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Age Specific Practice

3 Contact Hours
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Other, Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Respiratory Therapist (RT)
This course will be updated or discontinued on or before Thursday, December 15, 2022
Course Description
This course explains why patients may need to receive modified treatment and care based on their age groups. Health care professionals will gain a greater understanding of the physiological differences between a child, an adult, and an older adult, and how to determine each age group’s needs. They will be able to identify concerns for specific age group and how it can impact clinical interventions, including methods to avoid medication errors in pediatric patients and spotting self neglect among the elderly.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Dana Bartlett (RN, BSN, MA, MA, CSPI)

Outcomes

90% of participants will know what screening tests and preventive care are specific for four age groups: children, adolescents, adults and the elderly.

Objectives

After completing this course, the participant will be able to:

  1. Identify 3 screening tests used for each age group
  2. Discuss the rationale for the screening tests
  3. Discuss health needs for each age group
  4. Identify 2 safety issues for each age group
  5. Discuss the importance of safety issues based on the needs of the age group

Age Specific Competency: Health Assessment and Preventive Care

There are significant physical and developmental differences between infants and children, adolescents, adults, and aging adults. This module will discuss those differences and how they influence the healthcare needs of these specific populations. As compared to adulthood, the periods of infancy and childhood, adolescence, and old age are times of intense growth and development and compared to adulthood, and the health needs of these age groups will be discussed in greater depth and detail than those of adults. Nutrition and medication issues of adults will not be covered.

There are many authoritative sources for screening and preventive care guidelines, e.g., the Centers for Disease Control and Prevention, professional organizations like the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, the American Cancer Society, and the United States Preventive Services Task Force Association. These organizations are often not in complete agreement on the best way to screen for and prevent diseases, but although differing recommendations can be confusing for clinicians when making decisions about patients’ health, recommendations for screening and preventing specific conditions/disease are never significantly different from one source to another.

Infant and Children: Ages 1 Month to 12 Years

The anatomy and physiology of an infant or a child differ from an adult's in many ways other than height and weight, and clinical interventions must be applied with these factors in mind. Children have less pulmonary reserve than an adult and have a proportionally higher oxygen requirement. They can maintain central organ perfusion during significant fluid loss because of powerful peripheral vasoconstriction that shunts blood from the limbs to the central circulation. This leads to the cool, mottled extremities and decreased peripheral pulses, which is characteristic of shock in children. Children have less ability to increase cardiac output by increasing cardiac contractility; they maintain cardiac output with tachycardia. Children are more susceptible than adults to heat loss because they have proportionally larger heads and a greater surface-area/body-mass ratio than adults.

Table 1: Vital Signs – Infants and Children
AgeTemperaturePulseRespiratory RateSystolic Blood Pressure
1-12 months97.2 - 99.480 -14020 -3070 -100
1-3 years95.9 - 9980 -13020 -3080 -110
3-5 years95.9 - 9980 -12020 -3080 -110
6-12 years95.9 - 9970 -11020 -300 -120

Temperature, pulse, respiratory rate, and blood pressure that is considered normal for infants and children vary by age.

 

Assessment of Growth and Development of Infants and Children

The period between 1 month of age and 12 years of age is one of rapid change. Infants and children should be routinely assessed to determine if they are growing normally, and periodic evaluation of physical, emotional, and social development is one of the most important healthcare issues of this patient population. These assessments are performed by comparing the patient to developmental milestones, defined as abilities and behaviors that are normal for a specific age group. When a developmental milestone assessment is done the patient:

  • Will meet the standard, and growth and development are normal.
  • Fail to meet the standard, but the assessment parameter is not considered critically important, or the patient’s development is otherwise normal. Each infant and child will develop at her/his own pace, and failure to meet a developmental standard may simply reflect that child’s individual rate of growth and development.
  • Fail to meet the standard, and this failure is a warning sign of a serious problem with the patient’s growth and develop.

Several examples of developmental milestones and assessments are provided here.1 Notice that in infants and very young children cognitive and language abilities and hand/finger motor abilities are assessed, but visual and perceptual abilities are not.

Infant at 2 to 3 Months

In terms of movement and physical abilities, an infant 2 to 3 months of age should be able to raise his/her head while lying on the stomach, push up slightly with the arms while on the stomach, open and close the hands, and hold on to and shake objects.

In terms of perceptual ability, an infant 2 to 3 months of age should be able to follow a moving object with her/his eyes and respond to a voice and turn his/her head towards the direction of a sound.

In terms of social and emotional development, an infant 2 to 3 months of age will attempt to mimic facial expressions, begins to smile in response to people, and facial expressions become more numerous and complex.

Warnings signs of a possible serious growth and development issue in this age group include, but are not limited to failure to respond to loud noises or to voice, inability hold onto and move an object, failure to follow a moving object with the eyes, and failing to smile at people.

Child at 3 to 4 Years

Children from the ages of 3 to 4 should have the movement and physical abilities to walk unassisted up a flight of stairs one step at a time, pedal a tricycle, throw a ball overhand, and turn a doorknob.

The social and emotional development behaviors that are considered normal for this age group would include expression of a wide range of emotions, copying adult behavior, and describing what others are feeling.

The cognitive and language abilities of the 3 to 4-year-old child should include an increasingly sophisticated sense of time, the ability to follow a short series of instructions, speaking in sentences and in simple paragraphs, and an ability to name familiar objects and friends.

Warnings signs of a possible serious growth and development issue in this age group include, but are not limited to:

  • Cannot follow simple commands
  • Falls frequently or has difficulty climbing stairs
  • Has unclear speech
  • Does not imitate adults
  • Does not make eye contact
  • Does not want to play with other children or toys

Infants and children should also be assessed for their elimination habits, sleep patterns, social activities, and sibling and parental relationships.

Assessment and Examination Processes in Infants and Children

The assessment and examination process applied to an infant or a child must be adapted to the behavioral, emotional, and intellectual development of the patient.

Infant and Toddlers

Approach an infant or toddler in a calm, gentle and slow manner. Have the caregiver hold the patient when doing an assessment or treatment if possible. If the child has to lie down, let the parent stay next to the child.2 Use warm instruments and warm hands and allow the child to handle equipment like an otoscope or stethoscope if this is safe; some children find this to be reassuring. Assess the respiratory rate and status when an infant is quiet. Explain to the caregiver that the child may cry when a procedure is begun, but that an infant makes no connection between the approaching stimulus and pain. With toddlers, try to make the assessment or treatment of a game to reduce fear. Use your imagination and get the toddler involved by using storybooks, dolls or puppets. Provide reassurance during the assessment/procedure. Praise the child for doing well.

Preschoolers (4-5)

Preschoolers are very active. Motor skills are improving. Mentally, they begin using symbols and improving their memory. They have vivid imaginations, which may cause unseen fears. The preschooler is starting to develop independence, and he/she is sensitive to other’s feelings.

Speak at the language level the child can understand. Explain to the child just before a procedure what is going to be done, using sensory terms when possible. Use games and imagination to gain cooperation. Allow the child to handle equipment if possible. Enlist the child’s help and allow him to express his feelings. Preschoolers need praise, rewards, and easy to understand rules.

School-Aged Children (6-12)

School-aged children grow slowly until puberty. Mentally they are active and eager learners who can understand cause and effect. Building self-esteem is an important task during this period. The school-aged child is developing a greater sense of self, independence, and he wants to fit in with peers. The school-aged child is beginning to make lifestyle choices and may act with poor judgment. Peer pressure, alcohol, sex, drugs, and smoking need to be discussed with this age group.

Because of these issues, the school-aged child needs to be allowed to make decisions when feasible and within reasonable bounds. Provide privacy during assessment or treatment and explain all procedures at the child’s level of understanding. Be prepared to listen and be honest. Tell the child how he/she can be involved in his own care, and have children assist you in their care, if possible. Reassure the child that they did nothing wrong. They need to know that the illness or injury is not a punishment.

Preventive Care and Health Screening: Infant and Children

Infants and children - and all age groups - should be vaccinated for protection against infectious diseases. Vaccination schedules for infants and children are different from those for other age groups, and current recommendations for patients aged 0 to 18 years can be found on the Centers for Disease Control and Prevention website.3 The schedules can be found here.

Health screening for infants and children should be universal and targeted; all infants and children should be screened for the presence of certain diseases, and specific individuals and populations should be screened for diseases they are likely to suffer from.

Examples:

  • Infant universal screening for congenital hypothyroidism and phenylketonuria (PKU is mandated in all 50 states and the District of Columbia).
  • Recommendations for screening infants and children for lead poisoning are typically generated by city and state agencies, and this screening is targeted for at-risk individuals and populations, e.g., infants and children who live in areas with a high concentration of houses built before 1950 or in areas in which it is known that a certain percentage of children have elevated blood leads levels.

