CPN(C) Perioperative cheat sheet

NPO intervals per ASA: 2 h for clear liquids, 4 h for breast milk, 6 h for formula, nonhuman milk, and light meal; shorter intervals raise aspiration risk.

Baseline pediatric vital signs vary by age: newborns breathe 30-60/min and heart rate 100-160/min; by school age respirations fall to 18-25/min and heart rate to 70-110/min.

Upper respiratory infection within 2-4 weeks increases bronchospasm, laryngospasm, and cancellation risk; assess fever, purulent secretions, and wheeze at the time of surgery.

A history of prematurity (born before 37 weeks) with current postconceptional age under 60 weeks raises postoperative apnea risk after general anesthesia.

Preoperative labs are not routine for healthy children; hemoglobin and type-and-screen are indicated for anticipated blood loss, sickle cell disease, or significant anemia.

Informed consent in minors is given by a parent or legal guardian; assent is sought from developmentally able children, typically age 7 and older.

Active or recent varicella, measles, or respiratory infection warrants postponement per incubation and communicability windows to protect other patients and staff.

Anesthesia history of malignant hyperthermia, or a family history of it, mandates avoidance of volatile agents and succinylcholine and use of nontriggering technique.

Infant airway: large head, short neck, large tongue, floppy omega-shaped epiglottis, and narrowest point at the cricoid ring; the cricoid is the physiologic cuff.

Infants have a higher metabolic rate and oxygen consumption (about 6-8 mL/kg/min) with lower functional residual capacity, so desaturation occurs rapidly during apnea.

Neonatal cardiac output is rate-dependent because stroke volume is relatively fixed; bradycardia markedly reduces perfusion.

Total blood volume: neonate 85-90 mL/kg, infant 75-80 mL/kg, child 70-80 mL/kg; a 10% loss is roughly 8-9 mL/kg in a neonate.

Renal function matures by about 1-2 years; glomerular filtration rate is low in neonates, prolonging drug clearance and increasing fluid and electrolyte risk.

Infant liver is relatively large and the rib cage is compliant; abdominal organs sit higher, and the liver and spleen are more vulnerable to blunt trauma.

Thermoregulation is immature: large surface area to mass ratio and poor shivering cause rapid heat loss by evaporation, conduction, convection, and radiation.

The pediatric skeleton is more cartilaginous and flexible, so fractures may occur without obvious deformity; growth plates are vulnerable to injury.

Pediatric breathing circuits are Mapleson or circle systems; uncuffed or microcuffed tubes are sized by age formula (age/4 + 4) or by nares and little-finger diameter.

Laryngospasm is managed by removing the stimulus, applying 100% oxygen with continuous positive airway pressure, and deepening anesthesia; succinylcholine is used if it persists.

Emergence delirium typically occurs 10-30 minutes after awakening in preschool children and is distinguished from pain by inconsolable agitation without a clear source.

Propofol causes pain on injection and hypotension; ketamine preserves airway tone and respiration but increases secretions and emergence reactions.

Sevoflurane is the most common pediatric inhalational induction agent because it is nonpungent; it can trigger malignant hyperthermia in susceptible patients.

Postoperative nausea and vomiting prophylaxis uses ondansetron, dexamethasone, or droperidol; risk rises with strabismus, ear, and abdominal surgery.

Regional techniques such as caudal and ilioinguinal blocks reduce opioid need; local anesthetic maximum doses are about 2-3 mg/kg for bupivacaine and 5-7 mg/kg for lidocaine with epinephrine.

Difficult airway predictors include micrognathia, macroglossia, short neck, and craniofacial syndromes; supraglottic airways are an option for short procedures in appropriately selected children.

Surgical site infection prevention: administer prophylactic antibiotic within 60 minutes before incision, maintain normothermia, and use chlorhexidine-alcohol skin prep with full dry time.

Surgical hand antisepsis requires scrubbing to the elbows for the manufacturer-specified duration (commonly 3-5 minutes for first scrub) and keeping hands above elbows.

Sterile field rules: sterile items contact only sterile items; a sterile person stays within the field; nonsterile persons never reach over the sterile field.

Time-out before incision confirms patient identity, procedure and site, consent, allergies, antibiotic, imaging, and equipment availability.

