Well Care Examinations for pediatrics: growth and development of babies, children and adolescents

1
Well Care Examinations for pediatrics growth and
development of babies, children and adolescents

• Debbie King RN, MSN
• FNP, PNP, APRN

2
Communication in primary care pediatrics

• Professional interaction, sensitive yet
  nonjudgmental. Include parent and child.
• Common courtesies count. Socialize.
• Start interview with open ended questions, build
  rapport. Repeat important phrases.
• Use close ended questions for clarification.
• Limit medical jargon, be aware of body language
  and guide the interview.
• Empathize and acknowledge parental concerns.
• Recognize personal limitations
• Summarize the interview

3
Talking to Parents

• EFFECTIVE COMMUNICATION IS THE KEY.
• OBSERVE INTERACTION BETWEEN PARENT AND CHILD.
• ASSESS FAMILY DYNAMICS.
• ADDRESS PARENTAL CONCERNS IN A NONJUDGEMENTAL
  MANNER.

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Talking to Parents

• ESTABLISHMENT OF LONG TERM RELATIONSHIPS.
• PRIMARY CARE GIVERS ROLE IS MULTIDEMENSIONAL.
• IMPORTANT TO ADDRESS THE NONMEDICAL AND
  PSYCHOSOCIAL CONCERNS OF PARENTS.
• ADDRESS PARENTAL FEARS.
• ALLOW OPPORTUNITY FOR QUESTIONS.

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Normal newborn and infant development

• Influenced by biological and environmental
  factors.
• Primitive reflexes are present from birth until 6
  months. Suppression related to normal
  development and/or reappearance could indicate
  brain damage.
• Moro Reflex- allowing infants head to drop
  back. Disappears by 4 mos.
• Rooting Reflex and Sucking Reflex
• Palmer or Grasp Reflex-Disappears 3mos.
• Stepping Reflex-disappears 2mos.
• Tonic Neck Reflex-(fencer) Disappears 3mos

6
New Born Visits (3 days old)

• Introduction
• Congratulations
• Other children
• Pre-natal
• Due date

7
Newborn visit

• Type of delivery
• Birth weight
• Discharge weight and age
• Hearing test
• GBS status
• Mother and Baby blood types

8
Newborn visit

• PKU
• Hepatitis B 1
• Bilirubin ordered stat as needed
• Circumcision-research contends reduced risk of
  HIV in circumcised males
• Diet
• Breast/bottle

9
New Parent Education

• Provide verbal and written information
• Feeding
• Schedule
• BF support
• Positioning of the newborn
• Safety
• Illness

10
New parent education

• Exposure-limit visitors and outings
• BMs- vary with babies
• Hick-ups- are frequent
• Sneezing-normal and frequent
• Congestion-off and on and is normal

11
New parent education

• Dressing/layers- do not overdress
• Siblings
• Car seat
• Finger nails- file only for 6 weeks

12
New parent education

• Cord care- there is none
• Smoking-avoid exposure
• Sun-not directly, can use sun-block
• Oral Needs- Gums and Pacifier-new research
  contends pacifier use for all sleep periods is
  necessary to prevent SIDS

13
New parent education

• Illness protocols
• Office procedures with calls
• When to call
• Recheck schedule- varies

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General info

• Average weight 7 lb
• Average length 20-21 inches
• Normal average weight loss is 10 in first 3-4
  days
• Normal- is to regain back to birth weight by 14
  days

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General info

• Weight doubles by 4 months
• Weight triples by one year
• Weight quadruples by two years
• Normal weight gain is 6-8 oz per week for 6
  months
• Normal weight gain is 3-4 oz per week from 6-12
  months
• Normal weight gain 1-2 years old is 8-9 oz per
  month

16
FYI

• Theories are important in practice to help you
  know normals
• They will be on boards (only a few pediatric
  theorist questions)
• Should self study
• Erikson
• Mahler
• Skinner
• Maslow
• Kohlberg
• Piaget
• Roy

17
Breast Feeding

• Breast milk or iron fortified infant formulas
  provides complete nutrition for infants first 4-6
  months of life.
• First 1-2 months, 2-3 ounces of formula or 10
  minutes on each breast q 2-3 hours.
• Breast milk digests 1 ½ hr, formula digests up to
  4 hers. Breast-fed infants feed 8-12 times per 24
  period compared to formula fed infants at 6-8
  times per 24 hr period.
• Mothers milk (colostrum 7-10 days) is high in
  protein, immunoglobulins and secretory IgA.
  Allergy and infection protective.
• Breast feeding is the recommended method of
  feeding.

