NR 602 MIDTERM STUDY GUIDE WEEK 4

NR 602 MIDTERM STUDY GUIDE WEEK 4 Toddler: 12-24 months Preschoolers: 2-5 years old WHO growth charts should be used to measure weight and length for children less than 24 months CDC weight and length charts used for children older than 24 months Average 24 month weighs 26 lbs, length 33.5 in and HC 18.5 in Most have no palpable fontanelle by 12 months Ant fontanelle closes by 18-19 months 3-6 yrs weight gain expectation is 4.5-6.5 lbs/year 3-6 yrs height gain expectation is 2.5-3.5 inches/yr 4 yrs length at birth has doubled 4-5 years old legs grow faster than rest of the body Use of dominant hand may appear as early as 8-12 months generally emerges 2-4 years old; handedness established at 5yrs May develop bowel and bladder control by age 3, but many will not. Boys usually take longer than girls to maintain bedtime bladder control. Articulation: -24 months- 25% is understood by a stranger -24m-36m- 66% is understood by a stranger -3 years old- 90% should be understood by a stranger 3 and 4-year-old have a normal hesitance or show stuttering, considered abnormal if beyond 5 years of age Speech problems often can be from lack of stimulation, hearing problems, ear infections, developmental delay. Early detection important. Lexicon: girls typically say their first word between 8-11 months; boys by 14 months 2 year olds: have more than 200 words in their vocabulary 3 years old: 900 words in vocabulary 3-4 yrs old: able to follow simple commands, talks incessantly 4-5 year olds: add at least 50 new words a month; words in vocabulary (including names, coins, colors, knows days of the week) 5 year olds: should be able to define certain words with other words (cup: something you drink with) Syntax: 8 months: develop receptive language- they understand what a word means before they are able to use it themselves 12-28 months: use holophrases (single words) to express whole ideas 18 months: use telegraphic speech (get milk, go bye-bye) 2 years old: short sentences 3 years old: add plurals, 3-4 word sentences 4 years old: past tense 5 years old: syntax is close to adult style, 5-6 word sentences Peer relationships: Toddler: parallel play Preschoolers: more interactive and social, imaginary play Body image: Masturbation starts around 3-4 years old Theories: Erikson Industry team sports/cooperation Master social studies, math and reading sense of competence and accomplishment Development of a of “superego” or conscious develops during preschool age Inferiority children must learn that they will not be able to master every skill they attempt Criticism detrimental at this age Piaget Concrete operations More tolerant and perceptive of other’s viewpoint Children are able to use thought processes to experience events and actions Judgments made based on reason (conceptual) Ages 2-4-Starting to realize world outside their own, realizing they can make things happen (shift from egocentric. Belief in “magical” power of words. Ages 4-7- Preoperational intuitive thought- starting to understand time concept but limited. Example may understand “after lunch” instead of in 2 hours. Kohlberg (moral development) Judge an act based on consequences of reward and punishment They know the rules and behaviors expected of this, but do not understand the reasons behind them Can accept the concept of treating others as they would want to be treated. Judge an act based on intention not just consequences Piaget: Preoperational thinking (2-4yrs) - problem solving based on what they see directly egocentrism - only about them Centration - Focus only on 1 thing at a time Animism - things around them are alive Magical thinking - thoughts are all powerful - their thoughts can cause things to happen Developmental Assessment: BP starts at 3 years old or if at high risk Hearing and Vision at 4-5 years old Dentist: first tooth eruption or before 12 months; eruption of permanent teeth start at 5 yrs 3 years: Draw circle, cross and vertical/horizontal lines 4-5 years: Trace cross & copy a square, ties shoelaces 5-6 years: Draw a person, copies a diamond and triangle, can print name 2-4 yrs: Animism and magical thinking Magical thinking continues into 4-7 years Screening Tools: Ages and stages Questionnaire: helps with evaluating fine and gross motor development M-CHAT: evaluates for autism (used for children 16-30 months) Early language