted pupils, gynecomastia, irregular periods, small testes (pot), needle tracks, generalized pruritus (opioids), reflux, diarrhea, gastritis (opiate and alcohol use) perioral sores and pyodermas Section 13 Amy Holt 65. Regular screening in adolescents 66. Peak height velocity by Tanner stage for adolescent girls 67. Erickson’s Stage for adolescent: *12-17 y/o Identity vs Role Confusion- To be oneself; to share being oneself or not                                                                               being oneself. 68. 14 year-old on too many meds, our role after emergent care and stabilization is completed 69. Findings with diagnosis of school phobia -separation anxiety d/o, simple and social phobias, depression   s/sx:                 -severe difficulty attending school or refusal to go to school                 - severe emotional upset when goes to school                 - absence of significant antisocial d/o                 - staying at home with the parent’s knowledge                 - may complain of headaches, stomach aches, dizziness or fatigue diagnostic tools: -       depression/anxiety screen -       ADHD screen -       assess for sexual or physical abuse -       assess for learning disability -       assess for family dysfunction   Management: -       support parents in insisting on full time school participation -       notify school personnel to gain their support and encouragement -       assess home situation -       refer to psychiatrist if not improvement after 2 weeks Section 14 Ashley Esquibel 70. Common substance abuse middle school  p.384   - - - - - - - - - - 85. Vaccines that have decreased what diseases (Items 3, 6, 46, and 85 in this study guide address vaccines) • Smallpox • Hib - epiglottitis • IPV - polio • DTaP - tetanus, diphtheria, pertussis • HepB • HepA • MMR - measles, mumps, rubella • Varicella - chicken pox • Prevnar-- Pneumonia • Meningococcal-- Meningitis 86. Epligotitis s/s • Nonvaccination with Hib vaccine • Sore throat • Dysphagia • Difficulty in controlling secretions • Toxic appearance - especially in children • Acute distress - especially in children • Fever - especially in children • Tripod position • Difficulty breathing • Decreased oral intake • Muffled voice • Stridor • Irritability • Drooling Section 17 Monica Hevron 87. Requires hospitalizations: epilglotitis, retropharyngeal abscess, cervical adenitis, orbital cellulitis   *Epiglottitis (815-817) requires hospitalization because of the risk of sudden airway occlusion *Retropharyngeal abcess is a collection of pus in the tissues in the back of the throat. It can be a life-threatening medical condition *Cervical adenitis is an infection of a lymph node in the neck. Lymph nodes are part of the immune system and help fight infections. Another term for this infection is lymphadenitis (No hospitalization) *orbital cellulitis is an infection of the soft tissues within the eye socket. It is a serious condition that, without treatment, can lead to permanent vision loss and life-threatening complications.   88. Normal visual acuity at what age p.704 Visual acuity is developed by 12 months 89. Esotropia, exotropia, Nystagmus, strabismus Esotropia is when one or both eyes turn inward exotropia is when one or both eyes turn outward Strabismus is : “lazy eye” p. 715. Nystagmus is involuntary rhythmic movements of the eye p. 716 90. How to remove foreign body in ear • Must have adequate visualization and a cooperative patient. If it is not able to be removed on the first attempt, refer to ENT • Can try straightening the ear, pulling on the pinna and shaking the patient’s head             insects: suffocate with mineral oil and send to ENT           iron, nickel or cobalt can try magnet round or breakable objects: a wire loop, curette or right angle hook may be used- advance past the object and retract. soft, irregularly shaped objects: bayonet forceps, alligator forceps, curved hook spherical objects should be referred to ENT Disc batteries must be removed emergently. 91. Teeth grinding and what to look for         Also called bruxism common during sleep for 12 and under, during waking hours 13 and older parent reports grinding primary teeth show wear jaw muscle. fatigue   **Look for: Underlying stressors and secondhand smoke exposure, OSA, enlarged tonsils, could be an adverse effect of antipsychotics and antidepressants   The main risk factors for sleep-related bruxism are comorbid sleep disorders, especially obstructive sleep apnea (OSA) and parasomnias; anxiety and other psychiatric and neurologic disorders; and certain medications and substances (table 1).   