Pediatric Case Study
Part I. Cultural and Family Assessment
Culture and family are oftentimes neglected during patient assessment, especially when the person is viewed only in terms of disease, causes and treatment. However, providing holistic care that encompasses all aspects of the patient’s life has the potential to improve patient outcomes. In nursing theory, Callista Roy and Madeleine Leininger refer to culture as a belief system, a worldview through which the patient perceives health, care, nursing and the world in general (George, 2011). It is transmitted from one generation to the next through interaction in social institutions such as the family, school and church which results in homogeneity. These beliefs shape the ways of thinking and behavior of people.
The role of culture in health status should not be ignored. Patients respond to illness and health care in different ways depending on how they perceive the situation. For example, a belief that health is a form of divine punishment for wrongdoings would tend to refuse comfort care as a way of assuaging guilt. Cultural traditions concerning health and illness also affect patient practices and preferences for care. If a discrepancy in cultural beliefs between health provider and patient occur, a cultural conflict situation exists which may result in patient resistance to care, noncompliance or distress (George, 2011). It is important to evaluate culture in terms of cultural affiliation, values, cultural restrictions, communication, health practices and socioeconomic status and in order to tailor health care to accommodate these elements (Transcultural nursing, n.d.). One tool which can be used is the Andrews-Boyle Transcultural Nursing Assessment guide. It is also helpful to use the culture, language and heath literacy resources on ethnicity available through the Health Resources and Services Administration (HRSA) website.
The family, as a vehicle for the transmission of culture, is also an agent of health promotion. According to the family systems theory, it is deemed a circular system with members influencing others and themselves being influenced in the process (McDaniel et al., 2005). As such, there is interdependence where role performance of one member has an impact on that of the others. In this manner, the family is able to shape, reinforce or change the lifestyle of its members (McDaniel et al., 2005). Children tend to adopt the behavior of parents so that families usually share the same diet and engage in the same physical activities. Successful lifestyle modification then requires change in parental behaviors and full parental support as the child makes changes in lifestyle. An assessment of the family follows an anatomy-physiology model with a family genogram providing information on the members, and a family life cycle providing data on functioning (McDaniel et al., 2005).
The family is of Hispanic background with the mother born in the U.S. and the father immigrating when he was 8 years old. Both can speak Spanish though English is the main language they use at home now that the children are going to school. Child can speak and understand Spanish. The family is middle class. Both parents have not graduated from college and value hard work and education for their children. The child’s consistent academic performance in school reflects successful socialization of this value. The child joins church-related activities during the summer and is aware of Biblical stories and the values being advocated. They affiliate to a charismatic Christian church but are not active members since they do not know anybody at the local church. This reflects the tendency of Hispanics to base social participation on personal relationships (National Alliance, 2001). However, they have formed social networks with the other Hispanic families through encounters at school meetings and work. This gives them a sense of community.
Regarding health beliefs, nutrition is judged in terms of food amount and availability rather than quality. More food means more nutrition. As the family eats only two meals per day, these tend to be large and heavy to make up for the one skipped. Home-cooked foods are usually fried and traditional Hispanic cuisine, such as tortillas and rice, form only a small portion of the diet reflecting their acculturation. Due to economic and time constraints, cheaper and ready-to-eat fast foods constitute majority of dinner meals and are usually consumed Thursday through Saturday when the mother works until 6:00 PM. Fruits and vegetables are not integrated much into the diet because the children refuse to eat them.
Regarding leisure activity, the children usually watch television during Saturdays as the mother goes to work and the father considers it his rest day. On Sunday afternoons, the family visits with grandparents. Leisure is viewed as the opposite of work and physical exercise is deemed similar to work in terms of physical effort. For this reason, physical exercise is not a component of family leisure time.
The family also views signs and symptoms of illness as not always needing medical attention. For example, if symptoms are tolerable, there is no need to seek medical consultation. The mother often consults her parent or in-laws for health advice and home remedies regarding minor symptoms. For example, Health care is often sought during the acute stage of illness or when symptoms do not abate after some time and have become distressing. Thus, treatment of illnesses has not always been prompt.
