Newborn Transition and Assessment PDF

11/07/2024 The Newborn Transition and Assessment ○ Skin to Skin contact– is important, and helps lead to breastfeeding right away and bonding between parents and baby ○ Initiation of Respiration Developmen...

11/07/2024 The Newborn Transition and Assessment ○ Skin to Skin contact– is important, and helps lead to breastfeeding right away and bonding between parents and baby ○ Initiation of Respiration Development of the lungs: Fetal lung fluid expands the alveoli and aids in lung development 65% of which is absorbed by the time of birth Surfactant- detectable by 24-25 weeks Reduces surface tension within the alveoli Secretion of surfactant increases during labor and immediately after birth Steroids may be given to patients in preterm labor to help increase surfactant production and lung maturity Diabetes can delay surfactant production ○ Baby’s first breath First breath– forces remaining fluid out of alveoli (c-section and fast birth can delay) Mechanical factors Fetal chest is compressed during vaginal birth Recoil of the chest draws in a small amount of air into the lungs Chemical factors Increased partial pressure of CO2 and decreased pH Thermal factors Temperature change at birth Sensory factors Sound, light, smells, and pain ○ Fetal Circulation Lungs– vasoconstriction, high pressure, low blood flow Foramen Ovale– connects two atria, provides brain perfusion Ductus Arteriosus– bypasses lungs, provides lower limb perfusion, aorta Ductus Venosus- bypasses in the liver  ○ Changes at birth Respiratory changes With baby's first breath… ○ Pulmonary alveoli open up ○ Fall in pulmonary vascular resistance ○ Lungs expand ○ Increase in pulmonary blood flow Circulatory changes Systemic circulation is established Fetal shunts close Murmurs Pulmonary resistance falls for 4-6 weeks after birth Initial Assessment and Care at Birth ○ APGARs*** 0-3 = critical 4-6 = below normal 7-10 = generally normal Performed at 1min and 5min If less than 7… must repeat every 5 minutes for up to 20 minutes Appearance and color… best visualized by the buccal mucosa (oral mucus membranes) APGAR = 6 !! ○ Head-to-Toe Assessment 1-4 hours, adaptation to extrauterine life, Ballard score, health risk problem assessment, “eyes and thighs” Period of Reactivity*** Alert for the first hour of life- 1st period “Golden Hour” ○ Initial assessment ○ Encouraging eye-to-eye and skin-to-skin contact ○ Initiate first feeding (if an infant is stable) ○ Vitamin K injection, erythromycin ointment given K– helps with clotting in the blood Erythromycin– prevent STIs and infection Period of relative inactivity: 2-3 hours after birth ○ Increased sleepiness, decreased HR (100-140), stable RR (40-60) Second period of reactivity: 4-6 hours ○ 10 minutes to several hours Nursing Assessments and Interventions Vitals every 30 minutes, then hourly Identify infant and apply/initiate security system (name band/alarm band) Obtain weight, length, head circumference Evaluate gestation size/age ○ Ballard Exam/Score (helps us determine age/tone/reactivity)  Assess and monitor skin color, including acrocyanosis Assess suck/swallow ability (with feeding) Assess newborn reflexes and movement Assess for anomalies Infant Size Small for Gestational Age (SGA) ○ Size below the 10th percentile Appropriate for Gestational Age (AGA) ○ Size between 10-90th percentile Large for Gestational Age (LGA) ○ Size greater than 90th percentile Prevention of eye infection Receive prophylactic eye treatment to prevent ○ Ophthalmia neonatorum ○ Caused by gonorrhea or chlamydia Eye prophylaxis given ○ Erythromycin 0.5% ophthalmic treatment ○ Can blur vision temporarily ○ Usually at the end of the first hour ○ Technique !!! Swaddling! Hands down, feel comfortable, etc Prevention of Hemorrhage Vitamin K… clotting factor Helps prevent bleeding Prevention of Hep B Hep B can be transmitted… ○ During vaginal or c-sections ○ Close contact with family members who are infected No prophylaxis ○ 30-85% of newborns born to an infected mother will acquire hep b ○ 25% will die from liver cirrhosis or hepatocellular carcinoma First dose… 1-24 hrs ○ Prior to discharge Hep B immune globulin ○ First 12 hrs after birth if mother HAS Hep B ○ 24-hour Screening ○ Vitals: Accurate Data Apical pulse 1 full minute 4th intercostal space/MCL 5 locations of Cardiac Exam (APETM) Temperature Rectal, axillary, tympanic, temporal BP: taken on the leg… different sizes ○ Anthropometric measures: growth Length Lying down (until 2-3 when they can stand) Weight Safe on scale BMI after 2yrs Head circumference Measure from supraorbital ridges to the most prominent part of the occiput Every