In a population-based study of over 13,000 individuals 15 years of age and older who were assessed for sleep-related bruxism and other comorbidities by telephone-based questionnaire, the following factors were associated with an increased risk of sleep-related bruxism [5]:   ●OSA (odds ratio [OR] 1.8)   ●Heavy alcohol use (OR 1.8)   ●Loud snoring (OR 1.4)   ●Caffeine intake (OR 1.4)   ●Smoking (OR 1.4)   ●Anxiety (OR 1.3)   ●Highly stressful life circumstances (OR 1.3) Section 18 Luis Sanchez 92. How long is head circumference routinely measures: birth to 3 years at routine wellness visits 93. Snellen test results are and be able to explain Visual acuity is usually measured with a Snellen chart. ... "Normal" vision is 20/20. This means that the test subject sees the same line of letters at 20 feet that person with normal vision sees at 20 feet. 20/40 vision means that the test subject sees at 20 feet what a person with normal vision sees at 40 feet. 94. Hyphema and what to do A hyphema is a pooling or collection of blood inside the anterior chamber of the eye (the space between the cornea and the iris). The blood may cover most or all of the iris and the pupil, blocking vision partially or completely.   A hyphema is usually painful. If left untreated, it can cause permanent vision problems.   Symptoms:       visible blood in the front of the eye sensitivity to light pain blurry, clouded, or blocked vision blood might not be visible if the hyphema is small   Send referral to opthamologist WHILE WAITING ON OPTHAMOLOGIST VISIT: The following general measures are recommended in patients with hyphema and comprise appropriate initial care (table 1) [2-4]: Eye shield – An eye shield should be placed over the affected eye as soon as possible and subsequently removed only as required for examination and imaging. ● Bed rest and dim lighting – Limitation of activity to bed rest with bathroom privileges should occur until initial evaluation is complete. The patient should be placed in a dim, quiet room and should not read so that visual accommodation does not further stress injured blood vessels. Elevate the head of the bed – Elevation of the head to 30 degrees promotes inferior settling of blood in the anterior chamber away from the visual axis while maintaining arterial blood flow to the eye relative to the fully erect position [2,3]. Thirty degree elevation of the head also improves diagnosis of secondary hemorrhage and aids in clearance of the hyphema. ● Control pain – Pain control improves patient comfort and facilitates eye examination [3]. Topical analgesia with proparacaine or tetracaine may be applied temporarily in patients without an open globe; long term use may cause corneal toxicity. Dilating eye drops, discussed below, may also provide some pain relief. Nonsteroidal antiinflammatory agents (NSAIDS) are discouraged because of their platelet inhibiting properties. For patients in whom topical analgesia is inadequate, the clinician may consider oral or intravenous opioids. Hydrocodone or oxycodone in combination with acetaminophen is preferred to codeine because they are less prone to cause nausea and vomiting. Intravenous therapy with morphine or fentanyl may be needed in patients with large hyphemas (grade III to IV (figure 1)) or associated traumatic injury. ● Treat nausea and prevent vomiting – Patients with nausea or vomiting require treatment with antiemetics, such as ondansetron, to prevent sudden increase in intraocular pressure caused by emesis [3]. ● Dilating eye drops – For patients without narrow angle glaucoma, Cycloplegia, topically with cyclopentolate one percent (eg, Cyclogyl, Cylate, or Ocu-Pentolate), one drop, or scopolamine 0.25 percent one drop, often provides pain relief and allows for optimal examination of the posterior segment [2-4]. Dilating eye drops are contraindicated in patients with suspected open globe injury or narrow angle glaucoma [4]. ● Correct coagulopathy – Patients with bleeding tendency, such as hemophilia, von Willebrand disease, or thrombocytopenia should receive appropriate treatment to restore clotting capability [5,6].  Per UpToDate 95. Bacterial, viral, allergic conjunctivitis discharge (Valentina N). Conjunctivitis is a common patient complaint. It is the most likely diagnosis in a patient with a red eye and discharge. Acute conjunctivitis is usually a benign, self-limited condition or one that is easily treated. When making a diagnosis of acute conjunctivitis, one needs to make certain that sight-threatening and pathologic processes have been ruled out. In contrast to acute conjunctivitis, these entities, such as acute angle-closure glaucoma, iritis, and infectious keratitis, must be managed by ophthalmologists and will not be discussed here. Acute conjunctivitis can be classified as infectious or noninfectious and further divided into four main types: ●Infectious    (Bacterial - Viral) ●Noninfectious (Allergic - Nonallergic)  Studies suggest that the majority of cases in children are bacterial the prevalence of bacterial conjunctivitis seen in studies presumably reflects the greater likelihood that patients with copious discharge will present for care. Clinical experience suggests that most infectious conjunctivitis is viral in both adults and children. Bacterial conjunctivitis — Bacterial conjunctivitis is commonly caused by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. S. aureus infection is common in adults; the other pathogens are more common in children. Bacterial conjunctivitis is spread by direct contact with the patient and his or her secretions or with contaminated objects and surfaces. It is highly contagious.   