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Exam Of Newborn - Importance of Clinical
Experience

• General
• hydration
• Skin- Color- Birth marks
• If highly abnormal consider neuro consult
• Head- Shape- Size
• Eyes- red reflex- alignment
• crossing
• ENT- ear placement
• If abnormal check kidneys

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Newborn

• Mouth- palate
• Chest/heart-
• 140- ?murmur
• tachypnea
• poor feeding
• cool lower ext- ?COA
• pulses
• Lungs/resp- 30-60
• Abdomen- cord
• GU- Open, rectum

20
Newborn

• Musculoskeletal- hips
• Tone
• Neuro- (reflexes) startle, tone, grasp,
• rooting, sucking, gag, crying
• symmetry of movement

21
2 Week Visit

• Birth weight
• Weight today-should be back to BW
• Age of discharge-
• If this is first visit
• Do all of the first visit as well
• Diet
• Color
• Advise parents not use any medications

22
2 Week Visit

• Circumcision
• PKU
• Address concerns of parents
• Exam- 2 week is Repeat of New Born exam

23
1 Month Visit

• Temperature
• Height
• Weight
• HC
• Percentiles- Know how to plot yourself

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1 Month Visit

• Diet- Vitamins A,C,D for babies BF only
• Startles
• Lifts head holds erect
• Focus
• Head support

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1 Month Visit

• Hands fisted
• Eyes- sees short distance, may cross off and on,
  follows to mid line, may seem to look just by or
  over you
• Sleep-still pretty irregular
• Personality- fussy vs. happy

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1 Month Visit

• Spitting- amounts
• Sneezing/ congested
• Grunting
• Only sleeps, eats, and poos
• Colic
• May be noted around this age

27
1 Month Visit

• Medication not to be used this early
• Safety
• 1 month exam
• Same as New Born
• -Summarize
• Hep B 2 today
• -Warn- more immunizations at 2 months

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2 Month Visit

• Temperature
• Height
• Weight
• HC
• Percentiles-
• no pattern yet

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2 Month Visit

• Smiles
• Coos
• Focus and follow
• Tone- increased head control
• Diet-
• vitamins if breast fed
• no solids

30
2 Month Visit

• Cuddle, eye contact, play
• Increase tummy time
• Position
• Torticollis is common problem and may be avoided
  in many babies
• Intake amount
• elimination
• 2 month exam- Same as New Born
• Still no medications

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4 Month Visit

• Temperature
• Height
• Weight
• HC
• Percentiles- 3 is a pattern

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4 Month Visit

• Diet- BF, formula
• Laughs, ah-goo
• Reaches may start to bring to mouth
• May start to transfer hand to hand
• Rolls- front to back
• Sleep- longer at night
• Intake and elimination
• Still no medicines are recommended

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4 Month Visit

• Self Soothes
• Increase tummy time
• Review safety- car seats, toys
• Activities- ex. Johnny Jump Up
• 4 month exam- same as New Born
• extra focus on tone and strength
• encourage team work of parents
• Follow up on previous visits
• past concerns ex constipation, not sleeping
  much
• past unmet milestones
• If first visit gather all info that was needed at
  all previous visits.

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Solids

• Solid foods introduced at 6 months (weight twice
  of birth weight or 13lbs, consumption of 32oz of
  formula q day, frequent feeding gt 8-10 times per
  day.
• Iron fortified cereal (rice) is introduced.
• Fruits and veggies within a few weeks and meats
  introduced at 6-9 months.
• Order in not important, but only add 1-2 new
  foods per week.
• Careful of excessive juice intake Diarrhea
  and/or feeling full
• 2 ounces of juice per day per the AAP.
• Weaning from breast/bottle to cup 6-18 months.
  Homogenized milk at 12 months. Skim or 2 not
  before 2 years.

