Peds Exam 3

Ch 34 Onset of Duchenne

-3 years old - muscle weakness -Later - abnormal gait -Muscular enlargement caused by fatty infiltration (progressive) -Ambulation usually impossible by 12 yrs -Cause of death (usually by late teens/early 20s - respiratory tract infection/cardiac failure -Treatment - maintain function as long as possible/ may use corticosteroids • Early onset, usually between 3 and 5 years of age • Progressive muscular weakness, wasting, and contractures • Calf muscle hypertrophy in most patients • Loss of independent ambulation by 9-12 years of age • Slowly progressive, generalized weakness during adolescence • Relentless progression until death from respiratory or cardiac failure

CH 17 Psychosocial development- Erikson for adolescents

1. IDENTIFY DEVELOPMENT develop stable, coherent picture of onself from past and present experiences with a sense of where one is headed in the future. Erik Erikson (1968) describes identity achievement as one of the main psychosocial tasks of the adolescent years; "From among all possible and imaginable relations [the adolescent] must make a series of ever-narrowing selections of personal, occupational, gender-related, and ideological commitments." DURING ADOLESCENCE- cognitive development and social environment occurs to push individuals to reflect on their place in society, the way others view them, their own sense of self-worth, and their options regarding career,, service, and contributions in the future. For most individuals, the formation of a coherent self-identity occurs sometime during late adolescence and early adulthood. Erikson (1968) suggests that the key to identity achievement lies in adolescents' interactions with others—role model adults, caregivers, and, most significantly, peers. Cultural influences, the environmental surroundings, and the society norms in which an adolescent lives play important roles in determining the range of available alternatives for identity formation. Optimally, adolescents have the opportunity to explore a range of possible options related to ideological, occupational, and interpersonal roles before making an identity commitment. Experiences and opportunities within one's social environment influence both the content of identity and progression toward identity achievement. Among ethnic minority adolescents, those from a majority culture may experience restricted opportunities to explore alternative roles due to pressure from the community leaders who aim to preserve the contextual norm within the emerging generation. However, as the "melting pot" of America becomes more diverse with an increasing number of mixed-race families, and as political pressures and social media influences pervade all aspects of our culture, there are multiple forces among minority youth attempting to attain cultural identity. Possible barriers to identity formation among minority youth may include conflicting values between their minority ethnic group and the broader society, lack of adult role models who exemplify positive ethnic identity, and inadequate preparation or coping strategies for adolescents to manage stereotyping and prejudice that are frequently experienced among youth who derive from various cultures. However, many ethnic minority adolescents develop unique cultural norms within their community or adapt bicultural identities with the ability to navigate the cultural expectations of home, community, and society, creating positive connections to cultural identities that ultimately foster healthy adolescent development. It is critical for the nurse to be sensitive to variations in family systems and cultural variations among their adolescent patients, as well as in general within the community where they serve. Asking the adolescent about the home and school environment as well as cultural beliefs helps establish therapeutic communication. 2. DEVELOPMENT OF AUTONOMY Becoming an autonomous, self-governing person is another fundamental psychosocial task of adolescence. Autonomy includes emotional, cognitive, and behavioral components. Emotional autonomy is that aspect of independence related to changes in an individual's close relationships, and behavioral autonomy is the capacity to make independent decisions and follow through with them. Individuals generally begin the process of emotional autonomy during early adolescence by becoming more emotionally independent from their parents but remain cohesive with their friends. In the process of separating from their parents, younger adolescents often shift a portion of their emotional ties to other adults, often developing "crushes" on teachers, coaches, celebrities, or the parent/caregiver of a trusted friend while gradually becoming less emotionally dependent. This emotional autonomy typically progresses in phases. First, adolescents no longer rush to their parents for advice or comfort when they are worried or upset. Second, conformity to parents' opinions declines and peer influence increases. Young and middle adolescents no longer see their parents/caregivers as all-knowing or all-powerful. Third, teenagers invest more emotional energy in relationships outside their families. Decision-making abilities improve over the adolescent years; older adolescents become more aware than younger adolescents of risks and benefits involved with decisions, consider future consequences, turn to "experts" for advice rather than impulsively acting, and realize when vested interests may influence the advice of others. During middle and late adolescence, conformity to both parent and peer opinions declines, allowing for genuine behavioral autonomy. Subjective feelings of self-reliance increase steadily over the adolescent years until finally, older adolescents begin interacting with their parents as people and confidants, recognizing that both peers and parents have value. In contrast to popular stereotypes, the development of autonomy during adolescence does not always involve rebellion nor is it always accompanied by strained or tense family relationships, especially among families in which there is mutual respect, consistent communication, and support. In households where guidelines for adolescent behavior are clear and consistently enforced; where changes in guidelines are open to discussion; and where an atmosphere of interpersonal warmth, concern, and fairness exists, a gradual and smooth maturational process occurs over the course of the adolescent years. Problems in the development of autonomy are often understandable reactions to excessively controlling circumstances, lack of nurturing environment or consistency in caregiving, or growing up in the absence of clear expectations. In addition to dispelling the myths that major parent-child conflicts and adolescent rebellion are essential to the development of autonomy, research has shown that parent and peer influences are not necessarily opposing forces but can play complementary roles in the development of a healthy degree of individual independence. Experts emphasize that adolescents still need monitoring and input by parents during their search for an identity; abandonment of the adolescent during this phase is undesirable and may leave the adolescent feeling fragmented, alone, and adrift, resulting in the development of psychopathology (Meeus, 2016). 3. SEXUALITY Adolescence represents a critical time in the development of sexuality. Hormonal, physical, cognitive, and social changes that occur during adolescence all have an impact on sexual development and ultimately gender identity. Of all the developmental changes that affect adolescent sexuality, none is more obvious than the impact of puberty. Adolescents must come to terms with hormonal influences, physiologic manifestations such as menstruation and ejaculation, and physical changes such as breast and genital development. All these changes have a profound impact on the way teenagers perceive their bodies (i.e., body image). In addition to transitions in body image, increasing levels of pubertal hormones contribute to emotional liability and increased levels of sexual motivation among both boys and girls. The degree to which adolescents feel comfortable with their bodies may affect sexual behaviors and varies widely among teens. Changes in sexual motivations and feelings, happening at the same time as shifts in cognitive skills, contribute to painful conjectures ("Is what I'm feeling normal?"), self-conscious concerns ("Am I good looking enough?"), and hypothetical thinking ("What if he/she wants to have sex?"). The emergence of formal operational thinking also increases adolescents' decision-making capabilities concerning sexual issues. The important task of successfully incorporating sexuality into a developing or establishing intimate relationship is made possible by the advanced cognitive abilities that emerge over the course of adolescence. Part of adolescent identity formation involves the development of gender identity. For young adolescents, the process of gender identity development usually involves forming close friendships with same-gender peers with whom they may discuss various sexual topics or experiment sexually, often to satisfy curiosity. Sexual activity among young teenagers varies by gender. Masturbation provides an opportunity for sexual self-exploration; participation in this behavior is influenced by learned cultural attitudes and sex-role expectations. Boys typically begin masturbating during early adolescence; the age of first masturbation varies greatly for girls. Although some girls begin masturbating during early adolescence, many do not masturbate until after they have had intercourse. Once sexual exploration begins, approximately 33% of teens engage in oral sex and sexual intercourse in the same year (Haydon, Herring, Prinstein, et al., 2012). National reports show that 24% of teens have had vaginal intercourse by ninth grade; nearly 58% of teens graduating from high school report at least one sexual encounter (Kann, McManus, Harris, et al., 2016). Among teens who choose to delay sexual debut, the top three reasons reported are religious or moral beliefs, desire to postpone becoming a parent, and "haven't found the right person yet" (Reese, Choukas-Bradley, Herring, et al., 2014). Many teens choose to experiment or intentionally shift from typical intimate relationships with opposite-gender partners to same-gender experiences during middle adolescence. Opposite-gender romantic relationships typically begin after peer activities involving both boys and girls. The type and degree of seriousness of partner relationships vary; pairing off as couples becomes more common as middle adolescence progresses (Fig. 17.8). Initial relationships are usually noncommittal, extremely mobile, and seldom characterized by any deep romantic attachments. Sexual activity (whether with same- or opposite-gender or both-gender partners) becomes more common during middle to late adolescence. The relationship between romance and expressions of love and sexual expression is brought into focus during middle adolescence. Most young people oppose exploitation, or being pressured into participating in a sexual act, and typically do not consider sex solely for the sake of physical enjoyment without a personal relationship. Many adolescents find it hard to believe that sex can exist without love; therefore they view each relationship as "real love." However, some teen social groups have embraced "friends with benefits" norms that includes sexual activity among friends who are not considered exclusive or committed romantic partners. FIG. 17.8 Romantic relationships are an important part of adolescence. The meaning and implication of sexual activity as it affects psychosocial development may be quite different for adolescent boys and girls; that is, sexual socialization differs for males and females in our society. Typically, adolescent boys' first sexual experiences are in early adolescence through masturbation. Before dating or interest in romance, most boys have already experienced orgasm and know how to arouse themselves sexually. For boys, the development of sexuality during adolescence revolves around efforts to integrate the formation of close relationships into an already existing sense of sexual capability. Girls' first sexual experiences are likely to have a different meaning. The adolescent girl is more likely to experience sexual intercourse for the first time in a perceived intimate or meaningful relationship and may not experience organism. For girls, the development of sexuality involves the integration of sexual activity into an existing capacity for emotional involvement. An integrated sexual identity often emerges during late adolescence as individuals incorporate sexual experiences, feelings, and knowledge. For most, this identity is consistent with their own physical and mental capacities and with societal limits and expectations. Whatever their gender orientation, most older teenagers possess the capacity to have intimate relationships that satisfy the emotional and sexual needs of both partners. Sexual orientation is an important aspect of sexual identity. Sexual orientation is defined as a pattern of sexual arousal or romantic attraction toward persons of the opposite gender (heterosexual); of the same gender (homosexual, often called gay, lesbian, or queer); of both genders (bisexual); or may be in the process of gender transition (transgender) or asexual (not sexually aroused by either gender). Sexual orientation encompasses several dimensions: (1) sexual orientation identity that consists of how an individual defines his or her sexual orientation; (2) sexual attraction that includes the gender to which the individual is romantically and physically attracted; and (3) sexual behavior that consists of whom an individual has sexual relationships with (O'Neill & Wakefield, 2017). In individuals the direction and intensity of each dimension are not necessarily consistent with any of the others. For example, individuals may be attracted most strongly to their same gender, have sexual activity only with the opposite gender, and identify as gay or lesbian. As with all aspects of sexual identity, cultural meaning and expectation, gender, peer groups, opportunities for intimacy, and other environmental contexts all influence sexual orientation. Nurses who ask teens what gender term they prefer as identification in health care settings demonstrate support and understanding of emerging gender issues. The information is also important as the provider considers clinical management and screening for risks. Adolescence is the period during which individuals commonly begin to identify their sexual orientation as part of their developing sexual identity. However, cultural beliefs and values, societal and family pressures, or a lack of similar peers can influence this identification process. Among adolescents whose orientation encompasses any same-gender dimensions, the identity process during adolescence can be complicated, especially when community norms disapprove of orientations other than heterosexual. Adolescents who have witnessed harassment or violence directed at gay, lesbian, bisexual, and transgender people may be reluctant to self-identify their sexual orientation, even when their attractions and behaviors are exclusively same-gender or bisexual. The development of sexual orientation as part of sexual identity includes several developmental milestones during late childhood and throughout adolescence. These milestones do not necessarily occur in the same order for everyone, nor are they completed in the same amount of time. They include (1) the realization of romantic or erotic attraction to people of one (or both) genders; (2) erotic daydreaming about one or both genders; (3) romantic partners or dates without sexual activity; (4) sexual activity with people of the preferred gender or genders (also, for some teens, sexual activity with a nonpreferred gender, due to curiosity or social pressure); (5) self-identification of the orientation that best fits one's current circumstances and understanding; (6) publicly self-identifying that orientation, usually to intimate friends and family first, then the wider social group; and (7) an intimate, committed sexual relationship with a person of the gender appropriate to one's orientation. The order of these milestones varies greatly among adolescents, but adolescents who identify as gay, lesbian, bisexual, transgender, or queer (LGBTQ) tend to publicly self-identify later than their heterosexual peers. Without positive LGBTQ role models or a supportive family member or peer group, sexual minority teens can feel isolated, confused, and depressed, and they may delay or avoid sharing their gender orientation with anyone for fear of rejection or violence (see Critical Thinking Case Study box). When adolescents who would otherwise identify as bisexual can only find a peer group of gay and lesbian teens, they may focus on their same-gender dimensions of orientation and adopt the label of lesbian or gay; later, they may self-label as bisexual. Likewise, some gay and lesbian adolescents may first identify as heterosexual, then bisexual, before identifying as gay or lesbian. Critical Thinking Case Study Discussing Sexual Orientation With Adolescents John, a 17-year-old adolescent, comes into the school-based clinic and tells the nurse practitioner that he thinks he is gay. What is the most appropriate response for the nurse practitioner? 1. 1. What evidence should you consider regarding this condition? 2. 2. What additional information is required at this time? 3. 3. List the nursing intervention(s) that have the highest priority. 4. 4. Identify important patient-centered outcomes with reference to your nursing intervention. Answers are available at http://evolve.elsevier.com/wong/ncic. There is no evidence that gay, lesbian, or bisexual adults are more or less likely to create long-term, stable relationships than are heterosexual couples. It should be noted that bisexual adolescents and adults do not generally engage in sexual relationships with both genders concurrently; self-identification as bisexual usually refers to the ability to be attracted to either gender but does not imply that such a person requires partners of both genders or that one must be equally attracted to and have sexual experience with both genders in order to be bisexual. 4. INTIMACY Intimate relationships are emotional attachments between two people characterized by concern for each other's well-being; a willingness to disclose private, possibly sensitive topics; and a sharing of common interests and activities. Intimate relationships are distinct from sexual relationships; it is possible for individuals to have close intimate relationships without becoming sexually involved. At the same time, people can be involved in sexual relationships that are not particularly intimate. Intimate relationships first emerge during adolescence. Adolescents' close friendships are likely to include a strong emotional foundation in which individuals understand and care about one another. Puberty and its resultant changes in sexual impulses often raise new issues and concerns requiring serious, intimate discussions. Over the course of the adolescent years, individuals become more capable of and interested in emotional closeness with other people. The greater degree of behavioral independence often accompanying the transition into adolescence provides more opportunities for teenagers to be alone with friends and to come into meaningful contact with adults outside their families. Although research on intimacy during adolescence has focused on peer friendships, intimate relationships are by no means limited to peers. Teenagers may also develop intimate relationships with parents, siblings, and adults who are not part of their immediate families. Harry Stack Sullivan (1953) was among the first to describe the developmental course of intimacy. Usually adolescents develop the capacity for intimacy through preadolescent and early adolescent relationships with same-gender peers. Intimate relationships with opposite-sex peers develop relatively late during adolescence. Opposite-gender friendships may play a more important role in the development of intimacy among boys than among girls, who may develop and experience intimacy with other girls earlier in adolescence. Although teenagers may begin dating during early adolescence, these early dating relationships are not usually psychosocially intimate. Early dating relationships typically follow highly ritualized "scripts," in which adolescents are more likely to play stereotypic roles than to really be themselves. Participating in mixed-gender group activities, such as going to parties or other events, may have a positive impact on young teenagers' well-being. One-on-one dating during early adolescence, however, with a lot of time spent alone, may lead to sexual intimacy before a teen is ready. A moderate degree of dating, with serious relationships delayed until late adolescence, may be the ideal pattern of interpersonal involvement. (pg 526)

