Pedi ATI Flashcards
Pulse
Up to 1 week : 100-160 (fluctuations with activity) 1wk-3months: 100-220 3 months - 2 yrs: 80-150 2-12: 70-110 12+: 50-90
Temperature
birth-1auxillary: 97.9-98.9
1-12 oral: 98.1-99.9
12+ oral: 97.8-98.0
Respirations
Newborn: 30-60 with periods of apnea < 15 sec upto 1 yr: 30 1-2: 25-30 2-6: 21-24 6-12: 19-21 12+: 16-18
Blood Pressure
Influenced by age, height, and gentder. Compare to national measures infants: 60-80 systolic, 40-50 diastolic 1: 97-107/53-60 3: 100-110/61-68 6: 104-114/67-75 10: 112-122/73-80 16: 122-132/79-86 GIRLS
Fontanels
Posterior: 2-3 months
Anterior 12-18 months
Reflexes
Suck-root: birth to 4 months Palmar grasp: birth - 6 months Plantar grasp: birth to 8 months Moro (startle): birth to 4 months tonic neck (fencer) birth to 3-4 months Babinski: birth to 1 year stepping: birth to 4 weeks
Cranial Nerves
I Olfactory: smell
II Optic: intact visual acuity, peripheral and color vision (can track and object)
III Oculuomotor: PERRLA, no nystagmus, blinks
IV Trochlear: Look down and in
V Trigeminal: clench teeth, detects facial touch, root and suck reflex
VI Abducens: See laterally, follows your face
VII Facial: salt vs sweet, symmetrical face movements,
VIII Acoustic: no vertigo, intact hearing, tracks sound, blinks to loud
IX Glossopharyngeal: intact gag reflex, sour taste on back tongue
X Vagus: clear speech, no difficulty swallowing
XI Spinal Accessory: moves shoulders symmetrically with equal strength
XII Hypoglossal: midline tongue, moves in all directions, for and infant open mouth when nares occluded, no difficulty swallow
First year gross and fine motor skills
Months old; gross; fine
1; head lag; grasp reflex
2; lifts head off mattress; holds hands in open position
3; raises head and shoulders; no grasp, keeps hands loosely open
4; rolls from back to side; places objects in mouth
5; rolls front to back; uses palmar grasp
6; rolls back to front; holds bottle
7; bears full wt on feet; objects from hand to hand
8; sits unsupported; pincer grasp
9; pulls to standing; crude pincer grasp
10; prone to sitting; grasps rattle by handle
11; walks holding on; places objects in container
12; sit down from standing without help; TRIES to build 2 block tower
Piaget birth-24 months
Sensorimotor :
separation
object permanence (9 months)
mental representation (recognition of symbols)
Pyschosocial first year
Erickson: trust vs mistrust
Attachment: infant bonds with parents
Separation anxiety 4-8 months
Toddler
1-3 yrs
30 months wt is 4 x birth wt
grow 3 inches per year
15 months; walks without help, creeps up stairs; uses cup, 2 blocks
18 months; standing position; spoon, turn pages
2 yrs; walks up and down stairs; 6-7 blocks
2.5 yrs; jumps, stands one foot; draw circle, hand finger coordination
400 words, 2-3 word phrases
Piaget cognitive toddler
sensorimotor- preoperational
object permanence
mimicry-playing house
imitates others
Psychosocial toddler Erickson
autonomy vs shame and doubt independence, separation anxiety egocentric, moral development self concept - see separate from parents body image changes, gender identity at 3
Preschool
3-6
3: rides tricycle, jumps off step, stand on one foot for few sec
4: skips and hops on one foot, throws ball overhead
5: jump ropes, walks backward, stairs easily
dress independent, copy things on paper
Understand time past present future
Sentences, know colors
Piaget preschool cognitive
Preoperational
preconceptual thought 2-4: visual judgements, inanimate objects alive, immennent justice
intuitive thought 4-7: classify info, cause effect relationship
Psychosocial Erickson Preschool
initiative vs guilt
moral development
self concept of development (may regress if unable or stressed)
Body image, fear dark
Less separation anxiety, little stranger anxiety
Pretend play
12 hrs sleep
School age
6-12 years old Puberty begins Vision to 20-20 Coordination improves understands grammar and multiple meanings of words
Piaget cognitive school age