Infants lose heat quickly in the operating room; forced-air warming, warmed fluids, and increased room temperature reduce hypothermia and surgical site infection.

Fluid replacement uses the 4-2-1 rule for maintenance and 10-20 mL/kg boluses for hypovolemia; blood loss is replaced with crystalloid in a 3:1 ratio or colloid 1:1.

Counts of sponges, sharps, and instruments occur before incision, at wound closure, and at skin closure; the circulating nurse documents the count and any discrepancy.

Electrosurgery requires a well-applied dispersive pad on dry, well-perfused skin away from bony prominences and away from the surgical site.

Discharge criteria from phase I recovery include stable vital signs, patent airway, protective reflexes, adequate pain control, and return of baseline consciousness.

Aldrete scoring assesses activity, respiration, circulation, consciousness, and oxygen saturation; a score of 9-10 is generally required before phase II transfer.

Postanesthesia apnea risk in ex-premature infants under 60 weeks postconceptional age warrants extended monitoring, often 12-24 hours.

Pediatric early warning scores use age-specific thresholds for respiratory rate, heart rate, blood pressure, oxygen saturation, and consciousness to trigger escalation.

Laryngospasm and airway obstruction most often occur during emergence; signs include stridor, retractions, desaturation, and absent air movement.

Postoperative hemorrhage is suggested by tachycardia, delayed capillary refill, falling urine output, and dropping hematocrit before hypotension appears in children.

Malignant hyperthermia presents with rising end-tidal carbon dioxide, tachycardia, rigidity, and hyperthermia; treatment is dantrolene 2.5 mg/kg IV and cooling.

Postoperative vomiting after strabismus or tonsillectomy is common; positioning on the side protects the airway and reduces aspiration risk.

Use age-appropriate pain scales: FLACC for infants and toddlers, Wong-Baker FACES for ages 3 and older, numeric rating scale for ages 8 and older.

Neonates and infants feel pain; untreated pain causes physiologic stress with tachycardia, hypertension, and altered stress hormones.

Acetaminophen dosing is 10-15 mg/kg every 4-6 hours, with a maximum of 75 mg/kg/day; IV acetaminophen is 15 mg/kg every 6 hours.

Ibuprofen dosing is 10 mg/kg every 6-8 hours; avoid in dehydration, renal impairment, and children under 6 months.

Morphine IV is 0.05-0.1 mg/kg every 2-4 hours; monitor respiratory rate, sedation score, and oxygen saturation, and keep naloxone available.

Multimodal analgesia combines acetaminophen, NSAIDs, local anesthetics, and opioids to reduce opioid dose and side effects.

Caudal and epidural analgesia provide effective lower-body pain relief; monitor for urinary retention, motor block, and local anesthetic toxicity.

Nonpharmacologic methods include sucrose for neonates, swaddling, distraction, guided imagery, and parental presence; these are adjuncts, not substitutes for analgesia.

Family-centered care treats the family as a constant in the child's life and includes parents in assessment, care planning, and decision-making.

Separation anxiety peaks around 8-18 months; parental presence during induction reduces distress in appropriately prepared children.

Preoperative preparation uses developmentally appropriate language: play and simple explanations for toddlers, concrete teaching for school-age children, and privacy and autonomy for adolescents.

Children aged 3-6 often interpret illness as punishment; honest, nonjudgmental reassurance and simple explanations reduce guilt and fear.

Parental anxiety correlates with child anxiety; providing clear information and allowing parents to stay nearby reduces distress in both.

Siblings need age-appropriate information and reassurance, as they may feel neglected or responsible for the child's illness.

Cultural and religious preferences should be assessed and accommodated, including dietary, ritual, and modesty practices, within safe care limits.

Child life specialists use play, distraction, and medical preparation to reduce distress during procedures and recovery.

Wrong-site surgery prevention uses a standardized time-out with patient identity, procedure, site, side, consent, and imaging confirmed by the whole team.

Medication safety: pediatric doses are weight-based and double-checked; high-alert drugs such as opioids and insulin require independent verification.

Weight in kilograms is the single most important pediatric medication safety parameter; pounds-to-kilogram conversion errors are a leading source of overdose.

Retained surgical items are prevented by standardized counts and, for high-risk cases, intraoperative radiographs before closure.

