Final Exam Study Guide

Important to Know the function of anterior and posterior pituitary gland.
Anterior Pituitary Gland: (Adenohypophysis) The anterior pituitary gland regulates several physiological processes including stress, growth, reproduction and lactation (Adrenal, liver, bone, thryroid and gonads). -It is regulated by negative feedback and the hypothalamus. Major hormones:
ACTH: Stimulates the adrenal cortex.
TSH: Thyroid stimulating hormone, promotes secretion of thyroid hormone.
FSH: Follicle-stimulating hormone, promotes growth of reproductive system.
LH: Luteinizing hormone. Promotes sex hormone production
GH: Growth hormone, promotes growth, lipid and carbohydrate metabolism.
PRL: Prolactin, Milk production and progesterone/estrogen. -Hormones are secreted from the hypothalamus to the A. Pituitary so these hormones can be released.

Posterior Pituitary Gland: Mainly axons extended from the hypothalamus. These axons contain and release neurohypophysial hormones oxytocin and vasopressin.
Oxytocin: Targets the uterus, and mammary glands causing contractions and lactation.
Vasopressin (ADH): Antidiuretic hormone, arginine vasopressin, argipressin. Stimulates water retention absorbs it back into blood causing raises blood pressure by contracting arterioles, and inducing male aggression.

Very Important to know and understand Diabetic Ketoacidosis

Pathophysiology:
-In DKA, the lack of insulin prevents glucose from being utilized by the tissues so it continues to build up. Lack of insulin also triggers glycogen to release more glucose.
-The amount of glucose in the blood exceeds the kidney’s ability to keep it in the blood and so it begins to spill out into the urine. Because glucose is the most osmotically active molecule in the body, water follows it into the bladder and out with the urine. The fluid shift in the body goes from the ICF to the ECF and then to the vascular system. **As your serum glucose gets higher, so does the amount spilled into your urine and dehydration follows.
-ENERGY SOURCE: When glucose can’t be metabolized in the cell, we use fats. -Fats we use are metabolized into “Ketone Bodies”; This is were the academia comes from and acetone is the primary component. (causes fruity breath)

-Insulin -All insulin helps glucose get into cells, glucagon tries to stop that action. Insulin will suppress glucagon secreation and hepatic function which creates glucose through glycolysis. Glucagon cells are made in the pancreas Alpha cells. No sugar, glucagon is stimulated in pancreas to initiate glucose production through liver. Brings up sugar level, pancreas then see high blood sugar which secretes insulin, which helps sugar into the cells and suppresses glycogen section..and so on.

-DKA and how it dehydrates you -DKA creates a hypotonic solution, making water rush to the intravascular space from the ECF and ICF. This creates dehydration and more blood volume. More blood volume tells the kidneys to pee a lot. As you pee a lot you also pee out a ton of solutes so you must be careful with how you replace fluids and insulin administration.
QQQQQ: Confused as to what IV solutions you would give during treatment.

-Fluid compartments:
Intracellular: Fluid inside cells (bricks), includes 2/3 of body fluid.
Extracellular: Fluid outside the cells. Made up of interstitial space and vascular space. It composes the other 1/3 of fluid and it made of two components. -Interstitial fluid: Fluid between cells (mortar). Makes up ¾ of ECF. -Intravascular fluid: Blood vessels (copper pipe) Makes up ¼ of ECF.

-Difference between hypovolemia and dehydration -Hypovolemia is the loss of fluid from the vascular system and dehydaration is the loss of fluid from the ICF.

Signs and symptoms
-Polyurea: Increased frequency and amount of voids. This leads to hypovolemia, polydipsia (thirsty), low blood pressure ( increased heart rate, and low cellular potassium.
Treatment—immediate—types of IV fluids one would use, insulin drips
QQQQQ: Explain the route of potassium and why it needs to be watch with hyperglycemia and during treatment. I don’t understand the shifting process.

-Acid/base balance: signs and symptoms -Mild academia creates increased cardiac output because that is your body’s natural response to acidosis through more perfusion. With acidosis more hydrogen ions move into cells causing less in the vascular system. This causes the blood vessels to dilate which causes reflex tachycardia to compensate. With lower and lower academia heart rate actually slows with causes more CO2 in blood causing more dilation which can lead to shock and death. -Alkalosis: mild causes tetany and muscle rigidity and then death is serious cases.

