Health Problems of the School Age Child
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What are some s/s of school phobia? How can you help the child overcome school phobia?
- Symptoms are often vague and disappear on weekends
- The cause of school phobia should be investigated
- Rule out physical causes and alleviate other causes
- Encourage the child and promote return to school
- Involve school team members if necessary
What are some s/s of ADD and ADHD?
- Easily distracted
- Fidgets and squirms/difficulty sitting still
- Difficulty following instructions
- Loses things
- Difficulty taking turns
- Talks excessively
- Dangerous activities without thinking of consequences
How is ADD/ADHD diagnosed?
- Usually made after 3 years of age with no intellectual impairment
- Must be having issues in multiple environments as symptoms may be a result of the environment
- Neurological exam
- Team work needed between parents, drs, and teachers to confirm diagnosis
What medications are used for ADD/ADHD?
- Methylphenidate (Ritalin): CNS stimulant increases dopamine and norepinephrine. Avail in XR and transdermal patches
- Dextroamphetamine (Dexedrine): like Ritalin
- Atomoxetine (Strattera): Selective norepinephrine reuptake inhibitor
- Lisadextroamphetamine (Vyvanse)
- Metadate, Adderal,Concerta
- *Side effects include insomnia (give before 6p), anorexia, weight loss, HTN, and may suppress growth with long term use
What interventions can be done to promote wellness for students with ADD/ADHD?
- Consistent, structured environment
- Regular routine
- Minimal distractions
- Give only one instruction at a time
- Family support and supportive teachers at school
- Goals include developing the child's self esteem, confidence, and academic success
What is the difference between idiopathic and secondary convulsive disorders? What are the different types of seizures?
- Idiopathic/primary: epilepsy presenting usually 4-8 yrs
- Secondary: infection, head trauma, hemorrhage, tumor
What are the different kinds of seizures?
- Grand Mal (tonic/clonic)
- Akinetic (temporary loss of muscle control leads to falls)
- Myoclonic (spasm of specific muscle group with no loss of conscience)
- Infantile spasms
How are convulsive disorders diagnosed?
- CT, brain scan, MRI
- Physical and neurological assessment
What medications are used for convulsive disorders? What kind of diet is also helpful?
- Antiepileptic Drugs (AED):
- Diazepam (valium)
- Phenytoin (Dilantin)
- Carbamazapine (Tegretol)
- Fosphenytoin sodium (Cerebryx)
- Valproic Acid (depakene)
- *Ketogenic diet- low carb diet wit adequate protein can help decrease seizures in children who have seizures that are uncontrolled
What teaching and interventions should be done for students with convulsive disorders?
- Early diagnosis and control is key to prevent brain damage
- Should not participate in sports where a fall could cause substantial injury
- No unsupervised swimming or snorkeling
- Some states prohibit driving
- Should not combine anticonvulsant drugs and alcohol
What are some s/s of generalized allergies? How can general allergies by treated?
- Poor appetite
- Poor sleep
- Restricted physical activity
- Altered physical/personality development
- Treatment: elimination or avoidance of agent, desensitization with allergy injections, treat reactions with epinephrine, antihistamines and steroids for symptomatic relief
What is Hay fever? What are the s/s? How is it treated?
- Also called Allergic Rhinitis
- In children, most often caused by animal danger, house dust, pollens, molds
- S/S: watery nasal discharge, postnasal drip, sneezing, allergic salute (wiping nose upward), dark circles around eyes
- Treatment: antihistamine-decongestant dimetapp, claritin, zyrtec, singular, alavert, flonase
- *its best to simply remove the allergen and prevent the allergy
Describe the pathophysiology of asthma
- Spasms of the smooth muscle of bronchial tubes
- Edema of mucus membranes
- Increased production of this mucus
- Leads to respiratory obstruction (reversible)
- *triggered by hypersensitivity response to allergens, exercise, stress
- *most common cause of school absence
What are some common triggers for asthma? What are the s/s?
- Allergens, food, exercise, cold weather, irritants, stress, illness
- -Coughing & dyspnea
- -Possible wheezing
- -may be acute or slow onset
- -more frequent at night
How is asthma diagnosed? Describe using a peak flow meter?
- Pulmonary function tests
- Definitive diagnosis is when the obstruction is reversed with bronchodilators
- Peak flow meter can be used every day to measure lung function (green, yellow, red) and should be recorded to see problems that may be exacerbating
What medications are commonly used for asthma?
- Beta Adrenergic Agonists: albuterol
- -do not use >3-4x daily (short acting)
- -Serevent is long acting
- Corticosteroids: IV, PO, Inhaled
- -Advair (flovent and serevent combination)
- -monitor growth and rinse mouth after use
- Mast Cell Stabilizer: Cromolyn Sodium (Intal)
- -exercise induced asthma
- Acute status asthmaticus
- Sub Q or Racemic Epi via nebulizer
What teaching should be done for students with asthma and their families?