The family is close-knit and nuclear in structure with close relationships between parent and child. Father comes from a nurturing family revealed in continuous and high grandparent involvement in grandchildren care. Parents exercise a more democratic parenting style and disciplining children is through withdrawal of privileges such as watching television or going out with friends. This parenting style is permissive to the expression of emotions and ideas. There is marked sibling rivalry manifested in frequent arguments which is normal given the close age range between child and younger sister. Excitement over new sibling reflects child acceptance of a new member of the family and the role of older sister.
Part II. History and Physical, Diagnosis and Treatment Plan
Chief Complaint: 7-year-old female in for a well-child visit. Parent reports child “often complains of her tummy hurting.”
History of Present Illness
On previous visit, child has been diagnosed with seasonal rhinitis and is currently taking OTC Benadryl prn. About 4 weeks ago, she started feeling pain in her abdomen upon waking up in the morning. This occurs 3-4 days a week. Child is able to go to school despite the pain which corresponds to a score of 1 on the Functional Pain Scale. She rates her pain as mild on the Wong-Baker FACES scale; it has not changed in severity. Pain is described as continuous and child points to epigastric area as the localization of pain. It occurs even after successful bowel movement. It is partly relieved when she places her hand on her abdomen. No pain felt anywhere else. Child states pain sometimes goes away after she eats her morning snack in school. There is no associated nausea, vomiting, diarrhea, fever, flatulence or any other symptoms.
Review of Systems
Denies fever, chills or night sweats. No daytime sleepiness or significant fatigue. No appreciable weight loss.
Has no difficulty sleeping. No interruptions or nightmares.
Denies rashes or itching. No changes in color.
Denies vision changes. No difficulty hearing. Has frequent coryza with sniffling, itchy nose and eyes, and episodes of sneezing. She denies toothache, sore throat, or difficulty swallowing.
Denies cough or shortness of breath. No difficulty breathing even with exertion.
Denies chest pain or racing heart.
Complains of mild abdominal discomfort several mornings a week. No nausea or vomiting. Denies diarrhea. Has only 2-3 BMs a week, hard in consistency. With frequent constipation. Reports that tissue paper sometimes has blood on it.
Denies pain or difficulty with urination. Has had no episode of enuresis. Denies frequent urination.
Denies joint pain or muscle weakness. No limitations in activity or movement.
No history of diabetes or thyroid problems.
Has not had any blood transfusions. Denies easy bruisability or bleeding problems.
Has frequent nasal allergies and at least once a year of atopic dermatitis. Completed the CDC recommended immunizations for children but missed the flu vaccine last year.
No history of head injuries. Denies headaches or dizziness. No episodes of seizure.
No hyperactivity or impulsivity. Has good attention span. Denies feeling depressed. No sudden behavior changes as per parent report. Parent states that overall, child is cheerful and outgoing; she enjoys playing after school with her friends. Occasionally attends sleepovers. Expresses excitement over new sibling. She loves school and gets either an A or B in her classes.
As noted above. Neither parents smoke; mother stopped smoking after Samantha’s first ear infection. Maternal grandmother smokes cigarettes. Samantha admits that she has been teased by some of the girls in her class because of her weight. Her best friend is not overweight. Samantha and her sister get "in trouble" for arguing a few times a week and when she gets into "trouble"; she has privileges, such as TV, video games, or time with her friends taken away. Samantha says she argues with her sister because “she gets in my stuff and it really makes me mad sometimes!” Samantha admits that she really likes it when her Mom takes her to Dairy Queen for a Blizzard whenever her sister isn’t around.
Past Medical History: Parent states child has had otitis media x3 at 18 months, 3 years and then 4 years old; also has had intermittent atopic dermatitis starting when she was 3 years old. No history of wheezing or asthma. Parent reports strep pharyngitis once last year. No other infections. Growth rate has remained steady around the 50th percentile.
Family History: Father is aged 29 with a two-year history of type 2 diabetes, seasonal allergies and peptic ulcer disease. He is deemed “overweight.” Mother is aged 28 and healthy. She took allergy “shots” in her teens; currently G3P2, 4 months along. Maternal grandmother, aged 48, is alive and has hypertension. Maternal grandfather died at age 47 from colon cancer. Paternal grandmother is living at age 63 with type 2 diabetes, obesity, arthritis, and dyslipidemia. Paternal grandfather is also living, aged 66, and has hypertension and dyslipidemia. She has one female sibling aged 5 and healthy.