Concrete operations wt and volume unchanging simple analogies understands time classifies complex info understands emotions self-motivated solves problems
Erickson school age psychosocial
industry vs inferiority: learn things, motivated by tasks that increase self worth, fears of peer ridicule
Moral development: justice, law and order
Self respect, encourage where they can excel
Body image changes, sexual curiosity, privacy
Social: peer pressure, friendships, conformity
Adolescent
12-20 years
acne
girls stop growing 2 yrs after menarche
boys stop around 18-20
Girls order: breasts, pubic hair, menstruation
Boys order: Increase in testes and scrotum, pubic hair, rapid growth genitalia, axillary hair, lip hair, voice change
Piaget cognitive adolescents
Formal operations: think like adult, abstract, longer attention, imaginative and idealistic, logical decisions, future oriented, deductive reasoning, actions influence others
Erickson psychosocial adolescents
Identity vs role confusion: influenced by family expectations, group identity influences behavior
Vocational work habits and future plans
Sexuality
Invincible to health outcomes of risky behavior
Law and order-rules adjusted, not absolute
Self concept: friends, activities help
Body image: how the world views them
Pain scales
CRIES postop scale: 32 wks gestation to 20 wks old, cry, vitals, expression, sleep
FLACC: 2 months - 7 yrs; faces, legs, activity, cry, consolable,
FACES: 3 yrs and up; happy sad faces
VAS Visual analog: 7 and up (maybe as young as 4.5); 0-10, child points to # that best describes
Numeric: 5 and up
Word graphic: 4 and up
Oucher 3 and up
Noncommunicating check list: 3-18 yrs; 0-18 scale, vocal, social, facial, activity level, movement, physiologic changes
Meningitis
Viral (MMR) or bacterial (URI, bacteria, immunosupressed, crowded living, CSF access)
photophobia, headache, drowsy, irritable, N&V, seizures, nuchal rigidity, Brudzinskis sign (flex extremeties with flex neck), Kernig sign (pain when extending knee when hip flexed), fever and chills, petechia or pupura (immediate medical attention),
isolation droplet when suspected, decrease stimuli, low lights, cool room, lay without pillow, head slightly elevated, seizure precautions
ABX, corticosteroids, anticonvulsants, analgesics-nonopiods,
complications: increased ICP > brain damage
CBC, culture, CSF
PVC and Hib vaccinations help protect
CSF collection
empty bladder, fetal position or sitting if older, sedatives, EMLA cream L3-5, monitor for hematoma, lie flat for 4-8 hrs
Reye Syndrome
Liver dysfunction and Cerebral edema
hypoglycemia, shock
No Asprin for viral illness
Stage 1: lethargy, vomit, anorexia, liver dysfunction, brisk pupil rxn, can follow commands
Stage 2: confusion, combative, hyperventilate, hyperreflex, sluggish pupil, responds to pain
Stage 3: coma, seizures, flexion rigidity,
Stage 4: deeper coma, extension rigidity, fixed large pupil, brainstem dysfunction, minimal liver dysfunction
Stage 5: hypotonia, seizures, resp arrest, no liver dysfunction
Increased Liver, ammonia
Low hgb, hct, platelets
Liver biopsy (check clotting prior), NPO prior, hemorrhage and vitals post CSF
Fluids with I&O, position (avoid flextion and extension, head midline, elevate 30), vitamin K if bleeding, NG tube, intubation, seizure precaution, diuretic (mannitol), insulin
Complications: neurological speech, hearing, CP, paralysis, developmental delays; death
Seizure types
Generalized
Tonic-clonic (grand mal): aura, tonic episode, loss of conscious, clonic pisone, breathing may stop, cyanosis, biting, incontinence, confusion and sleepy
Tonic: only tonic phase, does not loose conscious, few seconds
Clonic: only clonic, no fatigue,
Absence: common in children, lasts seconds, blank stare, function resumes after
Myoclonic: brief jerk or stiffening, 1 or 2 sides, seconds
Atonic-kinetic: muscle tone lost, confusion after, falling
Partial:
Complex: automatisms lip smack, loss of conscious, amnesia before and after