- Discuss the disease process and triggers
- Recognition of impending attack
- Need for environmental control
- Avoidance of infection
- Exercise and premedicating
- How to use medication therapy and expected side effects
- How do use nebulizer, MDI, spacer
What are the s/s of appendicitis? How is it treated?
- Tenderness in RLQ (McBurney's Point & rebound tenderness)
- Decreased BS
- Elevated WBCS
- *sudden absence of pain may be r/t rupture
- Treatment: surgical removal
- -NPO, IV access
- -laxatives and enemas contraindicated
What is enuresis? How is it treated?
- Involuntary urination after expected age of achieving voiding control (often occurs at night)
- Treatment: DDAVP (synthetic vasopressin)
- -avoid diapering
- -avoid fluids prior to bed
- -void before bed and at designated time at night
- -provide positive reinforcement
- -usually resolves by age 6-8
What is Encopresis? How is it treated?
- Chronic involuntary fecal soiling beyond age when control is expected (3y/o)
- Constipation can be a common cause
- Treatment: increase fluids, fiber, dairy, lubricants
- Usually resolves successfully, otherwise refer for psych counseling
What is rheumatic fever and what are the major manifestations?
- Autoimmune reaction to group A Beta-hemolytic strep (like scarlet fever, strep throat, tonsillitis)
- Affects connective tissues such as heart, lungs, joints, brain)
- Follows infection by 1-5 weeks with slow/subtle s/s
- Listlessness & Pallor
- Anorexia & weight loss
- Muscle, joint, abdom pain
- Major manifestations: polyartritis, chorea (uncontrolled body movements), carditis
What are the minor and major criteria for rheumatic fever?
- Called Jones criteria: 1 major criteria OR 1 major and 2 minor
- Major criteria: carditis, polyarthritis, chorea, subcut nodules, erythema marginatum rash on trunk
- Minor criteria: fever, arthalgia (general ache)
How is rheumatic fever treated? What complications are you concerned about?
- Bedrest is essential during acute stage to decrease workload on heart
- Monitor ESR, C-reactive protein, leukocytosis
- Treated with ASA, penicillin (continued prophylactically for 5 yrs or age 21, possibly longer for cardiac complications), corticosteroids
- *main concern is residual disease, esp cardiac (valve damage, such as mitral valve stenosis)
How is Juvenile Diabetes Mellitus diagnosed?
- Fasting blood glucose >126
- 2 hour glucose >200
- HbA1c- 7.5 indicator of glucose levels in last 3 mo (4-6 is normal level)
- BUN, Creatinine and creatinine clearance to eval kidney function
- U/A, C&S
How is Type 1 DM Therapeutically managed?
- Insulin Therapy
- Glucose monitoring, with a goal range of less than 126 mg/dL
- Measurement of HbA1c
- UA for ketones, esp when ill (q3hr) or when glucose higher than 240 mg/dL
- Exercise and carb counting
- Teaching and compliance are key
What are the s/s of DKA? How is it treated?
- S/S: ketones in urine, high BG, fruity breath, kussmaul resps, cherry lips
- Treatment: IV fluid and insulin, correct electrolyte imbalances and monitor resp function
What are the sick day rules for a child with DM? When should you call the Dr?
- Monitor Blood Glucose frequently
- Do not stop taking insulin
- Check urine for ketones q3hr
- Be careful with OTC meds
- Have gave plan and ask for help (call Dr when BG >240 mg/dL)
- Force fluids
What are the s/s of insulin shock and how is it treated? When should you notify the MD?
- S/S of hypoglycemia (BG <60mg/dL)
- Sweaty, tremors, unconscious
- Treatment: give rapid carbs such as OJ, gluco tabs, then long carbs like peanut butter. If unconscious, give glucagon subcut or IM
- Call MD if BG persists >60mg after 2 snacks or 3 tabs
Describe how children of different ages interact with their DM treatment
- <4 y/o: focus teaching on parents
- 4-5: knows injection sites and prepares skin for finger sticks
- 6-7: knows foods not to eat, begins to help with injections, does own BG monitoring, needs many reminders
- 8-10: does own injection and BG monitoring, understands more about foods, needs reminders
- 11-13: knows if foods fit into plan
- 14+: plans meals and snacks, knows sliding scale, understands long term consequences but may still rebel
What is the difference between structural and nonstructural scoliosis? How is it tested and treated?
- Structural: spinal involvement in lateral curve
- Nonstructural: muscular involvement of lateral curve
- Screening with a scoliometer, forward bend test with hump on thoracic ribs (uneven scapula)
- Treated: electrical stimulation of muscles, Thoracic Lumbar Sacral Orthotic (TLSO) brace, traction, casts, spinal fusion (with or without rods)
What is Legg-Calve-Perthes Disease? What are the s/s and how is it treated?
- Asceptic necrosis of the head of the femur which can be caused by trauma, but generally cause is unknown
- S/S include pain in hip with limp, muscle spasm, limited mobility
- Must not bear weight on the affected hip as 4 stages are completed spans from 18 mo-4 yrs (the head of femur will eventually reossify over that time)
- Brace and reconstructive surgery
- NSAIDs for pain
What is Osteomyelitis? What are the s/s and how is it treated?
