Growth And Developmental Stages Of A Nine Year Old Boy

Warren Ralston, a nine-year-old presents in the ambulatory clinic with a chief concern of being “too fat” to fit any clothes. According to his mother, he began gaining excess weight about two years ago with no evidence of previous health records to trace weight increase. Both Warren and his mother are homeless and have been living at the City Mission shelter for the last month, depending on clothing donations. Warren’s mother states that no current donated clothes fit him. The mother states she is twenty-six years old but appears much older. She has an eighth grade education and ran away from home at age thirteen because she lived with her sexually abusive father. She became pregnant with Warren at age seventeen after experiencing being raped. Warren eats the meals given to him by Mission. Warren has no previous hospitalizations or major illnesses. His mother is unsure of him having all of his immunizations, stating she thinks he had “some” as a baby in Michigan. The mother received no prenatal care during her pregnancy, and Warren was born vaginally in a hospital emergency room, weighing six pounds and ten ounces. Warren eats all of his meals at Mission, generally healthy meals excluding snacks that include buttered popcorn, candy bars, jello with peaches, and cans of cola. Warren sleeps eight hours at night, but fears violence outside on the streets, sometimes making it hard for him to go to sleep and stay asleep.

The boy’s milestone developments are not recalled, although the mother is pleased with his ability to read and use math skills. The child has attended no more than six months of school in any year of school due to his recent moves. He is currently in third grade at a local grade school. A nine-year-old boy who stands four feet six inches and weighs one hundred and thirty two pounds with a body mass index of thirty-three will fall in the 84th percentile of height which means that Warren has a normal stature for his age. A similar nine-year-old boy of the same stature with a weight of one hundred and thirty-two pounds would put that child in the 99th percentile of weight for boys his age, meaning that the child weighs more than 99 percent of other nine-year-old boys with the same stature as him. In a school age child’s head, the nurse should see a normocephalic head shape with healthy hair growth and shine of the hair shaft. The scalp should be clean and without abrasions. Warren’s head is normocephalic but presents with sand-colored grains on the hair shafts and linear abrasions on his scalp. Warren has had lice infestations x2 and presents with sand-colored grains on his hair shafts, which may be indicative of a current lice infestation. The linear scratches on his scalp may be evidence of scratching at the scalp related to the lice infestation.

The nurse should next observe the eyes for signs of redness, frequent blinking, crust, squinting, or rubbing because this may be indicative of conjunctivitis, an infection of the conjunctiva covering the eye. The eyelashes and eyelids should be assessed for signs of redness or abnormalities to detect a hordeolum, an infection of the gland that lubricates the eyelash. Relate the position of the eyes to the nose and the center of the face to ensure the eyes are not sunken, protruding, or abnormally set on the face. Warren’s red reflex is present and he is able to follow with his eyes to all fields of vision. The red reflex is expected, it is evidence that the retina is intact and the lens and cornea are clear. He had an eye screening check at Mission last week, and his eyes are reported as normal. In observing a school aged child, the nurse should observe for flaring of the nostrils, this may indicate a need for oxygen. Using an otoscope light, the nurse should observe the mucous membrane of the nose, which should be a pink color. Warren’s nares are patent and his septum is midline meaning that he should have no problems breathing. A displaced septum such as those that occur after facial injuries can interfere with respiration and make nasal intubation in emergencies difficult. This should be documented on the child’s medical chart for future reference.

The nurse should next move on to the child’s ears, in which the tympanic membrane should always be present. The nurse should inspect for any redness and if the ears are of normal alignment. Warren’s ears are normally aligned but due to accumulated cerumen, the tympanic membranes are not viewable. Warren can respond to whispered words, indicating that the child has no problems with his hearing. The child’s mouth should be symmetrical and pink, with pink buccal membranes. The nurse should count the child’s teeth to determine if he has any missing teeth. Warren’s palate is intact and he has twenty-four teeth and six caries. He has all of the teeth he is expected to have, but has six areas of tooth decay which is a concern that he has not been brushing well or has not been eating healthy. The tongue should be smooth and moist. Warren has a geographic tongue which is a rough appearing tongue that may be accompanied by a fever. The gag reflex should be present, in which Warren’s is intact.