Organizations such as the American Academy of Pediatrics (AAP), the CDC, and the U.S. Preventive Services Task Force (USPSTF) have recommendations for both universal screening and targeted population-specific screening. There are also city, school board, state, and federal mandates and regulations for pediatric health screening. There is some disagreement among these sources regarding who should be screened, for what, and when. Table 2 lists the health screening recommendations from the American Academy of Pediatrics.4

Table 2: Health Screening for Infants, Children and Adolesents
ScreeningRecommendationAdditional Resources
Alcohol, drug, and tobacco useStarting age 11Patients should be assessed for the risk of use and screened if necessary.4
Anemia4 months – assess for the risk

12 months – screen

After 12 months – assess for risk
Screen as necessary.

The current edition of the American Academy of Pediatrics’ Pediatric Nutrition: Policy of the American Academy of Pediatrics, chapter on iron.
Autism18 and 24 monthsVisit Source
BilirubinNewborns 
Blood PressureAll patients 3-21Prior to 3 – risk assessment should be done

Guideline for Screening and Management in Children and Adolescents. These guidelines can be viewed here.
Body Mass Index (BMI)24 months to age 21 
Critical Congenital Heart DefectAll newborns using pulse oximetryFor more details, see Endorsement of Human and Health Services recommendation for pulse oximetry screening for critical congenital heart defect
DepressionStarting age 12The USPDTF recommends screening for depression in all patients 12 to 18 years old, and resources should be in place for follow-up and treatment if needed.5
Developmental screening9, 18, and 30 monthsThe Medical Home: An Algorithm for Developmental Surveillance and Screening, and they can be viewed here.
Developmental surveillanceAnnual for all patients 
DyslipidemiaAges 24 months, 4 years, 6 years, and 9 years to 21 years- Assess for riskFollow up if needed.

For more information, see the recommendations of the National Heart, Lung, and Blood Institute, Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. These can be viewed here.
Hearing screenAll newborns and 3-5 days old. It should be confirmed that the initial screen was done, the results of this screen should be verified

4 months to 3 years assess for risk

After 3 years – assess for risk
Screen and follow up as needed

See these guidelines for more information:
  • Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. View here.
  • After age 3 years View here.4
Height and weightAll patients, newborn to age 21 
HIV infectionStarting age 15Assess for risk and screen as necessary. The CDC recommends HIV testing in all adolescents who have contact with the healthcare system unless the patient opts out.30
LeadAge 6 months and 9 months – assess for risk

Age 12 months, 24 months – measure blood lead or assess for risk

Age 3, 4, 5, 6 years – assess for risk
Screen as needed

To do determine what kids are at risk visit Prevention of Childhood Lead Toxicity or the CDC’s Low Lead Level Exposure Harms Children: A Renewed Call for Primary Prevention.
Physical ExaminationAnnual for all patients 
Psychosocial behavioral assessmentAnnual for all patients 
Newborn blood panelAge 3 or 5 days – blood sample of uniform screening panelsThe uniform screening panel tests for genetic disorders, e.g., phenylketonuria and sickle cell disease. Details about the screening can be viewed here.
Sexually transmitted InfectionsStarting age 11Assess for the risk of STIs and screen as necessary.4

See the AAP’s Red Book: Report of the Committee on Infectious Diseases for guidelines on risk assessment.
Skin cancerStart at 6 Months educate and counselUSPSTF recommends parents of children 6 months of age and older, who have fair skin, be counseled about minimizing exposure to ultraviolet radiation as a way of reducing skin cancer.5
TuberculosisAges 1 month, 6 month, 12 month and every year from 2 years of age and up – assess for riskScreen as necessary. Use the AAP Red Book for guidance.
VaccinationsFollow current CDC recommendationsThe CDC recommended vaccination schedule for adolescents 18 years of age and younger can be viewed here.

Vaccination for preventing infection with the human papillomavirus (HPV) is discussed later in this section of the module.
Vision ScreenNewborn and up to 30 months, assess for risk

Age 3 and beyond – annual vision testing
Screen as necessary.

See Visual system assessment in infants, children, and young adults by pediatricians.6

Infant and Children: Nutrition and Eating

The nutrition and eating issues that are specific to infants and children are caloric, macronutrient, and micronutrient requirements, eating habits/patterns, food safety, and food insecurity. Note: Macronutrients are carbohydrates, fats, proteins, and water. Micronutrients are minerals and vitamins, e.g., calcium and iron, vitamin A and vitamin C.

The caloric, macronutrient, and micronutrient requirements of infants and children will depend on age, gender, and activity level. These requirements are not significantly different from those for other age groups, but some specifics are important to know, and there are guidelines for the daily caloric intake for infants and children.7 Example: For a 12-month-old child who weighs 20 pounds/9 kg, multiply the child’s weight times 89, subtract 100 and add 22 – 9 x89 = 801, 801-100 = 701 +22 = 723 calories a day.8

Macronutrient requirements differ by age, as well, and daily intakes listed below are summarized/compiled from recommendations from the AAP, the American Heart Association (AHA), the American Dietetic Association, and the United States Departments of Agriculture and Health and Human Services (USDA/HHS).9

  • Carbohydrates: In all children, these should be 45-65% of the daily caloric intake.
  • Fats: Fat intake should not be restricted in children 0 – 2 years of age. From age 2 to 3, fat intake should be 30-35% of daily caloric intake, and from age 4 to age 18, fat intake should be 25-35% of the daily caloric intake.
  • Protein: From age 1 to 3, protein should be 5-20% of daily caloric intake. From age 4 to 18, protein should be 10-30% of daily caloric intake.

Infants and children up to 2 years should drink whole milk, not skim or 2%.9 Exceptions can be made on a case by case basis. Infants and children need fat for the development of the nervous system.

The daily recommended intake for micronutrients is age specific, but supplementation to ensure adequate intake of micronutrients is not needed if the infant/child gets a varied diet and sufficient exposure to sunshine.9

Exceptions to this would be vitamin D supplementation for breastfeeding infants,10 and for children who are at risk for vitamin D deficiency due to their nutritional intake and/or lack of exposure to sunlight.10 Breast milk does not have enough vitamin D to meet the nutritional requirement of a breastfeeding infant, and the AAP recommends that breastfeeding infants should be given 400 IU of vitamin D every day.11 Premature infants, infants who are exclusively breastfed, exclusively breastfed and premature infants who are not getting vitamin D supplementation, and infants and children who have low dietary vitamin D intake should be screened for vitamin D deficiency.12

The daily recommended intake for micronutrients is age specific. A dietary reference intake calculator that can be used to determine age and gender-specific caloric intake need and macronutrient and micronutrient requirements are available at the website of the U. S. Department of Agriculture (USDA) here.

Other sources that are useful for determining nutrition needs are the US Department of Health and Human Services/National Institutes of Health (USDHSS/NIH) website, Health Information, Fact Sheets for Professionals. The Dietary Reference Intakes and the Daily Values can also be used, and they are both available at the National Institutes of Health website:

Eating patterns and habits of infants and children are quite different from those of adolescents, adults, and the elderly. Infants and children need to eat quite frequently, up to 7 times a day or more, and frequent snacks are a necessity. Food disinterest and food fussiness are eating patterns that most children exhibit at some time.

Food safety for infants and children is concerned with choking hazards and food-borne infections. Choking can occur because infants and children may not have full dentition; may not have learned how to chew foods thoroughly; can be easily distracted while eating, and; may be given foods of a certain size that cannot be chewed or are likely to be swallowed and aspirated such as peanuts, hard candies, and grapes.

Food-borne illnesses are a papillomavirus concern of this age group because the immune system has not fully developed.

Food insecurity is defined as being without reliable access to sufficient amounts of nutritious food, and the United States Department of Agriculture (USDA) estimated in 2018 that 11.1% of American households were in a state of food insecurity at some time during the year.13 Food insecurity is not a problem specific to infants and children, but the potential effects of food insecurity are worse for this age group because of rapid growth and development at this stage of life.

Infant and Children: Medications

Medication age-related issues for infants and children include pharmacokinetics, medication errors, dosing, and administration.

Medications have traditionally not been tested in children,14 and pediatricians had to prescribe doses and dosing schedules with information using/extrapolating from information about adult doses/dosing. It is often said when it comes to drugs, children are not small adults, and this has been proven true in many ways. For example, in 2017, the FDA issued a warning stating that codeine and tramadol should not be used in children < 12 years old. Adverse reactions to these drugs, some quite serious, were reported in this patient population and may have been caused by a difference in the activity of the CYP2D6 enzyme that resulted in high serum drug levels.14

Pharmacokinetics

Pharmacokinetics refers to the processes by which a drug is absorbed, distributed, metabolized, and excreted. These processes, in large part, determine the actions and effectiveness of a drug, and pharmacokinetics are influenced by the age of the patient. Infants and children are not simply smaller adults, and the absorption, distribution, metabolism, and excretion of drugs in this population can be quite different.