Also know Diabetes and treatment.
Insulin:
Lantus: Long lasting, onset is three hours and lasts 24 usually taken before bed.
Regular: **Only one you can give IV. Onset is 30 mins and peaks in 2 hours.
Lispro: Fast acting, 15 mins onset, given with a ratio of carbs during meals.

IV Fluids
Lactated Ringers/Normal saline: Isotonic solution. Give to trauma because it all stays in the ECF. So ¼ of that ECF will be in veins. **Has solutes that are proportional to ECF so it stays there. Used when treating acidosis because the metabolism of lactate counteracts acidosis.

D5W: Hypotonic (mostly water) So it will go into cells. The glucose in D5W will be used by the cells and all that is left is water- thus water will move into the cells. Usually used to maintain a person’s blood sugar if they cannot.

Hypertonic saline: is hypertonic, causes fluid to leave cells if engourged. **saline 9% or 5%.

Treatment of DKA
- Half normal saline is set at one and a half times the kids maintenance rate. Where the sugar goes the potassium goes. So this half normal saline will also have potassium in it and maybe phosphate which can be used for energy.
- Also want to give insulin. Infusion based on weight. Be careful because a whole bunch of insulin will drop potassium. A huge shift of glucose causes water to go with it so glucose control must be handled slowly.
- This is then titrated with insulin and another bag over the course of a day to help with glucose metabolism. D10W and 1/2 NS with potassium and phosphorous are titrated so that the glucose and fluid shift levels can be returned to equilibrium slowly.

What to do if child participates in rigorous sports, exercise.

SIADH pathophys, treatment
-Syndrome of innapropriate antidiuretic hormone: Unregulated secretion of vasopressin (Antidiuretic hormone). This hormone is released from the posterior pituitary gland after being signaled by the hypothalamus. This causes a retention of water causing sodium to become less proportional in cells.
**Result of SIADH is hyponatremia.
QQQQ: Does sodium leave the cells to go into vascular system or is there just low proportional sodium?
S/S: When sodium levels are down ( anorexia, nausea stomach cramps, severe is convulsions.=

TREATMENT: -The goal is to administer sodium without causing neurologic or cardiac complications. -Look at heart function, edema, lung sounds and assess pulses as well as heart rate before giving. -Loop diuretics or vasopressin-2 receptor antagonists. -Fluid restriction will help. -Intake and output measurements should always be taken.

Hypo hyper thyroidism negative feedback
Negative feedback loop: -TSH stimulates the thyroid gland to secrete TH. The hypothalamus is at the base of the brain. When there are low T4 T3 levels, the hypothalamus releases TRH (thyrotropin-releasing hormone). This TRH hormone stimulates the anterior pituitary gland to release TSH. TSH will then go to the thyroid to produce T3,T4. When T3, T4 are elevated in the blood the hypothalamus stops producing thyrotropin-releasing hormone to stop producing TSH. Signs & symptoms of each and lab test that would be abnormal for each For example TSH, T4 T3 Which one has Tachycardia as a symptom, which one has bradycardia as a symptom?
Thyroid function includes the hormones T4, T3 and calcitonin. The secretion of these hormones is controlled by TSH from the anterior pituitary gland which is turn is regulated by thyrotropin-releasing factor (TRF) from the hypothalamus through negative feedback. -T4,T3 are synthesized from the use of iodine storages. -The main function of T4,T3 is to regulate metabolic rate, the process of growth and tissue differentiation. A reduction in TH (T4, T3) has much more effect on growth than hypopituitarism because TH have more effect on growth than GH does in the anterior pituitary.