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6 Month Visit

• Temperature
• Height
• Weight
• HC
• Percentiles

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6 Month Visit

• Diet- start solids, so less liquids
• - finger foods, new research contends
  that meat be included in the food package for
  breast-fed infants at 6 months
• one new food every 3 days
• Reaches, grasps, racks
• Transfers hand to hand well
• Sits alone or almost
• Rolls both ways
• Set schedule- eating, sleep

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6 Month Visit

• Knows name
• Babbles
• Encourage crawling
• Vocalizes
• Safety! Child proof
• Teeth
• Intake and elimination
• May use Tylenol for pain or fever. Motrin is now
  approved down to six months. No other OTC meds
  approved

38
6 Month Visit

• 6 month Exam
• -Same as all past with focus on
• -Strength -Standing
• -Socializing with provider
• -Add Fluoride-if on well water
• -Summarize -Encourage

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9 Month Visit

• Temperature
• Height
• Weight
• HC
• Percentiles

40
9 Month Visit

• Diet- more table food, cup, self feed
• Schedule- toddler like
• Safety- add poison control
• Encourage mobility- crawling
• Should have started at 7 to 8 months
• Pulling up
• Beginning good pincer skills

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9 Month Visit

• Cruising
• Stands alone
• Responds to name
• Understands no, bye
• Parents may begin saying no and removing from
  unacceptable places, ECT
• May begin to respond to one step commands

42
9 Month Visit

• Babbles more-
• Starts about 8 months mama, dada- just sounds
• Same PE
• Intake and elimination
• Order/evaluate- HGB
• Summarize
• Next exam at 12 months
• Advise may see increase illness with increase in
  mobility

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12 Month Visit

• Height
• Weight
• HC
• Temperature
• Percentiles (Triple BW)

44
12 Month Visit

• Diet- all table food
• -except shell fish and honey
• -start whole milk, cup, self feed
• Sleep- schedule
• Continue to encourage
• -verbalizing, mobility, walking

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12 Month Visit

• Says mama and dada with meaning
• 3 to 5 words
• Waves
• Good pincer grasp
• Begins pointing
• Temper tantrums
• Plays games
• Follows one step command
• May be walking now (by 14 mo.)

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12 Month Visit

• Loves books and outside
• Safety is more important
• Car seat-24 months and 20 lbs. to face forward
• Teeth-just water and tooth brush

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12 Month Visit

• Follows one step command
• Stoops and recovers
• Imitates
• T.B./ lead questionnaires for exposure

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12 Month Visit

• 12 month exam
• -head to toe
• - More difficult
• -Be creative, playful
• -May notice hand preference soon, yet could be
  as late as 5 years for set handedness
• -testicles- should be down

49
12 Month Visit

• -hydrocele- gone
• -summarize this visit and growth and
  development since birth, seeing that areas have
  been covered and documented
• -Choose care givers carefully (baby-sitters)
• -Next visit 15 month and all basic vaccines
  will be completed except Hep A

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15 Month Visit

• Height
• Weight
• HC
• Temperature
• Percentile

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15 Month Visit

• Diet- same as 15 month
• - avoid juice trap, no juice is needed
• Schedule
• Walks well, even backward
• Climbs
• Knows some body parts
• Stacks 2 blocks

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15 Month Visit

• Behavior- big issue
• Books/ music
• 1 hr TV only or none or baby videos
• Follow directions
• Few words 7-10

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15 Month Visit

• 15 month exam
• - head to toe
• - very difficult to do with this age
• - heart first
• - mouth last
• - observe walking forward and backward

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15 Month Visit

• - FYI intoeing is normal until age 7
• Summarize
• Encourage parents
• Next visit at 18 month with focus on development

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18 month visit

• Same growth evaluation
• Diet- no battles!
• Sleep- constant schedule
• Safety- ex. Lead exposure
• Development- important issue now
• -can see signs of autism
• In a prospective study by the high risk
  siblings research consortium, Dr. Zwaigenbaum
  suggests that head growth accelerates over the
  first two years of life in children with autism.