Drug absorption: Drug absorption from the gastrointestinal tract depends on gastric pH, gastric acid secretion, the length of the bowel and the amount of the bowel surface that is capable of absorbing drugs, the gut flora, intestinal transit time, the rate of gastric emptying, and the activity of drug-metabolizing enzymes and drug transporting proteins in the gastrointestinal tract. All of these are reduced in neonates and premature infants, and they may be decreased or increased in children who are ill . Transdermal absorption may be increased in neonates and infants because their skin is thinner, and they have a relatively high skin surface to body weight ratio than do older children and adults.

Distribution: Children have a higher percentage of their body weight as water, and this changes as they get older; a premature infant’s body weight may be 80% water and a 1-year-old child’s 60%. The higher percentage and the change in percentage mean that water-soluble drugs must be prescribed at lower doses for children and doses will need to be adjusted for age. Drug distribution also depends on protein binding and albumin, total protein levels are relatively low from birth to age 1, and the activity of these proteins is decreased in young children, as well.

Metabolism: Metabolism of drugs by children is not the same as in adults. Liver and kidney function differ in children from adults,14 phase I and phase II drug metabolism can be quite different in infants and children when compared to adults. For example, the activity of drug-metabolizing enzymes can be quite low in infants, much lower than in adults, but this can quickly increase during the toddler and early childhood years, and these issues affect drug clearance and clinical effects.

Excretion: The kidneys are an important pathway for drug excretion. Kidney function in children differs from adults.15 Renal function changes and matures during the first few years of life, and renal function must be considered when using certain drugs that are primarily eliminated by glomerular filtration; example, Gentamicin is dosed in children at 2-2.5 mg/kg, IV, every 8 hours; the adult dose

Medication Errors

Medication errors are a common event in pediatric care, and they are associated with an increased risk of harm.16,17 Medication errors appear to happen more often in pediatric patients than in adults. The rate of occurrence is not known, but medication errors in the pediatric population are not uncommon. Alghamdi et al. found an occurrence of 14.6 errors per 100 medication orders, and it has been reported that up to 6% of hospitalized pediatric patients suffered harm from a medication error.17,18

Medication errors in pediatric patients are usually prescribing and dosing errors, and given that doses used for infants and children can be quite small and involve decimal points, there is obvious potential for 10-fold and 100-fold errors. In addition, many medications prescribed for infants and children are used as unlicensed or off-label, which creates obvious risks.18,19

Dosing

Drug dosing in children is different than in adults because it is weight-based or body surface area-based and because pharmacokinetic differences, it is not safe to assume that a 10 kg child should be given 1/10th of the dose given to a 100 kg adult. Dosing is also, in some ways, imprecise. Most drugs used for children have not been tested in children.14 The dosing guidelines have been developed from adult guidelines and/or research; in many cases, there is minimal pharmacokinetic information about specific drugs and children. The result of these issues has been dosing guidelines that vary significantly, and therefore, underdosing and overdosing in children is an ever-present risk.14

Administration

Medication administration can be traumatic for children and time consuming and difficult for parents and healthcare professionals. For infants, draw the liquid medication into a plastic dropper or disposable syringe. After elevating the infant’s head and shoulders, slowly drop the medication in the middle of the tongue. You may need to depress the chin with the thumb to open the mouth. If a toddler does not drink their medication, you can place a syringe without a needle between the cheek and gum and slowly give the medication.

The small size and underdeveloped musculature of infants and young children increase the risk of hitting nerves and/or blood vessels with an intramuscular (IM) injection. Recommended IM injections sites are listed below.20

  • Newborns and infants < 1 month of age: Anterolateral thigh muscle; the needle should be 5/8 inch/16 mm long.
  • Term infants 1-12 months: Anterolateral thigh muscle; the needle should be 1 inch/25 mm long.
  • Toddlers and children: The deltoid muscle of the arm; the needle should be 5/8inch/16 mm or the anterolateral thigh muscle with a 1-1/4 inch/25-32 mm long needle.

Infants and Children: Safety Issues

The primary safety issues of infancy and childhood are child abuse, accidents, and poisonings.

Child Abuse

The incidence of child abuse is difficult to ascertain, but it is a prevalent social issue that has serious short-term and long-term consequences.21,22 The CDC estimated that 1 in 7 children in any year are abused, and this number is likely an underestimate,23 and approximately 12% of abused children are injured (again, likely to be an underestimate) and that 10% of children taken to an ER have been abused or neglected.21,24 In addition, the statistics of child abuse can be deceiving because a child that is abused would be considered one case, but that child is likely to be abused many, many times.

Child abuse can be emotional, physical, psychological, and sexual, and it can also be in the form of neglect and caregiver fabricated illnesses, the last being commonly called Munchhausen by proxy.21, 24, 25 Risk factors for child abuse include (but are not limited to murder)21, 24:

  1. Characteristics of the child: Children under age 3 and children who have special needs are more likely to be abused.
  2. Parental factors: The parent/caretaker was abused, she/he has alcohol and/or substance abuse and/or mental illness, the caretaker is not biologically related to the child, the parent/caretaker is very young.
  3. Environmental/social factors: Domestic violence, poverty, social isolation.

There are many characteristic signs and symptoms and patterns of injury associated with child abuse like bruises, burns, fractures, and head trauma, all of which are indicators of that child abuse.24 For screening and detection purposes, clinicians should also keep in mind that the emotional and psychological condition of the child and the history surrounding possible incidents of child abuse are important. When considering the possibility of child abuse, consider these three issues.

  • Child-caregiver interaction: Is the child agitated, fearful, or otherwise emotionally and/or psychologically upset when she/he is with the caregiver? What are the caregiver’s attitude and behavior towards the child – attentive and concerned or cold, disinterested, and harsh?
  • History of the injury: Does the caregiver’s story of how and why the injury occurred make sense? Did the caregiver delay getting help for an injured child? Has the child had previous injuries or had the same injury before? Are the injuries increasing in frequency and severity? Does the child have an injury or a medical condition that could not happen to a child, like genital trauma, a sexually transmitted disease, or physical trauma that could not happen to a child given her/his age, body weight, and level of physical activity? Does the child have bruises or fractures that are clearly days, weeks, or months old, but the caregiver is claiming that the child was just injured?
  • Condition of the child: Is the child well nourished? Does he/she have frequent illnesses or injuries? Is the child withdrawn, apathetic, or fearful?

Health care professionals have a duty to report child abuse, and the responsibility is detailed in nurse practice acts, professional ethics codes, the standards of healthcare facilities, and state and local statutes. The Federal Child Abuse Prevention and Treatment Act requires every state to have in place procedures that detail who is required to report child abuse, and almost every state designates which professions are included. For more information, see Mandatory Reporters of Child Abuse and Neglect, published by the U.S. Department of Health and Human and available online here.

The CDC’s publication Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities, 2016, provides guidelines, plans, and resources for preventing child abuse. The publication can be accessed here. Other information from the CDC on this topic is on their website, Centers for Disease Control and Prevention. Violence Prevention. Child Abuse and Neglect Prevention. March 14, 2019.

Accidents and Poisonings

Accidental injuries like burns, drowning, falls, and automobile accidents are the number one cause of death in children 4 years of age and younger.21

Poisonings are a significant source of injury to children, as well. Most poisonings happen in children, and every year in the US, hundreds of thousands of children are poisoned or exposed to a potentially toxic substance.26 The CDC reported that every day in the United States 300 children are treated in ERs for a poisoning emergency, and two children die as a result of being poisoned.21

Children are naturally curious, and exploration of the environment is part of the growth process. They are much more likely to use hand-to-mouth behavior to determine the nature of an object, and they also lack the caution of older children. Serious harm and death caused by pediatric exploratory behavior are unusual; however, children are especially vulnerable to the effects of medications and hazardous substances because of body weight, and even one dose of certain medications or a tasting amount of certain substances can cause serious harm or death in a child.27

Table 3: Medications and Substance That Can Cause Serious Harm/Death in One Dose or a Taste Amount
Antiarrhythmics
Antimalarials
Benzocaine
Calcium channel blockers
Camphor
First-generation antipsychotics
Lindane
Methadone
Methyl salicylate
Morphine
Sulfonylureas
Theophylline
Tricyclic anti-depressants

Poisoning prevention during childhood is often a matter of simple, commonsense interventions like making sure that children cannot have access to medications and hazardous substances. The AAP has a poisoning prevention information/tips page on their website.

Adolescence

Adolescence is a time of significant physical, emotional, and social change.27 Adolescents grow in spurts, mature physically, and are able to reproduce. Mentally, they become more abstract thinkers, can consider many options, are able to choose their own values, and challenge authority. Socially and emotionally, adolescents are developing their own identity and building close relationships. Together all of these processes in the adolescent are termed puberty.