Simple: no loss of conscious, unusual sensations, dejavu, autonomic abnormalities change in vitals, one sided movement, bad smell
Status Epilepticus
lasts longer than 30 min, no postictal phase
Maintain airway, O2, IV access, ECG monitor, pulse ox, ABGs, loading dose of diazepam or lorazepam, continuous infusion of dilantin or cerebyx
Cushings reflex
hypertension with a widened pulse pressure (systolic-diastolic) and bradycardia
sign of increased ICP (normal is 10-15 mmhg)
Glascow coma scale
8- severe head injury and coma
9-12 moderate head injury
13 up minor head trauma
ICP
normal is 10 - 15 mm hg
to decrease it elevate head 30 degrees, avoid flexion extension and rotation of head, keep head midline, keep body in alignment, minimize suctioning, avoid cough or blowing, no straining,
monitor for fluid overload to not increase it
Corticosteroids decrease cerebral edema
Diuretic (mannitol)
Dilantin to prevent seizures
Morphine or fentanyl citrate for pain
Vision
Myopia-nearsighted: cant see distance; biconcave lens
hyperopia-farsighted: cant see close, normal until age 7; convex
astigmatism: tilting head may help, uneven vision
strabismus: misaligned, cant see print clearly, keeping one eye closed helps, crosseyed; patch strong eye
amblyopia-lazy eye: reduced acuity in one eye
hypoxemia
shortness of breath, anxiety, tachypneea, tachycardia, restless, pallor, cyanosis, adventitious breath sounds, confusion
elevated BP, resp distress nasal flaring and accessory muscles.
hypercarbia
elevated CO2
restless, hypertension, headache
oxygen toxicity
nonproductive cough, hypoventilation, nasal stuffiness, substernal pan, N&V, fatigue, headache, sore throat
Nasopharyngitis
common cold
virus for 7-10 days,
inflammation, rhinirrhea, cough, dry throat, sneeze, nasal voice, fever, decreased appetite, irritable
pharyngitis
strep throat GAHBS-hemolytic streptococci inflamed throat with exudate headache, fever, abdominal pain cervical lymphadenopathy truncal, axillary, perineal rash
bronchitis
tracheobronchitis, With URI, self limiting, provide symptom relief
persistant cough from inflammation
Bronchiolitis
RSV, bronchi and bronchioles,
rhinorhea, pharyngitis, fever, cough, wheeze, increased resp rate, nasal flare, retractions, cyanosis
Epiglottitis
Medical emergency haemophilus influenza sit with chin pointed out, mouth open, tongue out drool anxiety with resp distress no cough dysphonia (difficult speaking) dysphagia stridor on inspiration sore throat, high fever, restless
Acute laryngitis
viral, self limiting
hoarseness
Asthma meds
Bronchodilators albuterol, terbutaline for rapid relief; causes tachycardia and tremors; take 5 min before antiinflamatory inhaler
cholinergic antagonists, ipratropium, acute bronchospasms; causes dry mouth
corticosteroids; fluticasone, prednisone (take with food) leukotreine modifiers (singulair), mast cell stabilizers (intal), and monoclonal antibodies (xolair)
Status asthmaticus
life threatening, unresponsive to other trtmnt,
wheeze, labored breathing, accesory muscle, distended neck veins, risk for cardiac and resp arrest
Intubation, humidified O2, 3 nebulizer trtmts 20-30 mins apart; beta2-agonist and ipatropium, iv access, ABGs and electrolytes, corticosteroids, magnesium sulfate to relax smooth muscle, ketamine, nonrebreather mask
Cystic fibrosis
autosomal recessive-both parents carriers absence pancreatic enzymes fatty stools chloride sweat > 60 meq CPT before meals pancreatic enzymes with all food adequate fluid and sodium intake hypoglycemic agents bronchodilators antibiotics dornase alfa: thins mucus, nubulizer once day GI complications: meconium ileus, pancreatic fibrosis, obstruction High calorie and high protein ADEK vitamins (water soluable forms) stool softners and laxatives
Left to right shunt
VSD
ASD
PDA
Tetralogy of fallot
pulmonary stenosis
VSD
Overriding aorta
R ventricular hypertrophy
squatting position
Digoxin
myocardial contractility
hold if infants pulse <70
toxicity: bradycardia, dysrhythmias, N&V, anorexia
monitor levels