Ch 34 CP cerebral Palsy

A group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain." In addition to motor disorders, the condition often involves disturbances of sensation, perception, communication, cognition, and behavior; secondary musculoskeletal problems; and epilepsy." Etiology: -Brain development -Prenatal factors: Chorioamnionitis Infections Birth weight -Bacterial meningitis -Encephalitis -MVA's, falls, abuse Pathophysiology: òAnoxia òStrokes òKernicterus òMitochondrial disorders òGlutaricaciduria

Ch 32 Acne vulgaris vs Comodomal acne

Acne vulgaris is the most common skin problem treated by physicians during adolescence. Acne is caused by testosterone, a hormone present in boys and girls that increases during puberty. It stimulates the sebaceous glands of the skin to enlarge, or produce oil, and plug the pores. Comedogenesis (formation of comedones) results in a noninflammatory lesion that may be either an open comedone ("blackhead") or a closed comedone ("whitehead").the peak incidence occurs in middle to late adolescence (age 16 to 17 years in girls and 17 to 18 years in boys). It is more common in boys than in girls. After this age period, the disease usually decreases in severity, but it may persist into adulthood. The degree to which an individual is affected may range from nothing more than a few isolated comedones to a severe inflammatory reaction. Although the disease is self-limiting and not life threatening, it has great significance to adolescents. Health professionals should not underestimate the impact that acne has on teens. Numerous factors affect the development and course of acne. Its distribution in families and a high degree of concordance in identical twins suggest hereditary factors. Premenstrual flare-ups of acne occur in nearly 70% of adolescent girls, suggesting a hormonal cause. Studies do not indicate a clear association between stress and acne, but adolescents commonly cite stress as a cause for acne outbreaks. Cosmetics containing lanolin, petrolatum, vegetable oils, lauryl alcohol, butyl stearate, and oleic acid can increase comedone production. Exposure to oils in cooking grease can be a precursor in adolescents who work over fast-food restaurant hot oils. There may be an association with the intake of dairy products and high glycemic index foods that may potentiate hormonal and inflammatory factors that contribute to acne severity

