Gonzaga University NURS 652-- Module 1-2: Think like an FNP &HEENT

Terms in this set (185)

Which of the following is the most likely diagnosis for this infant? Note your rationale for rejection or acceptance of each diagnosis.
• Acute Otitis Media
• Otitis Media with Effusion
• Eustachian Tube Dysfunction

List brief and concise pertinent positive and negatives. (slide #48 Acute HEENT - Ears presentation)

Case Study
CC per mom "pulling at left ear"
• HPI: James is an otherwise healthy 7 month old infant, term, uneventful pregnancy. The parents report fever 102.6 with irritability that started yesterday and he did not sleep well last night. He has been pulling at his ear since yesterday. His not taking his bottle as usual. No change in urine or stool. He had Motrin about one hour ago.
• Social History: James lives at home with his parents and shares a bedroom with his older brother who is 6. His mom runs a day care in their home. Dad smokes cigarettes 1 pk/day.
• NKDA

• Exam
• Vitals: 101 (tympanic), pulse 150, resp 36 height and weight appropriate
• General: Alert, crying and fussy.
• Skin warm and dry no rashes or lesions.
• Head anterior fontanel flat, posterior fontanel closed.
• Eyes no exudate, teary, conjunctivae clear, sclerae white
• Ears Bilaterally canals clear without redness, no otorrhea present. Right TM pearly gray in color, with light reflex and landmarks intact, no perforation and normal movement on otoscopy. Left TM intense erythema crying, opaque short process not visible and TM appears convex; no light reflex and no mobility on pneumatic otoscopy.
• Mouth and throat oral mucosa pink, no lesions or exudate, tonsils 1+.
• Neck supple, no lymphadenopathy.
• Heart regular rate and rhythm.
• Lungs breath sounds clear and equal bilaterally, unlabored.
• Abdomen bowel sounds present, abdomen soft, nontender.
ANS: B

Symptoms of a concussion can vary, and some may be quite subtle, so it is important to conduct a full interview and examination when there is concern for this type of injury. Almost 90% of children with a concussion will complain of headache. There may also be complaints of light or noise sensitivity, nausea, and fatigue. It is not uncommon for these children to be very tired at the end of a school day. They may also be more irritable and have trouble with cognition, memory, and/or sleep.

The most important thing when caring for a patient suspected of having a concussion is to prevent another head injury. This means that the child who plays sports must stay off the field and out of the game until fully recovered. He or she may also need time away from school, and there may be restrictions on using electronics and reading. The trend in concussion management is leading toward a multidisciplinary approach in which primary care providers, neuropsychologists, and school athletic trainers work together to assess the child often and initiate a return-to-play plan. Children who have experienced a concussion need close follow up to ensure they are symptom free, both during exertion and while at rest, before resuming activities and sports. It is not uncommon for full recovery to take many weeks. Any child or adolescent experiencing a repeat concussion within one year's time will take even longer to recover fully. Research has shown that the effects of concussions are cumulative, so rest and recovery are crucial to preventing brain injury and long-term effects on memory and cognition.
Ask about hearing ability or difficulties, ear pain, and ear drainage. The general appearance and placement of the ears is important in pediatric assessment. Ears that are set low may indicate genitourinary or chromosomal abnormalities or a multisystem syndrome such as Turner syndrome. Assess for preauricular sinuses.

The otoscopic examination is described in detail in Chapter 6. This examination should be saved for last in infants and young children because of the distress it often causes. To examine the inner ear in an infant or young child, pull the pinna down and out. For examination in an older child, pull up and back as you would with an adult. As with adults, the tympanic membrane (TM) should be mobile and intact and should appear thin, smooth, and pearly gray with bright light reflexes. The mobility of the TM should be assessed by pneumatic otoscopy if a diagnosis of acute otitis media is expected. Although crying will cause erythema of the TMs, the light reflexes and mobility should remain intact. Diagnosis of acute otitis media should not be based solely on a reddened TM. Also observe for bubbles or an obvious fluid level line behind the TM, which indicates middle ear effusion.

A young child who frequently asks for things to be repeated, seems markedly inattentive, and responds inappropriately to questions should be investigated for hearing deficit. Middle ear effusions and acute otitis media may cause hearing deficits. The Hearing portion of the growth and development section of this chapter provides details on hearing screening (see pp. 551-554).

