Chapter 28: Principles of Growth and Development

GROWTH – increase in physical size (quantitative DEVELOPMENT – increase in skill or ability (qualitative)
changes) → Directly observing the child’s performance
→ Weight (g, kg, lbs) – most sensitive indicator → Noting parent’s description
→ Height (in, ft, cm) → MMDST

❖ MATURATION (readiness) – increase in competence and ❖ ASYNCHRONISM – not all parts of the body grow at the
adaptability same time or at the same rate; each child is unique

FACTORS INFLUENCING GROWTH AND DEVELOPMENT

Heredity: Nature
✓ Genetic inheritance Environmental Influences: Nurture
✓ Race ✓ Quality of Nutrition
✓ Gender - Girls are born lighter (by an ounce or two) and ✓ Socio-economic Status
shorter (by an inch or two) than boys. ✓ Health
✓ Nationality ✓ Ordinal position in the family
✓ Intelligence - Children with high intelligence do not ✓ Parent-child relationship
generally grow faster physically than other children, but
they do tend to advance faster in skills.

Temperament – inborn characteristics set at birth; how a child adapts to situation; typical way a child reacts to situations; the
usual reaction pattern of an individual, or an individual’s characteristic manner of thinking, behaving, or reacting to stimuli in the
environment.
→ Activity Level → Intensity of Reaction → Threshold of Response
→ Rythmicity → Distractibility → Mood Quality
→ Approach → Attention Span &
→ Adaptability Persistence

Easy Child Children - rated as “easy to care for” if they have a predictable rhythmicity, approach, and adapt to new situations
readily, have a mild-to-moderate intensity of reaction, and have an overall positive mood quality.
The Intermediate Child - Some characteristics of both easy and difficult groups are present.
The Difficult Child Children - are “difficult” if they are irregular in habits, have a negative mood quality, and withdraw rather
than approach new situations. Only about 10% of children fall into this category.
The Slow-to-Warm-Up Child Children fall into this category if, overall, they are fairly inactive, respond only mildly and adapt
slowly to new situations, and have a general negative mood.

Basic Divisions/Developmental Stages

PRENATAL – from conception to birth MIDDLE CHILDHOOD
INFANCY – period of most rapid G & D A. SCHOOL AGE – 7 to 12 years; period of slow
A. NEONATAL – first 28 days/4 weeks of life growth
B. FORMAL INFANCY – from 29th day to 1 year LATE CHILDHOOD
EARLY CHILDHOOD A. PREADOLESCENCE – 11 to 13 years
A. TODDLER – 1 to 3 years; period of slow growth B. ADOLESCENCE – 12 to 18 years; period of rapid
B. PRESCHOOL – 4 to 6 years; alternating rapid/slow growth and development

Principles Of Growth and Development

Continuous process from All body systems do not develop at There is an optimum time for
conception, ends in death “womb the same rate. initiation of experiences or
to tomb” Development is cephalocaudal. learning.
Growth and development proceed Development proceeds from Neonatal reflexes must be lost
in an orderly sequence. proximal to distal body parts. before development can proceed.
Occurs in a regular direction Development proceeds from gross A great deal of skill and behavior is
reflecting definite and predictable to refined skills. learned by practice.
patterns or trends

A. DIRECTIONAL – reflects the direction of development of neuromuscular functions

Cephalocaudal – head-to-tail; a child gains control of the headfirst, then arms, and then legs
B. SEQUENTIAL – growth happens in a set of patterns; a child crawling, walking, and then running
B. SECULAR – faster growth and development; puberty for girls is earlier

❖ Principle of Cephalocaudal ❖ Hierarchal integration

❖ Proximodistal Principle ❖ Independence of System

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 Theories of Child Development
A theory is a systematic statement of principles that provides a framework for explaining a phenomenon.
Developmental theories are theories that provide road maps for explaining human development.
Developmental Tasks – skills or growth responsibility arising at a particular time in an individual’s life, the achievement of which will
provide a foundation for the accomplishment of future tasks.
Sociocultural theories are those that stress the importance of environment on growth and development.
Learning theory suggests children are like blank pages that can be shaped by learning.
Cognitive theorists such as Piaget stress learning skills are the key to achieving success in life.
Epigenetic theories stress that genes are the true basis for growth and development.