Ch 6 Chicken pox

Agents—Varicella-zoster virus (VZV) Source—Primary secretions of respiratory tract of infected persons; to a lesser degree, skin lesions (scabs not infectious) Transmissions—Direct contact, droplet (airborne) spread, and contaminated objects Prodromal stage—Slight fever, malaise, and anorexia for first 24 hours; rash highly pruritic; begins as macule, rapidly progresses to papule and then vesicle (surrounded by erythematous base; becomes umbilicated and cloudy; breaks easily and forms crusts); all three stages (papule, vesicle, crust) present in varying degrees at one time Distribution—Centripetal, spreading to face and proximal extremities but sparse on distal limbs and less on areas not exposed to heat (i.e., from clothing or sun) Constitutional signs and symptoms—Elevated temperature from lymphadenopathy, irritability from pruritus Specific—Antiviral agent acyclovir (Zovirax); varicella-zoster immune globulin or intravenous immune globulin (IVIG) after exposure in high-risk children Supportive—Diphenhydramine hydrochloride or antihistamines to relieve itching; skin care to prevent secondary bacterial infection Complications—Secondary bacterial infections (abscesses, cellulitis, necrotizing fasciitis, pneumonia, sepsis) Encephalitis Varicella pneumonia (rare in healthy children) Hemorrhagic varicella (tiny hemorrhages in vesicles and numerous petechiae in skin) Chronic or transient thrombocytopenia Preventive—Childhood immunization Nursing Care Management: Maintain Standard, Airborne, and Contact Precautions if hospitalized until all lesions are crusted; for immunized child with mild breakthrough varicella, isolate until no new lesions are seen. Keep child in home away from susceptible individuals until vesicles have dried (usually 1 week after onset of disease), and isolate high-risk children from infected children. Administer skin care: give bath and change clothes and linens daily; administer topical calamine lotion; keep child's fingernails short and clean; apply mittens if child scratches. Keep child cool (may decrease number of lesions). Lessen pruritus; keep child occupied. Remove loose crusts that rub and irritate skin. Teach child to apply pressure to pruritic area rather than scratching it. Avoid use of aspirin (possible association with Reye syndrome).

Ch 6 Which diseases require which precautions: Airborne, droplet, contact precautions

Airborne: measles, varicella (including disseminated zoster), and tuberculosis. Droplet: Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis • Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis • Other serious bacterial respiratory tract infections spread by droplet transmission, including diphtheria (pharyngeal), mycoplasmal pneumonia, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children • Serious viral infections spread by droplet transmission, including adenovirus, influenza, mumps, human parvovirus B19, and rubella. Contact: Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance • Enteric infections with a low infectious dose or prolonged environmental survival, including Clostridium difficile; for diapered or incontinent patients: enterohemorrhagic Escherichia coli 0157:H7, Shigella organisms, hepatitis A, or rotavirus • Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children • Skin infections that are highly contagious or that may occur on dry skin, including diphtheria (cutaneous), herpes simplex virus (neonatal or mucocutaneous), impetigo, major (noncontained) abscesses, cellulitis or decubitus, pediculosis, scabies, staphylococcal furunculosis in infants and young children, zoster (disseminated or in the immunocompromised host) • Viral or hemorrhagic conjunctivitis • Viral hemorrhagic infections (Ebola, Lassa, or Marburg)

Ch 18 Types of drugs abused

Although rarely considered drugs by society, the chemically active substances frequently abused are the xanthines and theobromines contained in chocolate, tea, coffee, and colas. Ethyl alcohol and nicotine are other drugs that are legal and socially sanctioned. Any of these substances can produce mild to moderate euphoric or stimulant effects and can lead to physical and psychologic dependence. Drugs with mind-altering abilities that are available on the "street" and are of medical and legal concern are the hallucinogenic, narcotic, hypnotic, and stimulant drugs. In addition, health care professionals are concerned about the use of alcohol and volatile substances that are inhaled to achieve altered sensation (e.g., gasoline, antifreeze, plastic model airplane cement, organic solvents). Cough and cold preparations such as NyQuil, Coricidin, and Robitussin are common substances abused by adolescents and young adults. Many of the medications are often found in the medicine or kitchen cabinet at home and are available at a decreased cost compared with the more exotic drugs of abuse. The abuse of prescription and synthetic drugs such as opioids, benzodiazepines such as Xanax, and stimulants such as Adderall is increasing among adolescents and young people (Stager, 2016). Websites also promote the "safe use" of some psychoactive drugs and supply information on new "designer" drugs that are not detectable on a standard urine drug screening test.

Ch 18 Anorexia, bulimia

Anorexia nervosa (AN) -Is an eating disorder characterized by a refusal to maintain a minimally normal body weight, intense fear of gaining weight along with behavior that interferes with weight gain, and a body image disturbance. -Young people with AN tend to withdraw from peer relationships and engage in self-imposed social isolation. They continually strive for perfection, which may be demonstrated in other compulsive behaviors. They are usually overachievers, and their schoolwork is very important to them. Bulimia nervosa (from the Greek meaning "ox hunger") -Bulimia nervosa (BN) is characterized by repeated episodes of binge eating followed by inappropriate compensatory behaviors, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. -Bulimia is more common in older adolescent girls and young women; males with bulimia are less common. BN patients may be of average or slightly above-average weight. The diagnosis is confirmed, according to the American Psychiatric Association's DSM-5, by at least one binge-eating episode per week for the preceding 3 months. -Individuals with eating disorders commonly have psychiatric problems, including affective disorder, anxiety disorder, obsessive-compulsive disorder, and personality disorder.

CH 17 Body art

Body Art Body art (piercing and tattooing) is an aspect of adolescent identity formation. The skin has become the latest source of parent-adolescent conflict. Adolescents often seek body art as an expression of their personal identity and style. Tattoos may mark significant life events such as new relationships, births, and deaths. Piercing the ear, nose, lip, nipple, eyebrow, labia, navel, penis, or tongue may sometimes create a health problem. It is a nursing responsibility to caution girls and boys against having piercing performed by friends, parents, or themselves. Although in most cases piercings have few, if any, serious side effects, there is always a risk for complications such as infection, cyst or keloid formation, bleeding, dermatitis, or metal allergy. Using the same unsterilized needle to pierce body parts of multiple teenagers presents the same risk for HIV, hepatitis C virus, and hepatitis B virus transmission as occurs with other needle-sharing activities. Furthermore, there is a danger of contaminated tattoo ink that occurred in association with skin infections, such as nontuberculous Mycobacterium chelonae (Mudedla, Avendano, & Raman, 2015). Adolescents should be informed about the approximate time for healing after body piercing and the care of the pierced area during and after healing. Some body sites need extra precautions. For example, cartilage (ear, nose) has a poor blood supply and heals slowly and scars easily; nipple piercing puts adolescents at risk for breast abscesses. Finally, migration of the piercing is common with navel and other flat skin surface piercing. Piercing guns should not be used for piercing anything other than the earlobe because guns place the piercing too deeply. The presence of body art in the form of tattoos and branding is common among adolescents and young adults. Professionals as well as amateur artists administer tattoos. The greatest risk is for the tattoo artist, who comes in contact with the client's blood. Adolescents who are amateur tattoo artists benefit from discussions about Standard Precautions and the hepatitis B vaccination. Many states either have no regulations or do not enforce existing regulations of piercing and tattooing facilities. The local health department is a source of information about local regulatory requirements. The Centers for Disease Control and Prevention has a website that outlines safety concerns for persons performing and receiving body art: http://www.cdc.gov/niosh/topics/body_art/.

Ch 6 Pinworms

Enterobiasis, or pinworms, caused by the nematode Enterobius vermicularis, is the most common helminthic infection in the United States.Infection begins when the eggs are ingested or inhaled (the eggs float in the air). The eggs hatch in the upper intestine and then mature and migrate through the intestine. After mating, adult females migrate out the anus and lay eggs Clinical Manifestations of Pinworms Intense perianal itching is the principal symptom. Evidence of itching in young children includes the following: • General irritability • Restlessness • Poor sleep • Bed-wetting • Distractibility • Short attention span • Perianal dermatitis and excoriation secondary to itching • If worms migrate, possible vaginal (vulvovaginitis) and urethral infection The drugs available for treatment of pinworms include pyrantel pamoate (Pin-Rid, Antiminth) and albendazole. Mebendazole is not recommended for children younger than 2 years of age. Because pinworms are easily transmitted, all household members should be treated. The dose of antiparasitic medication should be repeated in 2 weeks to completely eradicate the parasite and prevent reinfection. Direct nursing care at identifying the parasite, eradicating the organism, and preventing reinfection. Parents need clear, detailed instructions for the tape test. A loop of transparent (not "frosted" or "magic") tape, sticky side out, is placed around the end of a tongue depressor, which is then firmly pressed against the child's perianal area. A convenient, commercially prepared tape is also available for this purpose. Pinworm specimens are collected in the morning as soon as the child awakens and before the child has a bowel movement or bathes. The procedure may need to be performed on 3 or more consecutive days before eggs are collected. Parents are instructed to place the tongue blade in a glass jar or loosely in a plastic bag so it can be brought in for microscopic examination. For specimens collected in the hospital, practitioner's office, or clinic, place the tape smoothly on a glass slide, sticky side down, for examination. Adherence to the drug regimen is usually excellent because only one or two doses are needed. The family should be reminded of the need to take a second dose in 2 weeks to ensure eradication of the eggs. To prevent reinfection, washing all clothes and bed linens in hot water and vacuuming the house may be recommended. However, there is little documentation on the effectiveness of these measures because pinworms survive on many surfaces. Helpful suggestions include hand washing after toileting and before eating, keeping the child's fingernails short to minimize the chance of ova collecting under the nails, dressing children in one-piece sleeping outfits, and daily showering rather than tub bathing. Inform families that recurrence is common. Treat repeated infections in the same manner as the first one.