milestone (ELM): brief screening for speech intelligibility (3-4 years old) Preschool decision: parents should select a preschool with a play based learning curriculum Immediate referral is required for children who stop eating, demonstrate cruelty to animals or other people, are self- harmful, start fires, or talk of harming themselves, their peers or others Children with scores below 85 on intelligence scales predictably have more difficulty in school Language development is the best indicator of cognitive development, language delays may indicate serious issues that require developmental and educational intervention Vision screening 5y, 6y, 8y, 10y, 12y. Referral with acuity less than 20/40 (aap guidelines) Hearing screening 5y, 6y, 8y, 10y. (aap guidelines) Immunization: Hep Bx3: NB, 1-2 mths, 6mths Hib x4: 1-2 mths, 4 mths, 6 mths, 12-15 mths Rotavirus x3: 1-2 mths, 4 mths, 6 mths PCV x4: 1-2 mths, 4 mths, 6 mths, 12-15 mths DTaP x5: 1-2 mths, 4 mths, 6 mths, 15-18 mths, 4yr Polio x4: 1-2 mths, 4 mths, 6 mths, 4-6y MMR x2: 12-15mths, 4yr Varicella x2: 12-15mths, 4yr Older child Tdap x 1: 11-14yr Meningitis x2: 11yr, 17yr HPV x2 (6mths apart): 11-13yrs Hep A x2 (6 mths apart): between 12-23mths, recommended before middle school if not had earlier Safety Helmets, seat belts, still keep cleaning supplies out of reach/locked up. Gross Motor Development 3 years •Rides a tricycle •Walks on tiptoes •Stands on 1 foot for a few seconds •Broad Jump 4 years •Catches a ball •Hops & skips on one foot •Walks up and down stairs using alternate feet 5 years •Jumps rope, begins to skate and swim •Walks backwards heel to toe •Skips and hops (alternate feet) Sleep 12 hours at night, no naps but quiet time Nightmares - During REM sleep, fully awakes, able to be reassured, occurs at end of the night Night terrors - No during REM, not aware of others, partial arousal, no memory of dream, earlier in the night Child Aggression: Not necessarily the behavior itself that is the issue but the frequency, severity, timing. Frustration is the biggest reason they act out. Can also happen if parent is depressed, child is neglected, etc. School Age Children Age 5-12 years Early Childhood (5 to 7 years) Middle (8 to 10 yrs) Late (11 to 12 yrs) Small amount of breast tissue in males normal during puberty-gynecomastia Encourage sports activities Growth and Development Building self-esteem- praise important Check immunizations at sick visits- no immunizations if fever within past 24 hours Get them to talk to you during the visit No shots until age 11 after 4 year old ones Age 7 cholesterol (guidelines between 7 and 11) If BMI 95%, obesity panel- A1c Vision and hearing often done in school Important to ask about friends and peer groups Physical development: strength coordination increase, growth spurts occur, cerebral cortex/frontal lobe develop Motor skills: run, jump, skip, hop, overhand motion, balance coordination improves Fine motor skills: improve dexterity, use scissors, writing tools, hand-eye coordination improves Psychosocial development: Erikson. Industry vs Inferiority. Industry: Development of formal skills, extrinsic rewards important like grades, cooperation, competition and coping leads to sense of accomplishment. Inferiority: ▪Danger during this period, especially for those with physical and mental limitations * No child is able to do everything well, and children must learn that they will not be able to master every skill they attempt Conceptual vs perceptual thinking: based on reason (conceptual) rather than what you see (perceptual). 95210 plan might be important, encourage reading. Communication and language development: Improved communication skills, 8-9 year olds can understand jokes, meanings, stuttering should resolve by school age. 10-12 year olds understand metaphors, ambiguities of language, speech and language disorders among the most developmental delays. Language development: 6-7 years: 2000 words, trouble with s, l, and r 7-8 years: should not have reversal of letters 8-9 years: can recognize and correct spelling and grammar 12 years: 4000 words, can correct syntax and semantics Social/Emotional: Social cognition results from parent child relationship Gain impulse control/manage emotions, learning to interpret social cues, parent should be parent, no friend Through peer relationships children learn that the world