SIGMUND FREUD’S PSYCHOSEXUAL THEORY

➢ Freud’s observations of mentally disturbed adults described adult behavior as being the result of instinctual drives of a primarily sexual
nature (libido) -– refers to developing instincts or sensual pleasure.
➢ He described child development as being a series of psychosexual stages in which a child’s sexual gratification becomes focused on a
particular body part at each stage.

INFANT (Oral Stage) – provide oral stimulation; do not discourage SCHOOL AGE (Latent Stage) – child’s personality development
thumb sucking appears nonactive/dormant; help children have positive
TODDLER (Anal Stage) – child learns to control experiences with learning, so their self-esteem continues to grow;
urination/defecation; help children achieve bladder and bowel Children develop their “moral compass” or religion; needs
control responsibilities to learn trust and integrity.
PRESCHOOLER (Phallic Stage) – child learns sexual identity; accept ADOLESCENT (Genital Stage) – develops sexual maturity; provide
children’s sexual interest opportunities to relate with opposite and own sex

Freud’s Theory of Personality: Id, Ego, And Superego

ID (Instincts) – the primitive and instinctual part of the mind that contains sexual and aggressive drives and hidden memories
EGO (Reality) – the realistic part that mediates between the desires of the id and the super-ego
SUPEREGO (Morality) – operates as a moral conscience

ERIK ERIKSON’S PSYCHOSOCIAL DEVELOPMENT THEORY

➢ A theory that stresses the importance of culture and society in development of the personality.
➢ A person’s social view of self is more important than instinctual drives in determining behavior, allows for a more optimistic view of the
possibilities for human growth.
➢ He describes eight developmental stages covering the entire life span. At each stage, there is a conflict between two opposing forces.

INFANT (Trust vs. Mistrust) – child learns to love and be loved; ADOLESCENT (Identity vs. Role Confusion) – adjusts to changes;
security; satisfy needs on time; consistent and adequate care; touch, seeks freedom from parents; virtue developed (devotion and
soft music, hugs and kisses, eye to eye contact fidelity); they must bring together everything they learned; provide
TODDLER (Autonomy vs. Shame/Doubt) – independence; virtue opportunity to discuss feelings about events important to him/her;
developed (self-control and willpower); give opportunity for decision- offer support and praise for decision-making
making; encourage the child to make decisions rather than judge YOUNG ADULT (Intimacy vs. Isolation) – ability to relate well with
PRESCHOOLER (Initiative vs. Guilt) – virtue developed (direction and other people; people need a strong sense of identity before they can
purpose); learning how to do things; opportunity to explore new reach out fully and offer friendship
places and events; allow play to include activities such as water, clay, MIDDLE AGED ADULTS (Generativity vs. Stagnation) – people extend
finger paint their concern from just themselves and their families to the
SCHOOL AGE (Industry vs. Inferiority) – virtue developed community and the world
(competence); pride and accomplishment grow; children encouraged THE OLDER ADULT (Integrity vs. Despair) – they play a role in
in their efforts to do practical tasks; give short assignments or childrearing because they give childcare to grandchildren while the
projects – child will feel rewarded parents work; adults with integrity feel good about the life choices
they made
SIGMUND FREUD’S PSYCHOSEXUAL THEORY ERIK ERIKSON’S PSYCHOSOCIAL THEORY
looked at ways mental illnesses develop looked at actions that lead to mental health
Looking at “illness” rather than “wellness” Theory stresses the importance of culture and society
Theory is gender biased; female is viewed less favorable Social view is more important than instinctual drives

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 JEAN PIAGET’S COGNITIVE DEVELOPMENT THEORY
➢ concepts of cognitive development, or
the way children learn and think.
➢ The ability to learn or understand from
experience, to acquire and retain
knowledge, to respond to a new
situation, and to solve problems. It is
measured by intelligence tests and by
observing children’s ability to function
effectively in different environments.
➢ Piaget defined four stages of cognitive
development, within the stages of
growth, then finer units or schemas. To
progress from one period to the next,
children reorganize their thinking
processes to bring them closer to adult
thinking.
➢ Piaget is criticized because he used only
a small sample of subjects to establish
his theory (his own children).
➢ Because children today begin activities
to learn counting and identifying color
or reading much earlier than they did at
the time the theory was devised, the
age groups and “norms” may no longer
be accurate.
➢ Playing computer games during the
preschool period will probably impact
the rate and type of children’s cognitive
developments in the future.