Assessment of Growth and Development in the Adolescent

Height and weight gain, the onset of sexual maturity, and cognitive, emotional, and social maturation are the biggest growth and development changes of adolescents. Each adolescent should be examined to ensure that she/he is growing as expected, sexual maturation is developing as expected, and the adolescent’s cognitive, emotional, and social maturation are proceeding normally.

Height and weight should be periodically assessed in all adolescents. Approximately 17-18% of adult height is gained during puberty,26 and the growth spurt typically occurs earlier in girls than in boys. Puberty is also a time in which body weight and lean body mass increase. Bone growth and bone density increase, as well, and adolescence is an important time for bone health. For girls, one half of total body calcium is in place during puberty and up to two-thirds in boys, making this a time of life that can affect the future health of the bones.27 Height and weight should be evaluated with each visit to a primary care physician,4 adolescents should be screened for eating disorders,29 and the USPSTF recommends that “clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.5

Sexual maturation for the adolescent is assessed by the development of secondary sexual characteristics: breast changes in females, development of pubic hair in females and males, and development of the genitals in males.26 The development of secondary sexual characteristics can be assessed using the sexual maturity rating scale developed by Tanner, e.g., certain changes in breast development by a certain age.26

Cognitive, emotional, and social maturation assessment for the adolescent should be focused on how the adolescent’s development in these areas is affecting adjustment at home, in school, and society.

Assessment and Examination Process and the Adolescent

Two important issues of the assessment and examination process for the adolescence are confidentiality and consent and autonomy.

Confidentiality and consent and the adolescent patient is a complex topic, and each state has different laws regarding these issues. In general, the adolescent is entitled to confidentiality when it comes to information about his/her health status and health care that has been delivered with her/his consent. In most cases, parental consent is required for medical/surgical treatment to be delivered to anyone under age 18, but there are exceptions: emergencies, emancipated minors, low risk/minor illnesses, mental health issues, and care involving contraception, pregnancy, and sexually transmitted diseases.31 For example, teenagers can be tested and treated for an STD, and this information is kept private, even from parents.

Autonomy is defined as the quality of being free and independent, and the establishment of autonomy is one of the major developmental challenges of adolescence. Encouraging autonomy for an adolescent during the assessment and examination process is highly recommended.29 This can be done by including the adolescent, to an appropriate degree, in all parts of the assessment and examination process, e.g., making sure to provide the patient with information (not just the parents), asking the patient about her/his health concerns. This is important for several reasons. It encourages the adolescent to view health as his/her responsibility and as something that can be positively influenced - or negatively influenced - by her/his actions. It also gives the adolescent valuable experience in decision making and planning. Including the adolescent in the assessment and examination process is far more likely to increase compliance with treatment and it encourages the patient to seek help if needed.

Health Screening and Preventive Care for Adolescents (See Table 2)

Table 2: Health Screening for Infants, Children and Adolesents
ScreeningRecommendationAdditional Resources
Alcohol, drug, and tobacco useStarting age 11Patients should be assessed for the risk of use and screened if necessary.4
Anemia4 months – assess for the risk

12 months – screen

After 12 months – assess for risk
Screen as necessary.

The current edition of the American Academy of Pediatrics’ Pediatric Nutrition: Policy of the American Academy of Pediatrics, chapter on iron.
Autism18 and 24 monthsVisit Source
BilirubinNewborns
Blood PressureAll patients 3-21Prior to 3 – risk assessment should be done

Guideline for Screening and Management in Children and Adolescents. These guidelines can be viewed here.
Body Mass Index (BMI)24 months to age 21
Critical Congenital Heart DefectAll newborns using pulse oximetryFor more details, see Endorsement of Human and Health Services recommendation for pulse oximetry screening for critical congenital heart defect
DepressionStarting age 12The USPDTF recommends screening for depression in all patients 12 to 18 years old, and resources should be in place for follow-up and treatment if needed.5
Developmental screening9, 18, and 30 monthsThe Medical Home: An Algorithm for Developmental Surveillance and Screening, and they can be viewed here.
Developmental surveillanceAnnual for all patients
DyslipidemiaAges 24 months, 4 years, 6 years, and 9 years to 21 years- Assess for riskFollow up if needed.

For more information, see the recommendations of the National Heart, Lung, and Blood Institute, Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. These can be viewed here.
Hearing screenAll newborns and 3-5 days old. It should be confirmed that the initial screen was done, the results of this screen should be verified

4 months to 3 years assess for risk

After 3 years – assess for risk
Screen and follow up as needed

See these guidelines for more information:

  • Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. View here.
  • After age 3 years View here.4
Height and weightAll patients, newborn to age 21
HIV infectionStarting age 15Assess for risk and screen as necessary. The CDC recommends HIV testing in all adolescents who have contact with the healthcare system unless the patient opts out.30
LeadAge 6 months and 9 months – assess for risk

Age 12 months, 24 months – measure blood lead or assess for risk

Age 3, 4, 5, 6 years – assess for risk
Screen as needed

To do determine what kids are at risk visit Prevention of Childhood Lead Toxicity or the CDC’s Low Lead Level Exposure Harms Children: A Renewed Call for Primary Prevention.
Physical ExaminationAnnual for all patients
Psychosocial behavioral assessment Annual for all patients
Newborn blood panelAge 3 or 5 days – blood sample of uniform screening panelsThe uniform screening panel tests for genetic disorders, e.g., phenylketonuria and sickle cell disease. Details about the screening can be viewed here.
Sexually transmitted InfectionsStarting age 11Assess for the risk of STIs and screen as necessary.4

See the AAP’s Red Book: Report of the Committee on Infectious Diseases for guidelines on risk assessment.
Skin cancerStart at 6 Months educate and counselUSPSTF recommends parents of children 6 months of age and older, who have fair skin, be counseled about minimizing exposure to ultraviolet radiation as a way of reducing skin cancer.5
TuberculosisAges 1 month, 6 month, 12 month and every year from 2 years of age and up – assess for riskScreen as necessary. Use the AAP Red Book for guidance.
VaccinationsFollow current CDC recommendationsThe CDC recommended vaccination schedule for adolescents 18 years of age and younger can be viewed here.

Vaccination for preventing infection with the human papillomavirus (HPV) is discussed later in this section of the module.
Vision ScreenNewborn and up to 30 months, assess for risk

Age 3 and beyond – annual vision testing
Screen as necessary.

See Visual system assessment in infants, children, and young adults by pediatricians.6

Adolescent: Nutrition

The energy requirements of an adolescent, especially a physically active adolescent, are obviously higher than that of a child and somewhat different than those of an adult or an older adult. However, aside from certain nutrients, the dietary requirements of adolescents are not significantly different. Two specific nutrition issues of adolescence and specific nutrition recommendations for adolescents are listed below. Readers can go to the Office of Dietary Supplements, a section of the USDHHS/NIH website, and there are Fact Sheets for Professionals on all the vitamins and minerals, and these include recommended daily intake. The website link is here.

Calcium: Adolescence is a critical time for bone growth and the recommended daily calcium intake for adolescents aged 13-18, male and female is 1300 mg a day compared to 1000 mg a day for adults.32, 33

Iron: Iron needs are increased during adolescence as blood volume and muscle mass increase, and females have the onset of menarche, and adolescents, especially adolescent girls, are at risk for iron deficiency. Adolescent girls should be screened for iron deficiency starting at age 13. The recommended daily intake of iron for adolescent females aged 14 to 18 is 15 mg (up from 8 mg in the previous years), and for adolescents aged 19, the daily intake should be 18 mg.34

Adolescent: Safety Issues

Safety issues that are of particular concern with adolescents are sexually transmitted diseases, alcohol, drug, and tobacco abuse/use, depression and suicide, accidents and unintentional injuries, especially automobile accidents,4 and interpersonal and sexual violence.35

Sexually Transmitted Diseases

Sexually transmitted diseases (STDs) are a major health issue in adolescents. Approximately half of the newly acquired STDs occur in people aged 15-24 and approximately one in four sexually active adolescent females has an STD.35 Adolescents are susceptible to STDs for behavioral, biological, cultural, and social reasons, e.g., adolescence is the time when sexual activity begins, adolescent females’ bodies are more prone to developing an STD and adolescents may not have the resources or inclination to seek preventive care or treatment.

All sexually active females younger than 25 years of age should be tested for chlamydia and gonorrhea once a year. All pregnant adolescents women should be tested for hepatitis B, HIV, and syphilis.

Infection with HPV is prevalent, and HPV can be transmitted by any form of sexual intimacy.36 The CDC recommends routine vaccination with the HPV vaccine for boys and girls starting between the ages of 9-11.37 The CDC also recommends HPV vaccination for females aged 13 to 26 and males 13 to 21 if they have not been previously adequately vaccinated; the vaccine is given in 2-3 doses and vaccination in these age groups would be done if a dose was missed.37 Routine screening for HPV is not recommended in females < 21 years of age.5

Alcohol, Drug Use, and Tobacco

The use and abuse of alcohol and drugs and tobacco use are significant problems in adolescents. The statistics listed below are from the 2018 National Survey on Drug Use and Health.38

Alcohol: In 2018 an estimated 1 in 11 adolescents aged 12 to 17 were current alcohol users and approximately 1 in 21 were binge drinkers.37

Drugs: In 2018, approximately 1 in 6 adolescents ages 12 to 17 had used an illicit drug in the past year and approximately 1 in 8 has used marijuana.37 Approximately 1 in 26 adolescents in this age range needed substance abuse treatment.