is somewhat different from their own. They learn how to deal with dominance and hostility, to relate to people in leadership and authority positions, and explore different ideas. -”Best Friends”: Important to the foundation of relationships in adulthood. They share secrets, private jokes, adventures, and come to each other’s aid in times of trouble. They also fight, break-up, and re-unite. -Clubs and Peer Groups: Rules and selection of joining. -Bullying: “Any recurring activity that intends to cause harm, distress, or control towards another in which there is a perceived imbalance of power between the aggressor and the victim” (Lamb, Pepler, and Craig, 2009). -Bullies are usually defiant towards adults, antisocial, and likely to break school rules. Victims often experience social distress such as worry, sadness, anxiety, depression, and nightmares. Gender: Early school-age – few gender differences; Older school-age – tend to associate with own gender Rules: Part of the enjoyment of the game is knowing the rules “Chants and Taunts”: Sense of power and pleasure with saying them. “Last one is the rotten egg!” “Step on a crack, you’ll break your mothers back!” Collections: Early School Age- odd assortment of things, messy Later School Age- more organized and selective Games: Adhering to the rules is a must! Reading: Newly acquired skill becomes increasingly satisfying. Never tire of stories (hearing or reading). Also enjoy creative and physical activities such as sewing, cooking, painting, swimming, soccer, or dance. Common fears: fear of the dark, self-consciousness, excessive worrying about past behavior. Symptoms of stress / fear: recurring stomach pains or headache, aggressive or stubborn behavior, regression to earlier behaviors such as thumb sucking, reluctance to participate, sleep problems, changes in eating, bed-wetting. Must provide reassurance to the child that they are safe, have honest and open communication, encourage them to express their feelings, and provide time for structured play. Just a noted about self-consciousness: school-age children generally have an accurate and positive self-perception. The more confidence that can be built during this period the better – it will carry forward into the future. May respond to pain with muscular rigidity: Anticipatory guidance: discuss sources of iron, calcium, vitamin c, vitamin d. Discuss prevention of obesity, exercise. Physical characteristics: ▪Slowed growth ▪2 inches per year ▪4-6 pounds per year Average 6 year old: 45 inches and 46 pounds Average 12 year old: 59 inches and 88 pounds ▪Pre-pubescence ▪From middle-childhood until 13 yrs old ▪Secondary characteristics Body image & Self concept Dental: ▪Permanent adult teeth development, Lose 4 teeth per year, Begin with eruption of 6 year molars ▪Attention to dental hygiene and caries is important The first physiological signs appear around 9 years of age (especially in girls) and are usually evident clearly visible in 11 to 12 year olds. Generally puberty begins at age 10 in girls and 12 in boys, but it can be normal for either sex after the age of 8 years. Nutrition: avoid empty calories, develop a new taste. Caloric needs for 6-12 year olds: boys 16-17 kcal/cm. girls: 13-14 kcal/cm. Sleep: start good habits such as no tablets in bed. ▪Highly individualized, Rarely takes naps Average 5 year old: 11 hours per night Average 12 year old: 9 hours per night ▪Bedtime resistance peaks from 8-11 years Safety: The most common cause of severe injury and death in the school-age child is motor vehicle accidents (MVA), either as a pedestrian or passenger. *The rear seat is the safest place for children less than 14 with booster seats until 80 pounds of 8 years of age. WEEK 2 : chapter 8 Adolescent 13 years is the age of consent in MD The common question on the minds of most adolescents: Am I normal? Adolescence: refers to the psychosocial and emotional transition from childhood to adulthood Physiologic Changes of the Adolescent • Increased size and strength of heart • Lungs increase in size • Continued brain development • Muscle & Fat changes • RR dec, HR dec, BP increases Tanner stages: Tanner 1: no growth of pubic hair Tanner 2: initial, scarcely pigmented straight hair Tanner 3: sparse, dark visibly pigmented curly hair Tanner 4: hair coarse and curly, abundant, but less than adult Tanner 5: lateral spreading; type