Burns Pediatric Primary Care 7th Edition Maaks Starr Brady Test Bank

Simulation Exercise: Diagnostic Review Guidelines and Rubric Guidelines Annual blood pressure measurement is recommended by the American Academy of Pediatrics for children ages 3 to 21 years, and in younger ages a risk assessment should be completed with further follow up initiated if a positive screen is identified (AAP, 2020). Despite these widely accepted recommendations, elevated blood pressure is misdiagnosed in 74-87% of pediatric patients (AAP, 2020b). The Reducing Diagnostic Errors in Primary Care Pediatrics (Project RedDE!) developed by the American Academy of Pediatrics provides clinicians with a systematic approach to assessing and managing elevated blood pressure in children and adolescents (AAP, 2020b). This simulation exercise aims to prepare the pediatric nurse practitioner student in screening, identifying and managing elevated blood pressure in children and adolescents. Additionally, this assignment allows the pediatric nurse practitioner student to recommend changes in practice to support quality improvement and safety in the outpatient setting. Participation in the simulation and completion of the written assignment detailed below is required to receive 4 hours of clinical simulation hours. References AAP (2020a). Recommendations for preventative pediatric health care. Retrieved from AAP (2020b). Pediatric elevated blood pressure. Retrieved from Objectives: This Simulation Exercise: Diagnostic Review assignment will assist the student to:  Recognize hypertension in the pediatric population.  Explain the evaluation for primary and secondary causes of hypertension, and its comorbidities in the pediatric population.  Describe the management plan for hypertension in the pediatric population.  Propose a solution to improving patient care as it pertains to a clinical dilemma. Instructions for simulation:  Review the American Academy of Pediatrics Clinical Practice Guidelines for Screening and Management of High Blood Pressure in Children and Adolescents  Review the guide on proper positioning and process for taking blood pressure measurements  Review the blood pressure norms for boys and girls  Watch the following videos: o Blood pressure measurement in children: v=JLzkNBpqwi0&feature=Bpqwi0 This study source was downloaded by from CourseH on :22:58 GMT -05:00 Thomas Jefferson University College of Nursing Pediatric Primary Care Program o Clinician perspective on the project RedDE!:   Instructions for written assignment: As you reflect on the simulation please provide responses to the questions below. Please provide evidence-based literature to support your responses. Please submit your responses to these questions in EXXAT as a reflection note, and associate it with 4 hours of clinical simulation hours: Case 1: Harry, a 15-year-old boy, comes into clinic for his school physical. He has no concerns, but his blood pressure is noted to be 138/88. This blood pressure is the same as when taken on 3 separate occasions as ordered by a previous provider 3 weeks ago when the elevated blood pressure was initially identified. Harry's height is 50th percentile, his BMI is 31 (116% of the 95th percentile), and his mom has had high blood pressure for years. Otherwise his history and exam are completely unremarkable. 1. What is your leading diagnosis for the cause of Harry hypertension? What are some less likely causes? What further work-up will you pursue at this point? My leading diagnosis for Harry would be primary hypertension. General characteristics of children with primary hypertension include older children over age 6, positive family history of hypertension, and being overweight and/or obese (Flynn et al., 2017). Some less likely causes of Harry’s hypertension include secondary causes such as renal disease , coarctation of the aorta, or endocrine abnormalities such as hormonal excess (Flynn et al., 2017). Children like Harry do not require an extensive evaluation for secondary causes of hypertension. Because of this, lifestyle modifications would be recommended and blood pressure would be followed for 6 months to watch for improvement. If no improvement, further workup such as electrolytes, BUN/creatinine, thyroid studies, urinalysis, and a referral to nephrology would be indicated (Maaks et al., 2020). Case 2: Perry is a 6-month-old, born at 32 weeks gestation, coming in for a health maintenance visit. He is found to have a blood pressure of 110/80. 