Tobacco: In 2018, approximately 99,000 adolescents aged 12-17 were daily cigarette users and in 2018, 1 in 5 high school students and 1 in 20 middle school students used e-cigarettes.37,39,40 Office of the Surgeon General, Alcohol, drug, and tobacco use: Starting at age 11, patients should be assessed for the risk of alcohol, drug, and tobacco use and screened if necessary.4 The Bright Futures guidelines recommend the use of the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) screening tool. This tool can be downloaded here.

Table 4: The CRAFFT Screen
Car - Have you ever ridden in a car driven by someone (including yourself who was “high” or had been using alcohol or drugs?
Relax - Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
Forget - Do you ever forget things you did while using alcohol or drugs?
Friends - Do your family of friends ever tell you that you should cut down on your drinking or drug use?
Trouble - Have you ever gotten into trouble while you were using alcohol or drugs?

One point is given for each yes answer. If the score is ≥ 2, then there is a problem with alcohol/drug use and adverse consequences and dependency are likely.

Screening for tobacco use can be done by asking using the system of 5 As: Ask, Advise, Assess, Assist, and Arrange:41 ask about tobacco use; advise about the dangers; assess the patient’s risk for using tobacco; assist him/her to avoid its use, and; arrange for smoking cessation intervention if needed.

The National Institute on Drug Abuse (NIDA) recommends several research-based programs for the prevention of drug use.42

  1. Principles of Substance Abuse Prevention for Early Childhood.
  2. Preventing Drug Use among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders.43

There are multiple interventions and approaches that have been used to prevent adolescent smoking. A recent review found that interventions that are based in healthcare settings and that focus on specific, individual reasons why adolescents start smoking, e.g., peer pressure, perceived social norms, the social context in which adolescent smoking occurs, and individual feelings of self-control are the most effective.44

Depression and Suicide

Major depression in adolescents is a common and serious problem, and it is associated with acute and chronic morbidity and mortality.45 In 2018 approximately 1 in 7 adolescents aged 12 to 17 had had had a major depressive event in the past year and 1 in 10 had had a major depressive event with severe impairment.37 Major depression in adolescents also frequently goes unrecognized, and the AAP and the USPSTF recommend depression screening starting at age 12.4, 5, 45 The AAP recommends using the Patient Health Questionnaire-2 (PHQ-2) as a screening tool, but clinicians can also use other screening tools; information about these can be found in the GLAD-C toolkit; this can be viewed here.

Patient Health Questionnaire-2
Over the past two weeks, how often have you been bothered by any of the following problems:

  • Little interest or pleasure in doing things?
  • Feeling down, depressed, or hopeless?

Suicide is the seconding leading cause of death in 12 to 25 year-olds. and the suicide rate in American adolescents has been steadily increasing in the past 10 years.46,47,48 Most adolescents who attempt or commit suicide have a serious psychiatric disorder, usually depression. Other factors that put adolescents at risk for suicide include (but are not limited to) anxiety disorders, emotion, physical and sexual trauma, family conflict, feelings of hopelessness, and a stressful life event.48

Accidents and Unintentional Injuries

Accidents and unintentional injuries are the number one cause of death in adolescents, and most of these deaths are caused by automobile accidents.49,50 Risky behavior is common during adolescence. The Youth Risk Behavior Surveillance, 2017, reported that 5.9% of adolescents never or rarely wore a seat belt, 16.5% had ridden in a car driven by someone who had been drinking, 15.7% had carried a weapon, and 13.8% did not use any contraceptive method while having intercourse.51

Interpersonal and Sexual Violence

The Youth Risk Behavior Surveillance, 2017, reported that 6.0% of students had been threatened with a weapon or injured with a weapon, and 23.6% had been in a physical fight.51 As regards sexual violence, 7.4% of students had been forced to have sexual intercourse and 68.3% had been forced to do sexual activity by someone they had been dating.51

The CDC’s program, STOP SV: A Technical Package to Prevent Sexual Violence, is not designed explicitly for adolescents but it provides basic information on the topic.51 The STOP SV program can be accessed here.

Adults: Ages 21-64 Years

Adults are sexually and physical maturity. Their nutritional needs are for maintenance, not growth. Chronic illnesses are either evident at this time of life or have yet to develop, so the adult faces the threat of illness or death from the impact of unhealthy lifestyles. Mentally, they learn new skills and information to solve problems. They are very concerned about affiliation, love, and intimacy: personal identity and an acceptance of self-enable the young adult to form their own independent decisions. Major stress factors occur as this individual establishes a career and family. Their fears include losing their jobs and status in established social relationships. The young adult chooses a lifestyle and career to fulfill goals, seeks closeness with others and may make a commitment to start a family and become an active member of his community.

The middle-aged adult begins to develop physical changes and (possibly) chronic health problems. Women go through menopause. Mentally, they use past experience to learn, create and solve problems. People of this age are concerned about staying productive, and they hope to contribute to future generations and strive to balance dreams with reality. They start planning for retirement and may end up taking care of parents or children.

Health Assessment of the Adult

Health assessment of the adult is, in many ways, less complex than health assessment of other age groups. Physical, emotional, and social development continues, but these have stabilized to a degree and profound changes in these areas of a person’s life are not as marked as they are in infancy and childhood, adolescence, and old age. The health assessment of an adult then should focus on the identification of lifestyle behaviors that may contribute to poor health and management of those disease states/chronic illnesses that have developed. Preventive care, health education, and encouragement of healthy behaviors are key issues for health assessment of this age group.

Health Screening and Preventive Care and Adults

Health screening is one of the primary ways in which illness can be prevented. In infancy, childhood, adolescence, and in the aging adult, the specific health screenings that are needed are determined by the physiological, emotional, and social stages of development particular to these age groups. However, as previously mentioned, profound changes in these areas of a person’s life are not as marked in adults as they are in infancy and childhood, adolescence, and old age. Because of those issues, health screening for adults is both broader and more specific, and the questions of for whom and when it should be done, how to interpret results, cost-effectiveness, and the proper and most efficacious screening tools are very important. Health screening is a complex topic and cannot be completely discussed in this module. However, several points about health screening in adults deserve mention.52 These apply to the use of screening tools for all populations.

  • Health screening tools should be evaluated for their sensitivity and specificity.
  • Simplicity and cost: Screening tools should ideally be simple and inexpensive.
  • Safety: First, do no harm is a guiding principle of all health care and it applies to screening tests. Risk cannot be eliminated but prevention of illness/injury is the primary use of a screening tool; a screening test should prevent, not create problems.
  • False positive and false negative consequences.
  • Over-diagnosis and overtreatment.
  • Acceptability to the patient.
  • Utility: The screening test should be able to identify a problem or potential problem for which practical, effective steps can be taken.

There is no universal agreement on adult health screening, but the recommendations in Table 5 are from the CDC, the U.S. Preventive Services Task Force, The Guide to Preventive Clinical Services 2014 and the 2015 review by Park.52 The recommendations listed in Table 5 are the ones for which screening advised for the general population without risk factors for specific disease. However, for some diseases, the risk factors are so prevalent that discussion of screening is reasonable, e.g., diabetes, lung cancer.

