Aquifer Case Study Developmental Evaluation And Screening

Aquifer Case Study Developmental Evaluation and Screening

 This discussion assignment provides a forum for discussing relevant topics for this week based on the course competencies covered. For this assignment, make sure you post your initial response to the Discussion Area by the due date assigned.

To support your work, use your course textbook readings and the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.Start reviewing and responding to the postings of your classmates as early in the week as possible. Respond to at least two of your classmates’ initial postings.

Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view with a rationale, challenging an aspect of the discussion, or indicating a relationship between two or more lines of reasoning in the discussion. Cite sources in your responses to other classmates. Complete your participation for this assignment by the end of the week.

For this assignment, you will complete an Aquifer case study based on the course objectives and weekly content. Aquifer cases emphasize core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, you will use the Aquifer case studies to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice.

The Aquifer assignments are highly interactive and a dynamic way to enhance your learning. Material from the Aquifer cases may be present in the quizzes, the midterm exam, and the final exam.

This week, complete the Aquifer Case titled Pediatrics 02: Infant female well-child visits (2, 6, and 9 months)

Apply information from the Aquifer Case Study to answer the following questions:

• Discuss the history that you would take on this child in preparation for the well-child visit. Include questions regarding her growth and development that are appropriate for her age.
• Describe the developmental tool to be used for Asia, its reliability and validity and how Asia scored developmentally on this tool. Is she developmentally appropriate for her age?
• What immunizations will Asia be given at this visit; what is the patient education and follow-up?

INTRODUCTION – Aquifer Case Study – Developmental Evaluation And Screening TEACHING

Your first patient in the pediatric clinic is Asia, a 2-month-old little girl who is brought to the clinic by her mother, Karen Foster, for a checkup and shots. This is her first visit to this clinic.

As part of your orientation, your preceptor, Dr. Clark, takes a few minutes to remind you about the components of a well-child visit:

TEACHING POINT

 Components Of A Well-Child Visit Interval History

■ Ask if there have been any illnesses or problems since the previous visit.

■ If this is the first visit, obtain a detailed birth history.

■ Using the available medical records, review any visit notes, hospitalizations, lab results, and radiology reports since the last visit.

Development

■ May be assessed using one of several developmental screening tests (e.g., the Parents’ Evaluation of Developmental Status [PEDS], or Ages and Stages Questionnaire [ASQ]).

■ The American Academy of Pediatrics (AAP) recommends developmental screening with a validated tool at the 9-month, 18-month, and 30-month checkups. Aquifer Case Study Developmental Evaluation and Screening

■ Specific autism screening is recommended at the 18-month and 24-month visits.

■ Developmental surveillance is recommended at every health maintenance visit where a validated developmental screening tool is not used.

■ Tests may involve parental reports and/or examination in the office.

Growth

■ Growth is best assessed using a growth chart and analyzing the data over time.

 Diet History

■ Inquire about feeding practices: breast or bottle (in infants), or types and frequency of food and drink (in older children), and any feeding difficulties the parent has noted.

Family History

■ Obtaining a family health history is an important component of the well- child visit that can provide information on genetic, behavioral, and environmental vulnerabilities.

■ A family health history should be obtained at the initial visit and updated yearly.

 Social History

 ■ Ask who lives in the household, who the primary caretakers are, and who takes care of the child when the parents are at work or school.

■ Also assess for environmental risks (e.g., smokers, guns in the home, lead exposure).

Physical Exam

Anticipatory Guidance

■ Each visit includes anticipatory guidance, which is your chance to help the parents anticipate the child’s development and nutritional needs and to advise them regarding the child’s safety.

Immunizations and lab work

■ Age-specific recommended immunizations and screening labs are performed at the conclusion of the visit.

PERINATAL HISTORY HISTORY

You ask Mrs. Foster how Asia has been doing. She replies that everything has been “going great.” Because this is the baby’s first visit, you obtain a birth history

“Were there any complications or infections during your pregnancy? Did you take any medications? Did you use any drugs or alcohol?”

“I had no problems except for a urine infection at the beginning of the pregnancy. It was treated with an antibiotic. Other than that, I didn’t use any medications and I didn’t drink alcohol, and I never have used any drugs.”