The purulent discharge continues throughout the day. The discharge is thick and globular; it may be yellow, white, or green. The appearance differs from that of viral or allergic conjunctivitis, which often present with a mostly watery discharge during the day, with a scanty, stringy component that is mucus rather than pus. On examination, patients with bacterial conjunctivitis typically have purulent discharge at the lid margins and in the corners of the eye. More purulent discharge appears within minutes of wiping the lids. This contrasts with patients with viral or allergic conjunctivitis, in whom the eyes appear watery; there may be mucus present on close inspection of the tear film or if one pulls down the lower lid, but pus does not appear spontaneously and continuously at the lid margin and in the corners of the eye. Hyperacute bacterial conjunctivitis — Neisseria species, particularly N. gonorrhoeae, can cause a hyperacute bacterial conjunctivitis that is severe and sight-threatening, requiring immediate ophthalmologic referral. The organism is usually transmitted from the genitalia to the hands and then to the eyes. Concurrent urethritis is typically present. The eye infection is characterized by a profuse purulent discharge present within 12 hours of inoculation, the amount of discharge is striking. Other symptoms are rapidly progressive and include redness, irritation, and tenderness to palpation. There is typically marked chemosis, lid swelling, and tender preauricular adenopathy. Gram-negative diplococci can be identified on Gram stain of the discharge. These patients require hospitalization for systemic and topical therapy and for monitoring of the ocular component. Keratitis and perforation can occur. Viral conjunctivitis — Viral conjunctivitis is typically caused by adenovirus, with many serotypes implicated. The conjunctivitis may be part of a viral prodrome followed by adenopathy, fever, pharyngitis, and upper respiratory tract infection, or the eye infection may be the only manifestation of the disease. Viral conjunctivitis is highly contagious; it is spread by direct contact with the patient and his or her secretions or with contaminated objects and surfaces. Viral conjunctivitis typically presents as injection; watery or mucoserous discharge and a burning, sandy, or gritty feeling in one eye. Patients may report "pus" in the eye, but on further questioning they have morning crusting followed by watery discharge, perhaps with some scanty mucus throughout the day. The second eye usually becomes involved within 24 to 48 hours, although unilateral signs and symptoms do not rule out a viral process. Patients often believe that they have a bacterial conjunctivitis that has spread to the fellow eye; On examination there is typically only mucoid discharge if one pulls down the lower lid or looks very closely in the corner of the eye. Usually there is profuse tearing rather than discharge. The tarsal conjunctiva may have a follicular or "bumpy" appearance. There may be an enlarged and tender preauricular node. Viral conjunctivitis is a self-limited process. The clinical course parallels that of the common cold. While recovery can begin with days, the symptoms frequently get worse for the first three to five days, with very gradual resolution over the following one to two weeks for a total course of two to three weeks. Just as a patient with a cold can have morning coughing and nasal congestion or discharge two weeks after symptoms first arise, patients with viral conjunctivitis may have morning crusting two weeks after the initial symptoms, although the daytime redness, irritation, and tearing should be much improved. Allergic conjunctivitis — Allergic conjunctivitis is caused by airborne allergens contacting the eye that, with specific immunoglobulin E (IgE) and the release of chemical mediators including histamine, eosinophil chemotactic factors, and platelet-activating factor, among others. It typically presents as bilateral redness, watery discharge, and itching. Itching is the cardinal symptom of allergy, distinguishing it from a viral etiology, which is more typically described as grittiness, burning, or irritation. Eye rubbing can worsen symptoms. Patients with allergic conjunctivitis often have a history of atopy, seasonal allergy, or specific allergy (eg, to cats). Similar to viral conjunctivitis, allergic conjunctivitis causes diffuse injection with a follicular appearance to the tarsal conjunctiva and profuse watery or mucoserous discharge. There may be morning crusting. It is the complaint of itching and the history of allergy or hay fever as well as a recent exposure that allows the distinction between allergic and viral conjunctivitis; the clinical findings are the same. In some cases of allergic conjunctivitis, there is marked chemosis (conjunctival edema); in extreme instances, there can be bullous chemosis, in which the bulging, edematous conjunctiva extends forward beyond the lid margins. Bullous chemosis is most commonly seen in patients with extreme hypersensitivity to cats. A detailed discussion of allergic disease is presented separately. 