Handoff communication uses structured tools such as SBAR or I-PASS to reduce information loss during transfer of care.

Pressure injury risk in children is reduced by padding bony prominences, repositioning, and securing lines and tubes away from skin.

Quality metrics include surgical site infection, unplanned reintubation, medication errors, and time-out compliance; PDSA cycles test improvement changes.

Fire safety in the operating room uses the fire triad (oxidizer, ignition, fuel) and a plan for stopping the flow of oxygen and removing burning material.

The perioperative nurse's scope of practice is defined by state nurse practice acts, facility policy, and professional standards such as AORN guidelines.

Informed consent requires capacity, disclosure of risks and benefits, understanding, and voluntariness; the surgeon obtains consent, and the nurse witnesses and verifies it.

Advocacy obligates the nurse to speak for the child's best interests, including reporting unsafe conditions and supporting parental involvement.

Autonomy, beneficence, nonmaleficence, and justice guide ethical decisions, including end-of-life care and allocation of scarce resources.

Mandatory reporting includes suspected child abuse or neglect, unsafe practice, and certain communicable diseases; reporting is a legal duty.

Confidentiality for minors follows legal and facility rules; adolescents may consent to certain services depending on jurisdiction.

Evidence-based practice integrates best evidence, clinical expertise, and patient and family values; peer review and continuing education support professional growth.

Delegation to unlicensed assistive personnel requires assessment of task complexity, patient stability, and the delegate's competence, with retained accountability.

NPO intervals per ASA: 2 h for clear liquids, 4 h for breast milk, 6 h for formula, nonhuman milk, and light meal; shorter intervals raise aspiration risk.

Baseline pediatric vital signs vary by age: newborns breathe 30-60/min and heart rate 100-160/min; by school age respirations fall to 18-25/min and heart rate to 70-110/min.

Upper respiratory infection within 2-4 weeks increases bronchospasm, laryngospasm, and cancellation risk; assess fever, purulent secretions, and wheeze at the time of surgery.

A history of prematurity (born before 37 weeks) with current postconceptional age under 60 weeks raises postoperative apnea risk after general anesthesia.

Preoperative labs are not routine for healthy children; hemoglobin and type-and-screen are indicated for anticipated blood loss, sickle cell disease, or significant anemia.

Informed consent in minors is given by a parent or legal guardian; assent is sought from developmentally able children, typically age 7 and older.

Active or recent varicella, measles, or respiratory infection warrants postponement per incubation and communicability windows to protect other patients and staff.

Anesthesia history of malignant hyperthermia, or a family history of it, mandates avoidance of volatile agents and succinylcholine and use of nontriggering technique.

Infant airway: large head, short neck, large tongue, floppy omega-shaped epiglottis, and narrowest point at the cricoid ring; the cricoid is the physiologic cuff.

Infants have a higher metabolic rate and oxygen consumption (about 6-8 mL/kg/min) with lower functional residual capacity, so desaturation occurs rapidly during apnea.

Neonatal cardiac output is rate-dependent because stroke volume is relatively fixed; bradycardia markedly reduces perfusion.

Total blood volume: neonate 85-90 mL/kg, infant 75-80 mL/kg, child 70-80 mL/kg; a 10% loss is roughly 8-9 mL/kg in a neonate.

Renal function matures by about 1-2 years; glomerular filtration rate is low in neonates, prolonging drug clearance and increasing fluid and electrolyte risk.

Infant liver is relatively large and the rib cage is compliant; abdominal organs sit higher, and the liver and spleen are more vulnerable to blunt trauma.

Thermoregulation is immature: large surface area to mass ratio and poor shivering cause rapid heat loss by evaporation, conduction, convection, and radiation.

The pediatric skeleton is more cartilaginous and flexible, so fractures may occur without obvious deformity; growth plates are vulnerable to injury.

Pediatric breathing circuits are Mapleson or circle systems; uncuffed or microcuffed tubes are sized by age formula (age/4 + 4) or by nares and little-finger diameter.

Laryngospasm is managed by removing the stimulus, applying 100% oxygen with continuous positive airway pressure, and deepening anesthesia; succinylcholine is used if it persists.

Emergence delirium typically occurs 10-30 minutes after awakening in preschool children and is distinguished from pain by inconsolable agitation without a clear source.