q 12 hrs, do not miss, do not give again if vomits, rinse after oral,
Lasix
potassium wasting diuretic, rids excess sodium and water
monitor I&O
hypokalemia: muscle weakness, irritable, drowsy, abnormal HR,
eat potassium foods: bran, potato, tomato, bananna, melon, oranges
weigh daily
Rheumatic fever
GABHS infection of throat, within 2-6 wks
URI hx, fever, fatigue, sore throat, activity intolerance, poor appetite, tachycardia, new murmur, chest pain, large joints, rash on trunk and inner extremeties (erythema marginatum), CNS involvement - chorea, irritable
rising ASO titer
Two major criteria or one major and two minor for dx
Major: carditis, subcutaneous nodules, polyarthritis, erythema marginatum, chorea
Minor: fever, arthralgia
Pcn V or Erythromycin for 10-14 days
prophylactic trtmnt: Pcn 200000U bid, a monthly PCN G injection, sulfadiazine 1g po daily for a minimum of 5 yrs
Iron
give with vitamin C
not with milk or antacids
diarrhea, constipation, nausea, tarry stools normal
empty stomach if tolerable
give with straw and rinse to prevent teeth staining
Z-track
Increase fiber
Sickle Cell
Africans, autosomal recessive, may pass down if just trait
hemoglobin electrophoresis definitive test
transcranial doppler done annually for risk for CVA
Fluids, pain meds, oxygen, blood products, rest and nutrition,
Types of dehydration
Isotonic: water and sodium lost equally, reduced circulating fluid, hypovolemic shock may result, serum sodium in normal limits 130-150
Hypotonic: electrolyte loss is greater than water loss, ECF to ICF, Smaller fluid loss but more severe physical manifestations, sodium less than 130
Hypertonic: water loss greater than electrolyte, ICF to ECF, Shock is not likely, neurological changes may occur, sodium greater than 150
Levels of dehydration
Mild: weight loss is 5% in infants, 3 to 4% in children. Capillary refill greater than two seconds, slight thirst, specific gravity greater than 1.02
Moderate: weight loss is 10% in infants, 6 to 8% in children. capillary refill 2 to 4 seconds, thirsty, irritable, slight increase in pulse, orthostatic blood-pressure, dry mucous membranes and tears, decreased skin turgor, specific gravity >1.020
Severe: weight loss 15% in infants, 10% in children. Capillary refill greater than four seconds, tachycardia, orthostatic blood pressure, shock, extreme thirst, dry membranes and tented skin, anterior fontanelle sunken, oliguria or anuria
Enuresis
pee pants 2x week for 3 months, at least 5 yrs old
rule out other causes
Antidiuretic desmopressin at bedtime, avoid fluids after dinner,
Tricyclic antidepressants tofranil 1 hr before bed
Anticholinergic ditropan reduces bladder contractions
Bladder stretching by holding fluid
Acute glomerulonephrities
most common is from streptococcal infection APSGN
6-7 yrs old,
renal manifestations 10-21 days after strep infection
decreased glomerular filtration rate>decreased urine
anorexia, pallor, pain, dyspnea, orthopnea, crackles, distended neck veins, edema, HTN,
eliminate sodium in the diet, possible potassium, possible fluid restriction, monitor BP and weight daily
ABX, diuretics, antihypertensives
Nephrotic syndrome
albumin passes to urine
hyperlipidemia, proteinuria, hypoalbuminemia, edema
3 types: minimal change is from 2-7 yrs old, unknown cause; secondary is from glomerular damage; congenital is inherited
Wt gain, anorexia, N&V, diarrhea, decreased activity, irritable, edema worse in morning, ascites, dark frothy little or no urine, elevated BP
24 hr urine - 3 or 4 plus protein, increased specific gravity
biopsy if unresponsive to steroid therapy
daily wt, measure abdomen daily, limit salt and fluids, increase protein in diet, rest
ABX
Corticosteroids 7-21 days then taper down (prone to infection)
Lasix (eat K foods)
25% albumin (watch for anaphylaxis)
Cyclophosphamide if steroids are not tolerated
Cerebral Palsy
most common permanent physical disability in kids
manifestions from mild to sever
nonprogressive impairment of motor function, muscle control, coordination, and posture.