Hypothyroidism: **One of the most common endocrine problems in children. -Represented by a deficiency in TH. Not really caused by diet insufficient iodine anymore.
Manifestations of hypothyroidism -Deceleration of growth due to T3,T4 decrease. -Skin changes, Dry skin, puffiness around eyes, sparse hair, constipation, sleepiness, mental decline.
**Tachycardia is seen with HYPERTHYROIDISM
**Bradycardia is seen with HYPOTHYROIDISM
Lab values:
Hypothyroidism: T4 (Decreased) T3 (Normal), TSH (elevated)
Hyperthyroidism: T4, T3 (markedly elevated) TSH (Decreased)

Steroids—side effects of them what happens if stopped abruptly
-Normal adrenal function: Your body naturally creates corticosteroids in your adrenal gland. They are part of the hypothalamic-pituitary-adrenal axis which is a negative feedback loop. At night the hypothalamus creates CRH which causes the anterior pituitary gland to create ATCH. In the morning the ATCH goes to the adrenal gland and causes a bunch of corticosteroids. These corticosteroids are responsible for decreasing inflammatory/immune response, water/electrolyte balance, increasing glucose level in blood, decreasing protein production and for the storage of fat.
-That being said: When you administer corticosteroids continuously, all of these things are happening all at once. The negative feedback loop is disrupted and the CRH from the hypothalamus stops being released which stops ATCH from being released in the anterior pituitary gland. You must slowly taper off corticosteroids because you are essentially without those hormones circulating.
**Most notable symptom after abrupt stoppage -Hypotension -Weakness and fatigue -nausea, vomiting, diarrhea

Precipitating factors of UTI -Males are more common than females in first 6 months (10x more likely if uncircumcised) -After this age females much more likely due to shorter urinary tract. -Wipe front to back, young girls have it close to their anus which could be contaminated with fecal matter. -E.coli is 80% of UTI’s.
**Cystitis: lower tract bladder
**Pylenopheritis: upper urinary tract and kidneys.
S/S of UTI in 2 years -Suprapubic/lower back pain, bladder spams, burning on urination. -Foul smelling urine, fever, hematuria. -Tender or enlarged kidneys

Glomerulenephritis
-S&S: Acute renal failure with decreased urine output, is rare but serious complication. -Edema, decreased urine output, discolored urine, pallor, irritability, vomiting, headaches, hypertension. -Elevated BUN/Creatinine: Great assessment of kidney function. BUN = waste products in blood and creatinine elevates when not excreted. Assess kidney function.
-Pathophysiology: Symptoms usually occur 10-14 days after strep infection. -Group A Beta-hemolytic Strep causes an immune response in the glomeruli which are the functional units of the kidney. The swelling and damaged tissues and swelling. Renal insufficiency results leading to sodium/water and waste retention.

Nephrotic syndrome- Primary disease accounts for 80% of cases.
S&S: Proteinuria, Hypoalbumineia(major protein in blood), Hyperlipidemia (fat in blood), edema (generalized), massive urinary protein loss. H&H/Platelets INCREASED
Pathophysiology( males>females
-Increased glomerular permeability ( proteinuria/hypoalbuminemia (lost in urine) this causes -Stimulation of liver (excessive clotting factors and hyperlipidemia -Intravascular hypovolemia ( Salt/water retention ( Edema, low serum sodium
Treatment
Supportive care: strict I/O, infection?, daily weight, edema.
Diet
-Low to moderate protein -sodium restrictions if large amount of edema
Steroids
-Two daily doses *Pregnisone drug of choice.
Diuretics

Acute renal Failure—causes treatment etc
-Sudden inability of the kidneys to excrete waste material, concentrate urine and conserve electrolytes.
-Caused by inadequate perfusion, kidney disease, or urinary tract obstruction.
-Also caused by severe dehydration or poor renal perfusion.
Complications include: Hypertension, hyperkalemia, anemia, seizures, cardiac failure
QQQQQ: Do I need to know more about this?

Differences of and risks associated with hemodialysis and peritoneal dialysis
Peritoneal dialysis: Can be taken home, considered ambulatory for people who can take care of themselves. Instilled in the peritoneal area (semipermeable membrane) via indwelling catheter. Happens inside body through osmosis in a membrane.
Risks include: weight gain, infection and weakened stomach muscles.

Hemodialysis: Vascular access, done by infused hemodialyzer with an artificial membrane..(fistula). Done for children if they don’t have capable others to perform task.
Blood is filtered outside the body and water and solutes are filtered.
Risks include: Infection (myocarditis), high and low blood pressure, muscle cramps, anemia, itching.

GU Hypospadius: Urethral opening of male is located underneath the penile shaft. Phimosis-When the foreskin cannot be retracted over the penal glands.