Ch 32 Wound care

General wound care consists of rinsing the wound with copious amounts of saline or lactated Ringer solution under pressure via a large syringe and of washing the surrounding skin with mild soap. A clean pressure dressing is applied, and the extremity is elevated if the wound is bleeding. Medical evaluation is advised because of the danger of tetanus and rabies, although dogs in most urban areas are required to be immunized against rabies. Bites from wild animals, such as squirrels, bats, raccoons, foxes, and skunks, are potentially dangerous. Prophylactic antibiotics are indicated for puncture wounds and wounds in areas that may prove to be cosmetically or functionally impaired if infected. Extensive lacerations are debrided and loosely sutured to allow drainage in the event of infection. Tetanus toxoid is administered according to standard guidelines (see Immunizations, Chapter 6), and rabies protocol is followed (see Rabies, Chapter 30). Injuries to poorly vascularized areas, such as the hands, are more likely to become infected than those in more vascularized areas, such as the face; puncture wounds are more likely to become infected than lacerations.

Ch 18 HPV

HPV infection, also known as condylomata acuminata, or genital warts, is the most common viral STI in the United States. -In women HPV lesions are most commonly seen in the posterior part of the introitus. Lesions also are found on the buttocks, vulva, vagina, anus, and cervix. Typically the lesions are small (2 to 3 mm in diameter and 10 to 15 mm in height), soft, papillary swellings occurring singly on the genital and anal-rectal region but may also appear as a cauliflower-like mass. -A woman with HPV lesions may complain of symptoms such as a profuse, irritating vaginal discharge; itching; dyspareunia; or postcoital bleeding. She also may report "bumps" on her vulva or labia. -The only definitive diagnostic test for the presence of HPV is histologic evaluation of a biopsy specimen. The HPV-DNA test can be used to screen for the high-risk types of HPV that are likely to cause cancer. -Semiannual or annual health examinations are recommended to assess disease recurrence and screening for cervical cancer. Women who have been treated for HPV infections should have annual Papanicolaou (Pap) tests -Three HPV vaccines have been licensed for use in adolescents, but Gardasil 9 is the only available HPV vaccine in the United States. The vaccine is routinely initiated among boys and girls at 11 to 12 years of age but can be given between the ages of 9 and 26 years. Gardasil is administered intramuscularly in a 2 or 3 shot method.

Ch 30 Assessment of pt after head injury

Head injury is a pathologic process involving the scalp, skull, meninges, or brain as a result of mechanical force. Unintentional injuries are the number one health risk for children and the leading cause of death in children older than 1 year of age. Children less than 1 year of age though had a significantly higher rate of severe head injury. The most common causes of head injury in children are falls, being struck by or striking an object with one's head, and motor vehicle accidents, in that order. A detailed health history, both past and present, is essential in evaluating the child with head trauma. Certain disorders such as drug allergies, hemophilia, diabetes mellitus, or epilepsy may produce similar symptoms. Even a minor traumatic injury can aggravate a preexisting disease process, thereby producing neurologic signs out of proportion to the injury. After a minor injury, initial unconsciousness (if present) is brief. The child ordinarily exhibits a transient period of confusion, somnolence, and listlessness; this period is most often accompanied by irritability, pallor, and one episode of vomiting. A severe head injury requires immediate evaluation and treatment. Because head injuries are often accompanied by injuries in other areas (e.g., spine, viscera, extremities), the examination is performed with care to avoid further damage. Box 30.5 lists manifestations of head injury. Priorities in the initial phase in the care of a child with a head injury include assessment of the CAB (circulation, airway, breathing); neurologic examination focusing on mental status, papillary responses, and motor responses; and assessment for spinal cord injury. The assessment is carried out quickly in relation to vital signs (see Emergency Treatment box). 1. Assess child: • C—Circulation • A—Airway • B—Breathing • Neurologic and thermoregulatory status 2. Stabilize neck and spine immediately. Use jaw thrust to open airway, not chin lift. 3. Clean any abrasions with soap and water. • Apply clean dressing. • If child is bleeding, apply ice to relieve pain and swelling. 4. Keep child NPO (nothing by mouth) until instructed otherwise. 5. Assess pain but give no analgesics or sedatives. 6. Check level of consciousness and pupillary reaction every 4 hours (including twice during night) for 48 hours. 7. Seek medical attention for any of the following: • Injury sustained at high speed (e.g., automobile) • Fall from a significant distance (height greater than that of the child) • Injury sustained from great force (e.g., baseball bat) • Injury sustained under suspicious circumstances • Loss of consciousness • Amnesia • Discomfort (crying) more than 10 minutes after injury • Headache that is severe, worsens, interferes with sleep, or lasts more than 24 hours • Vomiting three or more times or that begins or continues 4 to 6 hours after injury • Swelling in front of or above earlobe or swelling that increases in size • Fluid leak from ears or nose; blackened eyes • Confusion or abnormal behavior • Difficulty arousing child from sleep • Difficulty speaking • Blurring of vision or diplopia • Unsteady gait • Difficulty using extremities; weakness or incoordination • Neck pain or stiffness • Pupils dilated, fixed, or unequal • Infant with bulging fontanel • Seizures

Ch 30 Hydrocephalus

Hydrocephalus is a condition caused by an imbalance in the production and absorption of CSF in the ventricular system. The causes of hydrocephalus are varied and include either congenital (e.g., myelomeningocele, intrauterine viral infection [cytomegalovirus, toxoplasmosis], aqueduct stenosis) or acquired conditions such as intraventricular hemorrhage, tumor, CSF infection, or head injury. The result is either (1) impaired absorption of CSF fluid within the subarachnoid space, obliteration of the subarachnoid cisterns, or malfunction of the arachnoid villi (nonobstructive or communicating hydrocephalus) or (2) obstruction to the flow of CSF through the ventricular system (obstructive or noncommunicating hydrocephalus). Any imbalance of secretion and absorption causes an increased accumulation of CSF in the ventricles, which become dilated (ventriculomegaly) and compress the brain tissue against the surrounding rigid bony cranium. When this occurs before fusion of the cranial sutures, it causes enlargement of the skull and dilation of the ventricles. In children younger than 12 years old, previously closed sutures, especially the sagittal suture, may become diastatic or opened. After 12 years old, the sutures are fused and will not open. In infants with hydrocephalus, the head grows at an abnormal rate, although the first signs may be bulging fontanels with or without head enlargement (Fig. 30.12). The anterior fontanel is tense, often bulging, and nonpulsatile. Scalp veins are dilated, especially when the infant cries. With the increase in intracranial volume, the bones of the skull become thin and the sutures become palpably separated to produce the cracked-pot sound (Macewen sign) on percussion of the skull. In severe cases there may be frontal protrusion, or frontal bossing, with depressed eyes, and the eyes may be rotated downward, producing a setting-sun sign, in which the sclera may be visible above the iris. Pupils are sluggish, with unequal response to light. The infant is irritable and lethargic, feeds poorly, and may display changes in level of consciousness, opisthotonos (often extreme), and lower extremity spasticity. The infant cries when picked up or rocked and quiets when allowed to lie still. Early infantile reflexes may persist, and normally expected responses may not appear, indicating failure in the development of normal cortical inhibition. Infants with Chiari malformations may exhibit behaviors that reflect cranial nerve dysfunction as a result of brainstem compression, including swallowing difficulties, stridor, apnea, aspiration, respiratory difficulties, and arm weakness. The signs and symptoms in early to late childhood are caused by increased ICP, and specific manifestations are related to the location of the focal lesion. Most commonly resulting from posterior fossa neoplasms and aqueduct stenosis, the clinical manifestations are primarily those associated with space-occupying lesions (i.e., headache on awakening with improvement after emesis, papilledema, strabismus, and extrapyramidal tract signs such as ataxia. As with infants, the child is irritable, lethargic, apathetic, confused, and often incoherent. In one of the congenital defects with later onset (by age 3 months), the Dandy-Walker syndrome, characteristic manifestations are a bulging occiput, nystagmus, ataxia, and cranial nerve palsies. Manifestations of Chiari malformation in children over 3 years of age are related to spinal cord dysfunction rather than brainstem compression as observed in infants. Scoliosis proximal to the level of the myelomeningocele (usually associated with Chiari malformation) and development of upper extremity spasticity, which may progress to weakness and atrophy, are common. Cranial nerve deficits are rare. The treatment of hydrocephalus is directed toward relief of ventricular pressure, treatment of the cause of the ventriculomegaly, treatment of associated complications, and management of problems related to the effect of the disorder on psychomotor development. The treatment is, with few exceptions, surgical. The standard procedure for many years has been the ventriculoperitoneal (VP) shunt, especially in neonates and young infants.