Social History: Child attends public school, now in her first grade. She goes to afterschool care during the school year and to a summer care program during the summer. Activities there include structured play, free play and arts activities. During the summer months, she and her sister stay with their paternal grandparents for several days each month. Grandparents bring them to Vacation Bible School at the local church. Parent states child is not involved in extracurricular activities because of both the time commitment and the additional expense. The family lives just down the block from a neighborhood park but they rarely go there for leisure activities due to time constraints.
Current Health Maintenance and Well Child Teaching
1. Current medications:
Benadryl 10 ml prn
Reiterate the need to drink meds at bedtime because of potential sedative effects and to take drug with food to prevent GI distress (Doyle, 2009).
2. Use of CAM treatments
The family uses CAM mainly through home remedies for minor conditions as advised by parents. For example, the husband chews raw or fried garlic for his diabetes.
3. Drug allergies
Child does not have any known drug allergies.
4. Immunization status
She has completed the CDC recommendations for rotavirus, hepatitis A and B, diphtheria, tetanus, pertussis, pneumococcal disease, Haemophilus influenzae, polio, rubella and flu (Recommended immunizations, 2012). However, she missed last year’s flu shot. Emphasize the need to get flu shot this year.
5. Developmental assessment
Cognitive: child excels in school. Behavior: relates well with others, is able to form friendships, participates in peer activities (sleepovers); Emotions: able to express emotions though sometimes in a nonconstructive way (arguing with younger sister).
6. Dietary assessment
Skips breakfast, eats 2 meals a day with 1-2 snacks. Typically has 2-3 servings of dairy, 2-3 protein servings, 1-2 vegetable servings, 1-2 fruit servings, and 4-5 bread/grain servings daily. Family eats "fast food" for dinner about 3-4 times a week. Though her diet includes foods from all the food groups, she has less than the recommended servings of fruit and vegetables. She also has only 2 meals a day and one of them is likely to be fast food. At present, she is obese and caloric intake needs to be reduced and energy expenditure increased. Daily water intake is about 4 glasses with 3-4 glasses of soda or flavored drinks. Underscore the need to increase fiber and water intake and reduce consumption of high-calorie foods and drinks. This will also prevent frequent constipation.
7. Dental care assessment
She has 6 permanent teeth (upper middle incisors and lower middle and lateral incisors). She has had 2 tooth extractions and tolerated the procedure well. Parent states child often forgets to brush her teeth before going to bed. She goes to the dentist regularly. Emphasize the need to brush teeth at least twice a day to prevent caries and protect permanent teeth.
8. Safety issues
Set limits for creative play in terms of where they can play and what they can do because they become more adventurous. Ensure street safety, water safety, fire safety and safety from falls.
9. Sleep patterns
She has adequate and uninterrupted sleep. Usually goes to bed at 9:00 PM and wakes up at 6:00 AM with an average sleep of 9 hours.
Develop sense of responsibility by involving child in house chores such as clearing the table after meals or making their beds. Teach child to balance school work and play. Television or internet/computer time should be for 2 hours a day only and use should be supervised to prevent possible exposure to sex and violence. Teach child how to express emotions in more constructive ways instead of arguing.
Height: 49 in
Weight: 78 lbs.
BMI: 22.8 (98th percentile)
Clean, well nourished, obese, NAD.
Warm and dry; adequate turgor. No rash or lesion noted.
Normocephalic. Conjunctiva/sclera clear bilaterally, PERRL, EOMs equal and intact bilaterally. Red light reflex present bilaterally. TMs mildly inflamed with good light reflex bilaterally. Nares patent, septum intact, turbinates not inflamed, profuse clear nasal drainage noted. Posterior pharynx with scant clear postnasal drainage, tonsils pink 2-3 + without exudate. Normal dentition.
Lungs CTA bilaterally with good chest wall expansion.