visit until 2yrs Head Shape/symmetry ○ Fontanelles Head control Head posture Range of motion Skull  Capput Succedaneum ○ Localized edema over the vertex ○ Edema crosses the suture line ○ Disappears after a few days ○ Increased risk– vacuum deliveries Cephalohematoma ○ Blood under the scalp caused by pressure ○ Typically, over parietal bones ○ 42-48 hours after birth ○ Clear edges ending at suture lines ○ Will slowly reabsorb (up to 3 months) ○ Increases risks for jaundice ○ Normal Newborn Rashes ○ Newborn Reflexes fencing- goes away first ○ Genitalia Infant with a cervix Labia majora enlarged and may be darker Pseudo menstruation- a small amount of vaginal bleeding (normal) Infant with penis Darkened scrotum Hydrocele- a collection of fluid around one or both testes Cryptichidis- undescended testes ○ Can occur on one or both sides ○ Typically descend by 6 months ○ Fixed with orchiopexy Hypospadias- urethral meatus on the underside of the penis or on the perineum Epispadias- urethral meatus on the upper side of the penis ○ Voiding 93% by 24hrs, 99% by 48hrs after birth Initial bladder volume is 6-44mL of urine Expect normal color urine Day 1-2: void 2-6 times a day  Day 3-4: void 6-8 times a day Day 5+: void 6-8 times a day ○ Elimination Meconium formed in utero Eliminates meconium within 24-48 hours Meconium ○ Thick, tarry, dark green/black, passed in first 12 hours Transitional stools ○ Thin, brown to green Breastfed infant: Yellow, gold/soft or mushy, “seedy” Odor may be sweet-sour Typically 3+ stools/day until 6 weeks Formula-fed infant: Pale yellow, light brown formed and pasty stool Odor is typical Frequency varies… usually less than breastfed babies ○ Newborn Metabolic Screening Genetic, endocrine, metabolic disorders Capillary blood through heel stick After 24 hours of age, before discharge ○ Nursing Care Nursing assessment for jaundice every 8-12 hours Visual, universal predischarge bilirubin screening Adequate feeding… First feed= 1-2 hours post-birth Fed 8-12 times/24 hours Colostrum laxative to promote stooling (get rid of bilirubin) Bottle fed 8-12 times in 24 hours Common Problems in Newborns ○ Thermoregulation Predisposing factors to heat loss: Think skin, blood vessels close to surface Little subcutaneous fat 3x more surface area than adults in relation to mass The rate of heat loss is 4x greater than that of adults Protective factor Flexed position reduces the amount of skin surface exposed ○ Thermogenesis Signs of a cold infant Restlessness, crying, increased flexion and activity to maintain heat, vasoconstriction→ acrocyanosis, body metabolism rises → increased need for O2 and glucose NST: non-shivering thermogenesis Primary source of heat production ○ Brown fat/brown adipose tissue to produce heat! ○ GI/GU Can’t digest complex carbohydrates Until 4-6 months ○ Introduce solids around this time! Absorption, protein, lactose Tummy: burp and spit up after food Relaxed sphincters ○ Newborn Liver Glucose maintenance Glucose is stored as glycogen in the fetal liver for use after birth  Conjugation of bilirubin The liver is immature, and can’t keep up Crucial role in iron storage, metabolism of drugs, and production of factors needed for coagulation ○ Physiologic Jaundice*** Transient hyperbilirubinemia (newborn jaundice) Bilirubin… RBCs being broken down (byproduct) Normal process Occurs in 50% of term and 80% of preterm newborns Occurs in the 3-5 days after birth, when bilirubin levels peak at 5-6mg/dl… levels begin to fall days 5-7 Caused by accelerated destruction of fetal RBCs Increased reabsorption of bilirubin by liver Moves head down, resolves down to head ○ Early-onset breastfeeding jaundice Due to insufficient intake Greatest risk is in infants who are sleepy, have poor suck, or nurse infrequently BF babies… 3-6 times more likely to develop moderate jaundice or severe jaundice Interventions Assist parent with breastfeeding Consider pumping to stimulate milk production and increase the intake ○ Pathologic Jaundice Usually appears within 24 hours of birth Result of excessive destruction of RBCs or problems in bilirubin conjugation Sepsis (infection interferes) Blood incompatibilities Metabolic disorders Increased hemolysis of RBCs ○ Bruising, cephalohematoma from birth process ○ Late-onset breastfeeding jaundice True Breast Milk Jaundice Usually occurs after the first 3-5 days of life and lasts 3 weeks to 3 months Substances in maternal milk may increase the absorption of bilirubin from the intestine or interfere with conjugation Treatment ○ Close monitoring of total serum bilirubin (TSB) ○ Minimum of 8-12 feedings/day  ○ If TSB is too high… phototherapy begins, breastfeeding is