Health care dana bartlett, bsn, msn, ma, cspi



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PHQ-9 Screening Tool


Over the last 2 weeks, how often have you been bothered by any of the following problems?


  1. Little interest or pleasure in doing things.




  1. Feeling down, depressed, or hopeless.




  1. Trouble falling or staying asleep, or sleeping too much.




  1. Feeling tired or having little energy.




  1. Poor appetite or overeating.




  1. Feeling bad about yourself, or that you are a failure, or have let yourself or your family down.




  1. Trouble concentrating on things, such as reading the newspaper or watching television.




  1. Moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual.




  1. Thoughts that you would be better off dead or of hurting yourself in some way.



The possible answers and their respective scores are:

0 = Not at all

1 = Several days

2 = More than half the days

3 = Nearly every day

Depression score ranges:

5 to 9: Mild

10 to 14: Moderate

15 to 19: Moderately severe

20 to 27: Severe




Screening For Newborns, Children And Adolescents

Congenital Hypothyroidism

The thyroid hormone tri-iodothyronine (T3) is essential for normal childhood growth and development, especially in the first few years of life.111 During the first trimester the fetus is dependent on maternal thyroid hormones and maternal thyroid hormone requirements are increased at this time, as well.111,112 An increased maternal need, dependency of the fetus on maternal thyroid function, and hypothyroidism in a pregnant woman can cause serious consequences: impaired cognitive functioning in the child and complications of pregnancy such as low birth weight, miscarriage, preterm birth, and preeclampsia.112


Screening newborns for congenital hypothyroidism is mandatory in all 50 states and in the District of Columbia. The USPSTF recommends that T4 and TSH be measured when the infant is between two to four days old. If the tests are abnormal confirmatory testing should be done.5
Obesity

The prevalence of obesity in children and adolescents in the United States is approximately 17% and it is expected to increase.116,117

The USPSTF recommends that children and adolescents age 6 to 18 be screened for obesity.5 Obesity is defined as an age and gender specific BMI ≥ 95th percentile.5


Phenylketonuria

Phenylketonuria (PKU) is a relatively common inborn error of metabolism. People who have PKU do not have normal activity of the liver enzyme phenylalanine hydroxylase. Phenylalanine is an amino acid, a breakdown product of many proteins. Accumulations of phenylalanine can cause mental retardation, seizures, and other serious neurological problemns.111


Screening for PKU is mandated in all 50 states, and infants should be screened at or near seven days of age.5 The Guthrie Bacterial Inhibition Assay (BIA), automated fluorometric assay, or tandem mass spectrometry can be used.5
Sickle Cell Disease

Sickle cell disease is an inherited hematologic disorder. People who have sickle cell disease have hemoglobin S and when oxygen binds to hemoglobin S, red blood cells form an abnormal shape (the sickle shape) and they hemolyze, causing an anemia that deprives the tissues of oxygen and blocking blood vessels. Sickle cell disease primarily affects African Americans, and approximately 1 in every 365 African Americans has the disease.118


The USPSTF recommends that all newborn infants be screened for sickle cell disease using either thin-layer isoelectric focusing (IEF) or high performance liquid chromatography (HPLC).5


Visual Impairment in Children Ages 3 to 5

Children ages 3 to 5 years should be screened for ambylopia. Ambylopia, often called lazy eye, is defined as decreased vision in one eye. The term lazy eye is used because the affected eye often is fixed to the lateral or medial side. Ambylopia can result from an imbalance in the muscles that move and position the eyes or from neurological abnormalities and if it is untreated it can cause permanent vision loss. Effective treatments for ambylopia are available so early detection is critical. The USPSTF recommends that children three to five years of age have vision scrrening.5