Kohlberg’s Theory of Moral Development

➢ MORAL DEVELOPMENT - the ability to know right from wrong and to apply these to real-life situations.
➢ Moral stages closely approximate cognitive stages of development because children must be able to think abstractly (be able
to conceptualize an idea without a concrete picture) before being able to understand how rules apply even when no one is
there to enforce them.
➢ Kohlberg’s theory is frequently challenged as being male oriented because his original research was conducted entirely with
boys.
➢ Carol Gilligan (1993), a sociologist, argues that there are two modes of moral reasoning: the ethic of justice that focuses on
individual rights, and the ethic of care that focuses on responsibilities in relationships. She suggests that girls may not score
well on Kohlberg’s scale because, being more concerned with relationships than are boys, they make moral decisions based on
individual circumstances or the effect of their actions on others at a much younger age than boys, which skews their results on
a standard male-influenced scale.

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 KEY POINTS FOR REVIEW

● Knowledge of growth and development is important in health promotion and illness prevention because it lays the basis for
assessments and anticipatory guidance.

● Including growth and development guidelines in nursing care helps to achieve care that not only meets QSEN competencies but
that also best meets a family’s total needs.

● Genetic factors that influence growth and development are gender, ethnicity, intelligence, and health.

● Environmental influences include quality of nutrition, socioeconomic level, the parent–child relationship, ordinal position in the
family, and environmental health.

● To meet growth and development milestones, children (like adults) need to follow basic guidelines for a healthy diet, such as
eating a variety of foods, maintaining an ideal weight, avoiding extreme levels of saturated fat, eating foods with adequate starch
and fiber, and avoiding too much sugar.

● Temperament is a child’s characteristic manner of thinking, behaving, or reacting. Helping parents understand the effect of
temperament is a nursing role.

● Common theories of development are Freud’s psychoanalytic theory and Erikson’s theory of psychosocial development. Both
theories describe specific tasks children must complete at each stage of development to become a well-adapted adult.

● Piaget’s theory of cognitive development describes ways children learn.

● Kohlberg advanced a theory of moral development, or how children use moral reasoning to solve problems.

● Although growth and development occur in known patterns, the rate that a child develops and grows varies from child to child.
Caution parents not to be concerned that two siblings are very different as long as they both fi t within usual parameters.

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 Chapter 29: NURSING CARE OF A FAMILY WITH AN INFANT
Physiologic Status
❖ 1 month – 1 year of age
Cardiovascular System
❖ Most rapid growth and development
Heart Rate slows from 120-160 bpm to 100-120 bpm by the
end of 1st year
BP increases from an average of 80/40 to 100/60 mmHg
Prone to develop a physiologic anemia at 2-3 months
Hemoglobin converted from fetal to adult at 5-6 months
May experience a decrease in serum iron levels at 6 to 9
months as the last of iron stores established in utero are
used

Respiratory Status
RR slows from 30-60 cpm to 20-30 cpm at 1 year
Upper respiratory infections occur readily and more severe
than adults – lumen of Respiratory Tract small and mucus
production inefficient

Gastrointestinal System
Matures during the infant year
Physical Growth Limited ability to digest carbohydrates (deficient amylase)
until 3 months
✓ The physiologic changes that occur in the infant year reflect
Limited ability to digest saturated fat (deficient lipase)
both the increasing maturity and growth of body organs.
during the first year
Liver remains immature
Weight
☼ Inadequate conjugation of drugs
► 6 months – doubles birthweight ☼ Inefficient formation of carbohydrates, protein,
☼ Weight gain (1st 6 mos): 2 lb per month and vitamin for storage
☼ Weight gain (6 mos - 1 year) 1 lb per month
► 1 year – triples birthweight ❖ Until age 3 or 4 months, an extrusion reflex (food placed on an
The average 1-year-old boy weighs 10 kg (22 lb); the infant’s tongue is thrust forward and out of the mouth) prevents
average girl weighs 9.5 kg (21 lb). some infants from eating effectively if they are offered solid food
this early (not recommended).
Height
Increases by 50% ❖ Newborns can drink from a cup if a parent controls the fluid flow.
An infant can independently drink from a cup by age 8 or 10
Grows from the average birth length of 20 in. to about 30
months.
in. (50.8 to 76.2 cm)
Urinary System
Head Circumference
Kidneys remain immature and not as efficient at
Increases rapidly reflects rapid brain growth eliminating body wastes as in an adult
At 1 year, brain is 2/3 of its adult size
Some infants’ heads appear asymmetric until the second
Endocrine System
half of the first year
Insulin production deficient
Suggest to parents they continue to place the infant on the
Adrenocorticotropic production deficient
back to sleep but to spend “tummy time” daily with the
Infant may not be able to respond to stress effectively
infant placed in a prone position to prevent this flattening