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18 month visit

• Expected milestones
• - 2 word combos starting
• - Builds tower of 3 to 4 blocks
• - scribbles
• -throws ball
• -runs
• -climbs (even stairs with help)
• -sustains eye contact

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18 month visit

• -enjoys being bounced/swung
• -interested in other children
• -play hide and seek
• -pretends
• -points with index finger
• -plays appropriately with toys
• -follows two step command

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18 month visit

• -stacks 3-4 blocks
• -4 to 20 word vocab
• -listens to stories
• -names objects
• -scribbles
• -shows affection- kisses

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18 month exam

• Head to toe
• May still be difficult
• Not all bruises are abuse
• Encourage parents
• Foster independence

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18 month exam

• Wash own hands
• Pick up toys
• Remind some decrease in eating is nl
• Advise parents to call as needed
• Next check up is at 2 years

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Developmental Delay

• Delays in reaching milestones is serious
• May educate parents to practice with baby or
  toddler and reassess in a month
• If still delayed refer ASAP
• Early intervention is the key to reaching as much
  potential as possible

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General info

• Growth slows from 2-6 years
• Normal growth is about 3 inches per year
• Normal weight gain is about 4.5 lbs. per year
• An average 6 year old is about 46 lbs. and 46
  inches

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2 year visit

• Repeat of 18 month exam
• If new pt review milestones
• Make sure all past milestones have been met!
• Now should be able to
• Build tower with 6-7 blocks
• Jumps with two feet of the floor
• Uses pronouns
• Kicks a ball
• Has 2-5 word combos
• Copies a line
• Still measure on infant scale for height and
  weight and plot on infant growth chart

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2 year visit

• Usually more cooperative
• Advice on
• -toileting- may be able to verbalize needs
• Wait is my advise

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FYI

• FYI
• immunization- know schedule
• head circumference
• Macrocephaly- too large
• Microcephaly- too small
• Plagiocephaly- abnormal shape
• Torticollis head tilted due to tight neck
  muscles
• Know what to do- for each DX

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FYI

• Day care
• Assess plans at every visit
• DWP illness-expectation
• Biting

67
Teething (formation begins 3rd fetal month, ends
in adolescence)

• Central incisors upper 6-8 months, lower 5-7
  months
• Lateral incisors upper 8-11 mo., lower 7-10 mo.
• Cuspids upper and lower 16-20 mo.
• First molars upper and lower 10-16 mo.
• Second molars upper and lower 20-30 months

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FYI

• Refer to Harriet Lane for all normals on
• Respirations - based on age
• Blood pressures - based on age and size
• Heart rates - based on age
• may be helpful to keep charts in exam rooms

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Talking to Children

• SIZING EACH OTHER UP
• KIDS HAVE DIFFERENT CONCERNS
• AGE APPROPRIATE
• CAUTION NONVERBAL CUES
• CHILD FRIENDLY ENVIROMENT
• LET CHILD PARTICIPATE
• AVOID POWER CONTROL

70
3 year visit

• Add vision screen
• Stands for height and weight
• Need to switch to a standing growth chart
• No HC on normal child
• There is no place to chart on standing chart, but
  may use the infant chart if needed
• Add BP
• Chart on proper growth chart!

71
3 year visit

• Assess BMI
• TB questionnaire
• Pre-school?
• Verbal skills- 90 understood by strangers
• Knows colors
• Gives first and last name

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3 year visit

• Count 1-10
• Copies a circle
• Pedals tricycle
• Walks up stairs
• Knows gender
• Friends
• Dresses with help

73
3 year visit

• 3 year exam
• Head to toe- may still have round tummy
• Advise parents
• Stool holding is common
• Stuttering is common
• Time outs should be for 3 minutes
• But parent may need to adjust to be in control
• Encourage more playtime and reading

74
4 and 5 Well-care

• Height
• Weight
• Temperature
• Percentiles
• UA- age 5 and then PRN in future
• Hearing, vision

75
4 and 5 Well-care

• 4 year milestones
• Stacks 10 blocks
• Throws overhand
• Walks down stairs
• Runs with out losing balance
• Sings, draws
• Knows real vs. fiction
• Talks about day/life
• Knows gender
• 100 understandable

76
4 and 5 Well-care

• 5 year milestones
• Skips
• Rides bike
• Counts on fingers
• Draws shapes
• Draws a head, two extremities and eyes
• But no body yet
• Prints some letters

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4 and 5 Well-care

• Dresses alone except tying
• Self care with toileting
• Except maybe wiping
• Knows ABC and colors
• Knows about strangers
• Knows about secrets
• Gives appropriate answers
• What do you do if you are hungry?