1. Should his blood pressure have been checked? What do you make of the value? Yes, Perry should have his blood pressure checked. While normally blood pressure is checked in children over age 3, children under age 3 with a history of prematurity, heart or renal disease, malignancies, and transplant should also be monitored (Maaks et al., 2020). Abnormal birth history, including preterm birth, has been identified as a risk factor for hypertension and other CVD in adults (Flynn et al., 2017). In a 6-mont-old infant, blood This study source was downloaded by from CourseH on :22:58 GMT -05:00 Thomas Jefferson University College of Nursing Pediatric Primary Care Program pressure would be expected to be 65-90 systolic and 45-65 diastolic. Therefore, this reading is elevated and warrants further evaluation (Healthwise Staff, 2019). Case 3: Shawna, a 5 year old girl presents for a health maintenance visit. She is found to have a blood pressure of 125/85. Shawna's height and weight is 25th percentile, and her BMI is 15.3 (53rd percentile). Otherwise history and exam are completely unremarkable. 1. What, if any, further evaluation does Shawna require at this visit? What is your leading diagnosis for the cause of Shawna's hypertension? What are some less likely causes? What further work-up will you pursue at this point? Before any further evaluation is needed, Shawna’s blood pressure should be rechecked. Its possible that she could have been moving or talking during the exam which would cause elevated readings. If the blood pressure remains elevated, we would need to get two more blood pressure readings a few weeks apart and in different settings to ensure that it is truly elevated (Maaks et al., 2020). If hypertension is suspected, thorough evaluation is needed. A complete medical and family history should be reviewed to assess for risk factors, as well as diet and exercise patterns. A physical exam should be completed including blood pressures in both arms and one leg to assess for possible coarctation of the aorta (Flynn et al., 2017). Given Shawna’s weight, height, and BMI, primary hypertension is less likely. Therefore we need to assess for causes of secondary hypertension. Blood work should also be obtained to assess for renal, cardiac, and endocrine abnormalities that would reveal the cause of Shawna’s hypertension. This blood work should include urinalysis, electrolytes, BUN/creatinine, and thyroid studies. At that time, appropriate referrals can be made (Flynn et al., 2017). Case 4: The pediatric nurse practitioner who works in a family practice outpatient clinic notes that the blood pressure for several school aged and adolescent patients that she has cared for over the last week have had elevated blood pressures entered in the electronic medical record (EMR) from previous clinic visits, but which the rendering health care provider has not addressed. The pediatric nurse practitioner finds out in speaking with the practice administrator that the EMR is programmed with the norms for adults. After familiarizing yourself with current evidence, including ProjectRedDE! what steps can the pediatric nurse practitioner take to improve patient care and reduce error? ProjectRedDE is a toolkit that assists primary care providers in reducing diagnostic errors and improving care for children (American Academy of Pediatrics [AAP], n.d.). This toolkit goes through the measurements, screenings, recognition, diagnosis, follow-up, and reduction of diagnostic errors associated with elevated blood pressure, adolescent depression, and laboratory testing (AAP, n.d.). If the EMR at the clinic is programmed for adult norms, providers may not be recognizing when blood pressure are elevated in these children, because they are still lower than the adult norm. A few things can be done in this clinic to help improve care and reduce This study source was downloaded by from CourseH on :22:58 GMT -05:00 Thomas Jefferson University College of Nursing Pediatric Primary Care Program error. First off, providers need lots of education. It is important first to ensure that everyone in the clinic knows how to properly take a blood pressure. This includes using the right size cuff, proper positioning of the cuff and the patient, and troubleshooting (AAP, n.d.). Once we know that blood pressures are being accurately recorded, we need to make sure that the providers know what normal blood pressures are for each age group. This way, adequate action can be taken when needed for children with elevated readings. References American Academy of Pediatrics. (n.d.). Pediatric elevated blood pressure. Retrieved October 17, 2020, from Flynn, J. T., Kaelber, D. C., Baker-Smith, C. M., Blowey, D., Carroll, A. E., Daniels, S. R., . . . Urbina, E. M. (2017). Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics, 140(3). doi:10.1542/peds.2017- 1904 Healthwise Staff. (2019, June). Vital signs in children. Retrieved October 18, 2020, from Maaks, D.L.G, Starr, N.B., Brady, M.A., Gaylord, N.M., Driessnack, M., Duderstadt, K.G. (2020). Burns’ pediatric primary care: 7th edition. Elsevier.