Amblyopia is defined as a functional reduction in visual acuity that is caused by abnormal visual development during childhood. Amblyopia is the most common cause of visual impairment in children116,117 with a reported prevalence of 1%-4%.116-119 Ambylopia develops during a critical period of three months to eight years when the vision is maturing. Risk factors for ambylopia include having a first-degree relative with amblyopia; neurodevelopmental delay; premature birth; and, small size in relation to gestational age.116 Amblyopia affects boys and girls equally.
The USPSTF recommends that children age three to five have vision screening4 and screening for, and early detection of amblyopia can improve the prognosis for normal visual development.116,120,121 Screening is also important because amblyopia is an asymptomatic condition; certain types of amblyopia are characterized by an obvious lateral deviation of one eye (commonly called lazy eye) but some are not; and, the treatments for amblyopia are most effective when they are used early.121

Children who are pre-verbal are screened by using the fixation reflex test or the objection to occlusion test.116 Children who are three years of age or older can have their visual acuity checked by using the Snellen chart (the classic eye chart with letters and number, viewed from 20 feet away) or by using Allen figure cards.116


In the fixation reflex test one eye is occluded, the examiner moves an object back and forth across the child’s visual space, and the child’s ability to maintain contact - to fixate - is assessed. During the occlusion test the examiner watches the child’s response as each eye is alternately occluded. Children who have amblyopia will usually become upset when the good eye is occluded.
Intimate Partner Violence And Elderly Abuse

Intimate partner violence is defined by the CDC as physical violence, sexual violence, stalking and psychological aggression (including coercive acts) by a current or former intimate partner.62 Breiding, et al., (2014, 2008) noted that a substantial number of American women and men have suffered from one or more types of intimate partner violence (as many as one in four women and one in seven men)63,64 and intimate partner violence is often unreported and undiagnosed.63


Risk factors for suffering intimate partner violence include (but are not limited to 1) female gender, 2) prior history of intimate partner violence, 3) experiencing or witnessing violence as a child, and 4) chronic mental illness. Risk factors for perpetrating intimate partner violence include (but are not limited to) exposure to violence during childhood, marital difficulties, post-traumatic stress disorder (PTSD), substance use, and job loss.

The USPSTF recommends that asymptomatic women of childbearing age be screened for intimate partner violence and that screening and interventions provide a moderate benefit.5 There are many screening tools that can be used to detect intimate partner violence but there is no agreement as to which one is best.63,64 A recent (2016) survey65 of intimate partner violence screening tools found that the Women Abuse Screen Tool (WAST), Abuse Assessment Screen (AAS) and Humiliation, Afraid, Rape and Kick (HARK) are particularly useful.66,67 The WAST screen is provided below as an example.




Women Abuse Screen Tool

1. In general, how would you describe your relationship?

A lot of tension; some tension; no tension

2. Do you and your partner work out arguments with:

Great difficulty; some difficulty; no difficulty?

3. Do arguments ever result in you feeling down or bad about yourself?

Often; sometimes; never

4. Do arguments ever result in hitting, kicking or pushing?

Often; sometimes; never

5. Do you ever feel frightened by what your partner says or does?

Often; sometimes; never

6. Has your partner ever abused you physically?

Often; sometimes; never

7. Has your partner ever abused you emotionally?

Often; sometimes; never

8. Has your partner ever abused you sexually?

Often; sometimes; never

Elder abuse is a common problem in the United States and elsewhere. As with intimate partner violence, elder abuse is underreported but several studies have found a prevalence of 7.6% to 10%.68 Elder abuse has been defined and classified into five categories.68




  • Physical abuse or acts carried out with the intention to cause physical pain or injury

  • Psychological or verbal abuse

  • Sexual abuse, i.e., non-consensual sexual contact

  • Financial exploitation

  • Neglect

Risk factors for elder abuse include dementia, isolation, low income, poor social support, a shared living situation with a large number of relatives, and perpetrator characteristics such as alcohol use, mental illness, and exposure to violence as a child.69-71


The USPSTF does not have recommendations for elder abuse screening, noting that “… there were no studies on the accuracy, effectiveness, or harms of screening in this population.”5 However,

screening for or inquiry about elder abuse is recommended by organizations such as the National Center on Elder Abuse, the National Academy of Sciences, and the American Academy of Neurology and the American Medical Association recommend routine screening.71