Ch 30 VP ventriculoperitoneal shunt

Improved neurosurgical techniques have established surgical treatment as the therapy of choice in almost all cases of hydrocephalus. This is accomplished by direct removal of an obstruction, such as resection of a neoplasm, cyst, or hematoma, or, in rare instances of fluid overproduction, by choroid plexus extirpation (plexectomy or electric coagulation). However, most children require a shunt procedure that provides primary drainage of the CSF from the ventricles to an extracranial compartment, usually the peritoneum. The major complications of VP shunts are infection and malfunction. All shunts are subject to mechanical difficulties, such as kinking, plugging, or separation and migration of tubing. Malfunction is most often caused by mechanical obstruction either within the ventricles from particulate matter (tissue or exudate) or at the distal end from thrombosis or displacement as a result of growth. Functional obstruction of a shunt's antisiphon device remains a common complication. One of the most common and serious complications, shunt infection, can occur at any time, but the period of greatest risk is within the first month after placement. Within 2 years shunt infection rates are reported to be approximately 5% to 10%. Infections include sepsis, bacterial endocarditis, wound infection, shunt nephritis, meningitis, and ventriculitis and may be a result of intercurrent infections at the time of shunt placement. Brain abscess associated with colonic perforation and infection with a gram-negative enteric organism suggests an ascending shunt infection in a child who has a VP shunt. Meningitis and ventriculitis are of greatest concern because any complicating CNS infection is a significant predictor of future intellectual disability. Infection is treated with antibiotics administered intravenously or intrathecally for a minimum of 7 to 10 days. The use of perioperative antibiotic prophylaxis or antibiotic-impregnated shunts has significantly decreased shunt infection rates, particularly acute infections, among all age ranges of patients and all types of shunts

Ch 17 Peer groups

PG 535 Peer Groups One hallmark of adolescence is the increasing value young people place on friendships and relationships with peers (Fig. 17.9). Adolescents spend more time with their peers than do children. Compared with younger children, adolescent peer groups are more autonomous and more likely to include members of the opposite gender. Because of the changes that have taken place within family systems in contemporary society, peer groups play a significant role in the socialization of adolescents. FIG. 17.9 The peer group is a major influence in adolescent development. Peers serve as credible sources of information, serve as role models of social behaviors, and provide sources of social reinforcement or a bridge to alternative lifestyles. Close and supportive peer friendships have beneficial effects for young people (Fig. 17.10); however, adolescents with greater peeridentification than parental identification, especially when the peers model or promote risky behaviors, are more prone to negative and health-compromising behaviors. Thus the transition to greater peer involvement, like other developmental transitions of adolescence, is a process requiring guidance and skill and, optimally, a prolonged time to complete the transition. At a time when they are developing interpersonal skills to deal with peerpressure, young adolescents who lack adult supervision and opportunities for communication with adults may be more susceptible to peer influences and at a higher risk for poor peer-group selection than teenagers who have close relationships with caring adults. FIG. 17.10 The cell phone allows adolescents to talk or text message for hours with peers. The heightened value placed on adolescent peer relationships leads to questions about the quality and nature of peer influence. Rather than thinking of all peer influence as either good or bad, it is important to recognize that the influence of peers varies from one adolescent to another, from one peer group to another, and across different societies and cultures. Adolescents' selection of peer groups seems to be most strongly influenced by sociodemographic factors and the common patterns of behavior, including school achievement, religious participation, and social interactions such as sports, clubs, and employment. Peers can have either positive or negative effects on adolescent behavior. Negative effects include alcohol or illicit substance use, gang membership, and violent or reckless behaviors. Positive effects include an orientation supporting academic achievement, volunteer efforts or community engagement, or a commitment to religious, athletic, scholastic, philanthropic, or social youth groups. Peers can also be a positive force in health promotion. Same-age and older adolescents can encourage healthy behavior by serving as positive role models and promoting positive health norms in the peer group. Nurses can often gain insight on health behaviors and potential risks to adolescents by inquiring about peers during conversation and health histories. Examples of this include asking "Do any of your friends drink?" or "Are any of your friends driving yet?" Questions such as these give the nurse valuable information that typically reflects similar behaviors of the teen.

Ch 18 PID

Pelvic inflammatory disease (PID) -Is an infectious process that most commonly involves the uterine tubes, causing salpingitis; the uterus, causing endometritis; and, more rarely, the ovaries and peritoneal surfaces. -Most PID results from the ascending spread of microorganisms from the vagina and endocervix to the upper genital tract. -Risk factors for acquiring PID are those associated with the risk of contracting an STI, including under the age of 25 years, multiple partners, high rate of new partners, and low socioeconomic status -Women who have a long-term indwelling intrauterine device (IUD) are at increased risk for PID. PID tends to recur. -Women who have had PID are at increased risk for ectopic pregnancy, infertility, and chronic pelvic pain. -The woman with acute PID should be on bed rest in a semi-Fowler's position. Comfort measures include analgesics for pain and all other nursing measures applicable to a patient confined to bed. Few pelvic examinations should be done during the acute phase of the disease. During the recovery phase the woman should restrict her activity and make every effort to get adequate rest and a nutritionally sound diet.

Ch 17 Physical, sexual, and emotional abuse

Physical, Sexual, and Emotional Abuse Adolescents who have been physically, sexually, or emotionally abused during childhood or adolescence face challenges to healthy development. Reported cases of physical and sexual abuse declined 56% in physical abuse and 62% in sexual abuse from 1992 to 2010 (Finkelhor & Jones, 2012). Around one in four adolescents reports having been physically abused, primarily by family members and less commonly by someone outside the family. Certain groups of adolescents, such as gay, lesbian, or bisexual youth or those who are developmentally delayed, may be especially vulnerable to abuse. A common constellation of symptoms among adolescents who have been victims of sexual abuse includes substance abuse, depression, withdrawn mood, violence, and somatic complaints. Adolescents who have been abused are more likely than nonabused adolescents to engage in health-compromising behaviors such as self-mutilation, suicide attempts, injection drug use, and early sexual activity (Ferrara, Guadagno, Sbordone, et al., 2016; Maquire, Williams, Naughton, et al., 2015) and are at higher risk of being sexually exploited. Early identification of abuse can protect adolescents who have been victims of physical, sexual, and emotional trauma. For this reason, questions about abuse should be part of routine adolescent health visits. Ensure privacy before inquiring about abuse. If an adolescent reports a history of sexual or physical abuse, further questions should be directed toward any ongoing abuse; the circumstances surrounding the abuse incident; and the presence of physical, emotional, or behavioral sequelae, including involvement in risk-taking behaviors. Once a history of maltreatment is suspected or disclosed, health care providers have a legal responsibility to report the case to the appropriate child protection agency. The more acute the problem, the more quickly the report must be made. Adolescents reporting abuse should always be informed about steps in the reporting process before information is disclosed to local authorities. Adolescents who live in homes where there is constant conflict may run away, sometimes to a friend's home. The conflict may be real (interpersonal) or perceived (intrapersonal), and escalation to abuse or the fear of abuse may prompt the adolescent to leave home. In addition, an adolescent who encounters difficulty with authority figures in the home may leave home believing this will solve the problem. The adolescent may stay in school and maintain close ties with less threatening family members and friends; the term couch surfing may be used to refer to the adolescent who spends time at different friends' houses sleeping on the couch or in an available spare room to "crash" temporarily. Such adolescents are often at higher risk for further abuse and neglect.

Ch 32 Poison ivy

Poison Ivy, Oak, and Sumac Contact with the dry or succulent portions of any of three poisonous plants (ivy, oak, and sumac) produces localized, streaked or spotty, oozing, and painful impetiginous lesions that are often highly urticarial. The offending substance in these plants is an oil, urushiol, which is extremely potent. Sensitivity to urushiol is not inborn but is developed after one or two exposures and may change over a lifetime. All parts of the plants contain the oil, including dried leaves and stems (Fig. 32.5, A). Even smoke from burning brush piles can produce a reaction.Animals do not seem to be affected by the oil; however, dogs or other animals that have run or played in the plants may carry the sap on their fur, and animals that eat the plants can transfer the oil in their saliva. Shoes, tools, and toys can transfer the oil. Golf balls that have been in the rough are another source of contact. Urushiol takes effect as soon as it touches the skin. It penetrates through the epidermis as a mixture of compound molecules called catechols. These catechols bond skin proteins and initiate an immune response. The full-blown reaction is evident after about 2 days, with redness, swelling, and itching at the site of contact. Several days later, streaked or spotty blisters oozing serum from damaged cells produce the characteristic impetiginous lesions (see Fig. 32.5, B). The lesions dry and heal spontaneously, and itching stops by 10 to 14 days. Therapeutic Management Treatment of the lesions includes application of calamine lotion, soothing Burow solution compresses, and/or Aveeno baths to relieve discomfort. Topical corticosteroid gel is effective for prevention or relief of inflammation, especially when applied before blisters form. Oral corticosteroids may be needed for severe reactions, and those affecting the face, throat, or genital region. A sedative such as diphenhydramine may be ordered. Nursing Care Management The earlier the skin is cleansed, the greater the chance of removing the urushiol before it attaches to the skin. When it is known that the child has made contact with the plant, the area is immediately flushed (preferably within 15 minutes) with cold running water to neutralize the urushiol not yet bonded to the skin. Once the oil has been removed from the skin, the allergen has been neutralized. The rash that results from poison ivy cannot be spread to another child; only direct contact with the oil can cause the response. Harsh soap and scrubbing the exposed skin is contraindicated because it removes protective skin oils and dilutes the urushiol, allowing it to spread. All clothing that has come in contact with the plant is removed with care and thoroughly laundered in hot water and detergent. Every effort is made to prevent the child from scratching the lesions. Although the lesions do not spread by contact with the blister serum or from scratching, they can become secondarily infected. Prevention Prevention is best accomplished by avoiding contact and removing the plant from the environment. Teach all children, especially those known to be sensitive, to recognize the plant. Information regarding means for destroying plants can be obtained from the U.S. Department of Agriculture or U.S. Forestry Service. Home garden sprays that kill broad-leaf plants or all vegetation (e.g., Roundup or Spectracide) are ineffective. If poisonous plants are growing in public community area, the local authorities should be contacted to remove the plants.