96. Antibiotics with acute otitis media (Brandi Thompson) • Antibiotics are prescribed in a stepwise fashion beginning with a first-line antibiotic.  A lack of improvement in the patient's condition may require a change to a second- or third-line agent. • Primary Options 1. amoxicillin : children: 80-100 mg/kg/day orally given in divided doses every 12 hours for 10 days 2. amoxicillin/clavulanate : children >3 months of age: 80-100 mg/kg/day orally given in divided doses every 12 hours for 10 days more • Secondary Options 1. cefdinir : children >6 months of age: 14 mg/kg/day for 10 days 2. cefuroxime axetil : children: 30 mg/kg/day orally given in divided doses every 12 hours for 10 days • Tertiary Options 1. azithromycin : children ≥6 months of age: 10 mg/kg/day orally (immediate-release) on the first day, followed by 5 mg/kg/day for 4 days; or 10 mg/kg/day orally (immediate-release) for 3 days; or 30 mg/kg/day orally (immediate-release) as a single dose; or 60 mg/kg/day orally (extended-release) as a single dose 2. ceftriaxone : children: 50 mg/kg/day intramuscularly/intravenously for 3 days 97. Method to remove ear wax at various ages • Symptoms of Earwax Buildup 1. Too much earwax can cause rubbing of the ear or poking in the canal. 2. A piece of earwax can become dry and hard in the ear canal. This creates a feeling that an object is in the ear. 3. Complete blockage (plugging) of the ear canal by wax causes more symptoms. These include decreased or muffled hearing. 4. A large piece of earwax may be seen inside the ear canal. • Causes of Earwax Buildup 1. Cotton Swabs. Earwax buildup is usually from using cotton swabs. They push the wax back in and pack it down. 2. Fingers. A few children (perhaps 5%) normally produce more wax than others. It usually will come out if it's not pushed back by fingers. 3. Ear Plugs. Wearing ear plugs of any type can also push wax back. • Age 6 Years and Older - Ear Canal Flushing with Water: Under age 6, use only if advised by your child's doctor. 1. Buy a soft rubber ear syringe or bulb from the pharmacy. No prescription is needed. 2. Have your child lean over the sink. Reason: To catch the water. 3. Use lukewarm water (body temperature). Reason: To prevent dizziness. 4. Gently squirt the water into the ear canal. Then tilt your child's head and let the water run out. You may need to do this several (3-4) times. 5. If the earwax does not seem to be coming out, tilt the head. Then, flush it with the head tilted. Have the ear with the wax in it facing downward. Gravity will help the water wash it out (the waterfall effect). 6. Endpoint: Flush until the water that comes out is clear of wax. Also, the ear canal should be open when you look in with a light. 7. Afterwards dry the ear thoroughly. You can do this by putting a drop of rubbing alcohol in the ear canal. Or you can set a hair dryer on low. Hold it a foot away from the ear for 10 seconds. • Ear Drops - Use for 4 Days to Soften the Earwax: 1. If the earwax is hard, soften it before flushing the ear canal. Use ear drops to break up the earwax. 2. Homemade ear drops: 15% baking soda solution. Make it by adding ¼ teaspoon (1.25 mL) of baking soda to 2 teaspoons (10 mL) of water. 3. Other option for homemade ear drops: hydrogen peroxide and water solution. Mix equal parts of each. 4. Drug store option: Earwax removal ear drops (such as Debrox). No prescription is needed. 5. Use 5 drops in affected ear, 2 times daily, for 4 days. • How to Put in Ear Drops: 1. Lie on the side with blocked ear upward. 2. Place 5 drops into the ear canal. Pull the ear down and back to open the ear canal 3. Keep drops in ear for 10 minutes by continuing to lie down. 4. Then lie with the blocked side down. Let the ear drops run out onto some tissue. 5. Use twice daily for up to four days. 6. Then flushing should be able to get everything out. 98. s/s of buccal tumors, bennars apthay, epstein pearls • Epstein pearls- small white or yellow-tinted bump on the gum line or roof of the mouth. They do not cause and symptoms. They are common to babies who are born to older mothers, past the due dates, and has higher birth weights. Keratin entrapment within the soft and hard palates causes Epstein pearls. • Buccal Tumors (cancer of oral cavity, lining of the cheeks and back of the lips)- white or red lump in the mouth that does not go away for 2 weeks, red raised patch in the mouth that bleeds easily, lump or thickening in the mouth, pain increases when eating or drinking, soreness or feeling that something is caught in the throat, difficult moving the jaw or tongue, hoarseness, numbness of the tongue or areas of the mouth • Bednar's aphthae is a type of oral ulceration (mouth ulcers) which occurs in infants. The lesions are located on the palate and are caused by trauma. Bednar's aphthae are small, shallow ulcers on the edge of newborns' palates and are typically caused by traumatic action of a bottle nipple or even the mother's breast during feeding9). 