RRR without murmur or secondary sounds; no bruits. Peripheral Pulses: radial, 2+ amplitude, no bruits; femoral, 2+ amplitude, no bruits; dorsalis pedís, 2+ amplitude, no bruits, no extremity edema.
Tanner Stage 1.
Rounded, (+) bowel sounds in all quadrants. Nondistended. Soft, diffusely tender to deep palpation throughout. No hepatosplenomegaly or masses, no bruits.
No facial nodes; no inguinal lymphadenopathy.
Alert and oriented x3. CN II-XII intact. Motor and sensory function, reflexes, gait and coordination are all intact.
Appropriate affect and demeanor, normal speech pattern. Answers questions appropriately for age, converses easily.
Medical Differential Diagnoses
2. Functional abdominal pain syndrome.
3. Helicobacter pylori infection.
Abdominal pain is one of the most common reasons for children and their parents to see health care. A difficulty in diagnosing abdominal pain is that young children do not have the capacity to accurately describe the features of pain so as to aid in diagnosis. Patient history and physical examination is correlated to determine the most plausible diagnosis. The patient is frequently constipated passing stool just 2-3 times a week and often has difficulty in evacuation (Constipation, 2012). However, pain is not localized in the left lower quadrant or suprapubic areas where pain of colonic origin is usually located (Assessment, 2012). At the same time, pain is not relieved by bowel movement.
Since the child is without alarm symptoms such as nausea and vomiting, bleeding or unexplained weight loss and activities are growth and activities are not significantly hampered by the pain, a diagnosis of functional abdominal pain is possible. For this diagnosis to be made, however, symptom onset must be more than three months ago and the result of routine urine, stool and blood tests must be negative which rules out an organic cause (Functional abdominal pain, n.d.). Stress, fatigue and infection may make the symptoms worse but these happen in the morning after sufficient and uninterrupted sleep. Given the findings, there is need to rule out infection.
The most likely etiology of the patient’s recurrent abdominal pain is H. pylori infection. This type of GI condition almost always occurs during childhood with associated risk factors such as family size, the home environment, i.e. crowding, personal hygiene, education, low economic status and living with someone who is infected (Tolone et al., 2012). Based on family history, the father has had peptic ulcer disease where H. pylori infection is a common etiology (Torpy, 2012). H. pylori infection can be subclinical, i.e. with no manifestation of alarm symptoms and diagnostic study through stool analysis and urea breath test is the only means of confirming the disease (Chey & Wong, 2007).
1. Intermittent abdominal pain related to probable H. pylori infection as evidenced by complaints of mild abdominal pain in the mornings.
2. Imbalanced nutrition more than body requirements related to excessive intake compared to metabolic needs as evidenced by BMI in the 98th percentile, high-calorie diet and sedentary lifestyle (Doenges, Moorhouse & Murr, 2006).
3. Constipation related to inadequate water and fiber intake and physical activity as evidenced by hard formed stool, irregular bowel movement and straining with defecation.
1. Give prescription for proton-pump inhibitor, amoxicillin and clarithromycin twice daily for 7 days after positive susceptibility testing for clarithromycin. There is high-level but conflicting evidence as to the efficacy of treatment longer than 7 days (Koletzko et al., 2011) and considering that cost of treatment is an issue for the family, treatment duration is limited to one full week.
2. Recommend oral probiotics, 5–10 × 109 colony forming units per day of Lactobacillus species, for 1-3 three weeks as adjunct CAM treatment (Boyanova & Mitov, 2012). This is to help in eradicating H. pylori and reduce the probability of superinfection as a side effect of antibiotics as well (Wolvers et al., 2012). Probiotics enhance the function of resident bacteria in the gut to prevent colonization of pathogenic microorganisms.
3. Have patient return for follow-up after 4 weeks for urea breath testing to determine if bacteria have been eliminated (Koletzko et al., 2011). Results will confirm efficacy of treatment, reduce the chances of microbial resistance and ensure that patient will not suffer recurrence.