Cryptorchidism: Undescended, retractile or absence of testes. Colic: Unexplained crying everyday for more than three times a day in a healthy baby. Usually short lived and will subside. Pinworms: Intestinal parasite in humans. ( weight loss

Infectious diseases Strep causes possible sequalae
-Staph and strep most abundant on skin.
Can be the cause of MRSA, Cellulitis
Chickenpox causes, incubation communicability

Lyme disease causes, incubation communicability

Scarlet Fever
-Sand paper rash/deep red lines on chest
-Can cause heart valve defects but with penicillin it is easily treatable so relax mom and dad.

Meningitis and what the Lumbar puncture test results would be **CSF will have low sugar with a lot of WBC action**
Meningitis is acute inflammation of the meninges and CNS
-Caused primarily by E coli, and Group B. Strep-newborn. H. flu not so much anymore because of immunizations. – In newborns.
Strep neumo: most common in adolescents.
Page 1165 Meningititis.
Gonnorhea is common STD for Meningitis.
-Viral meningitis is far less serious while bacterial meningitis if left untreated after a couple of days can be life threatening. – supportive care. a. Primary prevention of meningitis

b. Signs & symptoms of a infant or child with meningitis

-Meningitis is very abrupt. Fever, chills, headache and vomiting come quickly.

-An altered mental state also quickly progresses. (Agitation/irritability)

-In infants their fontanels bulge and they have poor feeding.

-S/S in children include, stiff neck (nucal rigidity) , high fever, headache, confusion, seizures, sensitivity to light, sleepiness, change in mental state.

-S/S for infants include the same as ICP. (high pitched cry, excessive sleepiness, poor feeding, bulging fontanels, stiffness in neck)

c. Treatment

Gentamycin and cephalosporin are used initially- broad spectrum drugs

-Identify organism right away

-Isolation is key (Patient put under DROPLET PRECAUTOIONS)

-Reduce elevated ICP

Use broad spectrum drugs because it takes a while for labs to come back for specific bacterial agent.

Drugs to use include: Gentamycin, and cephalosporin.

Poison Ivy sequalae
Scarring due to itching and scabbing.
QQQQQQ

Musculoskeletal Risks of immobilization
Muscular system: Decreased Range of motion, Pt to help with blood flow and muscular function
Skeletal system: Can get contractures
Metabolic: Hypercalcemia (calcium goes to kidneys may get kidney stones keep hydrated
GI/GU: Constipation if there is no movement like walking
Cardio: Slows done, Heart get use to less stimulus and need for blood/oxygen
Respiratory: atelectasis (collapse of lung), need help expanding lungs.
Skin: Pressure sores and ulcers. Passive range of motion is needed. CP
-Umbrella term for the non-progressive, non-contagious that mainly effects body movement.
-Motor dysfunction affects muscle tone, posture and movement, immature brain.

Myleodysplasia
-Ineffective production of myeloid class of blood cells which are precursors to bone marrow development.
-Severe anemia require blood transfusions, low blood counts can develop due to progressive bone marrow failure.

DDH signs tests for
How to detect—Ortalani’s, Barlow’s, skin folds, etc
Ortolani click: A positive sign is a distinctive clunk which can be heard and felt as the femoral head relocates into the acetabulum. Abduct away to hear clunk which is the head popping back in.

Barlow’s maneuver : Use for screening to see if the child has DDH. Adduct the hips in and the hip should dislocate for a positive test. It is put back in with Ortolani’s maneuver.

Skin Folds: Skin folds will be seen in the effected side.

Ultrasound vs. XRay
Ultrasound: This is used for young infants usually under the age of 4 months

-Uses sound waves to created images of the hip socket and also gives pictures suggesting fluid build up.

-Ultrasounds are used because doctors like to see direct cartilage portions of the newborn.

Xray: Xray’s are done to give the doctor a sure idea whether the child needs surgery to correct a displaced hip or not.

Treatment-
Pavlik Harness: Pavilk Harness is suited to a child who has DDH. Harness should not be removed in early stages even if soiled. Diaper worn underneath the abduction straps.

Surgery: Surgery is only done if health care providers think the natural course or alignment will not work. 6 months.

Hip spica cast: Cast care: Check for nerve function and blood movement. Look for compartment syndrome stuff. Tuck the diaper between the child’s skin and the cast.

-Do not transport or move child by grabbing the center support bar.

