health problems of the school age child

enuresis

voluntary or involuntary episodes of urinary incontience

>2 episodes a week for 3 or more consecutive months

>5 years old

primary enuresis

never been continent for at least 6 months

secondary enuresis

was continent for at least 6 months and now having incontinence

nocturnal enuresis

nighttime bed wetting (while sleeping)

uses bathroom during day fine

diurnal enuresis

daytime incontinence (while awake)

enuresis etiology

genetic tendency

emotional factors

DM or DI

renal failure

UTI

seizures

overactive bladder or dysfunctional voiding

lack of arousal from sleep

neurogenic bladder; spinal cord injury

constipation

sexual abuse

enuresis nursing assesment

hydration and nutritional history

voiding pattern, do they allow enough time to void

toilet training history

developmental in line with chronological age

frequency of episodes

sleep history; easy to wake up?

emotional status; any big changes within the household recently?

med history

family history of enuresis?

rule out physical causes rt enuresis

UTI: urinalysis and urine culture

diabetes: urinalysis and blood glucose

constipation: diet modification and med management

seizures: med adjustment to decrease frequency of seizure thus reducing frequency of enuresis

enuresis management

parent education

stress to parent to avoid punishing pt for enuresis

encourage positive reinforcement

restrict fluid intake prior to bedtime

decreased or omit caffeine intake

allow ample time to void

alarm therapy

retention control training: pelvic muscle exercises

med management for enuresis: desmopressin (ddavp)

decreases the production of urine

>6 years old: 0.2mg PO QHS (up to 0.6mg/day)

tablet, disintegrating tablets, intranasal

SE: nausea, HA, hyponatremia

med management for enuresis: oxybutynin (ditropan)

anticholingergic/antispasmodic

start 5mg/day, max 20mg/day

oral suspension, immediate-release tablet, extended release tablet

SE: dry mouth, constipation, nausea, fatigue, dry eyes

med management for enuresis: imipramine (tofranil)

tricyclic antidepressant; suicide risk

anticholingergic effect

2.5mg/kg/day

6-12 years: 50mg; 12-14 years: 75mg PO QHS

SE: sedation, Ortho hypo, cardiac toxicity, arrhythmia

encopresis

voluntary or involuntary fecal incontinence

occurs > 1 a month for 3 or more months

chronological and developmental age of 4 years old

males > females

primary encopresis

child is 4 years old or older and has never achieved fecal continence

secondary encopresis

occurs in a child > 4 years old that has history of established fecal continence

encopresis etiology

most commonly due to constipation (80-95%)

environmental change; new home, new sibling

lax training methods

fear of public bathrooms

stool withholding (fear pain)

neglect

encopresis nursing assessment

hydration and nutritional history

stooling pattern, do the allow enough time to stool

toilet training history

developmental in line with chronological age

frequency of episodes

emotional status; any big changes within the household?

med history

painful passing of stool, pellet like

bloody?

abd distention

posturing and resisting passing of stool

encopresis treatment

diagnosis: abd x-ray, barium enema rule out anatomical abnormalities

maintain toileting diary

toilet training consistency

diet modification and staying hydrated

positive reinforcement

family counseling

lubricants/cathartics: mineral oil, osmotic laxatives, enemas

school phobia

child resisting to attend school or demonstrates extreme reluctance to attend school for sustained period resulting in anxiety or fear of school related experiences

peak age: 5-7 and 10-14 years

anxious

verges on panic state

crying

somatic complaints on school days: abd pain, HA, anorexia, emesis. resolve on weekend or days they get to stay home