and triangle spread of adult hair to medial surface of thighs Tanner 6: further extension laterally, upward, or dispersed (occurs in only 10% of women) Female stages: females enter puberty earlier than males do, following pattern: -ovaries increase in size, no visible changes occur -breast budding between 9-10 years old, and initial breast development at 12, breast buds approximately 6 months before the appearance of pubic hair, the timing of the onset of breast development in females has no relationship to breast size at the completion of puberty -95% of females reach peak height velocity (PHV) between the ages of 10 and 14 years old, and most girls experience PHV about 6-12 months before menarche, generally by 11-12 years -appearance of pubic hair - about 11.5 years old -first menstrual period- about 12.5 years old, it may be 18-24 months after menarche before females establish regular ovulatory cycles, first menstrual cycle typically consistent with tanner stage 3 Initial breast development usually begins as a unilateral disk-like subareolar swelling, and many are concerned with breast tumors -girls often have asymmetric breasts and need assurance that breasts become more or less the same size within a few years after the onset of breast budding They enter puberty with approximately 80% lean body weight and 20% body fat. By the time puberty ends, lean body mass drops to about 75% Male stages: the initial sign of male puberty is testicular enlargement on average at 11 years: -growth of the testes occurs approximately 6 months before the development of pubic hair in most males, once puberty begins, the left testis hangs lower than the right -pubic hair development happens similar to a girls (tanner stage) -first release of spermatozoa: occurs between 13.5-14.5 years old -growth spurt: occurs between 12-16, males can continue to grow, although minimally well beyond their teenage years -change in the male voice coincides with PHV (peak height velocity) Concerns for delayed puberty when there is no enlargement of the testes by age 13.5-14 years of age The taller the boy the more delayed onset of puberty In contrast to females, males increase in muscle mass and decrease fat Up to 65% of males experience gynecomastia especially within a year of achieving PHV, generally lasts 12-18 months and resolves on its own Acne starts in early puberty, and by mid puberty many males have moderate to severe acne Adolescents have formal operational thinking Egocentrism of adolescents: four major types of egocentrism: -imaginary audience: Everyone is thinking about them -personal fable: they are special -overthinking: they make things more complicated than they are -apparent hypocrisy: rules apply differently to them than others Principles and approaches to assessment: -teens must be evaluated independently from parents -should be reassured the information they share will be confidential (there are limits, providers are required to report information that puts the child or others in danger: physical or sexual abuse, some states require teen sexual activity, even if consensual, if an age difference of 3 or more years exist between the couple) Physical Assessment: - should have height, weight, BMI, and BP measured at each health maintenance visit -tanner stage should be recorded at each visit to evaluate progression -testicular growth can be directly assessed by palpation of the testes in the scrotum and comparison of their size with a standardized orchidometer -varicocele or enlarged veins palpable in the scrotum may develop at sexual maturity and are not cause for alarm unless a discrepancy in testicular size is noted -note gynecomastia -check for scoliosis -thyroid gland should be assessed -question attitudes regarding physical growth and development Cognitive development: -should include questions about school attendance, school performance, and educational/career goals Phases of adolescence: Early adolescence (11-14 years old): most difficult period -Physical development: tanner stage 3 or 4, some can be at 2 until 14 -Cognitive development: daydream frequently, set idealistic goals that change frequently, some experience a drop in academic performance in junior high school, which is related to motivation rather than ability -Social and emotional development: anti-adult, like their friends more -Health supervision: immunizations