“Was your doctor concerned with your prenatal screening labs for HIV, syphilis, hepatitis B, or group B strep?”

“No, not that I can remember.”

You glance at Asia’s chart and confirm the following about her birth:

Delivery date: Two days post due date Birth weight: 7 lbs, 11 oz (3.48 kg) Perinatal course:

● No complications in the nursery.

● Received hepatitis B vaccine (recorded in state immunization registry)

● No jaundice.

● Discharged two days post birth.

“Do you remember them telling you at the hospital that Asia passed her hearing test?”

“Yes, she did. I remember because someone else I met in the hospital had a baby that did not pass and they were deciding where the baby would go for definitive testing.

They told her not to worry too much because the nursery test was just a screening test and can have false results, and more intensive testing was needed.”

SOCIAL, FAMILY, AND DIET HISTORY HISTORY

Dr. Clark Reminds You That Social History And Diet Are Very Important In A Child’s Overall Growth And Development, So You Take A Detailed History In These Areas.

“Who Lives At Home With Asia? Does She Go To Daycare?”

“Her Dad, 2-Year-Old Brother, And I Live With Her At Home. She Doesn’t Go To Daycare Yet, But I’m Going Back To Work In A Month, So I’ll Have To Put Her In The Nursery Then.”

Do You Have Any Concerns About Conditions Or Diseases That Run In Your Family?” “Asia’s Father Has Asthma And Her Brother Gets Speech Therapy.”

“Is Asia Breastfeeding Or Bottle Feeding?”

“I Give Her Formula. She Takes About 4 Oz Every Three To Four Hours. I Mix One Can Of Concentrate With One Can Of Water. She Seems To Be Doing Fine With It, But Is There A Particular Formula That You Would Recommend?”

(See Below For Information That Would Help You Respond To Mother’s Concerns About Formula.)

“How Many Diapers Do You Change In A Day?”

“She Wets About Eight Diapers A Day. She Has One Or Two Greenish-Brown Stools Every Day.”

Aquifer Case Study – Developmental Evaluation And Screening TEACHING POINT

Nutrition Guidance

Breast Milk

■ Breast milk is the preferred source of nutrition for most babies.

■ Babies who are exclusively or partially breastfed should receive 400 International Units of supplemental vitamin D daily beginning soon after birth.

Formula

Commercial formulas provide complete nutrition for those babies whose mothers are unable or unwilling to breastfeed. Available formulas include those made with:

■ Cow’s milk protein

■ Soy protein, or

 ■ Hydrolyzed cow’s milk protein

There are also specialized formulas that provide protein in the form of simple amino acids (the true elemental formulas).

Preparing The Formula

■ Ready-to-feed formula: Baby is fed directly from the bottle

■ Powder: Two scoops of the powder are mixed with 4 oz water

 ■ Formula concentrate: ratio is one part concentrate to one part water

 There is no need to give an infant extra bottles containing water only, because formula or breast milk fulfills maintenance fluid requirements.

Transition To Regular Cow’s Milk

 Infants should take breast milk or formula until 12 months of age. According to the American Academy of Pediatrics:

■ Young infants cannot digest cow’s milk as completely or easily as they digest breast milk or formula.

■ Cow’s milk contains high concentrations of protein and minerals, which can stress a newborn’s immature kidneys.

■ Cow’s milk lacks iron, vitamin C, and other nutrients that infants need.

■ Cow’s milk can irritate the lining of the stomach and intestine, leading to blood loss in the stool.

■ Cow’s milk does not contain the optimal types of fat for growing infants.

 References

Why Formula Instead of Cow’s Milk? American Academy of Pediatrics.

https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Why- Formula-Instead-of-Cows-Milk.aspx. Updated November 21, 2015.

QUESTION REGARDING DIET

Teaching Early Growth

Most babies lose a little weight right after birth, then may regain their birth weight as early as 1 week of age, but are definitely expected to have regained their birth weight by 2 weeks of age.