Next, the neck should be assessed for symmetry, the trachea should be midline. The child should have a full range of motion in their neck, as Warren does. Warren does have two “shotty lymph nodes in his neck palpable on the right posterior cervical chain and one palpable in the left submental chain. Shotty lymph nodes are freely movable, about the size of a pea. The may present after an upper respiratory infection. A submental node may relate to a tooth abscess and the posterior cervical nodes follow a throat infection. Warren’s lymph nodes in these areas are shotty, and may be a possible sign of a current tooth abscess or throat infection. Moving on to the chest, the nurse should inspect the chest for retractions which may be a sign of respiratory distress, symmetry of the chest, and symmetrical motion of the chest as the child breathes. The nurse should be sure to assess the child’s respiratory rate, rhythm, and skin color for any pallor, bruising, or redness. The child’s breathing should appear relaxed and not stressed. Warren’s lung sounds are clear bilaterally by auscultation, his respiratory rate is twenty breaths per minute, he has no pubertal breast development currently, but his right shoulder is held higher than the left. Warren presents with beginning thoracic scoliosis, explaining his shoulder displacement. Warren’s heart rate is eighty-eight beats per minute and no murmurs are heard. The rhythm of the child’s heart rate should be regular, the normal range for heart rate in a school aged child should be eighty to one hundred and twenty beats per minute, leaving Warren on the lower side but within the normal range for his age group. A murmur is the sound of blood flowing with difficulty and is not a normal sound; however, Warren does not present with one. The school aged child’s abdomen should be scaphoid, but Warren presents with a protuberant abdomen, most likely due to excess subcutaneous fat. Bowel sounds should be present in all four quadrants, as Warren’s are. Warren has no masses present in his abdomen, as there should be none. His right hip is elevated in relation to his left, most likely in relation to his beginning scoliosis. The male genitalia should be assessed for any lesions, appearance and placement of the urethral opening, which should be slit-like and centered at the penis tip. Both testes should be present, and no swelling or masses should be present, the urethral meatus should present with no discharge or lesions and the femoral nodes should be palpated to assess for swelling indicating infection. Warren’s genitalia is identified as a normal immature male.

The child’s extremities should be observed for color and warmth. The fingernail beds should be checked for color, contour, and shape. The nails on this age group are normally pink, smooth, and convex. They should feel hard to the touch but not brittle enough to break. The nurse must check the wrists, elbows, and shoulder movements for movement and range of motion, as well as the ankles, knees, and hips. Warren has a full range of motion in all of his extremities, but his fingernails are short and ragged, as if bitten. He may be biting his nails because he is experiencing high levels of stress. The school aged child’s back should be symmetrical, and the spine should not be deviated. The spinal column should be non-tender. Warren’s lateral curve of his spine is 10 degrees on standing, 30 degrees bending, and his right scapula is elevated. The curvature of his spine deviating from the midline is related to his scoliosis. Last but not least physically, the child’s neurologic system should be assessed for deep tendon reflexes. Warren has a patellar reflex of 2+, which is an average response. His motor and sensory nerves are intact, and he is alert and oriented to place and name. In addition to place and name, it is important to assess that child is oriented to date and time, the nurse should be checking this as well as name and place.

The nurse can assess Warren’s motor function by asking him to make a face, grasp something with his hands, and push against something with his feet. The nurse should recall whether the child’s gait was adequate for balance and coordination. The face should be symmetrical when making a face, the grasp and pushing should be strong. When walking, Warren’s gait should be at an even pace with adequate foot placement. His feet should be shoulder width apart and his steps should not be too large or too short for his height.

The nurse would want to observe Warren’s gait when he gets up to walk. Cognitively, an average nine-year-old should have an IQ of 100; however, these tests are not always accurate. Children may score poorly because of test anxiety. The Wechsler Intelligence Scale for Children and the Stanford–Binet tests are used for older children. The Wechsler Intelligence test is meant for children aged six to sixteen and can be completed without reading or writing. The Stanford-Binet test is meant to gauge intellectuality through five cognitive factors including fluid reasoning, knowledge, quantity reasoning, visual-spatial processing, and working memory. Both verbal and non-verbal responses are measured during the test. Warren’s mother is pleased with his reading and math skills, and is described by his mother as “smarter than me”. He is currently in third grade, and his mother has an eighth grade education. Warren meets basic cognitive abilities of boys his age, but the nurse should also assess his ability to write. School aged children have a variety of emotional and social needs. There should be little stranger anxiety present in this age group, and the children should demonstrate playing with peers. At his age, Warren should be sleeping well, approximately nine to eleven hours is recommended. Warren sleeps eight hours every night, which may be deemed appropriate for him. He experiences some fear in going to sleep related to violence outside on the street. He had enrolled in a Big Brother and Boy Scout program two weeks ago. Warren does not appear to be struggling socially, and does not present with severe emotional trauma for his age group.