Propofol causes pain on injection and hypotension; ketamine preserves airway tone and respiration but increases secretions and emergence reactions.

Sevoflurane is the most common pediatric inhalational induction agent because it is nonpungent; it can trigger malignant hyperthermia in susceptible patients.

Postoperative nausea and vomiting prophylaxis uses ondansetron, dexamethasone, or droperidol; risk rises with strabismus, ear, and abdominal surgery.

Regional techniques such as caudal and ilioinguinal blocks reduce opioid need; local anesthetic maximum doses are about 2-3 mg/kg for bupivacaine and 5-7 mg/kg for lidocaine with epinephrine.

Difficult airway predictors include micrognathia, macroglossia, short neck, and craniofacial syndromes; supraglottic airways are an option for short procedures in appropriately selected children.

Surgical site infection prevention: administer prophylactic antibiotic within 60 minutes before incision, maintain normothermia, and use chlorhexidine-alcohol skin prep with full dry time.

Surgical hand antisepsis requires scrubbing to the elbows for the manufacturer-specified duration (commonly 3-5 minutes for first scrub) and keeping hands above elbows.

Sterile field rules: sterile items contact only sterile items; a sterile person stays within the field; nonsterile persons never reach over the sterile field.

Time-out before incision confirms patient identity, procedure and site, consent, allergies, antibiotic, imaging, and equipment availability.

Infants lose heat quickly in the operating room; forced-air warming, warmed fluids, and increased room temperature reduce hypothermia and surgical site infection.

Fluid replacement uses the 4-2-1 rule for maintenance and 10-20 mL/kg boluses for hypovolemia; blood loss is replaced with crystalloid in a 3:1 ratio or colloid 1:1.

Counts of sponges, sharps, and instruments occur before incision, at wound closure, and at skin closure; the circulating nurse documents the count and any discrepancy.

Electrosurgery requires a well-applied dispersive pad on dry, well-perfused skin away from bony prominences and away from the surgical site.

Discharge criteria from phase I recovery include stable vital signs, patent airway, protective reflexes, adequate pain control, and return of baseline consciousness.

Aldrete scoring assesses activity, respiration, circulation, consciousness, and oxygen saturation; a score of 9-10 is generally required before phase II transfer.

Postanesthesia apnea risk in ex-premature infants under 60 weeks postconceptional age warrants extended monitoring, often 12-24 hours.

Pediatric early warning scores use age-specific thresholds for respiratory rate, heart rate, blood pressure, oxygen saturation, and consciousness to trigger escalation.

Laryngospasm and airway obstruction most often occur during emergence; signs include stridor, retractions, desaturation, and absent air movement.

Postoperative hemorrhage is suggested by tachycardia, delayed capillary refill, falling urine output, and dropping hematocrit before hypotension appears in children.

Malignant hyperthermia presents with rising end-tidal carbon dioxide, tachycardia, rigidity, and hyperthermia; treatment is dantrolene 2.5 mg/kg IV and cooling.

Postoperative vomiting after strabismus or tonsillectomy is common; positioning on the side protects the airway and reduces aspiration risk.

Use age-appropriate pain scales: FLACC for infants and toddlers, Wong-Baker FACES for ages 3 and older, numeric rating scale for ages 8 and older.

Neonates and infants feel pain; untreated pain causes physiologic stress with tachycardia, hypertension, and altered stress hormones.

Acetaminophen dosing is 10-15 mg/kg every 4-6 hours, with a maximum of 75 mg/kg/day; IV acetaminophen is 15 mg/kg every 6 hours.

Ibuprofen dosing is 10 mg/kg every 6-8 hours; avoid in dehydration, renal impairment, and children under 6 months.

Morphine IV is 0.05-0.1 mg/kg every 2-4 hours; monitor respiratory rate, sedation score, and oxygen saturation, and keep naloxone available.

Multimodal analgesia combines acetaminophen, NSAIDs, local anesthetics, and opioids to reduce opioid dose and side effects.

Caudal and epidural analgesia provide effective lower-body pain relief; monitor for urinary retention, motor block, and local anesthetic toxicity.

Nonpharmacologic methods include sucrose for neonates, swaddling, distraction, guided imagery, and parental presence; these are adjuncts, not substitutes for analgesia.