typically continued to be recommended ○ If dangerously high, may pause breastfeeding for 1-3 days (use formula) ○ Management of hyperbilirubinemia *** Inpatient or outpatient treatment If severe, transfer to NICU Managed mainly with phototherapy Lamp, blanket, pad, or cover-body device Infants are only in a diaper! ○ 45-50cm away Nurses role Infants eyes must be protected with a mask/eye shield Close infants eyes Remove periodically to assess eyes ○ During feeding times, allow infant to see caregiver/parent, clean eyes with water if needed No ointments/creams should be applied… could cause burns Bilirubin should decrease in 4-6 hours ○ Hypoglycemia More common in preterm Signs and symptoms Jitteriness, poor muscle tone, poor feeding, tachycardia/tachypnea, apnea, irritability, lethargy Glucose: we want it to be 40+ ○ Immune System Passive immunity: crosses the placenta (can last weeks to months) Breastfeeding continues Active immunity: when they’re exposed and the body develops antibodies Look for low temp rather than fever… with immune function ○ Sepsis More at risk if there’s prolonged rupture of membranes, treat mom’s GBS Signs Instability for temp, increased HR, poor feeding ○ Caregiver Education and Resources Common concerns! 11/13/2024– Developmental Influences and Child Health Promotion Definitions *** ○ Growth- increase in physical size as a whole or its parts  ○ Development- an increase in function and complexity that occurs allowing an increase in capabilities ○ Learning- acquisition of knowledge or skills through experience, study, or being taught Learning can be affected by development ○ Maturation- physical change in the complexity of body structures that enable a child to function at increasingly higher levels Stages of Growth and Development Piaget’s Theory of Cognitive Development ○ Sensorimotor: 0-2 ○ Preoperational: 2-7 Egocentric… self focused! ○ Concrete operational: 7-11 Logic, empathy, perspective ○ Formal operational: 12+ Abstract, hypothetical ○ Looking at the child physically and cognitively Erikson’s Psychosocial Theory ○ Looking at the emotional care and coping skills Kohlberg’s Theory ○ MORAL development ○ Guiding parents about discipline and anticipating behaviors as normal  Factors that Influence Development ○ Physical and Neurological Growth Cephalocaudal (head-first) They grow head to toe! Proximodistal (center-out) They grow center out! Think about the lungs ○ Motor Development Gross motor (sitting, walking) Large groups of muscles Fine motor (hand-eye coordination) Dexterity ○ Language Development Receptive > Expressive Articulation follows a typical pattern Language follows milestones ○ Personal-Social Attachment Temperament Relational ○ Influencers Nutrition, Heredity, Environment, Health status, Culture, Family, Parental attitudes What can affect nutrition? Access, finances, school meals, parental education ○ Lead exposure for kids*** Social Determinants of Health Food security, safe place to sleep, clean housing, water and sanitation, education, access to health resources, health literacy Prevalence of screens reading/homework, streaming/television, internet/video games, phones, social media Stressors in Childhood Scheduling (over/under), bullying, trauma ○ ACEs (adverse childhood events) Higher scores predictive of adulthood (at risk…) Obesity, chronic disease (heart/liver), depression, alcohol and tobacco use/abuse  PEARLS (pediatric early adversity and related life effect screen) UCSF 2020 Social determinants Does not consider… Protective factors, influences outside of the home, not validated in children ○ How can we help? Resilience ○ State: who’s been supporting them (community/how you grew up) ○ Trait: within the person Both can play a factor ○ Number one predictor of resiliency in adulthood: a secure, supportive relationship early in childhood!! Parent, mentor, teacher Individual protective factors ○ Children having positive friendships and peer networks, doing well in school, having caring adults outside of the family, mentors/role models Self-esteem ○ Competence, sense of control, moral worth, worthiness of love/acceptance, affirmation With ourselves… also plugging positive affirmations! Nursing Role ○ Monitoring growth  Accurate measurements, accurate vital signs, nutritional assessment, physical activity assessments ○ Monitoring development (cognitive, language, motor, social-emotional) Engage in child play/conversation/care, screening tools, family report ○ Health promotion Immunizations, anticipatory guidance (next stage), safety ○ Knowing the normals and educating parents about the next stages and steps is important!! Trauma Informed Care ○ Guiding