school phobia etiology

fear of overcritical teacher

fear of failing

fear of discrimination/bullying

separation anxiety

dependent relationship

stressful home situation

school phobia nursing assessment

child’s self esteem and parent self esteem

nutritional and sleep habits

family and peer relationships

attendance record

signs of abuse

family history of psychological illness

behavior screening to rule out psych problems

school phobia diagnosis

anxiety panic disorder

depression

conduct disorder

learning disability

post traumatic stress

school phobia prevention

encourage independency

bedtime stories/books on starting school

school visit before school starts

role play routines

relaxation techniques

professional psych referral

med management if needed

childhood depression

mood disorder: acute or chronic, mild, moderate, or severe

negatively impacts daily life

easily overlooked

symptoms need to be present for >2 weeks

CDC notes 2.1% of children 3-17 years old have depression

s/s of childhood depression

frequent sadness, tearfulness, crying

decreased interest in or enjoyment of favorite activities

withdrawing from friends and family

low self esteem and guilt

extreme sensitivity to rejection or failure

weight changes; up or down

increased irritability, anger, or hostility

frequent complaints of physical illnesses such as HA and stomachaches

increased school absences

appear easily distracted

thought or expression of suicide or self destructive behaviors

childhood depression etiology

genetic component

social skills deficit

chronic stress

traumatic event

comorbidity: ADHD, drug and/or alcohol abuse, anxiety

childhood depression treatment nonpharm

psychotherapy, cognitive therapy, education

family therapy

childhood depression treatment: SSRIs

sertraline (Zoloft), paroxetine (paxil), bupropion (Wellbutrin), venlafaxine (effexor)

SE: n/v, insomnia, weight gain, HA, fatigue, anxious, suicidality

serotonin syndrome: start with low dose, don’t stop taking abruptly

childhood depression treatment: tricyclic antidepressants

imipramine (tofranil), amitriptyline (elavil)

SE: Ortho hypo, cardiac toxicity, arrhythmia

sedative effect

suicidality

don’t abruptly discontinue

ADD/ADHD brain

orbital frontal cortex believed to regulate impulsivity

norepinephrine and dopamine of prefrontal cortex is weak

prevalence of ADHD

average age at diagnosis is 7 years old

males > females (2:1)

ADHD neurodevelopmental disorder

inattention: fails to complete tasks in a timely manner, forgetful, disorganized, easily distracted, short attention span

impulsivity: interrupts others, blurts out answers

hyperactivity: difficult to sit sill, “on the go”

ADHD risk factors

primarily genetic however head trauma and miningitis are noted risk factors

gene environment interactions:
- cigarette, drug, or alcohol exposure
- LBW
- premature
- lead exposure
- maternal depression
- autism or other affective disorder
- family history of ADD/ADHD

differential diagnosis for ADHD

developmental delay

hearing loss

impaired vision

sleep apnea; sleep deprived

abuse

mood disorder

anxiety

thyroid disease

diagnosis of ADHD

behavioral checklists and adaptive scales; demonstrate 1 of 3 subtypes: 6 or more symptoms

combined (inattentive and hyperactive)

predominately inattentive type

predominately hyperactive-impulsive type

ADHD assessment tools

behavior needs to be consistent at home and school; should be the same thing teachers say as the parents

conners scale, Vanderbilt assessment scale

why treat ADHD

higher dropout/failure rate

increased criminal activity

increased risk of substance abuse

increased risk of abuse

difficulty with peer relationships

nonpharm treatment of ADHD

close communication with school

smaller groups

allow more time for tasks/tests

family counseling

routines and rules

504 (state specific) or IEP (preferred; goes with student if moves states)

decrease distraction; turn off TV, designated study area

improve organizational skilss

emphasize strengths, coping deficits

pharm treatment for ADHD

stimulants: block reuptake and increases release of NE and dopamine

non-stimulant: selective NE reuptake inhibitor; stimulates alpha 2 adrenergic receptors (slow down breakdown)

ADHD med: stimulants

methylphenidate (Ritalin, concerta, daytrana patch)

dextroamphetamine/amphetamine (Adderall, Adderall XR)

dexmethylphenidate HCl (focalin, focalin XR)

lisdexameftamine (Vyvanse)

can increase BP; appetite loss so take after breakfast

SE: appetite loss, abd pain, HA, insomnia, decrease growth, HTN, tachycardia, mania agitation/aggression, anxiety/irritability

antacid: increase SE and juices/vit C decrease absorption

monitor height, weight, BP, HR, cardiac eval in pts with risk factors

ADHD med non stimulants

antidepressants: bupropion hydrochloride (Wellbutrin)
n/v, weight loss or gain, insomnia, HA
increases suicidality risk

alpha2 adrenergic agonists: clonidine (kapvay), guanfacine (intuniv)
CNS depression: decrease BP, pulse, fatigue

selective norepinephrine reuptake inhibitor: atomoxetine (strattera)
increase HR, BP; n/v, abd pain, insomnia, HA, weight loss, irritability
increase suicidal risk

ADHD treatment side effects

weight changes bc lowers appetite

insomnia

HA

stomach discomfort

tics; report to provider then changes med

chest pain

ADHD follow up

2-4 weeks after initial treatment or when med is increased

once controlled, q 3-6 months

controlled substances: only can give 30 day supply at a time

follow up forms with teachers