for HPV, diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP), influenza, Hep A, and meningococcal meningitis is recommended (before middle school and before college), serum lipoprotein analysis should be done if not done earlier in childhood -Anticipatory Guidance: increase iron and calcium intake is needed when menstruation begins, and during periods of rapid growth Red flag if boys do not increase testicle size by age 13.5-14 Middle Adolescence (15-17 years old): stand out for their unique appearance -Physical development: physical development is nearing completion, less concern about body changes more interest in being physically attractive -Cognitive development: school and extracurricular activities are often the focus -Social and emotional development: tend to be more non-adult than anti-adult, a characteristic of early adolescents, sexual drive emerges and middle adolescents begin to explore their ability to attract a partner -Health supervision: influenza, developmental surveillance, and assessment of social and academic progress, quality of interpersonal relationships, school performance, and emotional wellness , screening for STIs if sexually active, PAP smears no longer recommended until after age 21 regardless of sexual status -Anticipatory guidance: focuses on teens expanding physical, cognitive, and socioemotional capabilities, consolidating self-concept and identifying areas of continued growth and development Late Adolescence (18 to 21 years old): autonomy -Physical development: typically complete -Cognitive development: adult level of reasoning -Social and emotional development: usually relate to the family as adults -Health supervision: influenza, screening STIs, PAP smear begins at 21, fasting lipoprotein analysis is recommended once during late adolescence, transition in providing medical records and referring the adolescent to an adult health care provider -Anticipatory guidance: centers on transition from being a teenager to taking on the responsibility and role of an adult Risk behavior assessment: -HEEADSS (Home, Education and employment, Eating, Activities, Drugs, Sexulaity, Suicide/Depression, and Safety) -Tobacco use: direct questioning is the best way to assess smoking patterns -Self-Injurious Behaviors: history should include focused questions about present and past experiences with self-injury, description and mental and emotional responses; the most common locations include the arms, legs, and front of the torso -Social media use: have open discussions regarding social media use, approach teens non-judgmentally to bring up usage concerns Sexual Activity average age of initiation is 17 yrs Nutritional Needs Increased! Female: 9-13 years - sedentary- cal/day, Moderately active - cal/day, Active - cal/day 14-18 years - sedentary - 1800 cal/day, Moderately active - 2000 cal/day, Active - 2400 cal/day Male: 9-13 years - sedentary - cal/day, Moderately active - cal/day, Active - cal/day 14-18 years - sedentary - cal/day, Mod active - cal/day, Active cal/day Adolescent interviewing Respect and understand the psychological stage of the adolescent Empower them to take ownership of their health and well being Establish trust Week 5: Pediatric Orthopedics 3/1/2018 Condition Manifestation Prevalent age H & P Dx test Treatment Teaching Nursemaid Elbow Immediate pain, whiny, not moving arm 1-5yrs Pain on palpation, no increase in pain over the supracondylar region, no swelling or deformity, Classic sign is subluxation Reduction maneuver (Only attempt the reduction after checking NV status and supracondylar region) Distal radius buckle fx Hx of outstretched hand fall Pain at distal radius, with grip and flexion, swelling. No initial deformity x-ray Splint, can be for 4-14 day before able to see ortho, short arm cast 4-6wks Return to play with full strength and ROM Non- accidental traumas Assess for abuse. Red flags: inconsistent hx, tx delayed, multiple fx xray ER will do xray of skull and skeletal survey Avoid judgement, team approach. Tactfully send to ED, work up will be done there 5-10% increased r/o death if unrecognized and sent home Growing pains Leg pain (usu. bilateral), usu. at night more common in boys 2-5yrs and tweens, during growth spurt rare to have fever, wt loss and malaise No xray, pain usu. in thighs & lower legs reassure, mild analgesic (Ibuprofen cos is an anti