principles, require organizational support, a shift in culture, the standard of care Cultural competence/safety/awareness Understanding the Child and Family ○ Temperament / Culture Manner of thinking, behaving, or reacting that is characteristic of individual Easy child: happy, compliant, predictable Difficult child: argumentative, defiant, angry Slow-to-warm-up child: shy, awkward, quiet All children are different! Look at how you’re reacting to them Role of Play in Development ○ Play is the work of children! Sensorimotor development Intellectual development Creativity, self-awareness, therapeutic value, socialization Moral value/development ○ Types of Play Be careful with screens! Unoccupied- watching (infants) Solitary- occupying themselves (0-2) Onlooker- 2 yrs, watching Parallel- 2+, sit next to each other/similar, own thing Associative- 3-4 yrs… playing together/others, no rules Cooperative- 4+, together, rules, often a winner Symbolic- pretend play (chef, mud pie) ○ Play in the Care Environment Ensuring that the children can still play! Ambulation, range of motion, injections, deep breathing, soaks, fluid intake, taking medicine, cast removal… all possibilities to take into account when encouraging children to play still Development and Health Promotion for Infants Well-checks/ Immunizations for infants Growth ○ Appropriate age and sex ○ Individual curve Weight should be DOUBLED by SIX months Weight should be TRIPLED by TWELVE months Length 50% increase by 12 months Head circumference- until 2 years old ○ Proportionate measuring! O.P. starts at 8 months, solid by 9-10 months separation anxiety (not wanting to be away from caregiver), stranger (idk this person)  Promoting Healthy Development ○ 5 R’s Read together Rhyme, play talk, sing Routines Reward Relationships Nurturing, respectful, consistent Leading Causes of Death in Infants ○ 1-12 months Congenital anomalies Disorders related to short gestation and LBW Sudden infant death syndrome Unintentional injuries Nutrition and oral health ○ Visit dentist with the emergence of the first tooth ○ 6-8 teeth by 12 months ○ Avoiding sugary foods/liquids ○ Initiate brushing ○ Fluoride recommendations Based on levels in environment no free water until 6mo! *** Sleep ○ 12-16 hours/day (including naps) ○ Routines! ○ Safe sleep Back is best, firm surface, swaddle until able to roll, no blankets/toys/etc, co-room until 6 months, no co-bedding Safety ○ Unintentional falls.crushing injuries ○ Injections Personal care products, analgesics, cleaning products, topical agents, foreign bodies ○ Carbon monoxide and smoke detectors ○ Car seats State law, rear-facing (< 2yrs or under 20lbs), free programs through MN dep of public safety ○ Burn reduction/drowning reduction ○ Choking hazards  ○ Lead reduction (screenings in well-child visits) *** Immunizations ○ Basic Defs Immunity- protection from an infectious disease, the body creates specific antibodies to fight that disease Vaccines- preparation that is used to stimulate the body’s immune response against disease Oral, spray, injection Vaccination- the act of introducing a vaccine into the body to produce protection from a specific disease Immunization- the body becomes protected against a disease through vaccination ○ Types Live attenuated (weakened) Killed (inactivated) Nucleic acid vaccine (mRNA) Tells the body how to make an antibody ○ Vaccine Schedule Video ** 11/21/24– School Age Children and Adolescents Theories of Development Chart Stressors: remain the same! Many similar things that can affect growth ○ Looking at bullying! Huge stressor within school Leading Causes of Death ○ 5-9yrs Accidents (unintentional injuries), cancer, assault (homicide) ○ 10-14yrs  Accidents (unintentional injuries), intentional self-harm (suicide), cancer ○ Adolescent (15-19yrs) Accidents (unintentional injuries), homicide, intentional self-harm (suicide) ○ Increases with fire-arm-related injuries! Promoting gun safety… normalizing and being non-judgemental School Age Children ○ 6-12 years ○ Growth: steady at 5lbs and 2in per year ○ Physical: eustachian tubes drop, lungs and immune system mature ○ Motor: coordination developing, but still adding muscle mass Overuse injuries from increased intensity Sports year-round… overusing specific areas of the body Osgood Schlatter Painful inflammation under the patella (irritation of the growth plate) Sever’s Disease Quadriceps can't keep up with growth., pulling on Achilles tendon… irritation and inflammation on the heel Goes away normally… icing, rest from activity, ibuprofen Common in jumping/high impact sports Development (school age) ○ Piaget: Pre-Operational-Concrete ○ Erikson: Industry