Question

Of the following, which best reflects the caloric requirement of most healthy term babies in the first 1 to 2 months of life? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

■ 50 kcal/kg/day

 ■ 100 kcal/kg/day

 ■ 150 kcal/kg/day

■ 200 kcal/kg/day SUBMIT

Answer Comment

The correct answer is

 Aquifer Case Study – Developmental Evaluation and Screening

 TEACHING POINT

 Caloric Requirements of 1- to 2-Month-Olds

TWO-MONTH GROWTH CHART

 PHYSICAL EXAM (Aquifer Case Study – Developmental Evaluation And Screening)

Asia’s height and weight growth chart

 You wash your hands and proceed to the physical exam portion of the visit, starting with Asia’s measurements.

Asia’s Measurements

■ Weight and length: 50th percentile

■ Head circumference: 75th percentile

■ Weight-for-length: 50th percentile

You determine that Asia’s growth is appropriate.

Tips for Examining a 2-Month-Old

 Babies at this age have not yet developed stranger anxiety, but you may want to perform an auscultation of heart and lung sounds early in the exam, especially if they are quiet and calm.

■ Babies should be examined in their diapers only.

■ Take care to cover the infant with a blanket if the room is cold.

 ■ It is helpful to smile and talk to the baby before your exam so that he/she can become comfortable with you.

■ The baby will likely smile back and make cooing noises during the exam.

TEACHING POINT

Growth Parameters Weight and Length

■ Review the weight and length as recorded, repeating any measurement that is concerning or seems inconsistent.

Head Circumference

 ■ Measure the circumference around the widest portion of the head, from the broadest part of the forehead to the occipital prominence at the back of the head.

Growth Chart

■ Plot your measurements on the growth chart.

PHYSICAL EXAM

 Asia’s height and weight growth chart

You wash your hands and proceed to the physical exam portion of the visit, starting with Asia’s measurements.

Asia’s Measurements

■ Weight and length: 50th percentile

■ Head circumference: 75th percentile

■ Weight-for-length: 50th percentile

You determine that Asia’s growth is appropriate.

 Tips for Examining a 2-Month-Old

 Babies at this age have not yet developed stranger anxiety, but you may want to perform an auscultation of heart and lung sounds early in the exam, especially if they are quiet and calm.

■ Babies should be examined in their diapers only.

■ Take care to cover the infant with a blanket if the room is cold.

■ It is helpful to smile and talk to the baby before your exam so that he/she can become comfortable with you.

■ The baby will likely smile back and make cooing noises during the exam.

TEACHING POINT

Growth Parameters

Weight and Length

■ Review the weight and length as recorded, repeating any measurement that is concerning or seems inconsistent.

Head Circumference

■ Measure the circumference around the widest portion of the head, from the broadest part of the forehead to the occipital prominence at the back of the head.

Growth Chart

■ Plot your measurements on the growth chart. Aquifer Case Study Developmental Evaluation and Screening

TWO-MONTH PHYSICAL EXAM PHYSICAL EXAM

Asia does not cry when you place her on the table; in fact, she smiles at you immediately.

Your examination findings:

Vital signs:

■ Temperature: Afebrile

■ Heart rate:100 beats/minute

■ Respiratory rate:40 breaths/minute

General: Active, alert, and nontoxic appearing

Head, eyes, ears, nose and throat (HEENT): Anterior fontanelle is soft and flat. Red reflex is present bilaterally; sclerae anicteric. Mild neonatal acne is present. Lips are moist and pink. Tympanic membranes clear bilaterally. Palate is intact.

Lungs: Clear bilaterally, with equal air movement.

Heart: Regular rate and rhythm with no murmurs. Femoral pulses present bilaterally.

Abdomen: Normal bowel sounds, no masses or hepatosplenomegaly; abdomen is soft, nontender, and nondistended.

Hips: Ortolani and Barlow maneuvers negative bilaterally. Aquifer Case Study Developmental Evaluation and Screening

Genitalia: Normal female genitalia.

Neurologic: Tone is normal. Moves all extremities equally. Moro reflex is present and symmetric. Toes are upgoing bilaterally on Babinski maneuver.

Skin: There are no rashes, except for erythematous papules and pustules on the cheeks..

Back: No sacral dimple or hair tuft present. TEACHING POINT

Moro Reflex

This reflex is elicited by an abrupt change in the infant’s head position and consists of two parts:

■ Symmetric abduction

■ Extension of the arms followed by adduction of the arms, sometimes with a cry.