Table 5: Health Screening and Preventive Care for Adults
ScreeningRecommendation
Alcohol and drug screeningSaitz recommends that the primary care clinician screen all patients for unhealthy alcohol use and drug use using basic screening questionnaires, e.g., the AUDIT-C for unhealthy alcohol use and the Substance Use Brief Screen for drug use.53

Audit-C
 
  1. How often do you have a drink containing alcohol?
  2. How many drinks containing alcohol do you have on a typical day when you are drinking?
  3. How often do you have six or more drinks on one occasion?
The answers are scored from 0 to 4, and the total score indicates the risk for problematic alcohol consumption.
Blood glucose, DiabetesThe USPSTF recommends screening that adults aged 40-70 who are overweight or obese should be screened for diabetes, and this screening should be part of a cardiovascular risk assessment.29 The American Diabetes Association (ADA) notes that many American adults who have diabetes are undiagnosed, and the ADA recommends screening adults for diabetes by assessing for risk factors (e.g., HTN, the presence of CKD) or with a risk assessment tool.54 Screening, detection, and implementation of lifestyle changes have been shown to significantly reduce the incidence of type 2 diabetes and the progression from pre-diabetes to type 2 diabetes.54
Breast cancerThere are multiple recommendations for breast cancer screening, e.g., the American Cancer Society (ACS) recommendations, the American Society of Breast Surgeons (ASBS) recommendations. The recommendations involve identification of risk factors as part of the screening process, which methods to use and when, and when to start and stop screening. For example, the ASBS recommends an assessment of the risk of breast cancer in women > age 25, yearly mammograms for all women starting at age 40 and for women who have a higher than average risk for breast cancer, supplemental imaging should be offered.55 The ACS notes that breast cancer screening in women aged 40 to 69 has been associated with a decrease in deaths from breast cancer, and women who are at average risk should have screening mammography starting at age 45, and this should continue if the patient is likely to live 10 years or more.56 The USPSTF recommends that screening before age 50 should be done on a case-by-case basis, and women between 40-49 should consider the risks and benefits of screening.29

Regarding breast self-exam or a physical examination of the breasts by a healthcare provider, the ACS states, “Research has not shown a clear benefit of regular physical breast exams done by either a health professional (clinical breast exams) or by women themselves (breast self-exams). There is very little evidence that these tests help find breast cancer early when women also get screening mammograms.55
BRCA mutationBRCA1 and BRCA2 are genes that produce tumor suppressor proteins, and inherited BRCA1 and BRCA2 mutations are considered risk factors for breast cancer. The lifetime risk of breast cancer in women is approximately 12% but if these mutations are present, the lifetime risk is 69-72%.55 The USPSTF recommends that women who have a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations should be assessed with a familial risk assessment tool.30
Cardiovascular risk assessmentPatients aged ≥20 years of age and older should have a cardiovascular risk assessment done every three years.44 This risk assessment can be done by using commonly available assessment tools: The Framingham risk score calculator or the American College of Cardiology/America Heart Association risk calculator.44
Cervical cancerThe American College of Obstetricians and Gynecologists (ACOG) and the USPSTF recommend that screening for cervical cancer should begin at age 21; women < 21 should not be screened, regardless of when they became sexually active or the presence of other behavior-related risk factors Committee on Practice Bulletins—Gynecology, 2016. These women should be tested every 3 years with a cervical cytology test alone, and for women aged 30-65, contesting Cervical cytology and HPV testing should be done every 5 years, or they can have cervical cytology every 3 years Committee on Practice Bulletins—Gynecology, 2016.
Colorectal CancerTHE ACS recommends that for people who have average risk, screening for colorectal cancer should begin at age 45, using a stool-based test or an invasive, visual test, e.g., colonoscopy.57 The stool-based test should be done every year or every 3 years (Stool DNA test), sigmoidoscopy and virtual colonoscopy every 5 years, and a colonoscopy every 10 years. Screening should continue if the patient is expected to live 10 years or more until age 75. From 76 to 85, the need for screening should be determined on a case-by-case basis, and after age 85, screening should not be done.57

For people who have an above-average risk, (e.g., IBD, family history of colorectal cancer) screening may need to begin before 45 and be screened more often.57
DepressionThe USPSTF recommends screening for depression in the general population and in pregnant and postpartum women.58 The conclusions of the USPSTF were that screening improves detection and identification of depression; depression screening combined with treatment improves outcomes, and there is little to no risk from depression screening. The optimal timing and intervals for depression screening have not been established. The USPSTF did not recommend a specific screening tool, but it did mention that the various forms of the Patient Health Questionnaire (PHQ), the Hospital Anxiety and Depression Scales, the Edinburgh Postnatal Depression Scale, and the Geriatric Depression Scale are commonly used.58

Pregnant and postpartum women who are at risk for perinatal depression should be referred for counseling.5
DyslipidemiaSokol59 recommends that patients aged 17-21 be screened for hyperlipidemia. If the patient is high-risk and the initial screen is normal, men should be screened again starting at age 25 and women at age 35. If the initial screen was normal and the patient is not high-risk, rescreen again at age 35 for men and age 45 for women.
Hepatitis BThe CDC recommends screening for hepatitis B in the following populations59:
 
  • All pregnant women
  • People who were born in an area with an intermediate or high prevalence of hepatitis B
  • People born in the United States to parents who are from an area with a high prevalence of hepatitis B
  • Infants born to a mother who is hepatitis B surface antigen (HBsAg) positive
  • Anyone who shares needles, has sex with, or lives with someone who is HBsAg positive
  • Injection drug users
  • Men who have sex with men
  • Hemodialysis patients
  • People who donate blood, plasma, organs, semen, or tissue
  • People who have elevated liver enzymes of unknown etiology
  • People who are on cytotoxic or immunosuppressive therapy.
Intimate partner violenceApproximately 36% of women and 33% of men in the United States have experienced intimate partner violence (IPV) at least once.5 There is evidence that screening for IPV can detect IPV and that screening, detection, and intervention can reduce the risk of IPV violence to women; there is inadequate evidence that screening and detection are preventive for men.5 Ther is no evidence that screening causes harm. Tools that can accurately screen women for IPV include the Humiliation, Afraid, Rape, Kick (HARK); Hurt, Insult, Threaten, Scream (HITS); Extended–Hurt, Insult, Threaten, Scream (E-HITS); Partner Violence Screen (PVS); and Woman Abuse Screening Tool (WAST).
Latent tuberculosisThe USPSTF recommends screening for latent TB in adult populations who are at risk for the disease.5 At-risk persons include:
 
  • Those who were born in an area, or formerly resided in an area, with a high prevalence of tuberculosis
  • People who live in close proximity to others, e.g., residents of homeless shelters or people who are incarcerated
  • People who are immunosuppressed
  • Anyone who has contact with someone who has active tuberculosis.
Approximately 30% of people exposed to tuberculosis will develop latent TB, and as many of 10% of people who develop latent TB will develop the active disease or have a reactivation. Although there is no evidence that screening adults for latent TB provides a direct benefit, the screening tests (tuberculin skin tests and interferon-gamma release assays) are moderately sensitive and specific, and if the patient is positive, treatment of latent TB does decrease the risk of progression to the active disease.5 There does not appear to be a risk for harm for this screening. The optimal timing interval for latent tuberculosis screening has not been determined.
Osteoporosis<The USPSTF recommends that post-menopausal women < 65 years of age who have an increased risk for osteoporosis be screened. Osteoporosis is very common, women are especially susceptible, and screening in this population has been shown to provide a moderate benefit.5
PregnancyAll pregnant women should be screened for chlamydia, hepatitis B, HIV, and syphilis.5,61 In addition, a standard panel of tests should be done, including (but not limited to) a complete blood count, documentation of immunity to rubella and varicella, urine protein, and ABO and Rh type and antibody screen should be done.62

All pregnant women should be screened for gestational diabetes.5 The ADA recommends the one-step technique: A 75-gram oral glucose tolerance test done at 24 to 28 weeks gestation.63
Prostate cancerThe USPSTF recommends that the risks and benefits of prostate-specific antigen (PSA) testing should be discussed with men aged 55 to 69.5 Prostate cancer is very common in older men, and screening can detect prostate cancer, but there is no evidence that it reduces all-cause mortality, and screening can result in unnecessary treatment, overtreatment, and complications and harm from treatment.5
Sexually transmitted diseasesThe CDC recommendations for screening for sexually transmitted diseases (STDs) are64:

Chlamydia
 
  • Sexually active women < 25 years of age
  • Sexually active women ≥ 25 years of age if they have risk factors
  • Men should be tested if they are in a high prevalence area for chlamydia or if they are men who have sex with men
  • People infected with HIV should be screened at the time of diagnosis and at least once a year after that. More frequent screening should be considered if the patient has risk factors for chlamydia
Gonorrhea
 
  • Sexually active women < 25 years of age
  • Sexually active women ≥ 25 years of age if they have risk factors
  • Men who have sex with men should be tested at least once a year at the sites of contact, e.g., rectum, urethra, even if condoms have been used
  • People infected with HIV should be screened at the time of diagnosis and at least once a year after that. More frequent screening should be considered if the patient has risk factors for chlamydia
Herpes
 
  • Serologic testing should be considered for women and men who have an STD, are presenting for evaluation of an STD, and especially for women who have multiple sex partners
  • For men who have sex with men, serologic testing should be considered if the patient’s herpes infection status is not known and the patient has had a previously undiagnosed genital tract infection and/or if the patient is at increased risk for being infected with HIV
  • Serologic testing should be considered if the patient is infected with HIV
Syphilis
 
  • Men who have sex with men should be tested at least once a year and should be tested every 3 to 6 months of they are at high risk
  • People infected with HIV should be screened at the time of diagnosis and at least once a year after that. More frequent screening should be considered if the patient has risk factors for syphilis infection
Trichomonas
 
  • Screening should be considered if the patient has a high risk for infection or she is receiving care in a high prevalence setting like an STD clinic or a correctional facility
  • Women who are infected with HIV and are sexually active should be tested at the time of entry to care and at after that, at least once a year
Skin cancerThe USPSTF recommends that clinicians determine their patients’ pattern of tobacco use, advise them to stop smoking, and offer behavioral interventions and FDA-approved smoking cessation pharmacotherapy.
Statins and prevention of CVD diseaseThe USPSTF recommends that adults aged 40-75 years of age who do not have a history of cardiovascular disease (CVD) but have 1 or more risk factors for CVD like dyslipidemia, diabetes, HTN, obesity, or smoking or have a calculated 10-year risk of developing CVD that is ≥ 10% should be prescribed a statin drug. Patients who have < 10% risk may be considered for statin therapy; the decision to do so should be made on a case-by-case basis. Evidence has shown that statin therapy provides what has been described as a moderate level of reduction in CVD events and mortality, and the harm of this therapy is small. The ACC/AHA Pooled Cohort Equations can be used to calculate 10-year risk.5
ImmunizationsThe adult immunization schedule recommended by the CDC can be viewed here.