Ch 32 Wound healing- primary, secondary, tertiary intention

Primary intention healing takes place when all layers of the wound margins (skin, subcutaneous tissue, and muscle) are neatly approximated, as with a surgical incision. Unless infection interferes or the wound edges separate, these wounds heal with a minimum of scarring.Repair by secondary intention takes place in wounds that occur from ulceration and lacerations in which the edges cannot be approximated, such as an avulsion or a third-degree burn. The inflammatory reaction may be greater, and the chance of infection is increased. Often debris, cells, and exudate must be cleaned away (debrided) before healing can take place. Healing takes place from the edges inward and from the bottom of the wound upward until the defect is filled. More granulation tissue and a larger scar are formed than in healing by primary intention. Repair by tertiary intention takes place when suturing is delayed after injury or the wound later breaks down and is sutured or resutured when granulation is present. More granulation tissue is formed than in healing by primary intention, and there is a greater chance that microorganisms will invade the wound, resulting in a larger and deeper scar than healing by primary intention. Frequently, suturing of a contaminated wound is deliberately delayed to afford better removal of infection before closing.

CH 17 Tanner stage boys: testicular enlargement, fine pubic hair, penis enlargement- length, darker/coarse hair penis enlargement- diameter, scrotum darker, more abundant hair penis, testes, scrotum are adult size and shape

READ AND LOOK AT PG 525 Pubertal Sexual Maturation Increases in reproductive hormones are responsible for dramatic changes in secondary sexual characteristics that occur during puberty. As with general growth, development of secondary sexual characteristics occurs in a predictable sequence. This sequence has been divided into a series of five phases termed the Tanner stages (Box 17.1 and Figs. 17.2 to 17.6). Although the sequence of sexual development is predictable, the age at which these changes occur and the rate of developmental progression vary considerably among individuals. Over the course of pubescence, many young people have questions about the timing, rate, and normalcy of their body changes. These concerns provide nurses with excellent opportunities to discuss health-related topics such as puberty, sexuality, contraception options, and prevention of sexually transmitted infections (STIs), as well as promotion of nutrition, exercise, and safe methods for weight control. Box 17.1 Tanner Stages The Tanner stages were developed by Dr. J. M. Tanner and colleagues. Tanner stages describe the stages of pubertal growth and are numbered from stage 1 (immature) to stage 5 (mature) for both males and females. In females the Tanner stages describe pubertal development based on breast size and the shape and distribution of pubic hair. In males the Tanner stages describe pubertal development based on the size and shape of the penis and scrotum and the shape and distribution of pubic hair.

CH 17 Girls go through puberty before boys. For a girl to have her menses, she has to have secondary sex characteristics present: breast development + hair growth

READ PREVIOUS CARD PG 525 REPEATED FROM PREVIOUS CARD The hallmark of late puberty is the first menstrual period, or menarche. Initial menstrual cycles are usually scanty and irregular (unpredictable) and are not always accompanied by ovulation. Gradually ovulation and regular, predicable menstrual periods occur about a year after menarche. The maturation cycle is typically a 2-year period from the appearance of breast buds to regular menstrual cycles but can range from 1 to 6 years. The mean age of menarche in the United States is 10.5 to 15.5 years, with an average age being 12.2 years for African American girls and 12.8 years for non-Hispanic Caucasian girls (Cabrera, Bright, Frane, et al., 2014). Girls may be considered to have pubertal delay if breast development has not occurred by age 13 years or if menarche has not occurred within 2 to 2.5 years of the onset of breast development (Villanueva & Argente, 2014). There is evidence that the mean age of menarche has gradually decreased over the past century in the United States and other developing countries. Females are experiences puberty at younger ages, with differences noted between Caucasian and African American girls. The explanation for this is not yet clear but appears to be influenced by complex physiologic, psychological, and environmental interrelationships and the reduced rates of disease as technology and medicine advances. This decline in the average age of menarche appears to have leveled off in recent years but continues to be studied (Papadimitriou, 2016). Internationally, a decline in the average age at first menses has not been seen in countries where children are more likely to be malnourished and suffer from chronic illness. Sexual maturation influences young people's satisfaction with their appearance, but the effects differ for girls and boys. For girls, physical maturation can lead to greater dissatisfaction with their appearance. For example, adolescent girls are more dissatisfied with their appearance and significantly likely to identify themselves as being overweight, even when they are at a normal weight for height (Fan, Jin, & Khubchandani, 2014). Normal increases in weight and fat deposition that accompany puberty among girls conflict with cultural norms that emphasize a slender look. Early-maturing girls suffer most because they begin to develop at a time when their peers still exemplify prepubertal slimness. Unfortunately, one response to changes in body shape among teenagers is to engage in extensive dieting at a time when nutritional requirements are at a peak. For some, the focus on slimness and dieting may trigger the development of eating disorders (see Chapter 18). Consequently, nurses play a key role in providing health promotion and educating teens about pubertal growth, eating behaviors, and body image, especially for early-maturing girls.

Ch 30 Seizures- please review from what you already know

Regardless of the etiologic factor or type of seizure, the basic mechanism is the same. Abnormal electrical discharges (1) may arise from the simultaneous activation of neurons in both hemispheres of the brain (generalized seizures); (2) may be restricted to one area of the cerebral cortex, producing manifestations characteristic of that particular anatomic focus; or (3) may begin in a localized area of the cortex as a focal seizure and spread to other portions of the brain and, if sufficiently extensive, produce generalized seizure activity. A seizure occurs when there is sudden excessive excitation and loss of inhibition within neuronal circuits, allowing the circuits to amplify their discharges simultaneously. These discharges occur in response to the activity of sodium, potassium, calcium, and chloride ion channels. Normally these discharges are restrained by inhibitory mechanisms. In response to physiologic stimuli, such as brain injury or infection, genetic abnormalities, severe hypoglycemia, electrolyte imbalance, sleep deprivation, and toxic exposures, these abnormal neuronal discharges can spread to nearby cortex and subcortical structures. Primary generalized seizures begin with abnormal discharges in both hemispheres, which can involve connections between the thalamus and neocortex. On the basis of these characteristic neuronal discharges (manifested as stereotypical symptoms observed and reported during seizures and/or as recorded by the EEG), seizures are designated as focal, generalized, and unclassified epileptic seizures. pg 1142-1149

Ch 18 Self-harm

Self-harm is defined as a direct and intentional damage to one's body without the intent to die. Types of Self-Harm Behaviors • Cutting • Poisoning • Strangulation • Branding • Scratching or scraping • Hitting or banging • Pulling hair or skin • Biting • Burning -Self-harm peaks at 15 to 16 years of age and starts to decline by 18 years of age. Self-harm is more prominent in females, among individuals with sexual orientation confusion, and among individuals with a history of physical or sexual abuse -Adolescents engage in self-harm to get relief from life stressors or abate emotions such as anger, frustration, or depression. Inflicting physical pain in the form of self-harm provides distraction from stress and feelings. Adolescents also experience euphoria when self-harming. Endorphins are released when the body is injured, resulting in a pleasurable sensation. Self-harming behaviors can become addictive. Warning signs: • Multiple cuts/burns on arms, legs, hips, or stomach • Wearing baggy clothes or long sleeves/pants to conceal wounds • Finding razors, scissors, lighters, or knives hidden in the adolescent's room • Spending long periods of time in a locked bedroom or bathroom, especially after conflicts with friends or family -The most effective treatment includes family therapy with goals to improve communication, teach conflict-resolution and problem-solving skills, and foster positive relationships.