78
4 and 5 Well-care

• Exam 4 and 5 year
• -head to toe exam
• -add cranial nerve exam know how!
• -add walk on toes and heels
• -jumps
• -check spine

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4 and 5 Well-care

• Remember! At All check ups review
• -seatbelt -teeth
• -school -safety
• -sun block -diet
• -elimination -strangers
• -sleep -sports
• -behavior -TV time!!- increase in education
  of limited time spent here
• -friends -chores

80
Personal and Social skills summary

• Indiscriminate social smile at 2-3 months.
• Discriminate social smile at 6 months.
• Stranger anxiety begins at 7 months and peaks at
  12 months.
• Separation anxiety begins between 8-9 months and
  peaks around 14 months.
• Peek-a-boo is a big hit at 7 months.
• Drinks from a cup at 12 months.
• Uses a spoon at 15-18 months.
• Washes/dries hands at 2 years.
• Uses a spoon well, buttons at 3 years.
• Washes/dries face at 4 years.
• Dresses without assistance at 5 years

81
School age 6-10

• Height
• Weight
• Temperature
• Percentile
• BP
• BMI

82
School age 6-10

• Development 6-10
• Varies
• Refer to current pediatric diagnosis and
  treatment and to Uphold and Graham
• Age 9-10
• Begin tanner assessment
• Assess preparation for puberty

83
Summary of skills

• Gross motor Skills

• Fine motor Skills

• Good head control in 2-3 months.
• Rolls front to back in 4-5months.
• Rolls back to front in 5-6 months.
• Sits alone 5-6 mos.
• Crawls 7-8 months
• Pulls to stand 9-10 m
• Walks forward12-14m
• Walks backward 14-16
• Walks up stairs 3yr
• Walks down stairs 4 yr.
• Skips 5 yrs.

• Grasp/shake rattle 2-3m
• Reach for object 3-4m
• Rakes 4-6 months
• Hand transfer 4-6 months
• Pincer 9-12 months
• Stack 2 blocks 14 months
• Copies line 2yrs.
• Copies circle 3 yrs.
• Draws person 3 parts 5 yr.
• Draws person 6 parts 6 yrs.

84
Language Development

• Normal hearing is essential speech/language
  development.
• Important developmental milestone.
• Children with suspected delays should be referred
  ASAP.
• Look for lack for response to sound at any age,
  failure to achieve language skills, and parental
  concerns.
• Vocalizing does not preclude a hearing loss.
• Language skills are either receptive or
  expressive.

85
Paigets Stages of Development

• Sensorimotor (birth-2 years). Children approach
  the world through sensations and motor actions.
  Develop object permanence, spatial relationships,
  and causality.
• Preoperational (2-6 years).Mental processes are
  liked to their own perception of reality. No
  separation of internal and external reality.
• Concrete operational (6-11years). Can perform
  mental operations if it relates to real objects.
  Concept of mass, volume, number.
• Formal Operations (gt11 years). Develop the
  capacity for abstract thought.

86
FYI Obesity

• Screen thyroid
• Screen lipid
• Screen metabolic panel
• With increased lipids-refer to cardiology
• screen fasting insulin
• With or without increased insulin-refer to endo
• Refer all to nutritionist

87
FYI Obesity

• Encourage sport participation
• Re-check height, weight in 3 months
• research shows the only true way to correct
  obesity in children is to prevent it.

88
General info

• Average school age child gains about 5 lbs. and
  2.5 inches per year
• Average 10 year old is 70 lbs. and 54 inches

89
Well Care 11-13 years

• Height
• Weight
• Temperature
• Percentiles
• BP
• BMI

90
Well Care 11-13 years

• Medications
• Parental concerns
• Sports concerns
• HEEADSSS
• Teen health history
• See text
• Adolescent questionnaires review together

91
HEADSS The "Review of Systems" for Adolescents

• 1. HEADSS is an acronym for the topics that the
  physician wants to be sure to cover home,
  education (ie, school), activities/employment,
  drugs, suicidality, and sex. Recently the HEADSS
  assessment was expanded to HEEADSSS 2 to
  include questions about eating and safety

92
Well Care 11-13 years

• Confidentiality!
• P.E.
• Head to toe
• Be considerate

93
Adolescence

• The period of life beginning with puberty and
  extending for an average of 8-10 years.
• Puberty focuses on physical changes resulting in
  the ability to reproduce.
• Mean age for the initiation of puberty is 11.2
  years but may range from 9.0 to 13.4.
• Females typically reach adolescence 2 years
  earlier than males.