vs Inferiority ○ Kohlberg: conventional; developing a conscious but still very simplistic Good behavior=good person Focus on family ○ Cognitive: brain size complete at age 10 Logical thinking, perspective, mastering skills, problem-solving, increased attention span, understanding major concepts Reversibility (water vs eggs) Classifications (sorting/grouping) Humor Language (rapid development… 200-300 new words/year) ○ Psychosocial Play: Learning rules of interactions Playground rules, team sports, broader activity range, clubs/groups, competition Social rules and relationships Family relationships, independence, friendships, school Self esteem= success, competence  Exploring areas of interest (where they fit) Well Visits ○ Yearly ○ Growth and development ○ Immunizations (given in accordance with at-risk pt populations and with immune system competence) 9-12 years TDaP HPV (9) ○ Without it, it can cause cervical/penile/throat cancer, and warts ○ If 11+, 3 doses (if younger than that, 2 doses) Meningococcal ○ 2 types ○ Meningitis ○ Important to give before college ○ Nutrition Appetite increases with growth spurts Healthy options Right-size portions Vitamin D (600 IU) Hydration Family meals vs fast meals Hard to do! Think about planning Obesity 20-21% of children 6-19yrs in the US ○ Screen time ○ Processed food ○ Food insecurity/deserts ○ Dental Health Secondary/permanent teeth erupt (6) 28/32 emerge 42% prevalence of dental caries Prevention Regular checkups Cleaning Brushing and flossing ○ Supposed to help kids until age 7 with brushing and getting all the spots Sealants  Limit sugar-sweetened drinks and treats Braces Dental injuries ○ Sleep/Activity Sleep Generally, need 9-10 hours of sleep/night No screens 1 hour before bed No phones in their room (or no phone) Routines; fewer but may be important Activity Developing physical and emotional maturity Variety of activities Sense of accomplishment ○ Discipline Consistent limits Realistic expectations Family responsibilities/chores Natural consequences ** Communication with teachers ○ Sexual development/education Before puberty 8+ with a vagina 9+ with penis Treat sex as a normal part of growth and development Partner with parents Provide family resources Many books and online resources now Community-based Begins in schools in 4-5th grade Continues through middle school Nursing considerations Level of maturity Self-consciousness and embarrassment Family-based Individualized care Incorporating values and beliefs Hormone secretion GnRH!! ○  Puberty Staging  Tanner Stages Need to know: hitting way too early, can lead to stunted grown or could have an underlying cause (genetics/cancer/hormone imbalance)... also important to notice if this is delayed Can also be important for patient education!! Questions Testicular enlargement, pubic hair growth, penile enlargement, growth of axillary hair, voice changes Ans: D ○ Safety Accidents Firearms: guns locked and unloaded  MVA: car seats, lap belts, rear seat, pedestrian Bicycle: helmets ATV: helmets, adult supervision Water safety: swim lessons, supervision Fire/burns: 9/11, safety in kitchen Sports: appropriate safety equipment ○ Concussions- over 1million/year Confusion immediately after Impaired balance one day after Slower reaction time and/or impaired memory and verbal learning around two days after ○ High incidence in football, hockey, lacrosse, and soccer (high-impact sports) ○ School and peers Time Second only to family as a socializing agent Societal values Peers are growing influence Challenges School refusal Latchkey ○ Home alone guide for MN Ages 0-8: none 8-10: less than 3 hrs 11-13: less than 12 hrs 14-15: less than 24 hrs Ages 16+: longer with an emergency plan Babysitting: 11+ years with the above guidelines ○ Stress Covid Food insecurity Bullying Stop, walk, squawk Social media Over-scheduling Nursing considerations Listen, screen for issues, provide education and resources Mental health  Suicide is the 2nd cause of death for ages 10+ Routine depression screening is recommended at the age 12 years High level of stress ○ Depression, anxiety, self-harm, eating disorders Adolescents ○ Ages 13-19/11-21 years Dramatic changes in growth and physical appearance Increased autonomy Increased coordination Increased participation in athletics and arts Bones not fully calcified until the end of puberty Increased risk for injury Well visits yearly (sports physicals) ○ Development Piaget: Formal operation Problem-solving abstract/futuristic thoughts Erikson: Identity vs. Role Confusion Characterized by faith in self Who am I? Unsure of self or role in society Kohlberg: Post-conventional The greatest good for