Ch 17 Know pubertal onset for boys and girls

Sexual Maturation in Girls The earliest, most easily visible changes of puberty in girls are changes in the nipple and areola and development of a small bud of breast tissue (thelarche). The average age of thelarche varies among ethnic groups: African American girls have an average age of 8.8 years, Caucasian girls average is 9.7 years, and Hispanic girls average 9.3 (Herman-Giddens, 2013). The appearance of pubic hair (pubarche) typically follows initial breast development though many have strands of underarm and/or pubic hair before breast development. Early in puberty there is often an increase in clear, white or yellowish vaginal discharge (physiologic leukorrhea), associated with hormonal changes and uterine development. Girls or their parents may be concerned that this vaginal discharge is a sign of infection. The nurse can reassure them that the discharge is normal and a sign that their body is maturing; the uterus is preparing for menstruation. Throughout puberty, there is continued breast enlargement and pubic hair progresses to adult-type sexual hair covering the mons pubis and labia majora. The hallmark of late puberty is the first menstrual period, or menarche. Initial menstrual cycles are usually scanty and irregular (unpredictable) and are not always accompanied by ovulation. Gradually ovulation and regular, predicable menstrual periods occur about a year after menarche. The maturation cycle is typically a 2-year period from the appearance of breast buds to regular menstrual cycles but can range from 1 to 6 years. The mean age of menarche in the United States is 10.5 to 15.5 years, with an average age being 12.2 years for African American girls and 12.8 years for non-Hispanic Caucasian girls (Cabrera, Bright, Frane, et al., 2014). Girls may be considered to have pubertal delay if breast development has not occurred by age 13 years or if menarche has not occurred within 2 to 2.5 years of the onset of breast development (Villanueva & Argente, 2014). There is evidence that the mean age of menarche has gradually decreased over the past century in the United States and other developing countries. Females are experiences puberty at younger ages, with differences noted between Caucasian and African American girls. The explanation for this is not yet clear but appears to be influenced by complex physiologic, psychological, and environmental interrelationships and the reduced rates of disease as technology and medicine advances. This decline in the average age of menarche appears to have leveled off in recent years but continues to be studied (Papadimitriou, 2016). Internationally, a decline in the average age at first menses has not been seen in countries where children are more likely to be malnourished and suffer from chronic illness. Sexual maturation influences young people's satisfaction with their appearance, but the effects differ for girls and boys. For girls, physical maturation can lead to greater dissatisfaction with their appearance. For example, adolescent girls are more dissatisfied with their appearance and significantly likely to identify themselves as being overweight, even when they are at a normal weight for height (Fan, Jin, & Khubchandani, 2014). Normal increases in weight and fat deposition that accompany puberty among girls conflict with cultural norms that emphasize a slender look. Early-maturing girls suffer most because they begin to develop at a time when their peers still exemplify prepubertal slimness. Unfortunately, one response to changes in body shape among teenagers is to engage in extensive dieting at a time when nutritional requirements are at a peak. For some, the focus on slimness and dieting may trigger the development of eating disorders (see Chapter 18). Consequently, nurses play a key role in providing health promotion and educating teens about pubertal growth, eating behaviors, and body image, especially for early-maturing girls. Sexual Maturation in Boys The first pubescent changes in boys are testicular enlargement accompanied by thinning, reddening, and increasing looseness of the scrotum. These events usually occur between 9.5 and 14 years of age. Early puberty is also characterized by the initial appearance of scant pubic hair, which continues throughout puberty. Penile enlargement begins, and testicular enlargement and pubic hair growth continue throughout midpuberty. During this period boys also undergo increasing muscularity, early voice changes, and development of early facial hair. Gynecomastia (breast enlargement and tenderness) is common during midpuberty, occurring in up to 70% of boys (Ali & Donohoue, 2016). Gynecomastia disappears within 2 years of development; however, it may persist in obese individuals. By midpuberty there is a definite increase in the length and width of the penis, testicular enlargement continues, and first ejaculation occurs. Axillary hair develops, and facial hair extends to cover the anterior neck. Final voice changes occur secondary to the growth of the larynx. Herman-Giddens, Steffes, Harris, and colleagues (2012) found that secondary sexual characteristics occurred earlier in US adolescents than those described in Tanner's studies in England in 1969. Mean ages for onset of Tanner 2 stage of genital development in African American males was 9.14 years, in Hispanic males the average onset was 10.04 years, and among non-Hispanic white males it was 10.14 years. The authors suggest that genetic factors, environmental factors, and lifestyle changes may be the cause for the earlier appearance of secondary sexual characteristics but note that further studies are needed to clarify these findings. Changes in the size and shape of the penis and testicles and changes in genital functioning can be areas of great concern for adolescent boys. Although the ability for penile erection is present at birth, only with pubertal maturation do boys have seminal emissions. Ejaculation may occur spontaneously as a nocturnal emission, or "wet dream"; as a result of self-stimulation (masturbation); or during sexual activity with others. Unless they are prepared, boys may find spontaneous ejaculations puzzling, troublesome, and embarrassing. Pubertal changes and related concerns create important opportunities for health promotion among young teenage boys. Nurses are valuable resources of accurate information and anticipatory guidance around issues related to sexual maturation. Precocious (early) puberty in both females and males may be a concern if secondary sexual characteristics occur before 8 years old. Concerns about pubertal delay should be considered for girls who do not exhibit menarche by age 15 years and among boys who exhibit no enlargement of the testes or scrotal changes by 14 years old (Villanueva & Argente, 2014). PG 525 Normal Patterns of Growth Once the process of growth begins, the sequence of changes is progressive and usually predictable. Awareness of this sequence is not only important for reassuring concerned adolescents and parents but also useful in diagnosing conditions associated with abnormal growth. In general, girls begin puberty and reach maturity about 2 years earlier than boys. The pubertal growth spurt begins as early as 9.5 years or as 10.5 years late as 14.5 years in girls, and as early as years and as late as 16 years in boys. General growth includes accumulation of body mass, along with increases in height and weight. Lean body mass, primarily muscle mass, increases in both girls and boys during early puberty. For girls, the rate of muscle mass growth peaks at menarche and then slows. For boys, muscle mass continues to increase throughout puberty, resulting in the attainment of significantly higher lean body mass in boys than in girls. In girls, gain in fat mass increases markedly early in puberty and continues to increase after menarche. In boys there is a peak deceleration in the rate of fat mass accumulation at the time of their growth spurt, and thereafter a slower and much less dramatic increase than in girls. The rate of linear growth (height) (Fig. 17.7) begins to increase in girls during early puberty, whereas in boys the rate does not increase until midpuberty. Peak height velocity (PHV) occurs at about 12 years of age in girls, around 6 to 12 months before menarche. PHV is used as a predictor of menarche; height at menarche is a predictor of ultimate adult height. Few girls grow more than 5 cm (2 inches) in height after menarche. Growth in girls' height usually ceases 2 to years after menarche. Boys typically reach PHV at about 14 years of age, after growth of the testicles and penis and the appearance of axillary and mature pubic hair. Among most boys, growth in height ceases at 18 or 20 years of age. Increases in leg length tend to precede growth of the trunk by about 6 to 9 months and that of the shoulders and chest by about 1 year. In short, teenagers tend to follow a linear growth pattern, in which they outgrow their shoes first, then their pants, and finally their shirts. Peak weight velocity occurs about 6 months after PHV in girls. In contrast, weight and height spurts occur simultaneously for boys. On average, girls gain 5 to 20 cm (2 to 8 inches) in height and 7 to 25 kg (15.5 to 55 lb) in weight during adolescence, and boys gain 10 to 30 cm (4 to 12 inches) in height and 7 to 30 kg (15.5 to 66 lb) in weight during adolescence.

Ch 18 Sexual assault/rape

Sexual assault—Comprehensive term that includes various types of forced or inappropriate sexual activity. Sexual assault includes both physical and psychologic coercion, as well as touch, penetration, and other sexual contact. Rape—Forced sexual intercourse that occurs by physical force or psychologic coercion. Rape includes vaginal, anal, or oral penetration by body parts or inanimate objects. -Typically, stranger rape is what comes to mind when one thinks of sexual assault; however, more than half of assaults are committed by someone known to the survivor. Although both males and females can be sexually assaulted, females are at greatest risk. -Information includes the date, time, location, and an accurate description of any type of sexual contact. The physical examination is carried out as soon as possible because physical evidence deteriorates rapidly. The victim should not bathe or shower before the examination. -The young person is always told in advance in understandable terms exactly what to expect in the way of tests and procedures, and the explanation is accompanied by strong emotional support. The victim is examined thoroughly, including nongenital areas, for evidence of injury that might substantiate the use of force. -A female observer or chaperone should be present during the history and examination of female victims who are examined by a male practitioner. Whether a parent should be present during the examination is determined on an individual basis. The parent's presence is usually encouraged if the parent is supportive and the young person agrees.

CH 18 Testicular torsion

Torsion of the testicle is a condition in which the tunica vaginalis, which normally encases the testicle, fails to do so and the testis hangs free from its vascular structures. This condition can result in partial or complete venous occlusion with rotation around this vascular axis. In severe torsion the organ can become swollen and painful; the scrotum becomes red, warm, and edematous and appears to be immobile or fixed as a result of spasm of the cremasteric fibers. Nurses should be alert to the possibility of testicular torsion in adolescents who complain of scrotal pain. Because torsion may result from trauma to the scrotum.