RF include brain anomalies, cerebral infection, head trauma, brain anoxia, premature or multiple births, low birth wt, perinatal asphyxia, kenicterus from hyperbilirubenemia,
poor head control or no smiling at 3 months,
arch back and stiff extremetires, floppy limbs,
cant sit by 8 months
uses only one side of body
feeding difficulty,
muscle spasms
persistent reflexes such as moro or tonic neck
MRI for dx
encourage development and self care
suction available for increased secretions, keep head elevated
Baclofen: decrease muscle spasm, oral or intrathecally, (monitor for muscle weakness, fatigue, diaphoresis, and constipation)
Valium for spasticity
Types of cerebral palsy
Spastic: hypertonicity, ^deep tendon reflex, clonus, poor muscle control; one up to all extremities can be effected; scoliosis; tip toe, scissor walk, contractures
dyskinetic: movements increase with stress, absent during sleep, normal reflexes, no clonus, speech impairment
Athetoid: involuntary jerking of trunk face neck and tounge
Dystonic: slow twisting of trunk and extremeties
Ataxic: wide gait, poor coordination, cant do repetitive mvmnts, difficulty with quick or precise movements, jerky speech
Spina Bifida
neural tube defect, degree of dysfunction depends on level of defect
Spina bifida occulta: defect not visible to eye, no manifestions, look for dimple
Spina bifida cystic:
meningocele: sac protrusion present with spinal fluid and meninges, no problems once repaired
myelomeningocele: sac meninges, spinal fluid, and nerves
slightly decreased sensation to complete paralysis possible, joint deformities, incontinence, develop delays, hydrocephalus (may need shunt placement), ^latex allergy
Neural tube closes during 3-5 wks gestation, due to insufficient folic acid
AFP may detect it (16-18 wks)
RAST: detects latex allergy
Assess sac every 2 hrs, place in prone position, moist (NACL) nonadherent dressing, passive ROM exercises,
Ditropan for bladder incontinence
Down Syndrome
hypotonicity, heart defects, thyroid dysfunction, dysfunctional immune system, high risk for leukemia
> over 35 yrs old, multifactorial
small head, flat forehead, low ears, slant eyes, protrude tongue, flat nose, transverse palmar crease, space between toe
AFP is low
Common respiratory infections, poor mucus drainage, dry mouth from mouth breathing-rinse it frequently
Juvenile Idiopathic Arthritis
systemic, oligoarthritis, polyarthritis, with possible rheumatoid factor
before 16, lasts 6 wks or longer with no cause, peaks 1-3 yrs
NSAIDS: GI discomfort of bleeding
DMARDS:
methotrexate slows degeneration, monitor liver and CBC, avoid alcohol, birth control
Enbrel immunosupressive, 1-2 weekly subQ
Corticosteroids: used for severe life threatening cases, eye solution, oral, or IV, joint injection, wt gain common, alters growth
Use of heat and splints, especially at night
Muscular Dystrophy
inherited with progressive deterioration
loss of muscular strength
Duchenne: most common, xlink recessive, 3-7 yrs onset, live to early adult
usually cant walk by age 12, mild cognitive delays, wt loss, fatigue, orthopnea
DNA test or muscle biopsy, CK is elevated,
maintain resp function, use incentive spirometer,
Prednisone: increases muscle strength, infection prone
Discuss end of life care such as feeding tubes and ventilation
Acne meds
Retin-A may irritate skin, use pea size at night, avoid sun
Benolyl peroxide: antibacterial, bleaches clothes but not skin
Topical antibacterials: inhibits growth, avoid sun and use suncreen
Accutane: prescribed by dermatologists, dry skin and mucus membranes, dry eyes, decreased night vision, headaches, photosensitive, elevated cholesterol & triglycerides, depression, suicide, monitor behavioral changes, teratogenic
Lab tests for burns
First 24 hrs
Hgb & hct are elevated due to loss and 3rd spacing
Sodium decreased due to 3rd spacing
Potassium increased due to cell destruction
After 48-72 hrs, fluid mobilization Hgb Hct decreased due to fluid shift back sodium decreased renal and wound loss potassiumm decreased renal loss and movement into cells WBC increased and then left shift Blood glucose elevated from stress ABGs hypoxic, metabolic acidosis Protein and albumin low