99. Dx, s/s of strep throat, viral tonsillitis, epiglottitis, diphtheria • Strep throat- streptococcal pharyngitis bacterial infection of throat. Signs and symptoms fever of 101 or higher, red swollen tonsils, white patches in the throat, tiny red spots on the roof of the mouth, appetite loss, upset stomach, headache, nausea, vomiting, rash. Rapid Strep test is used for diagnosis or throat culture. • Viral Tonsillitis- acute or chronic inflammation of the tonsils. Sudden onset of sore throat, fever, malaise, cough, headache, myalgias, and fatigue. Patients may also report rhinitis, conjunctivitis (adenovirus) congestions, cough with sputum production Clinical presentation indicated the diagnosis. Rapid antigen detection rest, antistreptolysin O titer test differential viral from bacterial. GAS infection indicated bacterial infection. • Epiglottitis- is an acute inflammation of the supraglottic region of the oropharynx. Characterized by inflammation and edema of the epiglottitis, vallecular, arytenoids, and aryepiglottic folds. Life-threatening because of potential laryngospasm and irrevocable loss of the airway. Cause by bacteria Haemophilus influenzae type B (Hib). Signs and symptoms dysphagia, fever, shortness of breath, leaning forward in effort to enhance air flow or sitting up. Other complications stridor, drooling, cough, respiratory distress and hoarseness. Triad position (leaning forward with hands braced on the knees). Definitive diagnosis of epiglottis is made by direct visualization via laryngoscopy with flexible fiberoptic scope. Sonography can be used noninvasive for emergent results. • Diphtheria- Diphtheria is an infection caused by the bacterium Corynebacterium diphtheriae. Bacteria that causes diphtheria can get into and attach to the lining of the respiratory system, which includes parts of the body that help you breathe. When this happens, the bacteria can produce a poison (toxin) that can cause: 1. A thick, gray membrane covering your throat and tonsils 2. A sore throat and hoarseness 3. Swollen glands (enlarged lymph nodes) in your neck 4. Difficulty breathing or rapid breathing 5. Nasal discharge 6. Drooling 7. Cyanosis 8. Fever and chills 9. Malaise 10. The poison destroys healthy tissues in the respiratory system. Within two to three days, the dead tissue forms a thick, gray coating that can build up in the throat or nose. Medical experts call this thick gray coating a “pseudomembrane.” It can cover tissues in the nose, tonsils, voice box, and throat, making it very hard to breathe and swallow. 100. Sinusitis and the location of sinuses - Sinusitis is an inflammation or swelling of the tissue lining the sinuses. Healthy sinuses are filled with air. But when they become blocked and filled with fluid, germs can grow and cause an infection • Signs and symptoms- Facial pain or pressure, nasal congestion, runny nose, loss of smell, cough, fever, bad breath, fatigue, or dental pain, purulent nasal discharge, headache that becomes more intense when you bend or lean forward, postnasal drip. Pain of teeth or forehead are worse in the morning and when the patient bends forward from the waist. • The sinuses are in your forehead (frontal sinuses), inside your cheekbones (maxillary sinuses), and behind the nose (ethmoid and sphenoid sinuses) 101. What to do when a mother is being rough • As a healthcare provider it is our duty to protect the child and intervene if the mother is being rough. Parental insufficiency in action. It causes all kinds of impacts later, and it is preventable with a little focus, consciousness raising by educating parents about parenting and child development, love, and patience. Calling child protective services for further home investigation is required. Section 20 102. When to refer for stuttering: Children with any of the criteria listed below should be referred for a speech and language assessment: • Concern by the parent, teacher, professional, or other caregiver about the child's speech or language • Slowed or stagnant speech and language development • Excessive drooling • Difficulty sucking, chewing, or swallowing • Difficulty coordinating movements of lips, tongue, and jaw • No babbling by nine months • No first words by 15 months • No consistent words by 18 months • No word combinations by 24 months • Speech is difficult for parents to understand at 24 months • Speech is difficult for strangers to understand at 36 months • Dysfluencies (stutters) consist of more than tension-free whole-word