all The end does not justify the means Moral compass Cognitive Brain maturation through 26 years ○ Higher reasoning ○ Impulse control ○ Emotional liability Concrete, abstract thought Appreciate the perspective of others Focus on community/society Decision-making Consequences of Alternative Actions Prioritization Sensory Vision and hearing developed ○ Refractive error with eye changes  ○ Contact lens use Language Advanced verbal expression Privacy is VITAL Reading advances articulation and vocabulary Impact of technology ○ Programming skills ○ Negative impact of abbreviated communication ○ Interpersonal skills Psychosocial Seeking autonomy Parental relationship shifts ○ protection/dependence > equality ○ Increased independence ○ Increased responsibility/privileges ○ Creates ambiguity Peer relationships often assume the primary role ○ Image ○ Social behaviors ○ Sense of belonging Discipline and Communication Approach- respect, open-ended questions, discussion > lecture, time to process, natural consequences, avoiding ultimatums Additional Nursing Considerations- allowing space for private conversation, explaining limits of confidentiality (12-13 confidentiality) ○ Stages ○ Well Checks Yearly Nutrition Increased nutritional needs  Body image concerns Behaviors ○ Food selection ○ Skipping meals ○ Fad diets Vegetarian ○ Meal prep ○ Need to balance Supplements ○ Creatine ○ Muscle builders ○ non-FDA approved Sleep 8-9 hours of sleep/night Maintaining a schedule! Many disruptions with school/activities/homework Shift in circadianrhythm (want to stay up and sleep in) Activity 30-60mins/day Safety Immunizations Mental Health Risk behaviors Drug or alcohol use Body art Sexuality and activity Cancer screens Scoliosis test Postural screening Questions ○ Ans: A,D,E ○ Ans: B ○ HEEADDSSS ASSESSMENT H- home environment Who lives with you? Where do you live? Have there been any recent changes in the living situation? Is anyone new in the home recently? Anyone who has left the home recently? Have you ever had to live away from home? How do you get along with those in the home? Any physical violence in the home? EE- employment/education Tell me about school. Is it a safe place? What are your favorite subjects? How are you performing academically? Do you have a trusted adult at school you can talk to? Do you have friends attending this school? Any experiences of bullying? Are you currently employed? How many hours do you work each week? What are your future education/employment goals? E- eat Tell me about what a normal day of eating looks like for you. What do you like/not like about your body? Does your weight or body shape cause you stress? Have you had any recent changes in your weight? ○ What do you think a healthy diet is? What would happen if you gained 10lbs? Does it ever seem like you are not in control of your eating patterns? Have you ever taken diet pills? A- activities What do you do for fun? (who/what/where/when) If you spend time online, what do you do for fun online? How many hours a day do you spend on a screen> Do you participate in sports? Which ones? How many hours a week are you active? How much sleep do you get? Do you have trouble sleeping> ○ Promoting social activities and going outside! D- drugs Do any of your friends or family members you tobacco? Alcohol? Other drugs? Do you use tobacco/e-cigs/alcohol? Other drugs/energy drinks/steroids/medications not prescribed?  Is there any history of alcohol/drug problems in your family? Does anyone at home use tobacco? Do you ever drink or use drugs when you’re alone? CRAFFT (asks about alcohol use and frequency) S- sex/sexuality Romantic relationships Sex- If you are using birth control/protection STIs ○ Sexual risk assessment Consent, number of partners, pregnancy risk, STIs, media influences, additional LGBTQ+ risks (suicide/homelessness/risky behavior/substance abuse) Being forced to perform If sex is enjoyable S- suicide/depression Screening assessments for MH issues Patient education and resources S- safety Have you ever been seriously injured? Do you feel safe at home or school? Have you been bullied? Have you ever had to carry a weapon to protect yourself? INJURY PREVENTION! ○ Hygiene Hormone shifts Acne Body odor Personal care Dental care Wisdom teeth Fluoride Orthodontics Injuries (milk) ○ Immunizations Starting at 11-12 MCV, Tdap, HPV, Men B Yearly Influenza, Covid Needle fears  25% of adults in the US are needle-phobic Strategies to reduce fear: numbing the skin, breast deeding or sucrose for infants, comfort positioning, distraction ○ Lots of transitions! Increases in social activities Driving Jobs Time management Decisions that affect health