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58FAMILY NURSE PRACTITIONER REVIEW AND RESOURCE MANUALControl MeasuresXMeasures directed against the reservoir: isolation, quarantine, insect sprayingXMeasures that interrupt the transmission of organisms: water purification, milk pasteurization, barrier protection during sexual intercourseXMeasures that reduce host susceptibility: immunization, appropriate use of antibiotics, improved nutritionConcepts of Epidemic vs. Endemic InfectionsXGeneration time: interval between receipt of infection and the maximal communicability of the host; applied to both subclinical and clinical infections (incubation periodapplies only to clinical cases); used to describe and analyze the spread of infectiousdiseases (i.e., common vehicle, single-exposure epidemic, determined by the incubation or generation time)XHerd immunity: resistance of a group to invasion and spread of an infectious agentbecause a large portion of the group is immune; decreases the likelihood of an epidemic in an areaXEndemic: a disease or infectious agent that is usually present in a populationXEpidemic: occurrence of disease in excess of what is normally expected in apopulationXMorbidity: occurrence of illness in a populationXMortality: occurrence of death in a populationHUMAN DEVELOPMENTDefinitionXMost development is patterned and orderly, with both a purpose and a direction.XDevelopment is continuous throughout life, although the degree of change in manyareas decreases after adolescence.XDevelopment may occur simultaneously in several areas, such as physical and social,but the rate of change in each area varies.XThe pace of development varies among persons.XPhysical and mental stress during periods of critical developmental change, such aspuberty, may make a person particularly susceptible to outside stressors.XAnticipatory guidance is an important component of patient and family educationthroughout the life span.Infant and Child DevelopmentXAssessment of growth is determined by routine monitoring of height, weight, headcircumference (until age 2), dental development, and appearance of secondary sexcharacteristics.XAdequacy of growth is determined by comparison with normal growth parameters(see Tables 3–2 through 3–5) and/or plotting the measurements of height, weight,

HEALTHCARE ISSUESTABLE 3–2.NORMAL GROWTH PARAMETERS FOR HEIGHT AND WEIGHTAGEWEIGHT*HEIGHT*Newborn95% of newborns weigh 5–10 lbsApproximately 5%–10% of bodyweight is lost in first few days,then birth weight is regained in7–10 days.95% of newborns are between 18 and22 in. long.Birth–6monthsWeekly gain 140–200 g(5–7 ounces). Birth weight doublesby 6 months.Monthly gain is 2.5 cm (1 in.).6–12 monthsWeekly gain 85–140 g (3–5 ounces).Birth weight triples by age 1 year.Monthly gain is 1.25 cm (0.5 in.). Birthlength increases by approximately50% by age 1 year.ToddlersYearly gain 2–3 kg (4½–6½ lbs).Growth is approximately 12 cm (5 in.)between ages 1 and 2 years; 6–8cm (2½–3½ in.) between ages 2 and3 years. Approximately 50% of adultheight is reached by age 2 years.School ageYearly gain approximately 2–3 kg(4½–6½ lbs ).Growth is approximately 5–6 cm(2–2½ in.) per year. Birth lengthdoubles by age 4 years and triples byage 13 years.Puberty—girls(10–14 years)Weight gain 15–55 lbs (mean38 lbs).Growth is approximately 5–25 cm(2–10 in.). 95% of adult height isachieved by menarche (skeletal ageof 13 years).Puberty—boys(11–16 years)Weight gain 15–65 lbs (mean52 lbs).Growth is approximately 10–30 cm(4–12 in.). 95% of adult height isachieved by skeletal age of 15 years.*These measurements are averages.Adapted from “CDC Growth Charts,” by National Center for Health Statistics, 2010. Retrievedfrom http://www.cdc.gov/growthcharts/and head circumference on a standard National Center for Health Statistics (NCHS)(2010) growth chart.XThere are two periods of rapid growth: infancy and adolescence; in between, growthis steady but slower.XThe growth of most body tissues parallels physical growth, which is most rapid inthe first 2 years; lymph tissue growth is rapid in the preschool and early school-ageyears; growth of reproductive organs remains slow until puberty.Patterns of DevelopmentXThe sequence of development is basically the same in all children, but the ratevaries.XAttainment of developmental landmarks in one area does not always run parallel toanother area of development.XDevelopment is dependent on maturation of the nervous system.59

