Pediatric Primary Care (35 page)

2.   If sexually active, discuss contraceptive methods, STI prevention. Counsel on abstinence.

3.   Educate about protection against STIs and pregnancy as indicated.

BIBLIOGRAPHY

Elster A, Kuznets N.
Guidelines for Adolescent Preventive Services.
Baltimore, MD: Williams & Wilkins; 1994.

Fisher J, Wildey L. Developmental management of adolescents. In: Burns C, et al., eds.,
Pediatric Primary Care: A Handbook For Nurse Practitioners.
3rd ed. Philadelphia: W.B. Saunders; 2004.

Fox J, ed.
Primary Health Care of Infants, Children, and Adolescents.
2nd ed. St. Louis: Mosby; 2002.

Green M, Palfrey J, eds.
Bright Futures: Guidelines For Health Supervision Of Infants, Children, and Adolescents.
2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health; 2002.

Neinstein L.
Adolescent Health Care: A Practical Guide.
4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002.

CHAPTER 19

Fourteen- to Eighteen-Year
Visit (Adolescent)

Mary Lou C. Rosenblatt

I.  GENERAL IMPRESSION

A.   This well visit is an opportunity to provide health care for individual who is faced with many developmental challenges on road to adulthood.

B.   Introduce yourself and your role to teen and parent. Explain that you need information from both parent and teen and will spend some time just with teen to check on his/her concerns.

C.   Be knowledgeable of your state's confidentiality and consent statutes and explain how that will be handled in practice. Assure both teen and parent that your first goal is wellbeing of teen.

D.   Listening skills are especially important with teens. Show interest in their concerns and address them. “Hear” pauses, hesitation, body language, and validate your understanding of meaning of nonverbal communication with teen.

E.   Be nonjudgmental and gather information before giving advice.

F.   Have supply of well-written and informative handouts on variety of issues.

G.   Involve parents by finding out what advice they give on sensitive subjects, such as substance abuse and sex. Interaction between parent and teen will give feedback on what is discussed in home and how open they are with each other. Encourage both parent and teen to talk about these subjects together.

H.   Ask about responsibilities teen has at home. Many parents advance privileges based on teen's ability to take care of his/her chores. This can also support fair negotiations that take place in family.

I.   Use tool such as HEADSSS assessment to take snapshot of teen's life and identify problem areas to focus on during acute visits. HEADSSS assessment: Ask open-ended questions about home, education, activities, drug use and depression, sexuality, suicide, and safety.

J.   Have resources available if issues such as drug abuse, school problems, physical. sexual abuse, depression, sexual activity, pregnancy are present.

K.   If an undesired behavior that is identified through screening can be dealt with during primary care office visit, state desired behavior, offer health information detailing risks of undesired behavior, benefit of change, and alternatives. If teen can commit to change, set goal and timeframe, offer support and resources, set up follow-up time.

II. NUTRITION

A.   History.

1.  Ask for 24-hour diet recall.

2.  Are any foods/food groups avoided and why?

3.  Is milk consumed? Skim, 2%, whole?

4.  Is meat eaten? What types?

5.  What fruits, vegetables does teen eat? How much juice is consumed?

6.  Trying to gain or lose weight? How?

7.  Are meals skipped? Is breakfast eaten?

8.  Are meals eaten on run or sitting down with family?

9.  What types of “junk” foods are consumed? How much?

10.  How often does he/she eat at fast food restaurants? What foods?

11.  Does teen watch TV and snack?

12.  How much soda is consumed? Regular or diet?

13.  What types of exercise is teen involved in?

14.  Does teen spend time thinking about how to be thin?

15.  Has he/she tried dieting, diet pills, laxatives, vomiting to control weight?

16.  Does teen ever eat in secret?

17.  Is teen dieting to fit into weight class for sports?

18.  Are any nutritional supplements taken?

B.   Teaching.

1.  Use My Plate (see
Appendix E
) to encourage healthy eating practices, daily requirements of protein, calcium, vitamins, fiber.

2.  Recognize that teen is likely making more choices on own, can start to read labels, becomes conscious of nutritional value.

3.  Skipping breakfast may make it harder to concentrate in school and lead to more hunger after school, possibly poor nutritional choices.

4.  Skipping meals may lead to more hunger, poor food choices.

5.  Encourage teen to talk with parent about planning meals, snacks.

6.  Encourage trying new foods.

7.  When limiting soda, drink more water, avoid excessive calories from juice products.

8.  Discuss sources of calcium.

9.  5-8% of teen girls have iron-deficiency anemia.

10.  Teens risk dental decay with high-sugar diets, poor dental hygiene.

11.  13-15% of children and adolescents are estimated to be overweight.

12.  Teach behavioral techniques for weight management, such as goal setting, self-monitoring, positive reinforcement, problem solving, social support.

13.  Incidence of eating disorders has increased and is estimated to affect 7% of male adolescents and 13% of female adolescents. Eating disorders can be associated with depression, substance abuse, low self-esteem.

14.  Discourage rapid weight gain/loss to fit into weight class for sports.

15.  Discourage major weight/dietary restrictions during growth spurt.

C.   Physical exam.

1.  Chart height, weight, body mass index (BMI); review growth curves with teen.

2.  BMI at or above 95th percentile is considered overweight/obese. For obese teens, BMI is objective measure that is useful in motivating them to recognize their risks of developing heart disease, diabetes.

D.   Labs.

1.  Screen hematocrit at beginning or ending puberty visit or both to check for anemia due to rapid growth, poor nutrition, menstrual losses.

2.  Glucose if there is family history of diabetes, symptoms of diabetes, or obesity and
Acanthosis nigricans.

3.  Cholesterol for adolescents with heart disease, hypertension, diabetes or if there is family history of heart disease or hyperlipidemia.

E.   Treatment plan.

1.  Encourage healthy eating practices.

2.  Encourage good exercise habits.

3.  For teens just starting to exercise, start slow, for example, walking for 20 minutes 3 times/week, so they can build up their exercise tolerance.

4.  For teens with special diets, such as vegetarian diets, be prepared to assess dietary content, give advice/referral resource to offer nutritional guidance, support.

5.  For obese teens, offer support and encouragement. When motivated, they may be ready for weight-loss program. Suggest starting by keeping daily food diary to look for problem areas in diet. Behavioral techniques, mentioned earlier, may be enough for some teens to get started with healthier eating practices. In supportive environment, family involvement may help to cut down excess intake. Some teens benefit from professional weight-loss programs. Refer morbidly obese patients to medical weightloss program.

6.  When eating disorders are suspected, careful assessment and monitoring are needed. Denial is common and should not offer reassurance. Patients require nutritional, medical management as well as mental health assessment and referral. Referral to eating disorder program will offer comprehensive approach to assessment and management.

III. ELIMINATION

A.   Teens are normally independent in their elimination practices.

B.   Constipation.

1.  Infrequent and/or difficult passage of feces.

2.  Common cause of abdominal pain.

C.   History.

1.  What are bowel habits?

2.  When was last bowel movement? Hard and dry? Any abdominal pain?

3.  How long has constipation been a problem?

4.  Is fiber present in teen's diet?