repetitions • Child is frustrated by communication difficulty • Child is teased by peers for "talking funny" • Child avoids talking situations • Child acquires vocabulary and sentence structure but does not use language appropriately for communicative purposes • Language is unusual or confused, or ideas are not expressed clearly • Child cannot follow instructions without supplemental visual cues • Loss of milestones • Poor memory skills at five to six years 103. Diagnostic criteria for autism spectrum disorder: The diagnosis of ASD is made clinically in children who meet established diagnostic criteria for ASD based on history and observation of behavior. • DSM, Fifth edition criteria – According to the DSM, Fifth edition (DSM-5) criteria, a diagnosis of ASD requires ALL of the following: 1. Persistent deficits in social communication and social interaction in multiple settings; demonstrated by deficits in all three of the following (either currently or by history): 1. Social-emotional reciprocity (eg, failure to produce mutually enjoyable and agreeable conversations or interactions because of a lack of mutual sharing of interests, lack of awareness or understanding of the thoughts or feelings of others) 2. Nonverbal communicative behaviors used for social interaction (eg, difficulty coordinating verbal communication with its nonverbal aspects [eye contact, facial expressions, gestures, body language, and/or prosody/tone of voice]) 3. Developing, maintaining, and understanding relationships (eg, difficulty adjusting behavior to social setting, lack of ability to show expected social behaviors, lack of interest in socializing, difficulty making friends even when interested in having friendships) 2. Restricted, repetitive patterns of behavior, interests, or activities; demonstrated by ≥2 of the following (either currently or by history): 1. Stereotyped or repetitive movements, use of objects, or speech (eg, stereotypies such as rocking, flapping, or spinning); echolalia (repeating parts of speech; repeating scripts from movies or prior conversations) 2. Insistence on sameness, unwavering adherence to routines, or ritualized patterns of verbal or nonverbal behavior (eg, ordering toys into a line) 3. Highly restricted, fixated interests that are abnormal in strength or focus (eg, preoccupation with certain objects [trains, vacuum cleaners, or parts of trains or vacuum cleaners]); perseverative interests (eg, excessive focus on a topic such as dinosaurs or natural disasters) 4. Increased or decreased response to sensory input or unusual interest in sensory aspects of the environment (eg, adverse response to particular sounds; apparent indifference to temperature; excessive touching/smelling of objects) 3. The symptoms must impair function (eg, social, academic, completing daily routines). 4. The symptoms must be present in the early developmental period. However, they may become apparent only after social demands exceed limited capacity; in later life, symptoms may be masked by learned strategies. 5. The symptoms are not better explained by intellectual disability (formerly referred to as mental retardation) or global developmental delay. 104. Eating disorders with purging s/s 105. Obesity with treatment plan:  info on pgs 185-190, 617-618   -children 2-18 years old with a BMI equal to or greater than the 95th percentile for their age and gender are considered obese.                  -children with a BMI of 30 are also considered obese.                  -Children with a BMI between the 85th and 94th percentile are considered overweight                   Causes:                             -Biological mechanisms:                                         -stress                                         -decreased activity                                         -poor diet                             - Food addiction                             -Decreased Physical activity                             - Temperament                                         -shorter attention span                             -psychosocial and environmental factors   Treatment:                         -lifestyle changes                                     -goal is to normalize weight so the child can “grow into” their weight                         -community changes                                     -encouraging physical activity                                     -encouraging breastfeeding                                     - providing safe spaces to exercise                         - Medications                                     -Primary treatment: lifestyle changes - Meds only when lifestyle changes fail or if extremely obese, with comorbidities                             -Orlistat- decreases fat absorption, children 12 and older OTC and c./rx *contraindicated in gallbladder disease, pregnancy, malabsorption syndromes and in sensitivity to the drug ** Side effects: fatty stool, GI upset: fiber supplements may help with   these S/E