Neuro ICP---S &S infants, children **An increase of CO2 will cause blood vessels to dilate (fluid build up)
Infants: Irritability, poor feeding -high pitched cry, difficult to sooth -Fontanels are tense and bulging -Cranial sutures are separated -Sunset eyes due to pressure pushing the eyes down and on the optic nerve.
Children:
-Headaches and vomiting** -Seizures -Blurred vision -Irritability and restlessness -Drowsiness, fatigue -Can’t follow commands and weight loss.
Late signs of ICP -Bradycardia -Decreased LOC and **no response to severe pain -Pupil size -cheyne-strokes (death)

Seizures
-Febrile Seizure: Usually benign with no epilepsy or neurological damage. -Avoid tepid baths: usually ineffective -Over 5 minutes call 911. Down syndrome physical characteristics
-Causes: Trisomy 21 genetic mutation
-Single palmar crease and hypotonia, cannot speak very well.
-Congenital hypothyroidism = growth delay, mild to moderate cognitive impairment.
**Cardiac problems and atlantoaxial instability (bones at top of neck are weak)
**high broad forehead, ears are lowered, small head.

Hematology/Oncology Anemia
- Anemia is defined as: a decrease in oxygen-carrying capacity of blood and decreased amount of oxygen to tissues.
-Lowered hemoglobin in the blood which is what actually carries oxygen to tissues for gas exchange.
-Will experience fatigue at first because your muscles and organs aren’t getting what they need to function properly. Sickle Cell anemia S & S Teaching plan
-Genetic: Hemoglobinopathic disorder. Inherited (autosomal recessive so 1:4 chance if both parents are carriers) disorder of hemoglobin synthesis.
- There is a mutation in gene that causes structural change and is unstable. Sickling doesn’t occur until after 12 months because infant has immature gene that doesn’t carry the defect. Once it matures and needs the adult gene (Hgb B) then is when it starts to sickle.
-Abnormally shaped RBC’s become entangled, block microcirculation, decreased blood flow to tissues, ischemia, infarction.

Triggers: Anything that causes an increase need for oxygen. Trauma, infection, stress, dehydration and increased blood viscosity. Hypoxia.

Treatment/Prophylaxis -No cure, treatment of episodes. -Children with disease will get many bacterial infections due to immunecompromise which is usually the cause of death of youngsters. Penicillin by age 2 months – Immunizations to prevent infections. -PAIN MANAGEMENT, O2, REST, HYDRATION, BLOOD REPLACEMENT. Nursing Considerations: Careful assessment. Instruct family to seek medical attention for child who has fever, watch for signs of crisis.

Leukemia-S & S
Leukemia is cancer of blood forming tissues. Trisomy chromosome 21 (DOWNS) are 20times more at risk.
-Uncontrolled overproduction of WBC’s by stem cells in bone marrow.
-Rapid proliferating growth of immature cells + reduction of cell death = accumulation of malignant cells in organs (most severely affected is spleen and liver)
-Leukemia cells are not like regular white blood cells, they grow faster and overcrowd the blood stream because they don’t stop growing when they should.
-**Since this is an infection of the bone marrow, it can cause reduction of RBC’s (anemia), lowered platelets leading to (inability to clot blood) and infection due to lowered function wbc’s.
Treatment:
-Chemotherapy given with lumbar puncture so it can get past the blood brain barrier.
-CNS irradiation
-Bone Marrow Transplant

Cardiovascular PDA treatment for or treatment to keep open
-Failure of fetal ductus arteriosus to close after birth.
-Blood flows from the aorta to the pulmonary artery as the systemic pressure starts to increase, producting a left to right shunt; increased workload on left and rt sides of heart.
-S/S: CHF, murmur, WIDENED PULSES AND BOUNDING PULSES
Treatment:
Medical administration of indomethacin (NSAID)
-PDA can be closed by placing a clip on the DA to ligate it shut.
-NONsurgical: use of coils that promote tissue growth and therefore occlude pda via catheterization.