- Infection of the bone (often staph and MRSA) usually from other primary infection
- S/S: fever, malaise, localized pain with tenderness, leukocytosis, ESR, pos blood cultures
- Treatment: immeadiate and intense IV antibiotics, surgical I & D
- -Combined PO and PICC line Vancomycin for 3mo
What is Duchenne Muscular Dystrophy? What are some s/s?
- Pseudohypertrophic x-linked (Affects males, females carriers) degenerative disease of muscles
- Child finds difficulty standing/walking
- As larger muscles weaken, often WC dependent by 9-11 with resp and cardiac involvement by 20 y/o
- Child may not be able to get up from squatting position (Gower's sign)
- Lordosis, pelvic waddling, frequent falls
What are the initial findings for Duchenne muscular dystrophy?
- Reach early developmental milestones, but have mild delays early in life
- Between ages 3-7, delay in motor development
- First symptoms: difficulty walking, running, riding bike, climbing stairs, frequent falls
- Mild to moderate cognitive impairment
What nursing interventions can be done for students with Duchenne muscular dystrophy?
- Encourage independence
- ROM, PROM, stay as active as possible
- Avoid obesity
- Promote body alignment and skin integrity (WC, braces)
- Monitor resp function
- Encourage fluids
- Surgical release of contractures
- Support family in end of life decisions
What is JIA?
- Juvenile idiopathic arthritis is the most common connective tissue disorder of childhood
- Cause is unknown, often autoimmune
- Most common in joints of knees and hands with peak incident ages 1-3 then 8-10
How is JIA treated?
- If untreated, leads to irreversible damage to joint cartilage, ligaments, menisci, eventually causing complete immobility
- Drug therapy focuses on decreasing inflammation
- Steroids/immunosuppressants such as prednisone
- Enteric Coated ASA (not to be used during viral illness for risk of Reyes)
- Methotrexate to slow joint degeneration (enbrel if unsuccessful)
- Exercise, splints, heat, ROM to prevent ankylosis of joint (immobility)
What nursing interventions and teaching can be done for JIA?
- Rest, evaluate pain
- Splint knees, hands, wrists during sleep to prevent deformities
- Warm, moist heat prior to exercise
- Warm baths
- PT/OT, ROM, swimming is best
- Allow time to complete self care
- Work with school for adjusted schedule
Describe the different types of fractures
- Compound/open: fractured bone protrudes through the skin
- Complicated: bone fragments have damaged other organs
- Comminuted: small fragments of bone are shattered into the surrounding tissue
- Greenstick: compressed side of bone bends, but the tension side breaks leading to an incomplete fracture
- Lateral, oblique, spiral, torus (one bone crushed into another)
Describe which fractures are most common at various ages
- School age: femur, tibia, humerus, wrist, fingers
- Various stages of healing: abuse
- Spiral fractures:physical abuse
- Most common of all: clavicle
What are physeal injuries and why are they concerning?
- Weakest point of the long bone is the cartilage growth plate
- May affect future bone growth
What are the clinical manifestations of fractures?
- Generalized swelling
- Pain or tenderness
- Diminished functional use
- May have bruising, severe muscular rigidity, crepitus
How are fractures treated? What are the different kinds of casts?
- Treated with realignment, immobilization, casting, closed manipulation, surgical reduction, internal and external fixation, and traction
- Casts can be fiberglass or plaster (plaster is heavy and takes a long time to dry)
Describe the different types of traction
- Pulling force applied to an extremity or different part of body
- Includes weights, ropes, pulleys used to realign and immobilize during healing
- Skin traction: Bryants (femoral), Bucks (hip, legg-calve-perthes), Russell (tibia), Dunlop/overhead (humerus)
- Skeletal traction (applied directly to bones with pins and wires): halo vest, crutchfield tong
- Distraction: Ilizarov external fixator used to lengthen the bone
What assessments need to be done for children with casts?
- Pain and Point tenderness
- Pulse distal to fracture point
- Paresthesia distal to fracture point
- Paralysis distal to fracture point
- Foul odor, drainage, heat at point, looseness, tightness, altered skin integrity, protect from getting wet
What three fungal infections are common in children? How is it diagnosed and treated?
- Tinea Capitis
- Tinea Corporis
- Tinea Pedis
- Can be diagnosed using black light, treated with antifungal topicals and possibly antifungal PO
Describe pedicilosis and its treatment
- Lice infestation on head, body, pubic area
- Treated with Permethine (Nix) and then nits removed with fine tooth comb
- Launder everything in hot water or put in plastic bag for number of days
What is scabies? What are the s/s and how is it treated?
- Skin infection of mites that burrow under the skin leading dark lines, esp in warm folds of body
- Intense itching that lasts weeks after successful treatment
- Treated with Elimite- put all over body at bed and rinsed off in morning. May be repeated and all close contacts should be treated
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