The Aging Adult: 65 and Older

The later years are a time of significant physical and physiological changes for adults 65 years and older. These physical and physiological changes, the increased prevalence of, and risk for acute and chronic diseases, and the emotional, psychological, social issues particular to aging adults require assessment and screening that are specific to this age group.

Of particular interest are the physiological, physical, and cognitive changes associated with aging. Some of the physiological and physical changes associated with aging are listed in Table 6.65

Table 6: Physiological and Physical Changes Associated with Aging
Atrophy of sweat glands
Decreased bladder muscle tone
Decreased bone density
Decreased immune system function
Decreased liver size
Decreased muscle mass
Decreased production of skin oils
Decreased renal mass and loss of glomeruli
Decreased sensitivity of baroreceptors
Decreased strength of respiratory muscles
Decreased visual acuity
Hearing difficulty
Loss of muscle strength

Cognitive changes in aging adults are universal and individual. The cognitive decline that is noticeable and problematic is not an inevitable consequence of aging. However, cognitive ability does change with aging,66 some of the changes are listed below, and clinicians would do well to remember these when assessing an older patient.

  • Memory of recent events may not be as good.
  • Divided attention, the so-called multi-tasking, is less easily done by older adults.
  • Verbal ability is preserved, but it may take an older adult more time to recall a word or to remember a name.
  • Problem-solving that requires a new and unfamiliar approach may take longer.
  • Information processing slows down with age.

Aging Adult: Health Assessment

The health assessment of an aging adult should focus on the issues that are specific to this age group. It should also focus on how the physical and physiological changes caused by aging have affected the older adult. A commonly used approach is the Comprehensive Geriatric Assessment (CGA). The CGA is defined as “as a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person67” and it assesses four aspects of the older adult’s health: Functional status, physical health, psychological health, and socioenvironmental health.68 The CGA can be structured in different ways but it typically includes an assessment of the abilities and health status parameters listed in Table 7.

Table 7: Comprehensive Geriatric Assessment
Cognitive abilities
Co-morbidities
Dentition
Emotional status
Fall risk
Functional capacity: ADL and self-care
Family status
Incontinence
Medication review
Mobility status
Nutritional status
Physical activity status
Vision and hearing status

A complete discussion of the methods and tools used to assess these abilities and health status parameters is beyond the scope of this module. Fall risk, assessment, and screening will be discussed in the section Safety Issues in the Aging Adult; medication review will be discussed in the section Medications and the Aging Adult; nutritional status will be discussed in the section Nutrition and the Aging Adult, and; assessment and screening of cognitive abilities emotional status, and vision and hearing will be briefly mentioned in the section Health Screening and Preventive Care for the Aging Adult. There are multiple screening and assessment tools for evaluating the performance of the activities of daily living.

Aging Adult: Process of Examination

Assessment and examination are processes of information gathering and information exchange, and with this in mind, they must be adjusted to accommodate the aging adult.

The aging adult may well be accompanied by a family member, and there is evidence indicating that this improves patient satisfaction with the assessment and examination and improves the amount and quality of informant retained by the patient.

Aging Adult: Health Screening and Preventive Care

As with other age groups, health screening and preventive care for aging adults should be both universal and patient-based. Given the prevalence of certain diseases in the general population (e.g., cardiovascular disease) and the physical and physiological changes of aging, it is advisable to screen all aging adults for certain conditions.

Table 8: Health Screening and Preventive Care for the Aging Adult
ScreeningRecommendation
Abdominal aortic aneurysmThe American Academy of Family Physicians (AAFP) recommends a one-time ultrasound screening test for al meg aged 65 to 75 who are smokers or have a family history of an abdominal aortic aneurysm that has to be repaired.69
Bone densityThe USPSTF recommends that women 65 years of age and older should be screened for osteoporosis using central dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine. There is no evidence that screening older men for osteoporosis provides any significant benefit.5
Breast cancerThe USPSTF concluded that there is insufficient evidence to recommend breast cancer screening in women 75 years of age and older.5 The ACS notes that breast cancer screening in women aged 40 to 69 has been associated with a decrease in deaths from breast cancer, and women who are at average risk should have screening mammography starting at age 45, and this should continue if the patient is likely to live 10 years or more.70
Carotid diseaseA one-time carotid ultrasound to detect the presence of carotid disease should be considered for patients who are > age 65 and who have a bruit and have coronary artery disease, need a coronary bypass, have symptomatic lower extremity arterial occlusive disease, and/or have high cholesterol or a history of smoking.69
Cervical cancer screeningWomen 65 years and older do not need screening for cervical cancer if they have had three consecutive normal Pap smears within a 10 years period or if they have had a hysterectomy for a benign condition. Screening should be considered for women older than age 65 if their screening history is unknown or inadequate or who are at high risk, e.g., a compromised immune system, a history of high-grade precancerous lesions or cervical cancer.5
Colon cancerScreening for colorectal cancer should begin at age 45 and should continue if the patient is expected to live 10 years or more until age 75. From 76 to 85, the need for screening should be determined on a case-by-case basis, and after age 85, screening should not be done. For people who have an above-average risk (e.g., IBD, family history of colorectal cancer) may need to begin screening before 45 and be screened more often.71
Cognitive impairment and dementiaThe USPSTF recommends against routine screening for cognitive impairment in older adults as there is insufficient evidence about benefits and harm.5
DepressionThe USPSTF recommends screening for depression in the general population and in pregnant and postpartum women.72 Depression is common in older adults, and depression in older adults is often unrecognized and under-diagnosed. The PHQ-2 screening test can be used to screen for depression. If the results are positive, follow up with the PHQ-9.67
Hearing impairmentHearing loss is a common problem in older adults. Up to one-third of all adults 65 years of age and older report some degree of hearing loss, and hearing loss is the third most prevalent chronic health condition in this patient population.73 However, routine screening of older adults for hearing loss is not recommended.5
Lung cancerRecommendations for lung cancer screening in older adults differ,73 but they all agree that screening should be considered in older adults (55 to 74 or 55 to 80, depending on the source) who have a 30+ pack per year history of smoking. The screening test would be a low-dose CT scan.
Prostate cancerRecommendations for and against screening for prostate cancer in men ages 50-69 are controversial, and there is no universal agreement on the topic. The U.S. Preventive Health Services Task Force notes that the “reduction in prostate cancer mortality 10 to 14 years after PSA-based screening is, at most, very small, even for men in the optimal age range of 55 to 69 years.” The American College of Physicians recommends that the prostate-specific antigen (PSA) test should be used to screen men ages 50-69 only in certain circumstances and men > 69 or men who have a life expectancy of < 10 years should not be screened with the PSA test.
Statins and prevention of CVD diseaseThe USPSTF recommends that adults aged 40-75 years of age who do not have a history of cardiovascular disease (CVD) but have 1 or more risk factors for CVD like dyslipidemia, diabetes, HTN, obesity, or smoking or have a calculated 10-year risk of developing CVD that is ≥ 10% should be prescribed a statin drug. Patients who have < 10% risk may be considered for statin therapy; the decision to do so should be made on a case-by-case basis. There is insufficient evidence to determine the balance of benefits versus risks for starting statin therapy in adults ≥ 76 years old.5
Vision screeningThe American Academy of Ophthalmology recommends performing an eye examination every one to two years for all adults 65 years of age and older.70 For certain ocular disorders like glaucoma, for patients at risk for diabetic retinopathy, and for people who have a high-risk for developing an ocular disorder, screening should be done more often and started at an earlier age.71,72

Aging Adult: Preventive Care

Healthy lifestyle: Older adults should be encouraged to follow a healthy lifestyle. Exercise can improve functional ability, it is protective against depression and reduces the severity of depression, and it can also help prevent falls.75,76,77

Patients who smoke should be offered behavioral and pharmacological smoking interventions, and the health benefits of smoking cessation are evident and significant even for long-term smokers who are elderly.78

Alcohol use disorder is less common in older adults than it is in many other age groups, but as many as 14.5% of older adults in the United States have a harmful pattern of alcohol consumption.79 Clinicians should assess patients for problematic alcohol consumption, and there are multiple screening tools available, e.g., the Audit-C or the CAGE tool.