The reflex is present at birth and disappears by age 4 months.

 The Moro reflex may be used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries.

DEEP DIVE

References

Bickley LS, Hoekelman RA. Bates’ Guide to Physical Examination and History Taking. 7th edition, Philadelphia: Lippincott; 1999.

Zitelli BJ, Davis HW. Atlas of Pediatric Physical Diagnosis. 4th ed., St. Louis, MO: C.V. Mosby; 2002:58.

CONTINUE

TWO-MONTH DEVELOPMENT

PHYSICAL EXAM

Expected tasks for age

Asia’s physical exam so far is normal, so you proceed to the developmental screen.

Mother’s Observations of Asia

■ Recognizes her parents and smiles a lot.

■ Asia’s mother has also noticed that Asia lifts her head and chest off the bed, but cannot roll over yet.

■ Sometimes I make cooing noises at home.

Your Observations

■ Asia can lift her chest off the table with her head held up around 90 degrees.

■ Follows past the midline.

■ Smiles often when you talk to her.

 Asia’s development is appropriate for her age. TEACHING POINT

Developmental Surveillance and Screening

Evaluating a child’s development may take place routinely during the well-child visit and at any other patient encounter if the examiner or parent has concerns, even during an acute visit or hospitalization.

Developmental Surveillance

Checking milestones (comparing a child’s behaviors to expected behaviors by age) is known as developmental surveillance.

Developmental surveillance generally includes assessment of milestones in four domains.

■ Gross motor

■ Fine motor

■ Communication/social

 ■ Cognitive/adaptive

If the child is not capable of passing the milestones in any of the four areas at or near the appropriate age, then these areas are of concern for possible delay and should be followed up or further testing or evaluation should be done.

Developmental Screening

Surveillance is not as sensitive or specific as using a validated developmental screening test to pick up true developmental or behavioral abnormalities.

Screening with a validated tool is recommended at 9, 18, and 24 months of age.

 For more information on developmental screening, see the AAP’s Policy Statement and Aquifer’s tool for learning the milestones, which includes videos demonstrating expected milestones in all four domains at each recommended well-visit age (2 months, 4 months, 6 months) from birth to age 5.

DEEP DIVE

References

 2009 Glascoe FP, Robertshaw NS, Ellsworth & Vandermeer Press, LLC, 1013 Austin Court, Nolensville, TN 37135. http://www.pedstest.com.

Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics.

2006;118(1). Policy statement reaffirmed by the AAP November 2014 http://pediatrics.aappublications.org/content/118/1/405.full.

CONTINUE

TWO-MONTH ANTICIPATORY GUIDANCE

 MANAGEMENT

At this point you reassure Asia’s mother that she has a very healthy baby, and you ask her if she has any questions. Mrs. Foster wonders when she should start giving Asia solid foods and whether she should give her vitamins. She also asks when she will sleep through the night:

TEACHING POINT

Anticipatory Guidance at the 2-month Visit

 Solid Foods

 ■ Babies are developmentally ready to begin spoon feeding solid foods between 4 and 6 months of age.

Vitamin D

 The Recommended Allowance Of Vitamin D For Children Up To 12 Months Of Age Is 400 Units Per Day.

■ While There Is Remarkable Evidence On The Nutritional Superiority Of Breast Milk, There Has Been A Concern That The Amount Of Vitamin D In Breast Milk Is Not Adequate. Unless Infants Drink 32 Ounces (One Quart) Of Formula Or Milk A Day (Both Of Which Are Supplemented With Vitamin D), They May Not Receive Enough Vitamin D.

■ All Breastfeeding Infants And All Infants Drinking Less Than A Quart Per Day Of Formula Should Receive Vitamin D Supplementation.

■ Infants Who Are Breastfeeding Should Begin Supplementation With Liquid Vitamin Drops In The First Few Days Of Life.

More Information On Vitamin D: AAP Policy Statement On Prevention Of Rickets And Vitamin D Deficiency In Infants, Children, And Adolescents.