60FAMILY NURSE PRACTITIONER REVIEW AND RESOURCE MANUALXGeneralized activity precedes specific movements (a young infant kicks and wavesarms with excitement, whereas an older infant reaches out and grasps).XDevelopment occurs in a cephalocaudal direction (head control develops beforewalking) and a proximal-to-distal direction (shoulders before fingers).XCertain primitive reflexes must be lost before the corresponding voluntary movement is acquired (grasp reflex lost before deliberately grasping objects can occur).Tooth EruptionXDeciduous teeth usually begin at 6 months of age with the central incisors and movelaterally.XAll 20 deciduous teeth are usually in place by 2½ to 3 years of age.XDelayed dentition is considered when no teeth have erupted by 13 months of age.XShedding of deciduous teeth begins at about 6 years of age and continues throughage 12.XEruption of the first permanent teeth occurs with the first molars, at about age6 years.XEruption of all 32 permanent teeth may not be complete until ages 17 to 21, withthird molars.Developmental Landmarks and MilestonesXDevelopment typically assessed in four areas: gross motor, fine motor, language,and social skillsXPurpose is to identify children in need of further assessment and determine if adevelopmental disability existsXAll states required to have a system to identify and treat developmental disabilities inchildren ages 3 to 5 years; most states have voluntarily extended this age rangeInterpreting ResultsXAttainment of milestones is in ranges.XA significant finding in any developmental assessment is the loss of developmental milestones previously achieved or lack of key milestones by certain age (seeTable 3–3).XLanguage and fine motor skills are sensitive indicators of intellectual development.XEarly attainment of gross motor skills is not a significant indicator of advanced intellectual development, but does usually preclude the diagnosis of intellectual disability.Developmental warning signs can be found in Table 3–4.XNo child is intellectually disabled if delayed in one area but normal in all others.Adolescent Pubertal ChangesBoysXAverage age of onset is 10.5 to 16 yearsXPrecocious puberty is the development of secondary sex characteristics before age9 and is often associated with a pathological etiology in boys.XDelayed puberty is lack of changes by age 14 years.

HEALTHCARE ISSUESTABLE 3–3.DEVELOPMENTAL MILESTONESTASKSAVERAGE AGE (RANGE)*GROSS MOTOR SKILLSMoves head from side to sideLifts shoulders while proneRolls overHead control (no bobbing)Sits alonePulls to standCrawls (reciprocal)CruisesWalks aloneRuns, walks upstairs holding railThrows ball overhandPedals tricycleBalances on one footHops on one footTandem walkSkips2 weeks2 months4 months (2–6 months)4 months6 months (5–9 months)9 months (6–10 months)9 months (8–11 months)9 months (8–13 months)12 months (9–15 months)18 months (14–21 months)19–20 months (16–24 months)28 months (21–36 months)28–30 months (22–38 months)4 years (3–4½ years)5 years (3½–5 years)5 yearsFINE MOTOR SKILLSUnfistsHolds objects placed in handReaches for objectsTransfers objectsUlnar rakingInferior pincerMature pincerDeliberate throwSpontaneous scribbleTower of 2Tower of 4Tower of 6Imitates lineTower of 10Copies circleUses scissorsCopies squareDraws 3-part figureCopies triangleDraws 6-part figure3–4 months3–4 months (2½–5 months)4 months (3–5 months)6 months (4½–7 months)6 months (5–7 months)9–10 months11–12 months12–13 months14–16 months (12–16 months)15 months (12½–20 months)18 months (16–20 months)24 months (17–30 months)24 months (19–30 months)36 months36 months (2½–3½ years)3 years4 years (4–5 years)4 years (3½–5 years)5 years5½ years (4½–6 years)LANGUAGE (RECEPTIVE AND EXPRESSIVE)Localizes soundBabbling vowelsBabbling da”/“mama”—specific4–9 months5–6 months6–7 months9–10 months10–12 months(CONTINUED)61