Aging Adult: Nutrition

The nutrition needs and issues that are specific to aging adults are vitamin B12 and vitamin D deficiency and malnutrition.79

Evaluation of the nutritional status of the aging adult should include measurement of weight, a record of the 24-hour nutritional intake, and a physical exam that is focused on signs and symptoms indicative of poor nutrition and micronutrient deficiency.79

Weight loss is clinically significant if there has been ≥ a 2% percent decrease from baseline body weight in one month; ≥ a 5% decrease in three months, or; ≥10% decrease in six months.79

The prevalence of vitamin B12 deficiency in the elderly has been reported to be as high as 23% and approximately 15% of older adults in the United States.79,80 The elderly are at a higher risk for B12 deficiency because of decreased intake, malabsorption, and a higher incidence of pernicious anemia,81,82 and B12 deficiency in the elderly can contribute to the development of anemia, cognitive decline, and dementia.82 Oral supplements or IM injections can be used to treat B12 deficiency. There is no universal recommendation to screen older adults for B12 deficiency.

Vitamin D deficiency is a common problem in older adults in the United States due to inadequate intake and lack of exposure to the sun, and low vitamin D levels have been associated with many health problems.83 Clinicians should consider screening older adults for vitamin D deficiency; It is not clear at what blood level of vitamin D supplementation should be started. Adults from age 51 and up should consume 800 IU of vitamin D a day.

Malnutrition: Malnutrition is a state of nutrition in which energy, protein, and other nutrient deficiencies have a measurable adverse effect on the body, functional ability, and clinical outcome.84 Malnutrition is common in older adults, occurring in up to 10% of older adults living independently and much higher percentages in older adults that are hospitalized or living in a long-term care facility.69,70,85 Malnutrition in older adults occurs for many reasons, including (but not limited to) chronic diseases, dysphagia, poor intake, socioeconomic factors, dental issues, depression, loss of taste, financial constraints, and adverse drug effects.84,85 Older adults appear to adapt less well to poor nutrition, and malnutrition in the elderly increases morbidity and mortality and has many other serious consequences like decreased muscle mass, diminished functional abilities, impaired recovery, and diminished immune function.85

Volkert85 recommends that all older adults be routinely screened for malnutrition.

Aging Adult: Medications

Age-related medication issues in aging adults are pharmacokinetics, adverse drug reactions, polypharmacy, the inappropriate use of medications, co-morbidities, and the need for a medication review.

Pharmacokinetics change as we age.86 The size and capabilities of, and blood flow to organs that are responsible for absorption, metabolism, and excretion of drugs diminishes significantly.87 Body fat increases, body water content decreases, and the level of serum proteins decreases, all of which affect drug distribution.88

The most obvious practical consideration for these differences in pharmacokinetics is the dosage. For example, benzodiazepines are typically prescribed in lower doses for aging adults, and close monitoring of the patient during treatment with these drugs is recommended as the use of benzodiazepines in this population is strongly associated with falls.86,89 Decreased renal clearance, decreased hepatic metabolism, and greater absorption into fat stores can cause high plasma levels of benzodiazepines, increasing the risk for sedation and other adverse effects.

Adverse drug reactions are defined as an injury caused by a medication.90 Adverse drug reactions are widespread in aging adults.87,88,90 and these patients are at a high risk for adverse drug reactions because of polypharmacy; changes in how drugs are absorbed, metabolized, distributed, and excreted; use of inappropriate medications; co-morbidities that affect pharmacokinetics and pre-dispose to adverse drug reactions; the difficulty in recognizing an adverse drug reaction in this population; improper prescribing and monitoring, and lack of regular medication reviews.87,90

Polypharmacy is not universally defined, but 5 or more medications in active use is an often used and practical definition.86 Polypharmacy is common in the elderly adult, with nearly 20% of community-dwelling adults 65 years of age and older taking 10 or more medications.

Polypharmacy is often a natural consequence of the multiple medical problems of the older population. Another common cause is a phenomenon called the prescribing cascade. In the prescribing cascade a new medication is prescribed to treat signs and symptoms that are presumably from a new illness but are actually an unrecognized adverse reaction from a current medication86 For example, anti-Parkinson’s drugs may be started to treat symptoms caused by anti-psychotics, adding to the risk for adverse effects and drug-drug interactions.

There are significant consequences and many potential problems associated with polypharmacy in aging adults. Polypharmacy in this population often means patients have a higher risk for adverse effects and drug-drug interactions; they may be taking drugs that they no longer need or drugs that have the same clinical effect; in can increase non-adherence to the medication regimen, and ; it is associated with increased morbidity and mortality, increased risk of hospitalization and emergency room visits.91

Potentially inappropriate medications are drugs that should not be used or should be avoided in older adults because the risk of adverse effects is greater than the benefits, and safer alternatives may be effective.92 The use of potentially inappropriate drugs has been reported to be as high as 53.7%, and these drugs are a significant cause of adverse drug effects, hospitalizations, and mortality in this patient population.92 The American Geriatric Society has a list of mediations that are considered potentially inappropriate for older adults. This list is called the BEERs Criteria,93 and it includes medications like benzodiazepines (risk of cognitive impairment and falls), antipsychotics (increased risk for stroke), peripheral alpha 1 blockers used for hypertension (risk of orthostatic hypotension), and long-acting sulfonylureas (prolonged half-life in older adults can cause hypoglycemia).

Co-morbidities have a noticeable effect on medication uses in aging adults. The greater the number of medical problems the greater the number of medications is likely to be prescribed, increasing the risk of adverse effects and drug-drug interactions.

A medication review has been defined as a structured, critical examination of the patient’s medicines intended to optimize the beneficial effects of the medication regimen and minimize drug-related problems. Medications reviews are time-consuming and it is not clear as to who would most benefit from them, but a medication review may be helpful in reducing the incidence of common problems such as cognitive dysfunction, incontinence, and falling that are associated with polypharmacy and with the inappropriate use of medications in aging adults.

Aging Adult: Safety Issues

There are multiple safety issues that affect the aging adult: two of the most common and serious that are of immediate concern to nurses are elder abuse and falls.

Elder abuse is a pervasive and serious safety issue for aging adults. According to the National Council on Aging, approximately 1 of every 10 Americans 60 years of age or older have experienced elder abuse, and it has been estimated that only 1 out of 14 cases of elder abuse are reported.94

Elder abuse has been defined in different ways, but it is typically considered to be intentional actions that either cause harm or a risk of harm done by a caregiver or someone in a position of trust.94 There are five types of elder abuse, listed and defined below.95

Financial exploitation: Misusing and or exploiting an older adult's financial resources.

Neglect: Failing to provide the necessities of life.

Physical abuse: Inflicting injury or pain.

Psychological abuse: Threats, verbal assault, harassment, intimidation.

Sexual abuse: Nonconsensual touching or sexual activities.

Factors that increase the risk for elder abuse include, but are not limited to, advanced age, female gender, dementia, inability to provide self-care, and characteristics of the caretaker.94,95,96 Signs of elder abuse vary depending on the type of abuse. For example, physical abuse can be characterized by bruises, burns, fractures or pressure ulcers; neglect by weight loss, unexplained illnesses, or an unexplained worsening of a chronic health condition.96 Screening patients for elder abuse is recommended by several professional organizations, but there is no evidence that this screening is helpful or effective.97 Screening tools that can be used include the Brief Abuse Screen for the Elderly (BASE) and the Elder Assessment Instrument (EAI).96

A fall is described as an unexpected event in which someone comes to rest on the floor or the ground.98 Falls are a common event in older adults, and it has been estimated that falls occur in up 40% of adults 65 years of age and older, the incidence is higher for residents of long-term care facilities and adults over age 75.98 There are multiple risk factors that contribute to falls in the elderly, including (but not limited to) medical conditions like dementia or stroke; adverse effects of medications, polypharmacy, or the use of specific medications that cause CNS depression, orthostatic hypotension, or affect balance; advanced age, living alone, sedentary lifestyle; muscle weakness and impaired vision, and; environmental hazards.98

Falls in the elderly can cause serious injuries and other consequences like impaired mobility, and a fall assessment is recommended for all older adults, at least once a year, and more frequently for at-risk patients.98,99 Screening involves questioning about fall history, e.g., do you have difficulty with balance or gait, have you had a fall in the past 12 months; if the patient or caretaker report positively to the questions, a more formal fall assessment can be done and there are several well-validated screening tests for fall assessment like the Timed Get Up and Go.98,99

Fall prevention strategies can prevent falls, and given the multitude of possible causes, the interventions are done on a case-by-case basis. The patient may need a medication review and adjustment; exercise has been shown to reduce the risk of falls; the patient may need a psychologic intervention, or an environmental intervention is necessary.98,100

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