Coarctation
-Narrowing near the ductus arteriosus, causes increased pressure in the upper extremities and lowered pressure in the lower extremities.
S/S: Bounding pulses in the upper extremities and lowered pressure in the lower extremities. -signs of CHF, dizziness, headaches, fainting, epitaxis (nosebleeds)
Treatment:
-Surgical: enlargement of narrowed section using a graft or sectional connection. -Nonsurgical includes ballooning,
**If the left ventricle can’t provide enough force the lower limbs won’t get enough blood.
**Difficulty breathing, poor feeding, failure to thrive, dizziness, shortness of breath, fainting episodes, chest pain, fatigue, chest pain, headaches, nosebleeds and cold legs/feet.

Decreased pulmonary flow defects
-Results in little to no blood reaching the lungs to get oxygenated.
-Right sided pressures exceed those on the left because of obstructed pulmonary blood flow resulting in a shunt. -Manifestations include the bodies way of trying to compensate. Dyspnea (trouble breathing) increased breathing, murmur, cyanosis on exertion, poor weight gain, less energy to eat, clubbed nails, delayed developmental milestones due to brain lacking oxygen.

GI Intusseption
Intussusception is an obstruction disorder.
**Most common with children with cystic fibrosis.
Process is an invagination of one segment of the bowel into another. Telescoping causes inflammation, edema and decreased blood flow.

S/S: Sudden onset of acute abdominal pain. Vomiting (bilious, or fatty), bloody stools. Palpable abdominal mass.
-Currant bloody stools -Also lethargy with crying in 15-30 minute cycles.

Diarrhea treatment
Can involve the stomach and intestine, small intestine, colon
Acute-chronic day spand is 14 days.
-Younger kids we give them oral rehydration fluids which is the first thing to give.
Diarrhea is going to get worst with milk but if they can keep up with the diarrhea then its okay.

CF What is it? Sodium transport out of the cell. -Genetic illness more common in Caucasian. Autosomal recessive trait.
Patho: CFTR is protein product associated with abnormal transport of chloride across cell membranes. With the abnormal transport of chloride causes a retention of water. This increases the viscosity of mucous gland secretions. Secretions therefore clog and plug pancreatic ducts and bronchioles.
-Pancreatic enzymes get blocked from reaching duodenum which stops
How is it diagnosed – no meconium stool in the first 24 hours.
-Sweat chloride test. 2-5x greater in controls. , genetic test
Early, infant, child symptoms, early= meconium infant = fatty stools, failure to thrive. Child = FTT, respiratory issues.
-**Replacement of pancreatic enzyme

a. Psycho-Social aspects of CF as a chronic disease.

-high rate of divorce.

-end up dying with CF. Average age is 36.

Pyloric stenosis treatment and postop care QQQQQ
-Narrowing or stiffening of pyloric valve at the bottom on stomach -Causes severe projectile non-bilious vomiting. -Danger comes from dehydration and electrolyte disturbances.
Treatment includes surgery. Pre op: Replace fluids and electrolytes NPO through IV based on lab values. Post op: Some vomiting happens after surgery for two days. -IV fluids given until baby can hold down food -NG tube may be administered -Look for weight gain, color, I/O, clear fluids after surgery with glucose. -Look at surgical site for signs of infection and drainage.

Hircshprung’s S &S treatment
Loss of nerve cells so there is no parestalsis.
-Stool accumulates ( bowel distention ( intestinal distention and ischemia ( enterocolitis and death.
-Surgical resection of aganglionic portion of bowel.
-Post op: Ostomy bag, NG tube assessment and functionallity until they have normal function and bowel sounds back.
Measurements after surgery of the abdomen so you can see if there is any distension due to blockages.
Fluid electrolyte balance – look at the NG tube for acid looking contents of the stomach because that is normal.
Give lactated ringers to help with electrolyte balance.

Resp. RSV treatment
-Virus that causes infections of the lungs/respiratory tract.
-Mostly supportive care for virus infections
-Supportive care includes acetaminophen to reduce fever, dry mouth watch for dehydration, sunken eyes.
Hospital care: IV fluids with humidified oxygen. Ventilation if needed. Bronchodilators if needed for real difficulty with breathing.

LTB-S &S Treatment -Caused by….RSV, PARAINFLUENZA VIRUS, S/S: Gradual onset , starts with URI symptoms. Proceeds to low grade fever, barking cough, stridor (inhale) hoarseness. -Tx: Includes humidity (tent, hood) -Make sure patient has patent airway. -Minimize respiratory distress, must monitor carefully.