4. Return to clinic earlier if symptoms worsen or recur prior to next follow-up appointment.
5. Recommend diet modification combined with increasing water intake and physical exercise for weight reduction and maintenance as well as reduce incidence of constipation. Use the HABITS tool in the identification and monitoring of significant behaviors related to diet, physical activity and physical inactivity (Wright et al., 2010). Some of the questions include regularity of meals, fruit and vegetable consumption, water intake, fast food consumption, duration of outdoor play and time spent watching television. This tool was developed for pediatric patients in low-income families residing in inner-city neighborhoods (Wright et al., 2010). Set goals with the child and family regarding behaviors. Evaluate progress regularly through telephone follow-ups or during subsequent clinic visits.
6. Literature suggests a comprehensive approach to obesity management addressing all risk factors and involving the family, school and community (Towey, Harrell & Lee, 2011). Community programs provide modeling and reinforcement of ideal behaviors. They send the message that lifestyle change towards an ideal weight is possible and allows learning from the experiences of others. Explore existing programs in the community supporting diet and physical activity modification which the family can maximize and refer the family accordingly. Taking note of the fact that Hispanic patients put primacy on personal relationships over impersonal relationships (National Alliance, 2001), referral should be made by introducing the family directly to the program proponents to establish rapport which facilitates participation.
A discussion of the disease, its causes and sequela if unmanaged must be discussed. Treatment options should be presented along with their expected outcomes and side effects. Discuss the purposes of each drug in the triple therapy, their side effects and the special considerations when taking each drug. Stress the need to continue with antibacterial therapy despite relief in abdominal pain. Explain bacterial resistance as a likely outcome of noncompliance. Discuss also with the family the child’s constipation. Reiterate the need for regular bowel movements especially with their familial risk factor for colon cancer. However, an issue when working with Hispanic families is that they have a high regard for the practitioner and out of deference, they tend not to voice out their disagreement, questions or confusion over treatment (National Alliance, 2001). Thus, it is crucial to encourage the expression of questions and concerns so as to ensure compliance. To confirm understanding, ask the family questions about what has been discussed.
The use of CAM treatments is not new to the family though these have been recommended not by health care providers but by the extended family. Thus, the family is considerably receptive to probiotics. Reiterate the fact that antibiotics can reduce the effects of Lactobacillus. As such, probiotics should be taken 2-4 hours following a dose of antibiotics and must be administered with food since the microorganisms work best in a high-acidity environment (Boyanova & Mitov, 2012). Further, stability of effects is obtained when the probiotic product is used at a minimum of one week to a maximum of three weeks based on preliminary investigation. Suggest that a way to ensure child compliance is to buy probiotics already incorporated in milk or yogurt drinks or to mix the pure probiotics with juice. This is so the product does not become associated to medicine.
Explain that high-fat diets and obesity is a risk factor to chronic and debilitating illnesses such as heart attack, stroke, colon cancer and adult onset diabetes. Emphasize the need to reduce weight by changes in diet and exercise. Discuss the role of parental support in children’s successful weight reduction (Waters et al., 2011). Assist family in exploring affordable and practical options for balanced culturally accepted low-fat meals and addressing the barriers to diet modification. Discuss meal planning as a way of implementing diet changes at home. Explore also the strategies to help increase physical activity such as climbing stairs instead of taking the elevator or spending family time at the park. Examine daily schedules to see where increased physical activity can be incorporated. Evaluate learning by asking family to make a sample meal plan and physical activity plan.
More recently, the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHN) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHN) engaged in a joint effort to establish international guidelines in managing this condition (Koletzko et al., 2011). Literature searches were done through eight journal databases inclusive of literature published from 2000 through 2009. All recommendations presented in the literature were examined by an international panel representing the disciplines of pediatric gastroenterology, epidemiology, microbiology and pathology via the Delphi technique (Koletzko et al., 2011). The quality of evidence for each recommendation was graded accordingly. A synthesis of high-level evidence yielded 21 recommendations regarding diagnosis and treatment. High-level evidence means that the panel is confident about the recommendation and would not likely change their position despite the results of further studies (Koletzko et al., 2011).