62FAMILY NURSE PRACTITIONER REVIEW AND RESOURCE MANUALTASKSAVERAGE AGE (RANGE)*LANGUAGE (RECEPTIVE AND EXPRESSIVE) (CONTINUED)13 words11–13 monthsFollows one-step command11–15 months10–15 words, 25% intelligible15–18 monthsPoints to named pictures when asked “show me”18–24 monthsApproximately 50-word vocabulary; 2-word combinations21–24 monthsApproximately 100-word vocabulary by 2nd birthday; says“me” and “mine” (As a rule, the number of words in asentence equals the child’s age [2 by age 2, 3 by age 3])2- to 3-word phrases2 yearsFollows 2-step commands without gesture30 monthsFew possessives (“my ball”) and progressives (the –ing:“I playing”)30 monthsConcept of “I” questions30 monthsKnows few colors, pronouns, plurals, full name, age,approximately 250-word vocabulary, 3–4 word sentences(75% intelligible)36 monthsCounts to 4, can say a nursery rhyme, asks and answerswhy, how, when, knows opposite analogies, and usespast tense4 years Uses complex sentences, understands meaning of words,counts to 10, has fluent speech, uses future tense5 yearsSOCIAL, INTERACTIVE, VISIONRegards face0–1 monthSmiles responsively1–1½ monthsHand regard4–5 monthsSmiles at mirror image5 monthsPlays peek-a-boo5½–8½ monthsPlays pat-a-cake10 monthsWaves goodbye10 months (7–14 months)Indicates wants12 months (10–14 months)Imitates housework15 months (13–18 months)Washes and dries hands22 months (19 months–2½ years)Puts on clothing22 months*Ages will vary with different tests.Adapted from ”Child Development,” CDC, 2016. Retrieved from tmlXFirst change is testicular enlargement, followed by pubic hair development at thebase of the penis (adrenarche); testicular size larger than 2 to 2.5 cm indicates puberty has begun.XPenile growth occurs approximately 6 to 12 months after testicular enlargement;penis grows from a prepubertal size of 3.5 to 5.5 cm to an adult length of 12 cm (7.5to 15.5 cm).

HEALTHCARE ISSUESTABLE 3–4.DEVELOPMENTAL WARNING SIGNS6 weeksAbsence of auditory alertnessLack of visual fixation (focusing)Excessive head lag on pulling-to-sitting position6 monthsPersistence of hand regardFailure to follow 180º (for both near and far objects)Persistent fistingPreference of one hand10 monthsAbsence of babbleNo smiling or social responsivenessAbsence of weight-bearing while hand heldFailure to sit without support18 monthsNo spontaneous vocalizationsNo single wordsNo pincer graspInability to stand without support2 yearsNo recognizable wordsNo walkingXGrowth spurt begins about 1 year after the first testicular changes (average age 12.5years), peaks after 1.5 years, and lasts 2 to 4 years.XAccompanying changes, such as axillary and facial hair and deepening voice, occurlater in puberty.GirlsXAverage age of onset is 11 years, with a range of 8 to 13 years.XPrecocious puberty is the onset of changes before 8 years of age or menarchebefore age 10 years.XDelayed puberty is no breast development by age 13 years or no menses by 15 to 16 years.XFirst pubertal change is usually breast budding under the areola and pubertal fine hairover the mons pubis (adrenarche or pubarche).XMenarche occurs at an average age of 12.5 years (range 10 to 15).HEALTH MAINTENANCECurrent factors support greater emphasis on health promotion and disease prevention.Healthy People 2020 (U.S. Department of Health and Human Services, n.d.):XA set of goals and objectives based on annual targets to guide the nation’s healthpromotion and prevention effortsXNational objectives that emphasize disease prevention and define leading healthindicators necessary to measure health; as a group, reflect major health concerns inUnited States in 21st century63

64FAMILY NURSE PRACTITIONER REVIEW AND RESOURCE MANUALXEmphasizes social determinants of health and promotion of health across all stagesof life and use of technology, such as interactive websites, as main vehicle of dissemination of evidence-based resources for implementationXLeading health indicators selected on the basis of their ability to motivate action,availability of data to measure progress, and importance as public health issues. Theyinclude:ZAccess to health servicesZClinical preventive servicesZEnvironmental qualityZInjury and violenceZMaternal, infant, and child healthZMental healthZNutrition, physical activity, and obesityZOral healthZReproductive and sexual healthZSocial determinantsZSubstance abuseZTobaccoHEALTH MAINTENANCE PRACTICELifestyle/Health BehaviorsRoutine counseling and chemoprophylaxis in primary prevention may prevent certain conditions(see Table 3–5). Specific health behaviors that are amenable to intervention can be found inTable 3–6.ExerciseXRecommendation is 30 minutes of moderate physical activity on most days of theweek; does not have to be continuousXRecommendation is as important for children as for adultsChild and Adolescent Pre-Participation Sports AssessmentXChildren and adolescents participating in sports should have a pre-participation evaluation (PPE). Almost all states require medical clearance before sports participation,although no standardization of PPEs exists and evaluations may vary. The AmericanAcademy of Pediatrics and the American Association of Sports Medicine Physicianseach have developed guidelines.XThe PPE should involve parents for athletes younger than 18 years of age.XThe goal of the PPE is to identify those who may need conditioning or rehabilitation,need further evaluation for clearance, and should be excluded from participation.Particular attention should be directed at the cardiopulmonary and musculoskeletalsystems.