Pain perception signs, symptoms for different age groups
Young infant: -Rigid thrashing body response -Loud crying, facial expression and grimace
Older Infant: -Loud crying -Facial expression of pain and anger -Physical resistance =pushing stimulant of pain away.
Young Child: -Loud crying, screaming = verbal expression “ow” -Thrashing arms legs and pushing stimulus of pain away -Anticipating pain = can be relieved with distraction comfort with teddy bear etc. -Lacks cooperation
School-Aged Child: -See all behaviors of young child with procedure -Stalling behavior -Muscular rigidity, clenched fists, stiffness, closed eyes

Pain management of post op patients and comatose patients
Infants/Toddlers: FLACC -This is a number system ranking in severity descriptions of the Face, Legs, Activity, Cry, and Consolability. -It is a 0-10 Scale with 10 being the most severe in discomfort. -Ages 1 month to 3 years.
Preschool and school age: Face pain rating scale -Used for children as young as 3. -Tell me the face that you have.
Older school age and adolescents: Number scale and word graphic -Older children have an easier time telling the nurse what they are experiencing and a simple number graph.

Child abuse assessment of

Growth & development. Specifically less than 5 years of age. Introduction of milk, foods etc. teething object permanence, temper tantrums,
Infants (Trust)
Toddlers (Autonomy vs. Shame/doubt)
Preschool (initiative vs. guilt)
School age (industry vs. identity)
Adolescents (identity vs. confusion)

Infants
*Baby should be rolling over by 6 months.
*Chest and head circumference should be equal at 12 months.
*Posterior fontanel closes first by 6 months and anterior closes within 12-18
*Infants may have sinus arrhythmias (increase with inhale, decrease with exhale)
Nutrition
-Breastmilk = more nutrious and has maternal antibodies. -Breastmilk until 6 months = no iron in breastmilk, baby’s storage runs out and it must be supplemented. -Whole milk at 12 months = fats are needed for growth and brain development -Vit D = bone development
**No honey = botchalistic characteristics = paralyzes throat
**Don’t microwave milk = distorts fats, burns baby’s throat, and kills antiinfective properties
Sleep
-3-4 months baby can make it through night without feedings -No bottle at night = tooth decay -Sleep on back = reduces SIDS
Activites
Face to face holding = stimulation and face recognition
Activites on floor with blanket = develop muscles
**Infant can’t pull themselves up by 12 months = possible hip dysplasia
Dental
-Age of child in months – 6 = teeth baby has.
S/S of teething -nawing on things, fever (100.5), drooling

Toddler (egocentric and very self absorbed)
Nutrition
-By 12 months should be eating with rest of family
-Muscle growth doubles = must be eating the right foods
-Avoid large round foods = choking
-Calcium + vitamin D = bone growth and development

Sleep Activity -12 hours of sleep = nighttime rituals, very high energy -no tv No bedtime bottle – brush bid – fluoride sups
Injury Prevention: -lock doors, cover outlets, watch out for hot water, no bathroom -booster seats in cars.

Preschool (Initiative vs. guilt)
Nutrition
-Calcium until 18 -Skim milk now = less fat **Can target childhood obesity here.
**No excessive fruit drinks = dental/ GI problems
Activity
-Allow them to explore -Can watch TV but you want them outside playing.
Lead Poisoning
-S/S: nausea/vomiting, constipation, abdominal pain -developing brain/nervous system especially vulnerable.
School age (Industry vs. Identity)
Exercise and activity -Running, jumping, playing outside, swimming, biking.
Sports: Boys and girls should play separate, boys are more masculine.
-Encouraged to do clubs and sports to learn skills and how to interact with other people.
Dental
-Age of the loose tooth, rise of permanent teeth.
Injuries
**Most common cause of severe injury and death is motor vehicle accident -Safest place for child in car is backseat -Wear helmets
Adolescents (Identity vs. Confusion)
**Boys will eat all the time due to rapid physical growth.
Nutrition
-Eating habits more influenced by peers than family.
**MOTOR VEHICLE ACCIDENTS ARE THE SINGLE GREATEST CAUSE OF SERIOUS INJURY OR DEATH IN ADOLESCENTS
Suicide
-Kids aren’t future thinkers
-Cries for help and attention
-Most successful is firearms (boys more than girls) = boys are more impulsive
Overdose is most common attempt