inflammatory), gentle massage. Clavicle Fx Bony point tenderness over clavicle, skin tenting, necrosis possible visible deformity, increased pain, point tenderness at clavicle. Palpate Acromioclavicular joint & Sternoclavicular joint. Skin tenting can progress to pressure necrosis- open fracture! xray Refer to ED immediately, risk of frozen shoulder and necrosis of the socket. Immobilize 4-6 weeks in a sling . PE: bony point tenderness over clavicle, must palpate AC and SC. Must check for abrasions or lacerations- open fx! Want to prevent frozen shoulder and necrosis of joint. Narcotic pain often required, consult ortho if open, significant angulation, lateral third fracture, or significant shortening. Must assess need for immobilization vs immobilization and reduction. No contact sports 8 weeks Gradual return to play, must have full ROM and strength to return to play Osgood- Schlatter disease Osteochondritis of the tibial tuberosity. Increasing knee pain, Overuse injury or repetitive stress of the quadriceps muscle Common in girls & boys ages 10-15 years participating in competitive sports but in boys Soft tissue edema over proximal tibial tuberosity Tenderness to palpation of proximal tibial tuberosity. Sharp bump over the shin called tibial tubercle. Pain with knee extension against resistance Absence of effusion, pain of anterior knee NSAIDS, ice, restrict activity, PT, May not need to refer but refer to ortho if does not improve. Pain subsides with rest and activity modification, may last for awhile, restrict activities Sever’s disease results from inflammation of the growth plate in the heel. higher risk in pronated foot, flat or high arches, short leg syndrome & overwt . AKA calcaneal apophysitis, most common etiology of heel pain in growing children, pain in Sever disease is believed to be repetitive trauma to the weaker structure of the apophysitis induced by pull of the Achilles on its insertion growing children, also during growth spurt of adolescent children painful heel. Difficulty walking, discomfort when heel is squeezed, stiffness upon awakening, toe-walking, limping. xray may not be necessary unless condition persists after tx NSAIDS, ice baths, heel pads, heel stretching, calf strengthening. May refer to PT and OT if no improvement Symptoms worse during or after activity, better with rest, progression to activity as tolerated Legg calves - perthes Avascular necrosis of the femoral head. Insidious onset, painful limp, hip pain then groin, thigh and knee pain, hip motion. Can be bilateral, self-limiting 3-12 yrs, in boys **age is a big factor in determining outcomes (early identification is key) Afebrile, Trendelenburg and assess gait, leg length discrepancy, antalgic (avoid pain) gait, thigh atrophy, decreased abduction and internal rotation of hip. xray showing There is a flattening and fragmentation of the femoral head. Bone scan can ID avascular necrosis Refer, self limiting, limp can last 2-4yrs, stretching, bedrest, casting, NSAIDS, Pelvic/femoral osteotomy to contain femoral head. crutches & bracing Goal: to prevent hip from dislocating Slipped capital femoral epiphysis fx of the growth plate which leads to the slipping of the femoral epiphysis off the femoral neck Overwt and association with hypo- thyroidism and endocrine disorders; seen in preteens and teens usually complains of thigh or knee pain and holds the extremity externally rotated. Resists internal rotation. knee pain is hip pain unless proven otherwise, can have groin pain radiating to the knee, worsening pain xray +ve Pinning of the joint, child should be admitted to the hospital immediately and placed on bed rest. Refer immediately to ortho surgeon. Place on crutches or wheelchair, non-weight bearing needs to be emphasized. Transient synovitis acute onset of atraumatic groin or hip/thigh pain that is unilateral and a limp or unwillingness to bear weight 2-8 yrs acute onset, Sudden pain, r/o bacterial infection of joint or bone. US IDs effusion seen in TS and septic arthritis. Xray can show medial joint space widening & can exclude SCFE & Fx. WBC, ESR, CRP are norm or slightly elevated. Xray is norm unless effusion is present. Bone scan can differentiate TS and SA from osteomyelitis association of preceding viral illness 2wks-1mth prior with n/v, diarrhea and cold symptoms Plain radiographs exclude SCFE and fracture, x-ray may show medial