Red Flag: Red Flags for the Ear Examination
• Pain over the mastoid process, which may indicate mastoiditis.

• Foreign bodies, which should be considered if the child complains of strange sounds or sensations in one ear or if there is an obvious blockage or odd color noted on otoscopic examination.

• Hearing deficit.
Ask about voiding patterns (number of wet diapers in infants, frequency of urination in older children), pain, discharge, and menstrual cycle if applicable. A clean-catch urine sample should be obtained for urinalysis at all well checkups beginning at age 3, with further testing warranted with abnormal findings.

Female Genitalia

Enlarged labia or mild vaginal bleeding in a female newborn are considered a normal response to maternal hormones. Observe for labial adhesions, which occur mostly in girls 3 months to 6 years of age. No treatment is needed as long as urine and vaginal secretions are not obstructed. Observe the presence and distribution of pubic hair.

Male Genitalia

Observe the location of the urethral meatus. Hypospadias is a congenital defect that causes the meatus to be on the ventral surface of the penis, and epispadias results in dorsal placement of the meatus. Palpate the scrotum for the presence of testes; cryptorchidism is the term for an undescended testicle. If the testes are not immediately palpable in the scrotum but can be "milked" down into the scrotum, consider them descended. If one or both testes are undescended at 1 year of age, referral to a specialist is indicated. Male newborns frequently have an enlarged scrotum as a normal finding.

At any age, if a male child complains of pain in the scrotal area, it should be thoroughly evaluated. Testicular torsion occurs mostly in adolescents but can occur at any age. It will present with severe pain in the scrotal area. Even pain that occurs and resolves on its own should be evaluated for torsion since a testicle can twist and untwist on its own. Prompt surgical intervention is often needed to prevent recurrence, which could result in testicular ischemia.

Red Flag: Red Flags for the Genitourinary Examination
• Ambiguous genitalia

• Premature puberty

• Hypospadias

• Scrotal pain
Ask about pain or limited movement, joint pain, and history of fractures. Although a comprehensive musculoskeletal assessment should be performed, an emphasis should be placed on specific joints.

Hips

Assessment for hip dislocation is extremely important in all infants and children under 2. Hip dislocation is most common in females and in infants delivered in a breech position (including by Cesarean section). It is more prevalent in whites, Eskimos, and Navajos. A variety of specialized maneuvers are useful in assessment for hip dislocation. Table 18.2 differentiates between the Barlow's, Ortolani's, and Galeazzi's maneuvers.

Figure Thumbnail
Table 18.2. Special Maneuvers

Although not considered definitively diagnostic of a dislocated hip, the thighs, inguinal area, and gluteal area should be assessed for asymmetric skin folds as potential indications of dislocation. When assessing for hip dislocation or dysplasia, it is essential to differentiate between normal "clicks" and the worrisome "clunk." Normal clicks may be felt when doing some hip manipulation as a result of laxity and movement of ligaments. A definitive clunk is felt when a bone (the femur) actually comes out of its socket. Even though doing these maneuvers is extremely important, it is also important to remember that as the infant ages, limited abduction becomes an increasingly definitive sign of hip dysplasia. Limited abduction (less than 60%) is also the key sign to look for in bilateral dislocation. If hip dislocation or dysplasia is suspected, radiographic studies are usually done. In an infant under 3 months of age, ultrasound is the usual choice, although this method can still give unreliable results because much of the hip joint is cartilaginous. After 3 months of age, the preferred method of radiological evaluation is anteroposterior and frog lateral x-rays.

Gait

Observe a child's gait during well examination. Toddlers commonly walk with a wide-based gait and a bowlegged (genu varum) appearance. A knock-kneed (genu valgum) appearance is common in preschoolers.

Back

Assessment for scoliosis (a lateral curvature of the spine) should be performed at each well visit starting at age 10. With the child standing straight and arms at his or her side, observe for equal shoulder height. While the child bends forward, assess for curvature of the spine as well as rib humps. If abnormal findings are present, radiographs should be obtained for confirmation and to guide possible referral. Both the age of the child and the degree of the curve will guide treatment, if any. Scoliosis is more worrisome in a child who is prepubertal because there is more growth to occur and therefore more time for a curve to worsen.