Prevention and Personal Health Counseling

Counseling is a vital component of preventive medicine. Screening tests detect health problems and identify people at risk. But screening tests should be followed by counseling and patient education if the patient has, or is at risk for a specific disease or disorder. The USPSTF recommends that when appropriate, adult patients should be counseled about the following.5




  • Alcohol misuse

  • Breastfeeding

  • Falls

  • Healthful diet and physical activity

  • Motor vehicle occupant restraints

  • Obesity

  • Sexually transmitted infections

  • Skin cancer

  • Tobacco use

Children and adolescents should be counseled, when appropriate, about:5




  • Alcohol misuse

  • Illicit drug use

  • Motor vehicle occupant restraints

  • Obesity

  • Sexually transmitted infections

  • Skin cancer


Vaccinations

Vaccinations are a critically important part of preventive medicine. The vaccination schedules presented here are the recommendations of the CDC.


CDC Vaccination Schedules

Vaccine

Age Group

19-21 years

22-26 years

27-49 years

50-59 years

60-64 years

65 years


Influenza 2,

←1 dose annually→

Tetanus, diphtheria, pertussis (Td/Tdap) 3,

Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs

Varicella 4,

←2 doses→

Human papillomavirus (HPV) Female 5,

←3 doses→

 

 

 

 

Human papillomavirus (HPV) Male 5,

←3

doses→

 

 

 

 

Zoster 6

 

 

 

 

←1 dose→

Measles, mumps, rubella (MMR) 7,

←1 or 2 doses→

 

 

 

Pneumococcal 13-valent conjugate (PCV13)8,

←1 dose→

Pneumococcal polysaccharide (PPSV23)9,10

←1 or 2 doses→

←1 dose→

Meningococcal 11,

←1 or more doses→

Hepatitis A 12,

←2 doses→

Hepatitis B 13,

←3 doses→

Haemophilus influenzae type b (Hib)14,


←1 or 3 doses→


Pediatrics: 0 – 15 Months Vaccination Schedule

Vaccine

Birth

1 mo

2 mos

4 mos

6 mos

9 mos

12 mos

15 mos

Hepatitis B1 (HepB)

←1st dose→

←2nd dose→

 

←3rd dose→

Rotavirus2(RV)
RV1 (2-dose series); RV5 (3-dose series)


 

 

←1st dose→

←2nd dose→

See footnote 2

 

 

 

Diphtheria, tetanus, & acellular pertussis3(DTaP: <7 yrs)

 

 

←1st dose→

←2nd dose→

←3rd dose→

 

←4th dose→

Tetanus, diphtheria, & acellular pertussis4 (Tdap: ≥7 yrs)

 

 

 

 

 

 

 

 

Haemophilus influenzae type b5 (Hib)

 

 

←1st dose→

←2nd dose→

See footnote 5

 

←3rd or 4th dose,
See footnote 5→

Pneumococcal conjugate6 (PCV13)

 

 

←1st dose→

←2nd dose→

←3rd dose→

 

←4th dose→

Pneumococcal polysaccharide6(PPSV23)

 

 

 

 

 

 

 

 

Inactivated poliovirus7 (IPV)(<18 yrs)

 

 

←1st dose→

←2nd dose→

←3rd dose→

Influenza8(IIV; LAIV) 2 doses for some: See footnote 8

 

 

 

 

Annual vaccination (IIV only)

Measles, mumps, rubella9 (MMR)

 

 

 

 

 

 

←1st dose→

Varicella10 (VAR)

 

 

 

 

 

 

←1st dose→

Hepatitis A11 (HepA)

 

 

 

 

 

 

←2 dose series, See footnote 11→

Human papillomavirus12 (HPV2: females only; HPV4: males and females)

 

 

 

 

 

 

 

 

Meningococcal13 (Hib-Men-CY ≥ 6 weeks; MenACWY-D≥9 mos; MenACWY-CRM ≥ 2 mos)

 

 





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