Immune System
Chest Circumference
Becomes functional by 2 months
Less than 2 cm from HC at birth
By 1 year: able to produce IgG and IgM antibodies
Even with head circumference at 6 months

Thermoregulation
Abdomen
Ability to adjust to cold is mature by 6 months and has
Remains protuberant until the child walks
developed additional adipose tissue to serve as insulation
Cervical, thoracic, and lumbar vertebral curves develop as
❖ Extracellular fluid accounts for approx. 35% of body weight
infants hold up their head, sit, and walk.
❖ Intracellular fluid account for approx. 40% by the end of
Lengthening of the lower extremities during the last 6
first year
months of infancy readies the child for walking and often is
❖ Makes the infant susceptible to dehydration from illnesses
the final growth that changes the appearance from
“babylike” to “toddler like.”

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 Teeth 3 MONTHS
The first baby tooth: GROSS MOTOR Holds head and chest up when in prone;
(typically a central DEVELOPMENT Landau reflex develops; Has slight head
incisor) usually erupts at lag when pulled in sitting; Stepping &
age 6 months, followed tonic neck reflex fading
by a new one monthly. FINE MOTOR Reach attractive objects in front of them
Some newborns (about 1 DEVELOPMENT Grasp reflexes disappear.
in 2,000) may be born Follows object past midline with eyes
with teeth (natal teeth) PLAY Spends time looking at hands (hand
or have teeth erupt in regard); “tummy time” important during
the first 4 weeks of life the day
(neonatal teeth). Can handle small blocks or small rattles
Deciduous teeth are SOCIALIZATION In response to a nodding, smiling face, or
essential for allowing & LANGUAGE a friendly tone of voice, will squeal with
proper growth of the pleasure or laugh out loud
dental arch. Smiling at the sight of a parent’s face

Developmental Milestones 4 MONTHS

GROSS MOTOR Lifts their chest off the bed & look
✓ Are major markers of growth and development that serves
DEVELOPMENT around actively; Turns back to front; no
as basis of assessing developmental delay or advancement.
longer has head lag when pulled in sitting
✓ Includes motor and cognitive development, language and
position; bears partial weight on feet
play behavior
Able to manipulate large objects
✓ To assess, measure the ff:
► Gross Motor Development FINE MOTOR Brings their hands together; Shake a
▬ Ability to accomplish large body movements DEVELOPMENT rattle for a long period of time
► Fine Motor Development Stepping, tonic neck, extrusion reflexes
▬ Ability to coordinate hand movements are fading
Able to recognize familiar objects
Thumb opposition (ability to bring the
NEONATE
thumb and fingers together) begins
GROSS MOTOR Largely reflex actions; Complete head
PLAY Needs space to practice rolling over
DEVELOPMENT lag; Prone: can turn head to side
SOCIALIZATION “talkative”, cooing, babbling, and
FINE MOTOR Keeps hands fisted; Able to follow object
& LANGUAGE gurgling when spoken to; laughs aloud
DEVELOPMENT to midline with eyes
When heard a distinctive sound, they
PLAY Enjoys watching face of primary
turn and look in that direction
caregiver, Listening to soothing music
Can recognize their primary caregiver
SOCIALIZATION Cry without tears
& LANGUAGE Infants can smell accurately within 1 or 2
5 MONTHS
hours after birth
GROSS MOTOR Turns both ways (roll over); rests weight
DEVELOPMENT on forearms when prone; Seen to
1 MONTH
straighten his/her back when held in
GROSS MOTOR Prone: Lifts head and can easily turn to
sitting position; Moro reflex is fading;
DEVELOPMENT side; When pulled to sitting position:
Bears partial weight when held upright
head lag; Stepping reflex still present
FINE MOTOR Accepts objects & grasp with whole
FINE MOTOR Have strong grasp reflex
DEVELOPMENT hands; can reach and pick up objects
DEVELOPMENT
without the object being offered and
PLAY Can fix eyes on objects (looks at mobile);
often play with their toes as objects.
Enjoys watching face of primary
PLAY Handles rattle well; Ready for a variety of
caregiver - a face may become their
objects (plastic ring, blocks, squeeze toy)
favorite “toy”
SOCIALIZATION Says some simple vowel sounds (goo-
Watching a mobile over their crib or
& LANGUAGE goo, gah-gah)
playpen
Can localize sounds downward and to
the side (turning their head & look down)
2 MONTHS
May show displeasure when an object is
GROSS MOTOR Holds head up in prone position but
taken away from them
DEVELOPMENT cannot raise chest
FINE MOTOR Can hold object momentarily; Hands are
6 MONTHS
DEVELOPMENT held open E RUPTION OF THE FIRST TEMPORARY TEETH (2 LOWER CENTRAL INCISOR )
Binocular vision (the ability to fuse two GROSS MOTOR Rest weight on their hands with
images into one)
DEVELOPMENT extended arms; can rest chest & upper
PLAY Enjoys bright light part of their abdomen off the table
SOCIALIZATION Makes cooing sounds; Differentiate cry; FINE MOTOR Can hold objects in both hands; Can hold
& LANGUAGE Social smile DEVELOPMENT a spoon & start feeding themselves (with
Turns head to attempt to locate a sound much spilling); Moro, palmar grasp and
tonic neck reflex completely faded
Capable of organized depth perception
Hsci 102: Care of Infants and Children Prepared by: llal
 PLAY Enjoys bathtub toys (rubber ducks or Offers toys to people but cannot release
plastic boats); enjoys rubber ring for them
teething; will drop one toy when a PLAY Plays games like peek-a-boo and patty-
second one is offered cake since they can clap
SOCIALIZATION May say vowel sounds (oh-oh); says SOCIALIZATION object permanence
& LANGUAGE “Oh!” as a way of attracting attention & LANGUAGE Responds to own name and listen
Learns the art of imitating acutely when spoken to
Able to locate sounds made above them Understands the word NO & bye-bye