Family-centered care treats the family as a constant in the child's life and includes parents in assessment, care planning, and decision-making.

Separation anxiety peaks around 8-18 months; parental presence during induction reduces distress in appropriately prepared children.

Preoperative preparation uses developmentally appropriate language: play and simple explanations for toddlers, concrete teaching for school-age children, and privacy and autonomy for adolescents.

Children aged 3-6 often interpret illness as punishment; honest, nonjudgmental reassurance and simple explanations reduce guilt and fear.

Parental anxiety correlates with child anxiety; providing clear information and allowing parents to stay nearby reduces distress in both.

Siblings need age-appropriate information and reassurance, as they may feel neglected or responsible for the child's illness.

Cultural and religious preferences should be assessed and accommodated, including dietary, ritual, and modesty practices, within safe care limits.

Child life specialists use play, distraction, and medical preparation to reduce distress during procedures and recovery.

Wrong-site surgery prevention uses a standardized time-out with patient identity, procedure, site, side, consent, and imaging confirmed by the whole team.

Medication safety: pediatric doses are weight-based and double-checked; high-alert drugs such as opioids and insulin require independent verification.

Weight in kilograms is the single most important pediatric medication safety parameter; pounds-to-kilogram conversion errors are a leading source of overdose.

Retained surgical items are prevented by standardized counts and, for high-risk cases, intraoperative radiographs before closure.

Handoff communication uses structured tools such as SBAR or I-PASS to reduce information loss during transfer of care.

Pressure injury risk in children is reduced by padding bony prominences, repositioning, and securing lines and tubes away from skin.

Quality metrics include surgical site infection, unplanned reintubation, medication errors, and time-out compliance; PDSA cycles test improvement changes.

Fire safety in the operating room uses the fire triad (oxidizer, ignition, fuel) and a plan for stopping the flow of oxygen and removing burning material.

The perioperative nurse's scope of practice is defined by state nurse practice acts, facility policy, and professional standards such as AORN guidelines.

Informed consent requires capacity, disclosure of risks and benefits, understanding, and voluntariness; the surgeon obtains consent, and the nurse witnesses and verifies it.

Advocacy obligates the nurse to speak for the child's best interests, including reporting unsafe conditions and supporting parental involvement.

Autonomy, beneficence, nonmaleficence, and justice guide ethical decisions, including end-of-life care and allocation of scarce resources.

Mandatory reporting includes suspected child abuse or neglect, unsafe practice, and certain communicable diseases; reporting is a legal duty.

Confidentiality for minors follows legal and facility rules; adolescents may consent to certain services depending on jurisdiction.

Evidence-based practice integrates best evidence, clinical expertise, and patient and family values; peer review and continuing education support professional growth.

Delegation to unlicensed assistive personnel requires assessment of task complexity, patient stability, and the delegate's competence, with retained accountability.

NPO intervals per ASA: 2 h for clear liquids, 4 h for breast milk, 6 h for formula, nonhuman milk, and light meal; shorter intervals raise aspiration risk.

Baseline pediatric vital signs vary by age: newborns breathe 30-60/min and heart rate 100-160/min; by school age respirations fall to 18-25/min and heart rate to 70-110/min.

Upper respiratory infection within 2-4 weeks increases bronchospasm, laryngospasm, and cancellation risk; assess fever, purulent secretions, and wheeze at the time of surgery.

A history of prematurity (born before 37 weeks) with current postconceptional age under 60 weeks raises postoperative apnea risk after general anesthesia.

Preoperative labs are not routine for healthy children; hemoglobin and type-and-screen are indicated for anticipated blood loss, sickle cell disease, or significant anemia.

Informed consent in minors is given by a parent or legal guardian; assent is sought from developmentally able children, typically age 7 and older.

Active or recent varicella, measles, or respiratory infection warrants postponement per incubation and communicability windows to protect other patients and staff.

Anesthesia history of malignant hyperthermia, or a family history of it, mandates avoidance of volatile agents and succinylcholine and use of nontriggering technique.

Infant airway: large head, short neck, large tongue, floppy omega-shaped epiglottis, and narrowest point at the cricoid ring; the cricoid is the physiologic cuff.