joint space widening, lab work would be WBC, ESR, CRP, and if normal likelys TS, if elevated can still be that so MRI or aspiration of the fluid present on hip. Bone scan can differentiate between septic arthritis or TS from osteomyelitis Oesteomylitis Infection of the bone. Mostly long bone. May have hx of trauma. Most common organism is S. aureus Fever and ill appearing, limp or refusal to stand, point tenderness. Acute: Fever that may be abrupt. Irritability or lethargy in young children. Pain, swelling, warmth and redness at the area of the infection Chronic: Chronic fatigue, pain, swelling, warmth, drainage. May have fever Elevated ESR, CRP and WBC. Needle aspiration of fluid. Bone scan. Need BCx too IV antibx long term 4-6mths Septic Arthritis Microbial agent in the joint space. Ortho emergency, delay will lead to irreversible damage Pseudoparalysis due to pain, unable to perform ROM, severe pain and acute inflammation US can ID effusion, If the US is positive for an effusion it should be followed up by lab work (CBC with diff, CRP, ESR). elevated WBC, ESR CRP may indicate SA or osteomyelitis, confirm with MRI or an aspiration of fluid Lyme’s arthritis Arthritis is Initial sign of lyme’s disease in children. targets large joints symptoms mimic SA Scoliosis spinal curvature occurring in normal healthy patients more freq in females Adam’s forward bending test. perform neuro exam. assess for hairy patches, dimple, nevi, muscle weakness, neuro abnormalities Scoliometer MRI, CT scan Exercise, brace 25-40 degrees for 20-22 hrs/day, Spinal fusion for 45-50 degrees Ortho emergencies and urgencies: septic arthritis, neurovascular compromise, compartment syndrome, unstable slipped capital femoral Bowed legs- blount's disease, should be corrected by 4 In-toeing -18 mths start to straighten out usu done by 3 or 4y Out-toeing Toe-walking – may be seen with autism, may be out of habit Concern with kids with rickets, will see bowed legs at 4 – vit D levels, calcium Where is the source of pain and what is the condition? Hip - SCIFE Thigh - Femur condition Knee - Leg - tibia Ankle joint - MG Foot - Tarsals & metatarsals Age and likelihood of disorder Newborns and infants ( 1 yr) Toddlers (1-3 yr) Older children (4-10 yr) Pre-teens and teens ( 10 yrs) Obtaining hx What is the specific concern? • Pain/tenderness, limp, trauma/injury, or overuse, swelling, ability to bear weight, ROM…where? UE, LE, groin, foot/ankle, back… Who is concerned? When does it manifest? Daytime, nighttime, activity, jumping, walking up & down stairs? Characteristics? Duration? Improving or worsening? Any witnessed trauma Swelling without trauma - is more worrisome Swelling with trauma Warmth or erythema Swelling and erythema- thinking of cellulitis Systemic symptoms- fever, rash, foreign body, mass (could be sarcoma with mass) Ask for ROM Unable to walk With shoulder breaks, would check pain control, blood flow (circulation checks), compartment syndrome Assess for fluid with bulge sign and ballottement sign. Thomas test is for hip flexion if contracture is suspected 24 hour creatine-creatinine ratio to test for muscle disease Urine Uric acid –24 hr specimen for gout Urine Tests – creatine-creatinine ratio for test presence of muscle disease; Urine deoxypyridinolie – assess bone resorption process A Bone scan can differentiate septic arthritis or TS from osteomyelitis. In more chronic case it can be used to identify avascular necrosis or Legg-Calve-Perthes disease earlier in the course than can a plain radiograph. Bone scan can also help diagnose tumors and myelodysplastic disease Sprains Overstretching or tear Ligament injury (Excessive stretching of a ligament) Twisting motion Grade I—mild bleeding and inflammation Grade II—severe stretching and some tearing and inflammation and hematoma Grade III—complete tearing of ligament Grade IV—bony attachment of ligament broken away Treatment of sprains: first-degree: rest, ice for 24 to 48 hr, compression bandage, and elevation second-degree: immobilization, partial weight bearing as tear heals third-degree: immobilization for 4 to 6 weeks, possible surgery Nursing care for sprains R- rest I- ice C- compression E- elevation Strain Microscopic tear in the muscle May cause bleeding “Pulled muscle” Inappropriate lifting or sudden acceleration-deceleration Fractures Random Case study in class Mono- prolonged fever