7 MONTHS 11 MONTHS
GROSS MOTOR Sits alone but only when the hands are GROSS MOTOR “Cruises” (walks with support) by holding
DEVELOPMENT held forward for balance, Bounces with DEVELOPMENT on to low tables
enjoyment in a standing position FINE MOTOR Enjoy putting things in and taking things
Reaches out to be picked up; first tooth DEVELOPMENT out of containers
(central incisor) erupts PLAY Cruising is the favorite activity
FINE MOTOR Transfers object from one hand to SOCIALIZATION One word + “Ma-ma” & “Da-da”
DEVELOPMENT another; hold a first object when a & LANGUAGE
second one is offered
Pat their own image in a mirror 12 MONTHS
PLAY Likes objects that are good size for GROSS MOTOR Stands alone; some infants take first step
transferring; Interested in items (blocks, DEVELOPMENT Landau reflex fades
rattles, plastic keys, brightly colored FINE MOTOR Holds cup and spoon well; helps to dress
balls) DEVELOPMENT (pushes arm into sleeve); can hold a
Interested in brightly colored balls or crayon well enough to draw a semi-
toys that previously rolled out of reach straight line; can hold a cup and spoon to
SOCIALIZATION Can imitate vowel sounds well (oh-oh, feed themselves well; can take off socks
& LANGUAGE ah-ah) and push their hands into sleeves
Shows beginning fear of strangers (may PLAY Likes toys that fit inside each other (pots
cry when taken from their parents, and pans); nursery rhymes; will like pull
attempt to cling to him or her and reach toys as soon as walking; enjoy putting
out to be taken back) objects such as small blocks in containers
and taking them out again
8 MONTHS They drop objects from a highchair or
GROSS MOTOR Sits without support playpen and watch where they fall or roll
DEVELOPMENT Plantar Grasp reflex disappears They are capable of reproducing new
FINE MOTOR Advanced eye-hand coordination so events (they deliberately hit a mobile
DEVELOPMENT random reaching and ineffective once, it moves, and they hit it again).
grasping already have disappeared SOCIALIZATION Says two words plus ma-ma and da-da
PLAY Sensitive to differences in texture & LANGUAGE Overcome their fear of strangers and are
Enjoys toys that have different feel to alert and responsive again
them (velvet, fuzzy, smooth/rough items) Likes being at the table for meals and
SOCIALIZATION Has peaked fear of strangers (ability to joining in family activities
& LANGUAGE tell known from unknown people)
Eighth-month anxiety o stranger anxiety Promoting Achievement of the Developmental Task:
Trust Versus Mistrust
9 MONTHS
GROSS MOTOR Creeps and crawls A synonym for trust in this connotation is love
DEVELOPMENT Sits steadily that they can lean forward &
regain their balance
Can stand holding on to a table Promoting Nutritional Health of an Infant
FINE MOTOR Can separate fingers ✓ For infants whose mothers choose not to breastfeed, a
DEVELOPMENT Voluntary release of objects commercial iron-fortified formula may be used.
PLAY Needs space for creeping
Begins to enjoy nesting toys, rings of Guidelines:
assorted sizes - Should have no more than 30 oz (900 mL) of formula per day
Some are interested in pots and pans - Should switch from formula to whole-fat milk after age 12
SOCIALIZATION Speaks first word: “da-da” or “ba-ba” months and continued until age 2
& LANGUAGE Aware of changes in tone of voice. - Don’t prop up baby bottles: prevent risk of aspiration, otitis
media and tooth decay
10 MONTHS
GROSS MOTOR Can pull themselves to standing position, ❖ Breastfed infants: nursing vigorously every 3-4 hours & do
DEVELOPMENT but cannot let themselves down yet not seem satisfied
FINE MOTOR Use pincer grasp (thumb & finger) to pick ❖ Formula fed: taking more than 32 oz (960 mL) of formula
DEVELOPMENT up small objects per day & do not seem satisfied
Uses one finger to point to objects ❖ Loss of extrusion reflex