Developmental recommendation #1: Promoting Warren’s Physical Activity And Eating Habits

The CDC recommends that children of Warren’s age should be getting sixty minutes or one hour of physical activity per day. Aerobic activity should make up most of the child’s hour of activity. This could be described as physical activity that gets the body going, such as brisk walking or running. Most school aged children get their aerobic activity in at gym or recess, as they are running around playing games with each other. Some games may include baseball, soccer, tag, or basketball. The activities during play should also include bone-strengthening workouts which may include skipping rope or climbing on a jungle gym. Encouraging Warren to increase his physical activity will trigger his body to burn subcutaneous fat, thus allowing Warren to lose weight and reach optimal physical endurance for his age. However, Warren will need to work on other aspects of his life to be healthy and reach an appropriate body mass index, including eating healthier snacks and meals. Warren will need to balance his daily intake of protein, fat, carbohydrates, fiber, and dairy. Children should not eat many foods high in fat, sugar, or sodium every day, but rather as treats on an occasion. Oils such as butter, olive oil, and vegetable oil should be used sparingly in meals. These children should be eating two servings of meat, poultry, beans, or nuts every day. They should be getting three servings of dairy every day, including milk, cheese, or yogurt, as well as five to seven servings of fruits and vegetables a day. Pairing exercising and eating healthy, Warren will be able to decrease his weight achieve a healthy body mass index. Children should be eating healthy and exercising at least one hour each day despite being a healthy weight or not.

Developmental recommendation #2 Promoting Dental Hygiene for Warren

School aged children may need some verbal prompting or reminders to maintain their dental hygiene daily. Children Warren’s age should be brushing their teeth twice a day and flossing at least once a day. Maintaining a healthy dental routine will decrease the child’s risk for caries and abscesses. In children older than six years old, they should be using a fluoride toothpaste. By one year of age, the child should visit a dentist for their first checkup, to make sure that their gums are healthy and that there are teeth starting to break through the gum line. Warren has had six oral caries, which may be from his intake of sugar. He must cut back on the sugar intake not only for his physical health, but for his dental health as well. He must make sure he is maintaining his dental routine to care for his teeth. Children should be prompted and watched while brushing their teeth around this age to ensure they are brushing correctly.

Teaching About Protecting A Back With Scoliosis And Relieving Pain

Someone with scoliosis should invest in getting a good mattress and pillow. A too-soft pillow will leave the head unsupported, resulting in neck pain that radiates down the rest of the spine. Some yoga poses also help with existing back pain, and while backbends seem intense for someone with a spine curvature, they are important to practice in order to stretch out the muscles in the back. Starting slowly with smaller postures, one can gradually work themselves up to Upward Facing Bow Pose. Along with yoga relieving pain, non-surgical procedures such as acupuncture, chiropractic work, massage therapy, and physical therapy can relieve built up pain and tension in the back. Deciding on what treatments to begin needs to be discussed with the person’s provider. The doctor will clear the person for the procedure most safe for them, and may be able to refer them to or recommend a provider to the person with scoliosis. The pain one feels in their back often begins in their feet, so someone with scoliosis should wear comfortable footwear. When shopping for footwear, the person should look for shoes with an arch that fits the natural curve of their foot to give them the most support possible. Slouching or leaning to one side means aggravating the curve in the spine that is the source of the immediate and current pain. Warren should keep his back straight as if he were standing against a wall, and his chin parallel to the floor. His shoulders may stay uneven, but he should not let that worry him as such a posture cannot be willed away by a thought. He should also avoid crossing his legs because this position is quick to throw off alignment. Lastly, Warren should sit in chairs with lumbar back support to avoid lower back pain. Chairs with no support or too much cushion will cause the spine to shift into an uncomfortable position and holds the position for an amount of time while sitting.

Warren’s Interprofessional Healthcare Team

As Warren is a nine-year-old boy with obesity and scoliosis, members of his healthcare team may include his pediatrician and family doctor. He may have some extra healthcare members involved in specialty areas for his back, such as a chiropractor or a physical therapist in order to stretch his back muscles or help manage and relieve his pain. He may also need to schedule an appointment with an orthopedist, a specialty doctor who specializes in bones and treating disorders of the bones, such as scoliosis. As far as Warren’s obesity, he may need to attend appointments with a dietician, who will encourage him with healthy eating, and will recommend changes in areas of his eating and snacking. A dietician will coach him in what he can eat and how much of the food he can eat, and will assist him in losing weight and balancing his body with his nutrient requirements for his age. While the mother has had a rough past, she may need to schedule an appointment with a psychiatrist for herself and Warren because while she has unresolved emotional issues that she needs to discuss and come to terms with, Warren may also need emotional support with his frequent moves and being afraid to go to sleep at the shelter at night related to fear of violence outside on the street.