Infants have a higher metabolic rate and oxygen consumption (about 6-8 mL/kg/min) with lower functional residual capacity, so desaturation occurs rapidly during apnea.

Neonatal cardiac output is rate-dependent because stroke volume is relatively fixed; bradycardia markedly reduces perfusion.

Total blood volume: neonate 85-90 mL/kg, infant 75-80 mL/kg, child 70-80 mL/kg; a 10% loss is roughly 8-9 mL/kg in a neonate.

Renal function matures by about 1-2 years; glomerular filtration rate is low in neonates, prolonging drug clearance and increasing fluid and electrolyte risk.

Infant liver is relatively large and the rib cage is compliant; abdominal organs sit higher, and the liver and spleen are more vulnerable to blunt trauma.

Thermoregulation is immature: large surface area to mass ratio and poor shivering cause rapid heat loss by evaporation, conduction, convection, and radiation.

The pediatric skeleton is more cartilaginous and flexible, so fractures may occur without obvious deformity; growth plates are vulnerable to injury.

Pediatric breathing circuits are Mapleson or circle systems; uncuffed or microcuffed tubes are sized by age formula (age/4 + 4) or by nares and little-finger diameter.

Laryngospasm is managed by removing the stimulus, applying 100% oxygen with continuous positive airway pressure, and deepening anesthesia; succinylcholine is used if it persists.

Emergence delirium typically occurs 10-30 minutes after awakening in preschool children and is distinguished from pain by inconsolable agitation without a clear source.

Propofol causes pain on injection and hypotension; ketamine preserves airway tone and respiration but increases secretions and emergence reactions.

Sevoflurane is the most common pediatric inhalational induction agent because it is nonpungent; it can trigger malignant hyperthermia in susceptible patients.

Postoperative nausea and vomiting prophylaxis uses ondansetron, dexamethasone, or droperidol; risk rises with strabismus, ear, and abdominal surgery.

Regional techniques such as caudal and ilioinguinal blocks reduce opioid need; local anesthetic maximum doses are about 2-3 mg/kg for bupivacaine and 5-7 mg/kg for lidocaine with epinephrine.

Difficult airway predictors include micrognathia, macroglossia, short neck, and craniofacial syndromes; supraglottic airways are an option for short procedures in appropriately selected children.

Surgical site infection prevention: administer prophylactic antibiotic within 60 minutes before incision, maintain normothermia, and use chlorhexidine-alcohol skin prep with full dry time.

Surgical hand antisepsis requires scrubbing to the elbows for the manufacturer-specified duration (commonly 3-5 minutes for first scrub) and keeping hands above elbows.

Sterile field rules: sterile items contact only sterile items; a sterile person stays within the field; nonsterile persons never reach over the sterile field.

Time-out before incision confirms patient identity, procedure and site, consent, allergies, antibiotic, imaging, and equipment availability.

Infants lose heat quickly in the operating room; forced-air warming, warmed fluids, and increased room temperature reduce hypothermia and surgical site infection.

Fluid replacement uses the 4-2-1 rule for maintenance and 10-20 mL/kg boluses for hypovolemia; blood loss is replaced with crystalloid in a 3:1 ratio or colloid 1:1.

Counts of sponges, sharps, and instruments occur before incision, at wound closure, and at skin closure; the circulating nurse documents the count and any discrepancy.

Electrosurgery requires a well-applied dispersive pad on dry, well-perfused skin away from bony prominences and away from the surgical site.

Discharge criteria from phase I recovery include stable vital signs, patent airway, protective reflexes, adequate pain control, and return of baseline consciousness.

Aldrete scoring assesses activity, respiration, circulation, consciousness, and oxygen saturation; a score of 9-10 is generally required before phase II transfer.

Postanesthesia apnea risk in ex-premature infants under 60 weeks postconceptional age warrants extended monitoring, often 12-24 hours.

Pediatric early warning scores use age-specific thresholds for respiratory rate, heart rate, blood pressure, oxygen saturation, and consciousness to trigger escalation.

Laryngospasm and airway obstruction most often occur during emergence; signs include stridor, retractions, desaturation, and absent air movement.

Postoperative hemorrhage is suggested by tachycardia, delayed capillary refill, falling urine output, and dropping hematocrit before hypotension appears in children.