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Tips in introducing SOLID FOOD: Falls
1. Introduce one food at a time, wait 5-7 days between new → Always keep crib rails fully up
items. → DO NOT leave infant unattended on an open surface
2. Introduce small amount of new food at a time (1-2 tsp) → Use gates across stairways & other potentially dangerous
3. Respect infant food preferences areas
4. Use minimal salt and sugar → Never leave an infant on an unprotected surface, such as a
5. DO NOT place food in bottles with formula bed or couch, even if the infant is in an infant seat.
6. Introduce food with a positive food → Place a gate at the top and bottom of stairways; do not
allow your infant to walk with a sharp object in the hands
When to introduce solid food? or mouth.
Quantity and Types of Food: → Raise crib rails and make sure they are locked before
1. Cereal (5-6 months) walking away from the crib.
- Iron-fortified infant cereal mixed with breastmilk, orange → Do not leave a child unattended in a highchair; avoid using
juice or formula an infant walker near a stairway.
- Aids in preventing iron-deficiency anemia; least allergenic
type of food; easily digested Motor vehicle
- First cereal introduced is usually rice cereal → Use car seats properly: should be used without interruption
- Offered twice a day (Morning and evening) through the preschool age or until reaches 40-60 lbs
→ Infants up to 20 lbs should be placed in rear facing seats in
2. Vegetables (7 months) the back seat
- Good source of Vit A; adds new texture & flavor to diet → Never transport an infant in an automobile unless the
- Iron content generally higher; second food added to the diet infant is buckled into an age-appropriate seat in the back
- Offered at lunch; offer both green and yellow vegetables seat of the car.
→ Be aware of the proper technique for tethering the car seat
3. Fruit (8 months) to the car.
- Best source of Vit C; good source of Vit A → Do not be distracted by an infant while driving.
- Adds new texture & flavor to diet → Do not leave an infant unattended in a parked car (the
- Can be given in addition to cereal for breakfast and dinner infant can become dehydrated from excess heat, can move
the gear shift, or be abducted).
4. Meat (9 months)
- Good source of protein, iron, and B vitamins Suffocation
- Beef and pork have more iron than chicken, offer more → Allow no plastic bags within infant’s reach; don’t use
frequently pillows in cribs.
- Add as part of the evening meal → Store unused appliances such as refrigerators or stoves
with the doors removed.
5. Egg Yolk (10 months) → Buy a crib that is approved for safety
- Good source of iron → Remove constricting clothing such as a bib or pacifier string
- Contain the bulk of the iron content (egg yolk); egg white from neck at bedtime.
contains the bulk of protein
- Protein of the egg white can lead to allergy or can be difficult Drowning
for an infant to digest → Do not leave infants alone in a bathtub or unsupervised
- Give hard-boiled eggs near water (even buckets of cleaning water).