94
Adolescence

• During adolescence, a teenagers weight doubles,
  and height increases 15-20.
• During puberty, major organs double in size,
  lymphoid tissue decreases in mass.
• Musculature increases in size and strength.
• Boys attain greater strength and mass continues
  into late puberty.
• Motor coordination lags behind in growth and
  stature and musculature but improves.

95
Talking to Adolescences

• Unique challenges IE physical awkwardness,
  emotional turmoil, and social isolation, labeled
  difficult.
• Provider needs to use a different approach.
• Information must come from adolescent.
• Be prepared for overbearing parents.
• 3 stages of adolescents early 11-13, middle
  14-16, late 16-18. Taylor exam.
• Discuss confidentiality. Exceptions are suicidal
  or homicidal behavior, sexual or physical abuse.
  Treatment of STDS.

96
Growth and Development of Puberty

• Physical changes of puberty include
• Growth spurts
• Development of secondary sexual characteristics
• Maturation of genital organs
• Onset of menstruation for girls

97
Male Growth Spurts

• Height spurt beings at age 11. Reach peak height
  velocity 13 ½ to 14yrs.
• Boys increase the quantity of body fat before
  beginning their height spurt.
• They lose fat until the growth spurt has finished
  and gradually again increase fat.
• 1st sign of puberty begins around 10 and 12
  marked by scrotal and testicular growth.
• Pubic hair can occur any time between ages 10 and
  15.

98
Boys

• Penis grows significantly a year or so after the
  onset of testicular and pubic hair(10-13).
• 1st ejaculation is a notable event, occurring 1
  year after initiation of testicular growth.
• 90 of boys have this event between 11-15.
• Gynecomastia occurs in a majority of boys.
  Usually disappears within 2 years.
• Pubertal development may not be completed until
  age 18.

99
Boys

• Height velocity is higher in males(8-11cm) than
  in females(6 ½ -9 ½cm) per year.
• Axillary hair, deepening of the voice, and the
  development of chest hair occurs in mid puberty,
  about 2 years after onset of growth of pubic
  hair.
• Facial and body hair begin to increase at ages
  16-17.

100
Female Adolescents

• Onset of growth spurt is between 8-17.
• Mean age for peak height velocity growth is 12
  years.
• Average duration of growth spurt is 3 years.
• Females grow 2½-5 inches in height per year and
  gain 8-20 lbs.
• Increase in height may lead to poor posture.
• Pelvis grows and becomes shapely.
• Increase of adipose tissue from 15-27.

101
Secondary Sex Characteristics

• Thelarche (breast development)
• Stimulated by estrogen
• Breast size varies and asymmetry is common
• Development of a breast bud from glandular tissue
• Areola widens and eventually elevates from the
  chest wall
• Mature breast is characterized by the protrusion
  of the nipple

102
Secondary Sex Characteristics

• Adrenarche (pubic hair growth)
• Concurrent with breast development, or a little
  later in most girls
• Initial growth is slightly pigmented and straight
• Starts off with fine growth on the labia majora
• Quantity of hair increases and distribution
  spreads from the labia to the mons veris
• Texture becomes coarser, curlier, and darker
• Final stage established in about 2 yrs. with
  typical female triangular distribution with a
  horizontal upper border

103
Tanner Staging

• Breast Development or Thelarche
• Pubic Hair Development or Adrenarche or
  Pubarche
• Male Genital Development

104
External and Internal Genitalia

• Labia major, mons veris and symphysis pubis
  develop as fat is deposited.
• As a result of increase in fat, the labia majora
  fall inward and obscure the labia minora.
• Clitoris becomes larger and more erectile and the
  entire introitus appears larger.
• Estrogen causes vaginal lining to transform into
  think stratified squamous epithelial cells
  containing glycogen.