Ch 32 Verruca

Verruca (warts) Cause—Human papillomavirus (various types) Manifestations: Usually well-circumscribed, gray or brown, elevated, firm papules with a roughened, finely papillomatous texture Occur anywhere but usually appear on exposed areas such as fingers, hands, face, and soles May be single or multiple Asymptomatic Management:Not uniformly successful Local destructive therapy, individualized according to location, type, and number—surgical removal, electrocautery, curettage, cryotherapy (liquid nitrogen), caustic solutions (lactic acid and salicylic acid in flexible collodion, retinoic acid, salicylic acid plasters), laser ablation Comments:Common in children Tend to disappear spontaneously Course unpredictable Most destructive techniques tend to leave scars Autoinoculable Repeated irritation will cause to enlarge

Ch 32 VAC- vacuum assisted closure pg 1215

Wound healing may be facilitated by recombinant growth factor or a vacuum-assisted closure device. These therapies may be employed when wounds are large and in a location that creates challenges for therapy (e.g., sacral or groin wound) or when the child has associated conditions such as malnutrition or a comprised immune system, putting "normal" wound healing at risk. Recombinant growth factors are human platelet-derived growth factors that are engineered outside the body. They foster the formation of new granulation tissue by stimulating the migration of fibroblasts, macrophages, smooth muscle cells, and capillary endothelial cells to the wound site. The vacuum-assisted closure (VAC) device uses a technique that involves placing a foam dressing into the wound, covering it with an occlusive dressing, and applying gentle, continuous suction. The negative pressure of the suction is applied from the foam dressing to the wound surfaces. The mechanical force removes excess fluids from the wound, stimulates formation of granulation tissue, restores capillary flow, and fosters closure of the wound. VAC has been used to prepare wounds for a skin graft and to treat surgical wounds, burns, and pressure ulcers (Han & Ceilley, 2017). The safety and efficacy of the VAC technique for infants and children has been documented in recent studies

Ch 34 NTD Neural Tube Defects - Myelomeningocele

develops during the first 28 days of pregnancy when the neural tube fails to close and fuse at some point along its length. Usually the sac is encased in a fine membrane that is prone to tears through which cerebrospinal fluid (CSF) leaks. In other instances the sac may be covered by dura, meninges, or skin, in which case there is rapid and spontaneous epithelialization. The largest number (75%) of myelomeningoceles occur in the lumbar or lumbosacral area. The location and magnitude of the defect determine the nature and extent of neurologic impairment. When the defect is below the second lumbar vertebra, the nerves of the cauda equina are involved, giving rise to symptoms such as flaccid, areflexic partial paralysis of the lower extremities and varying degrees of sensory deficit. Unlike a spinal cord injury, the degree of deficit is not necessarily uniform on both sides but may vary between extremities, depending on the compromise to specific nerves from malformation or tethering. The anomaly most frequently associated with myelomeningocele is hydrocephalus; approximately 80% to 85% of children with SB develop hydrocephalus. Although present at birth, hydrocephalus may not be apparent until shortly thereafter, or after the primary closure of the opening on the back. Careful monitoring of head circumference, fontanel tension, and ventricular size by head ultrasonography can indicate its presence. Hydrocephalus can occur because the NTD itself disrupts the flow of CSF. In many cases Chiari malformation (type II) is responsible. Type II Chiari malformation (a downward herniation of the brain into the brainstem) is present, though asymptomatic, in many children with SB. It can, however, adversely affect respiratory function, causing episodic apnea. Other clinical symptoms of problematic Chiari malformation include stridor, hoarse cry from vocal cord paralysis, feeding difficulties, aspiration pneumonia, and, in older children, upper extremity spasticity. The appearance of such symptoms should not be taken for granted; immediate referral is required to prevent further neurologic deterioration.

Ch 31 Diabetes Medication

o Controlling blood sugar (glucose) levels is the major goal of diabetes treatment, in order to prevent complications of the disease. Type 1 diabetes is managed with insulin as well as dietary changes and exercise. Type 2 diabetes may be managed with non-insulin medications, insulin, weight reduction, or dietary changes. o Examples of possible treatments for type 2 diabetes include: o Metformin (Glucophage, Glumetza, others). Generally, metformin is the first medication prescribed for type 2 diabetes. ... o Sulfonylureas. ... o Meglitinides. ... o Thiazolidinediones. ... o DPP-4 inhibitors. ... o GLP-1 receptor agonists. ... o SGLT2 inhibitors. ... o Insulin. o Examples of possible treatments for type 1 diabetes include: o Long-acting insulins include insulin glargine (Lantus, Toujeo Solostar), insulin detemir (Levemir) and insulin degludec (Tresiba). Intermediate-acting insulins include insulin NPH (Novolin N, Humulin N) o For Diabetes Insipidus treatment: o The usual treatment is hormone replacement using DDAVP, which is a synthetic analog of the endogenous hormone arginine vasopressin (AVP). DDAVP can be given orally, intranasally, or parenterally. The intranasal and oral forms of DDAVP are most commonly used in children. Oral DDAVP has few complications and is easier to give, which likely increases compliance

Ch 31 Diabetes Type 1 vs Type 2

o Diabetes is a condition in which sufficient amounts of insulin are either not produced, or the body is unable to use the insulin that is produced. Diabetes can be defined as a metabolic disorder because the disease affects the way the body uses food to make glucose, the main source of fuel for the body. Diabetes may be the result of conditions such as genetic syndromes, chemicals, medications, malnutrition, infections, viruses, or other illnesses. The three main types of diabetes include: o Diabetes Mellitus o Type 1 diabetes. Type 1 diabetes is an autoimmune disease in which the body's immune system attacks the cells that produce insulin, resulting in either no insulin or a low amount of insulin. People with type 1 diabetes must take insulin daily in order to live. o Type 2 diabetes. Type 2 diabetes is a result of the body's inability to make enough, or to properly use, insulin. Type 2 diabetes may be controlled with diet, exercise, and weight loss, but it may also require oral or injected medication and/or insulin injections. o Gestational diabetes. Gestational diabetes is a condition in which the glucose level is elevated and other diabetic symptoms appear during pregnancy when the woman has not previously been diagnosed with diabetes. In many cases of gestational diabetes, all diabetic symptoms disappear following delivery. o Diabetes Insipidus: The principal disorder of posterior pituitary hypofunction is diabetes insipidus (DI). Also known as neurogenic DI, central diabetes insipidus results from the under secretion of antidiuretic hormone (ADH), also known as vasopressin. This disease results in the production of large volumes of urine (polyuria), which leads to a state of uncontrolled diuresis

Ch 31 Diabetes Clinical manifestations

o The cardinal signs of DI are polyuria and polydipsia. In the older child, signs can include excessive urination accompanied by insatiable thirst so intense that the child does little more than go to the toilet and drink fluids. Frequently the first sign is enuresis. In the infant the initial symptom is irritability that is relieved with feedings of water but not milk. The infant is also prone to severe dehydration, electrolyte imbalance, hyperthermia, azotemia, and potential circulatory collapse. Other symptoms such as vomiting, constipation, fever, irritability, sleep issues, failure to thrive, and growth problems may be seen.

CH 31 Diabetes Illness management

o The initial objective is identification of the disorder. Because an early sign may be sudden enuresis in a child who is toilet trained, excessive thirst with bed-wetting is an indication for further investigation. Another clue is persistent irritability and crying in an infant that is relieved only by bottle-feedings of water. After head trauma or certain neurosurgical procedures, the development of DI can be anticipated; therefore closely monitor these patients. o Assessment includes measurement of body weight, serum electrolytes, blood urea nitrogen (BUN), hematocrit, and urine specific gravity taken before surgery and every other day after the procedure. Fluid intake and output should be carefully measured and recorded. Alert patients are able to adjust intake to urine losses, but unconscious or very young patients require closer fluid observation. In children who are not toilet trained, collection of urine specimens may require application of a urine-collecting device.

Ch 31 Parathyroid & thyroid

o The parathyroid glands secrete parathyroid hormone (PTH). Along with vitamin D and calcitonin, PTH regulates the homeostasis of serum calcium concentrations (Lal & Clark, 2011). The effect of PTH on calcium is opposite that of calcitonin. Box 31.8 lists the principal effects of PTH on its target sites. PTH and vitamin D work together to maintain serum calcium levels within a narrow normal range and mineralization of bone. Secretion of PTH is controlled by a negative feedback system involving the serum calcium ion concentration. Low ionized calcium levels stimulate PTH secretion, causing absorption of calcium by the target tissues; high ionized calcium concentrations suppress PTH. o The thyroid gland secretes two types of hormones: thyroid hormone (TH) and calcitonin. TH is made up of the hormones thyroxine (T4) and triiodothyronine (T3). The anterior pituitary hormone TSH controls the secretion of TH. TSH is regulated by the hypothalamic hormone thyrotropin-releasing factor (TRF) as a negative feedback response. Hypothyroidism or hyperthyroidism may result from a defect in the thyroid or from a disturbance in the secretion of TSH or TRF. Because the functions of T3 and T4 are qualitatively the same, the term thyroid hormone (TH) is used throughout the discussion

Ch 31 Diabetes Nutrition

o vegetables. nonstarchy: includes broccoli, carrots, greens, peppers, and tomatoes. o fruits—includes oranges, melon, berries, apples, bananas, and grapes. o grains—at least half of your grains for the day should be whole grains. o protein. o dairy—nonfat or low fat

clinical manifestations of CP

òDelayed Gross Motor Development òAbnormal Motor Performance òAlterations of Muscle Tone òAbnormal Posture òReflex Abnormalities òAssociated Disabilities and Problems management of CP: òMobilizing devices òSurgery òSpeech-language therapy òMedication therapy òPT/OT

Ch 34 NTD Neural Tube Defects

òNeural tube is embryonic beginning for the brain and spinal column òBrain and spinal cord become encased in protective sheath of bone and meninges òNeural tube closes approximately 30 days after conception òFailed closure of neural tube òMay involve entire length of neural tube or small portion

Ch 34 NTD Neural Tube Defects - Spina Bifida

òSpina bifida is a congenital neural tube defect. òThe neural tube is a embryonic structure that in time develops into the infant's brain and spinal cord and the tissues that enclose them. òThe neural tube forms early in pregnancy and closes by the 28th day after conception. ò With spinal bifida a portion of the neural tube does not develop or close properly resulting in a defect with the infant's spinal cord and backbone. òRisk factors: -Folate deficiency -Anti-seizure medications (Valproic acid) -Diabetes -Obesity -Increased body temperature