Malignant hyperthermia presents with rising end-tidal carbon dioxide, tachycardia, rigidity, and hyperthermia; treatment is dantrolene 2.5 mg/kg IV and cooling.

Postoperative vomiting after strabismus or tonsillectomy is common; positioning on the side protects the airway and reduces aspiration risk.

Use age-appropriate pain scales: FLACC for infants and toddlers, Wong-Baker FACES for ages 3 and older, numeric rating scale for ages 8 and older.

Neonates and infants feel pain; untreated pain causes physiologic stress with tachycardia, hypertension, and altered stress hormones.

Acetaminophen dosing is 10-15 mg/kg every 4-6 hours, with a maximum of 75 mg/kg/day; IV acetaminophen is 15 mg/kg every 6 hours.

Ibuprofen dosing is 10 mg/kg every 6-8 hours; avoid in dehydration, renal impairment, and children under 6 months.

Morphine IV is 0.05-0.1 mg/kg every 2-4 hours; monitor respiratory rate, sedation score, and oxygen saturation, and keep naloxone available.

Multimodal analgesia combines acetaminophen, NSAIDs, local anesthetics, and opioids to reduce opioid dose and side effects.

Caudal and epidural analgesia provide effective lower-body pain relief; monitor for urinary retention, motor block, and local anesthetic toxicity.

Nonpharmacologic methods include sucrose for neonates, swaddling, distraction, guided imagery, and parental presence; these are adjuncts, not substitutes for analgesia.

Family-centered care treats the family as a constant in the child's life and includes parents in assessment, care planning, and decision-making.

Separation anxiety peaks around 8-18 months; parental presence during induction reduces distress in appropriately prepared children.

Preoperative preparation uses developmentally appropriate language: play and simple explanations for toddlers, concrete teaching for school-age children, and privacy and autonomy for adolescents.

Children aged 3-6 often interpret illness as punishment; honest, nonjudgmental reassurance and simple explanations reduce guilt and fear.

Parental anxiety correlates with child anxiety; providing clear information and allowing parents to stay nearby reduces distress in both.

Siblings need age-appropriate information and reassurance, as they may feel neglected or responsible for the child's illness.

Cultural and religious preferences should be assessed and accommodated, including dietary, ritual, and modesty practices, within safe care limits.

Child life specialists use play, distraction, and medical preparation to reduce distress during procedures and recovery.

Wrong-site surgery prevention uses a standardized time-out with patient identity, procedure, site, side, consent, and imaging confirmed by the whole team.

Medication safety: pediatric doses are weight-based and double-checked; high-alert drugs such as opioids and insulin require independent verification.

Weight in kilograms is the single most important pediatric medication safety parameter; pounds-to-kilogram conversion errors are a leading source of overdose.

Retained surgical items are prevented by standardized counts and, for high-risk cases, intraoperative radiographs before closure.

Handoff communication uses structured tools such as SBAR or I-PASS to reduce information loss during transfer of care.

Pressure injury risk in children is reduced by padding bony prominences, repositioning, and securing lines and tubes away from skin.

Quality metrics include surgical site infection, unplanned reintubation, medication errors, and time-out compliance; PDSA cycles test improvement changes.

Fire safety in the operating room uses the fire triad (oxidizer, ignition, fuel) and a plan for stopping the flow of oxygen and removing burning material.

The perioperative nurse's scope of practice is defined by state nurse practice acts, facility policy, and professional standards such as AORN guidelines.

Informed consent requires capacity, disclosure of risks and benefits, understanding, and voluntariness; the surgeon obtains consent, and the nurse witnesses and verifies it.

Advocacy obligates the nurse to speak for the child's best interests, including reporting unsafe conditions and supporting parental involvement.

Autonomy, beneficence, nonmaleficence, and justice guide ethical decisions, including end-of-life care and allocation of scarce resources.

Mandatory reporting includes suspected child abuse or neglect, unsafe practice, and certain communicable diseases; reporting is a legal duty.

Confidentiality for minors follows legal and facility rules; adolescents may consent to certain services depending on jurisdiction.

Evidence-based practice integrates best evidence, clinical expertise, and patient and family values; peer review and continuing education support professional growth.

Delegation to unlicensed assistive personnel requires assessment of task complexity, patient stability, and the delegate's competence, with retained accountability.