105
External and Internal Genitalia

• Thickness of vaginal lining varies with cyclic
  circulating levels of hormones.
• Vaginal secretions result from decrease hormone
  stimulation.
• Leukorrhea(white mucoid discharge) often precedes
  menarche by approx. 1 year.
• Uterus changes from tubular formation into a
  hollow muscular organ.
• Endometrial lining proliferates in preparation
  for menarche.

106
External and Internal Genitalia

• Fallopian tubes grow.
• Ovaries increase in size and develop an adequate
  vascular system to trigger the release of
  luteinizing hormone and to initiate ovulation.
• Anovulatory menstrual cycle is due to slower
  development of ovarian function compared to
  endometrial function.

107
Menarche

• Grand finale of puberty in women, average 12.5
  years.
• Occurs approximately 1-3 years after thelarche
  and during Tanner Stage 3 or 4.
• Initial menstrual cycle may be irregular in
  quantity and duration.
• Frequently anovulatory, secondary to immature
  ovarian function.
• Rhythmic menstrual pattern set in about 3-4 years
  after menarche begins.

108
Early Adolescence 11-13 years

• Interests focus on same gender peer group
  identification. Peer acceptance importance.
• Define normalcy in relation to their peers.
• Thinking is concrete. Lacks the ability for
  abstract thinking. Easily overwhelmed and
  overruled.
• Expresses sexuality through dress, body language,
  and curiosity about sexual acts.
• Research contends the last area of the brain to
  mature is the part capable of deciding, Ill
  finish my homework, take out the garage, and then
  Ill IM my friends

109
Middle Adolescence 14-16 yrs.

• Most turbulent stage. Psychologically egocentric
  and preoccupied with self.
• Self esteem is established through recognition of
  the peer group.
• Behavior is characterized by profound mood swing
  and rebellion.
• Struggles for independence. Uses abstract
  reasoning and introspection for a better
  understanding of self and other.
• Sexual behavior is explorative and exploitative.

110
Risk factors for suicide attempt in adolescent

• Lack of social connections
• Alcohol and substance use
• Non-intact family of origin
• Firearms in the household
• Poor communication with parents
• Prior suicide attempt
• History of abuse/violence victimization
• Sexual identity issues

111
Suicide risks

• Family history of
• Depression
• Suicide attempts
• Mood disorders in mothers
• Alcoholism or legal troubles in father
• Stressful life events, to include
• Break-up with a partner (in males)
• Separation of parents
• Disciplinary crisis
• Problems at school or work, or not being
  affiliated with either.

112
14-16 Well-care

• Height
• Weight
• Temperature
• Percentiles
• BP
• BMI

113
14-16 Well-care

• Vision, hearing
• Medication
• Sports form
• HEEADSSS
• Adolescent questionnaire review together

114
14-16 Well-care

• Discuss driving and risky behavior
• P.E.- head to toe
• -girls are usually tanner IV at this age

115
FYI- Eye exams

• Begin attempting well care visits at gge 5 or 6,
  or with any neuro complaints at sick visits
• Optic nerve
• Optic disk/cup
• Darken room
• Practice makes perfect

116
17-21 Well-Care

• Treat as adult
• P.E.
• STD screen
• Paps- start age 21 or 3 yrs. after 1st
  intercourse
• FYI-get up to date on street drugs, or at least
  have a cheat sheet to refer to.
• For example do you know that the effects of
  inhalants include hearing loss, neuropathies,
  limb spasms, CNS damage, bone marrow damage,
  liver and kidney damage, O2 depletion..

117
Late Adolescence 17-21 yrs.

• Develops a sense of self and purpose to life.
• Sexual behavior is more expressive and less
  exploitative.
• Intimate and monogamous relationships are
  developed.
• Abstract reasoning skills are fully developed.
• Individual is able to interact with the adult
  world and consider long term implications.

118
Review immunization

• -Hep B -Pneumococcal
• -DTAP -Influenza/ FluMist
• -HIB -Varicella
• -IPV -MMR RotaTeq
• Hep A -Menactra
• Boostrix and ADACEL
• Two new ones- for HPV- Gardasil and Cervarix
• You should bring the CDC immunization guide with
  you for the quiz!