When compared, there were similarities and conflicts in the recommendations of both guidelines. For instance, both agree that the use of the urea breath test (UBT) is the most reliable non-invasive diagnostic technique. Both also agree that triple-drug therapy is the first-line treatment and testing to confirm bacterial eradication needs to be initiated four weeks post therapy. However, the ACG recommended a length of treatment of 10-14 days, whereas the ESPGHN-NASPAGHN recommended the duration to be 7-14 days (Koletzko et al., 2011; Chey & Wong, 2007). While the ACG recommended a test-and-treat strategy for subclinical infection, the ESPGHN-NASPAGHN recommends against it. Finally, the ESPGHN-NASPAGHN has clear recommendations for clarithromycin susceptibility testing prior to initiating treatment while the ACG guidelines only identified bacterial resistance as a possible barrier to positive drug therapy outcomes (Koletzko et al., 2011; Chey & Wong, 2007).
In settling the differences in recommendations, the intended population of each guideline ultimately must be considered. The ACG guideline was meant for use in adult patients since only research done among adult patients was included in the evaluation. On the other hand, the ESPGHN-NASPAGHN created guidelines for specific use in the pediatric setting. Physiologic differences between adults and children do exist which also accounts for differences in responses to treatment. Therefore, it is important to utilize guidelines based on evidence from the same patient population to which it will be used for. Clearly, the ESPGHN-NASPAGHN guideline should be adopted to guide decision making in this case study.
Complementary alternative medicine (CAM) is presently defined by the National Center for Complementary and Alternative Medicine (NCCAM) as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine” (What is complementary, 2011). There are different modalities of CAM, namely alternative care systems, mind-body techniques, biologic therapy, body manipulation techniques, and energy therapy. The most commonly used is biologic therapy which is the use of herbal supplements and other natural products and prescription of specific diets (Snyder & Lindquist, 2006).
On the contrary, CAM arises from non-Western cultures. It views the person as holistic, the product of his biologic, social, psychologic, environmental and spiritual aspects (Jeongsoon et al., 2011). Health is attained when there is harmony within the self and between self and the universe. Care is provided within a therapeutic relationship and aims for the restoration and maintenance of balance in the realms of mind, body and spirit (Zahourek, 2008). CAM promotes autonomy because the person draws on his natural capacity for health promotion and healing Snyder & Lindquist, 2006).
The main issue with CAM, however, is its evidence base. The NCCAM has stimulated research in the area of complementary and alternative medicine and has formulated guidelines for to assist practitioners and consumers when making decisions regarding the appropriateness of the treatment for specific conditions (Clinical practice guidelines, 2012). Specifically, these guidelines describe the expected benefits and potential side effects; summarize pertinent evidence in terms of quality, quantity, consistency and gaps; rate the confidence level provided by available evidence and the subsequent strength of recommending the treatment; and discuss contradictory opinions with regards to the recommendation (Standards, 2011).
A probiotic is “an oral supplement or a food product that contains a sufficient number of viable microorganisms to alter the microflora of the host and has the potential for beneficial health” (Thomas & Greer, 2010). Based on this principle, and as proven in clinical trials, there is evidence that probiotics can improve H. pylori infection symptoms and reduce antibiotic side effects as a complementary therapy to triple-drug treatment (Weicher, Schroten & Adam, 2012). There are many probiotics products available and they contain varying amounts and types of microorganisms. The most common microorganisms are the Lactobacillus species.
The American Academy of Pediatrics has reviewed the evidence for the use of probiotics for H. pylori infection and has ruled that the absence of randomized controlled trials (RCTs) means it should not be recommended in children (Thomas & Greer, 2010). RCTs are researches that compare children who receive probiotic treatments with children who do not in order to establish if there is a significant difference in terms of outcomes to warrant recommendation. However, the results of preliminary researches are deemed promising and further research needs to be done using RCT as study design. In addition, a literature review from a nutrition perspective provides some degree of evidence showing benefits of use for H. pylori infection (Wolvers et al., 2012).
Barriers to utilization of probiotics include its added costs, the lack of high-level evidence and child preferences. A decision may be arrived at by the family that since the long-term effects of this CAM treatment has not been established, it is not worthwhile spending on it. Compliance also depends if the child would actually want to drink probiotic products. Presenting the probiotic to the child not as a medicine but more like a tasty supplement drink can induce compliance. Facilitators to adopting probiotics as a complementary treatment are previous utilization of CAM treatments with positive results.
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