Joints

Assess joints by palpating for pain, heat, or deformity. Active range of motion gives information about how muscles and bones are working together for functional movement. Assess active range of motion by engaging a child in games in the examination room. For example, have the child perform jumping jacks, clap, pretend to be a certain animal, and walk heel to toe on a line on the floor. Passive range of motion gives information about joint mobility and stability and the limits of tendons and muscles. Excessive range of motion may indicate an unstable joint. Assess passive range of motion by flexing and extending the joints through various movements with child relaxed or lying supine.

Elbow

A child's elbow commonly and easily gets dislocated (nursemaid's elbow or toddler's elbow). Dislocation is indicated by refusal to use an arm, especially when accompanied by crying and an appropriate history.

Red Flag: Red Flags for the Musculoskeletal Examination
• Refusal to bear weight or walk

• Refusal to use or bend an arm

• Heat, redness, or swelling of one or more joints

• Hip clunks

• Toe walking—can be a normal phase and also can be associated with cerebral palsy, tight heel cords, autism, or muscular dystrophy
Ask about episodes of seizure or loss of consciousness, tremors, or tics. A large part of the assessment of the neurological system in a child can be accomplished by observation during the visit. Watch for symmetry and quality of movement; observe gait, posture, coordination, balance, strength, and tone. Children are generally very active, and by watching the way they climb on the examination table, hop around the room, and manipulate objects and toys, you can gain a lot of information. In a newborn or small infant, observe for symmetry of movements, muscle tone, and pitch of the cry. Test deep tendon reflexes. Assess newborn reflexes—absence or persistence past expected age of disappearance may indicate severe central nervous system (CNS) dysfunction and should be investigated fully. Table 18.3 details newborn reflexes.

Red Flag: Red Flags for the Neurological Examination
• Absence, or persistence past the expected age, of newborn reflexes

• Spasticity or poor muscle tone

• Unresponsiveness or depressed level of consciousness

• Any loss or regression of developmental milestones

• Abnormal cranial nerve responses

The pediatric assessment should integrate cranial nerve evaluation. Table 18.4 describes the pediatric assessment of cranial nerves.

During the neurological assessment, assess for developmental milestones. Although children develop at their own speed, any regression in developmental milestones is a major concern. The Denver II is a useful tool when evaluating developmental milestones. See information on developmental milestones elsewhere in this chapter.

Practitioners caring for children should be aware of the following three neurological disorders/conditions and the signs and symptoms that children may exhibit, indicating the need for further evaluation.
Autism is a bioneurological developmental disorder and generally presents before the age of 3. It is characterized by marked impairment in skills related to social interaction, language development and communication, and imagination and play. Abnormal social skill development is the classic indicator of autism or autism spectrum disorders (ASDs). These social skill deficits may include abnormal eye contact, failure to respond to name, failure to use gestures or pointing, and lack of interest in other children. Language development is typically delayed in autistic children. Such children also frequently exhibit an inability to adjust to new surroundings and show an absence of imaginary play. They commonly engage in unusual or repetitive behaviors and often do not "play" with toys but instead spend hours arranging them or organizing them in a certain way.

The American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013 with some revisions to the diagnostic criteria for autism. Several disorders that were defined separately in the previous manual have been grouped together under ASD. While a nurse practitioner is generally not expected to be the sole health-care provider rendering a diagnosis of autism, it is important to be aware of the diagnostic criteria and presentation that should prompt further evaluation or referral.

Ask parents if their infant studies their faces by 2 months, smiles at them by 6 months, and babbles by 1 year. Ask if their 1-year-old points to things to indicate his or her wants or just for a parent to notice the object. Does their 18-month-old imitate play with objects like a hairbrush or a phone? Does their 2-year-old put two words together meaningfully on his or her own? If a child exhibits any of the following red flags, he or she should be referred for further evaluation.

Red Flag: Red Flags for Autism
• No big smiles or expressions of happiness by 6 months

• No back-and-forth sounds, gestures, or facial expressions by 9 months

• No babbling by 12 months

• No pointing, waving, or reaching by 12 months

• No words by 16 months

• No 2-word phrases by 24 months (without imitating)

• Any language regression or unusual use of language
Attention deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder that affects an estimated 5% to 10% of the school-age population. Its main symptoms are inattention with increased distractibility, poor impulse control, and motor restlessness and hyperactivity. There are three subtypes of ADHD: The predominantly inattentive type of ADHD is more common in females, and the predominantly hyperactive-impulsive type and combined type are more frequently diagnosed in males. When assessing a child for ADHD, it is important to ascertain the degree of symptoms, when they were first noticed, and in what settings they are present. It is also important to remember that many children with ADHD have comorbid psychiatric diagnoses.