Promoting Infant Safety Animal bites

✓ Accidents are a leading cause of death on children from 1 → Do not allow an infant to approach a strange dog; supervise
month through 24 years of age. play with family pets.
✓ Most accidents in infancy occur because parents either
underestimate or overestimate a child’s ability. Poisoning
✓ Help parents become sensitive to their infant’s progress. → Never present medication as a candy; buy medications in
✓ Be aware that the frequency of injury is increased when containers with safety caps; put away in a high cabinet
parents are under stress. immediately after use; and never leave medication in a
✓ Take special precautions at these times. pocket or handbag.
✓ Choose babysitters carefully and explain and enforce all → Never take medication in front of infants. Place all
precautions when sitters are in charge. medication and poisons in locked cabinets or overhead
shelves.
Aspiration → Do not use lead-based paint in any area of the home.
→ Be certain any object an infant can grasp and bring to the → Hang plants or set on high surfaces.
mouth is either safe to eat or too big to fi t in the mouth. → Post telephone number of the national poison control
→ Remove potentially harmful items (pins, dust balls, small center by the telephone (1-222-1222).
objects, plastic bags)
→ When solid foods are introduced, encourage parents to Burns
offer small pieces of hot dogs or grapes → Test warmth of formula and food before feeding (use extra
→ Do not offer foods such as popcorn or peanuts precaution with microwave warming).
→ Reassess toys for loose pieces or parts → Do not smoke or drink hot liquids while holding or caring
→ Store baby powder out of reach; inspect toys and pacifiers for an infant.
for small parts that could be aspirated if broken off.
Hsci 102: Care of Infants and Children Prepared by: llal
→ Buy flame-retardant clothing for infants; turn handles of
pans toward back of stove. KEY POINTS FOR REVIEW
→ Use a sunscreen on a child over 6 months when out in direct
or indirect sunlight and limit the child’s sun exposure to less
than 30 minutes at a time. ● The infant period is from 1 month to 12 months of age.
→ If a vaporizer is used, use a cool-mist, not a hot-mist type; Children typically double their birth weight at 4 to 6 months
remain in room to monitor so child cannot reach vaporizer. and triple it at 1 year.
Monitor infants carefully near candles.
→ Do not leave infants unsupervised near hot-water faucets. ● Infants develop their first tooth at about 6 months; by 12
→ Keep a screen in front of a fireplace or heater. months, they have six to eight teeth.
→ Do not allow infants to blow out matches or candles (don’t
teach infants that fi re is fun). ● Important gross motor milestones during the infant year are
→ Keep electric wires and cords out of reach; cover electrical lifting the chest off a bed at 2 months, sitting at 6 to 8 months,
outlets with safety plugs. creeping at 9 months, “cruising” at 10 to 11 months, and
walking at 12 months.
Bathing Safety
→ Check the temperature & depth of water: ● Important fi ne motor accomplishments are the ability to
Temperature: 32.2 to 37.8 °C (90 to 100 °F) pass an object from one hand to the other (7 months of age)
Depth of water: 2 inches or 5 cm at most and a pincer grasp (10 months of age).