American Academy Of Pediatrics Task Force On Sudden Infant Death Syndrome. SIDS And Other Sleep-Related Infant Deaths: Updated 2016 Recommendations For A Safe Infant Sleeping Environment. Pediatrics. 2016;138(5):E20162938

Accessed March 15, 2018.

American Academy Of Pediatrics Task Force On Sudden Infant Death Syndrome. SIDS And Other Sleep-Related Infant Deaths: Updated 2016 Recommendations For A Safe Infant Sleeping Environment. Pediatrics. 2016;138(5):E20162938. Accessed March 15, 2018.

Child Care

 ■ Many parents appreciate receiving materials on choosing a childcare center.

Sleep

■ Most babies sleep through the night by age 4 to 6 months.

■ To help prevent SIDS, the AAP recommends that, for the first year of life, babies should sleep on their backs in their cribs on a firm surface, without soft objects like bumper pads, comforters, or stuffed animals, ideally, in their parents’ room.

■ More information on safe sleep: AAP Updated 2016 Recommendations for a Safe Infant Sleeping Environment

Safety

● Family members who smoke should be advised to quit or, at the very least, should avoid smoking around the infant.

● Small objects and plastic bags should be kept away from the baby to avoid choking and suffocation.

● Do not drink hot liquids while holding the baby. Aquifer Case Study Developmental Evaluation and Screening

● Do not leave the infant alone on high places like the sofa or changing table.

Always keep a hand on these squiggly babies!

 References

 American Academy of Pediatrics. Choosing a Childcare Center.

http://www.healthychildren.org/English/family-life/work-play/Pages/Choosing-a-Childcar e-Center.aspx.

Wagner, CL, Greer, FR, and the section on Breastfeeding and Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents:

American Academy of Pediatrics Clinical Report. Pediatrics 2008;122(5); 1142-1152. http://pediatrics.aappublications.org/content/122/5/1142.full.

PHYSICAL EXAM

 You wash your hands and prepare for the physical exam. Before you approach Asia, you notice that she is sitting on her mom’s lap with good head control and that she is very curious about her environment. You take her from her mother and place her on the examination table. She cries initially, but you are able to engage her by smiling and playing with her.

■ Asia is alert and active, often reaching for your stethoscope.

■ She is infertile and her vital signs are normal.

■ Her entire physical exam, including her neurologic exam and red reflex, is normal. Aquifer Case Study Developmental Evaluation and Screening

TEACHING POINT

The Red Reflex

 Description

 The red reflex is the red or orange color reflected from the fundus through the pupil when viewed through an ophthalmoscope approximately 10 inches from the patient. It gives direct information about the clarity of the eye structures and therefore is a substitute for a careful fundoscopic exam, since a 6-month-old will not hold his or her gaze long enough for the examiner to visualize the retina consistently. Examination of The red reflex should be performed in a darkened room. In infants with more darkly pigmented skin the reflex may appear more gray than red.This reflex should be elicited in all infants and children, beginning at birth.

 Absence of a symmetric red reflex or the presence of leukocoria (white pupil) may indicate underlying abnormalities, including:

■ Cataracts

■ Glaucoma

■ Retinoblastoma

■ Chorioretinitis

 When To Refer

 A pediatric ophthalmologist should be consulted immediately if leukocoria, an abnormal or asymmetric red reflex, or signs of nonaccidental trauma are identified on physical examination. Aquifer Case Study Developmental Evaluation and Screening

References

 Bickley LS, Hoekelman RA. Bates’ Guide to Physical Examination and History Taking. 7th ed., Philadelphia: Lippincott; 1999.

CONTINUE

 SIX-MONTH DEVELOPMENTAL EXAM

 TEACHING

Aquifer Case Study – Developmental Evaluation and Screening

Developmental Observations About Asia

■ Pulls to a seated position without a head lag.

■ Able to sit well without additional support.

■ Grabs block with her nearest hand and transfers it to the other hand and places it in her mouth.

■ Uses raking grasp to try to pick up a small toy on the table.

■ Frequently babbles, but not saying any specific words.

Question

Has Asia performed the expected developmental milestones for a 6-month-old infant? The best option is indicated below. Your selections are indicated by the shaded boxes.

● Yes

● No SUBMIT