According to the DSM-5, a child with ADHD must exhibit behavior that is developmentally inappropriate and clearly interferes with the quality of social, school, or work functions. The behavior must also meet the following criteria:

• Has been present before the age of 12

• Has been present for at least 6 months

• Is present in at least two settings

• Is not related to another disorder

A diagnosis of ADHD should not be made quickly or without a complete evaluation. A thorough history should include any injury to the CNS, any medications the child takes, any family history of similar symptoms, and any social or family situations that might contribute to the inappropriate behaviors. Because of the importance of symptoms being present in more than one setting, it is a good idea to utilize a behavior rating scale that compares answers from both a parent and another caregiver like a teacher. The Connor Rating Scale is an example of this type of checklist.

Other diagnoses to consider when evaluating a child with ADHD-like symptoms include anxiety disorders, depression, sleep disorders, and learning disabilities.
According to researchers in the field of concussion management, 1 in 10 children who play high school contact sports will suffer from a concussion annually. It is estimated that half of all concussions go undetected and unreported. As more is known about this injury, it is imperative for professional caregivers to recognize the signs and symptoms of a concussion and be familiar with the appropriate therapy.

One common myth in regard to concussion is that a loss of consciousness is required for one to occur. In fact, only 10% of concussions are associated with a loss of consciousness. It should also be noted that a concussion can result from any forceful trauma to the neck, face, jaw, or anywhere else on the body where an impulsive force can be transmitted to the head.

Symptoms of a concussion can vary, and some may be quite subtle, so it is important to conduct a full interview and examination when there is concern for this type of injury. Almost 90% of children with a concussion will complain of headache. There may also be complaints of light or noise sensitivity, nausea, and fatigue. It is not uncommon for these children to be very tired at the end of a school day. They may also be more irritable and have trouble with cognition, memory, or sleep.

Concussion symptoms can be divided into four main categories: physical, cognitive, sleep-related, and emotional. Box 18.2 lists various symptoms that fall into each category and should guide your interview with patients suspected of experiencing a concussion.

The most important thing when caring for a patient suspected of having a concussion is to prevent another head injury. This means that the child who plays sports must stay off the field and out of the game until fully recovered. He or she may also need time away from school, and there may be restrictions on using electronics and reading. The trend in concussion management is leading toward a multidisciplinary approach in which primary care providers, neuropsychologists, and school athletic trainers work together to assess the child often and initiate a return-to-play plan.

Children who have experienced a concussion need close follow-up to ensure they are symptom free both during exertion and while at rest before resuming activities and sports. It is not uncommon for full recovery to take many weeks. Any child or adolescent experiencing a repeat concussion within one year's time will take even longer to recover fully. Research has shown that the effects of concussions are cumulative, so rest and recovery are crucial to preventing brain injury and long-term effects on memory and cognition.
Ask about birthmarks, lesions, and skin conditions. Common birthmarks are listed here:

• Stork bites commonly appear on eyelids, nasolabial area, or nape of neck, and usually disappear by 12 months.

• Nevus flammeus (port-wine stain) is pinkish red in color and grows as the child grows.

• Strawberry nevus (raised hemangioma) may not be present at birth; it usually starts out as a grayish white area and later becomes red and raised; most resolve spontaneously by age 10.

• Mongolian spots are usually seen in newborns of African American, Latin, or Asian descent; they are generally found in the sacral or gluteal region.

Red Flag: Red Flags for the Skin Examination
• Any mole or lesion that is changing, has irregular borders, or is growing should be examined by a dermatologist.

Assess all skin for color, texture, and turgor; check for any rashes, lesions, pruritus, or bruising. Observe for skin conditions that may indicate underlying pathology, such as depigmented nevi, cafe-au-lait spots, and hemangiomas on the scalp.

The incidence of community-acquired methicillin-resistant staphylococcus aureus (MRSA) has been on the rise and is now managed quite frequently in the primary care setting. In children, a common presentation is a small bump that may resemble a bug bite and then quickly enlarges and turns into a pustule. In infants, this is commonly seen in the diaper area, but it can occur anywhere. A culture and sensitivity should be obtained on any questionable lesions or abscesses to confirm diagnosis.
;