HEALTHCARE ISSUESTABLE 3–5.CHEMOPROPHYLAXIS FOR DISEASE ING PRIMARY DISEASENeural tubedefectsHemorrhagicdisease of thenewbornOphthalmianeonatorumGroup BStreptococcus(GBS)(prevention inthe newborn)Dental cariesDisorders of the cranium, spine,and nervous system that occurwhen the neural tube fails toclose. Folic acid supplementationhas resulted in more than 50%reduction in these birth defects.The average North American dietincludes less than half of therecommended dietary intake offolic acid.Newborn gut lacks the bacterianecessary to synthesize vitaminK, which is used for coagulation.Primary purpose is the preventionof gonococcal and Chlamydialconjunctivitis in the neonate.Silver nitrate is not effectiveagainst Chlamydia.In the early 1970s, GBS was aprimary cause of neonatal sepsisand meningitis. Preventionstrategies began to screenwomen for GBS and provideantibiotic prophylaxis for womenwho were positive or had specificrisk factors.Reduction of dental caries can beaccomplished with fluoride andsealants. Excess fluoride willcause fluorosis (mottling of theteeth).All women of childbearing years,whether pregnant or not, shouldtake 0.4 mg daily of folic acid eitheralone or as part of a multivitaminsupplement. The dose is increasedwith pregnancy.Vitamin K (phytonadione), 1 mg, isadministered once immediately afterbirth.Instilled immediately postpartum:a single application of 1% silvernitrate ophthalmic drops, 0.5%erythromycin ophthalmic ointment,or 1% tetracycline ophthalmicointmentScreen pregnant women for GBS inone of two ways: Obtain vaginal and rectal culturesat 35–37 weeks’ gestation. If no culture results are available,the decision for chemoprophylaxis is based on the presence ofone or more risk factors: deliveryat 37 weeks’ gestation or less,membranes ruptured for morethan18 hours, intrapartum fever of38º C or higher, or mother had aprevious infant with GBS diseaseor had GBS bacteriuria herself.Whichever screening method isused, the treatment is the same: IVpenicillin G, 5 million units, followedby 2–5 million units every 4 hoursuntil delivery. Treatment is mosteffective if at least two doses ofpenicillin are given.Dose of fluoride is dependent onfluoride concentration in the waterand age of the child. Sealants areplastic coverings applied by thedentist for secondary molars.(CONTINUED)65

66FAMILY NURSE PRACTITIONER REVIEW AND RESOURCE MANUALCONDITIONRATIONALERECOMMENDATIONSDISEASE PREVENTION IN HIGH-RISK PEOPLETreatment is focused on symptomrelief. Airway management withbronchodilators, hydration, andantivirals may be used to manageRSV.Respiratorysyncytial virus(RSV)RSV is responsible for the majorityof lower respiratory tractinfections in children. RSV is aparamyxovirus that producesfusion of human cells in tissue.RSV attacks the upper and lowerrespiratory tracts, often causinglife-threatening pneumonia andbronchiolitis. Bronchiolitis maybegin as a mild upper respiratorytract infection that progressesto difficulty breathing with acough and wheeze. RSV causespotentially life-threatening airwayobstruction.Infectiveendocarditis(IE) orsubacutebacterialendocarditis(SBE)Recommended prophylaxis: oralSBE prophylaxis with antibioticsamoxicillin, 50 mg/kg (maximumis recommended for people2 grams) 1 hour prior to thewith specific cardiac conditionsprocedure. If allergic to penicillin,who are undergoing proceduresuse cephalexin (50 mg/kg, maximumthat may induce a transient2 grams) or azithromycin orbacteremia.clarithromycin (15 mg/kg, maximumHigh-risk conditions include500 mg).prosthetic valves, most congenitalPost-procedural antibiotics are noheart malformations, rheumaticlonger recommended.heart disease, hypertrophiccardiomyopathy, mitral valveprolapse with regurgitation, andprevious bacterial endocarditis.High-risk procedures includemost type of dental work (toothextractions, cleaning, andsurgery) and operations withinthe oropharynx, gastrointestinal,and genitourinary tract. Failuresmay occur even with adherence torecommendations.Extend

reduction, health promotion, and chronic disease management care rather than exclusive disease management. X There is increased emphasis on evidence-based practice (the use of current and best evidence to make decisions about care) and early translation of the best evidence into practice to improve