NS or LR first 24 hrs, colloid with albumin or plasma expanders after 24 hrs; urine output of 1-2 ml-kg-hr, 30 ml-hr if over 66 lbs
No plants or flowers cuz of psuedomonas infections, increase calories and protein,
Silver nitrate, silvadene, mafenide acetate, bacitracin
Diabetes mellitus
15 g carbs equal to 1 carbohydrate exchange
When sick monitor glucose every 3-4 hrs, stay hydrated, test for ketones, rest, call in BG >240, fever >102 and tylenol doesnt help
hypoglycemia: shaky, sweaty, anxiety, irritable, nervous, chills, nausea, headache, weak, confusion. 15-20g carbs, recheck BG in 15 min, if 250, test ketones. Can be caused by infection and stress
Insulin
Rapid; lispro humalog; 15, 30-60; 3-4
Short; Humulin R; 30-6-; 2-3; 5-7
Intermediate; NPH Humulin N; 1-2, 4-12, 18-24
Long; lantus glargine; 1, none, 10-24 Do not mix
diabetic ketoacidosis
> 300, breakdown fat and accumulation of ketones. Rapid onset, mortality high
insufficient insulin, acute stress trauma or surgery, poor management of illness
N&V, abdominal pain, 3Ps, confusion, dehydration, kussmaul resp rapid and deep fruity smell,
provide rapid NS, followed by hypotonic .45%NS, when glucose is down to 250 add glucose to IV to reduce cerebral edema from drastic changes; IV bolus insulin 0.1 unit-kg followed by continuous regular insulin at 0.1unit-kg-hr; monitor BG hourly
montor K levels, initally elevated, when insulin given they are low, make sure urine output is good when giving K
ph<7 acidosis, give sodium bicarb slow IV
Otitis Media
AOM acute infection, yellow or red TM, purulent drainage,
OME effusion, no infection, orange TM, rhinitis, cough, diarrhea
Either one could cause long term speech delays
Tylenol,
Amoxicillin, Augmentin, zithromax for 10-14 days
Benzocaine ear drops
Myringotomy or tympanoplasty; avoid water
HAART therapy
For HIV AIDS
uses 3-4 meds
enfuvirtide helps decrease the virus and limit spread
Nucleoside reverse transcriptase inhibitors NRTIs- retrovir
NonNRTIs NNRTIs rescriptor and sustiva
Protease inhibitors Norvir, Agenerase, Viracept
Monitor labs, CBC, WBC, liver, hDL, cholesterol and triglycerides
Antibiotics Trimethoprim sulfamethoxazole - prophylactic trtmnt for PCP in newborns
Zovirax for herpes
Amphotericin B for fungal
Pancytopenia drugs
bone marrow supression with anemia, neutropenia, thrombocytopenia
often side effect of chemo
bleeding precautions
Filgrastim (neupogen) stimulates WBCs, subQ daily epoetin alfa (procrit) stimulates RBCs, subQ 2-3x week oprelvekin (interleukin 11, nuemega) stimulates platelets, subQdaily
Leukemia
ALL acute lymphoid (most common in kids)
AML acute myelogenous or nonlymphoid leukemia
bone marrow dysfunction>anemia, neutropenia, increased production of immature WBCs
most common childhood cancer, bone marrow biopsy needed, CSF with lumbar puncture to determine CNS involvement, sonograms, liver and kidney functions
Chemo in four phases: induction, CNS prophylactic, intensification, maintenance
HCST transplant, bone marrow or stem cells, protective isolation, mask glove gown, no flowers,
bleeding and infection precautions
Lead poisoning
from paint or remodeling dust
low dose exposure: distracted, impulsive, hyperactive, hearing impaired, mild intelectual difficulty
high dose: mental retardation, blindness, paralysis, coma, seizures, death
Other manfestations: renal impairment, impaired calcium function, anemia
Trtmnt: chelation therapy using calcium EDTA
Potassium foods
bran cereal potato tomato banana melon oranges
Iron Foods
dried fruit chicken red meat legumes nuts green leafy veggies iron fortified bread and flour give with empty stomach and vitamin C do not take with milk
Latex foods
banana avocado kiwi chestnut diapers elastic
Labs
Name, norm, abnormal
Sweat chloride 60 indicates CF sodium 130-150 hypoglycemia 250 fasting BG >126 HbA1c 4-6%, >8% is not good, target is <7%
hgb hct 2 months 9-14; 28-42 6-12 yrs 11.5-15.5; 35-45 12-18 male 13-16; 37-49 12-18 female 12-16; 36-46
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