Childproofing ● Important milestones of language development during the

→ Insert safety plugs in wall outlets first year are differentiating a cry (2 months of age), making
→ Prevent access to electrical cords simple vowel sounds (5 to 6 months of age), and saying two
→ Use of walkers should be discouraged words besides “ma-ma” and “da-da” (12 months of age). The
more infants are spoken to, the easier it is for them to acquire
Food Safety language.
→ Check temp. of formula & foods; should feel lukewarm
when a few drops are placed on caregiver’s skin ● Providing infants with proper toys for play helps
→ Do not warm formula, breastmilk, or food in microwave development. All infant toys need to be checked to be certain
they are too large to be aspirated (wider than a toilet paper
► Be aware some infants are more active, curious, and roll).
impulsive and therefore more vulnerable to unintentional
injury than others. ● Important milestones of vision development are the ability
to follow a moving object past the midline (3 months of age)
COLIC and ability to focus securely without eyes crossing (6 months
Thorough history: of age).
- Duration of the problem & frequency (lasts 3 hours a day
& occurs at least 3 days every week ● According to Erikson (1993), the developmental task of the
- Character & associated symptoms infant year is the development of a sense of trust versus
- Number & type of bowel movement mistrust. Helping parents spend quality time with their infant
- Family medical history – rule out allergy to milk helps a sense of trust to develop and helps in planning nursing
- Feeding pattern – type of formula & preparation care that not only meets QSEN competencies but that also
best meets the family’s total needs.
Management:
- During feeding, hold the baby upright & burp infant ● Safety is important. Infants must be protected from falls and
adequately after feeding the aspiration of small objects. Skills an infant cannot
- For breastfed infant, a change in maternal diet – avoid accomplish one day, such as crawling (which can lead to
gassy foods danger), may be accomplished the next.
- Infants should receive small, frequent feedings
- Avoid placing a hot water bottle on the infant’s stomach ● Solid food is generally introduced into an infant’s diet at 5 to
- Give small, frequent feedings to prevent distention and 6 months of age. Before infants can eat solid food, they must
discomfort lose their extrusion reflex.
- Offering a pacifier can be comforting.
- Reducing stimuli, taking infants for car rides, or playing a ● Common concerns related to infant development include
music box that simulates the sound of a heartbeat are often teething, thumb-sucking, use of pacifiers, sleep problems,
reported as being helpful constipation, colic, diaper dermatitis, babybottle syndrome
(decayed teeth from sucking on a bottle of formula while they
DIAPER RASH/DIAPER DERMATITIS sleep), and obesity. Nurses play a key role in teaching parents
- Caused by irritation of the skin from being in contact with about these problems and suggestions to deal with them.
stool & urine
- Prevented through frequent diaper change, applying an ● Remember that parent–infant attachment is critical to
ointment, and exposing the diaper area to air mental health. Urge parents to continue to give as much care
- Some infants may have to sleep without diapers at night as possible to ill infants to maintain this important
- Changing the brand or type of diaper or washing solution relationship.

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 Chapter 30: NURSING CARE OF A FAMILY WITH A TODDLER
Age 1 to 3 years
Wide array of developmental tasks and change Dentition
Parents grow during this period: support their child’s Eight new teeth (canines & first molars) erupt at 2
growing independence with a patience and sensitivity, All 20 deciduous teeth present by 2.5 to 3 years of age
learn methods for handling the child’s frustrations
Parents may find that if they promise a child a treat when Physiologic Status
the child is in the middle of a temper tantrum, that will stop
the tantrum, but it will not prevent other tantrums from Body Systems
occurring in the future. Body systems continue to mature during this time.
Respirations slow slightly but continue to be mainly
abdominal.
Physical Growth
Respiratory System: lumen of vessels enlarge progressively
✓ While toddlers are making great strides developmentally, – threat to lower respiratory infections becomes less
their physical growth begins to slow. Heart rate slows from 110 to 90 beats/min.
Blood pressure increases to about 99/64 mmHg.
CHARACTER TRAITS: The brain develops to about 90% of its adult size.
▬ Rigid, ritualistic, and stereotypic Stomach secretions become more acid; therefore,
▬ Negativistic, their favorite word is “NO” as their way to gastrointestinal infections also become less common.
search for independence Stomach capacity increases to the point a child can eat
three meals a day.
NURSING SIGNIFICANCE: Control of the urinary and anal sphincters becomes
▬ Limit questions; offer options possible with complete myelination of the spinal cord, so
▬ Temper tantrums – ignore the behavior toilet training is possible.
Immune globulin (Ig)G and IgM antibody production
Weight becomes mature at 2 years of age. The passive immunity
Gains from 4-6 lbs (1.8-2.7 kg) per year obtained during intrauterine life is no longer operative.
Birth weight quadruples by 2.5 years
Developmental Milestones
Height
✓ Less numerous but no less dramatic than those of the infant
Grows about 5 inches (12cm per year
year because this is a period of slow and steady, not
Height at 2 years is about half of the expected adult height
sudden, growth.
✓ Toddler development is influenced to some extent by the
Head Circumference amount of social contact and the number of opportunities
Increases only about 2cm during the second year compared children must explore and experience new degrees of
to about 12 cm during the first year independence.
✓ It is strongly influenced by individual readiness for a new
Chest Circumference skill.
By 2 years, chest circumference has grown greater than the
head circumference 15 MONTHS
GROSS MOTOR Walks alone well; can sit self in chair
Body Contour DEVELOPMENT Can creep upstairs
Toddlers tend to have a prominent abdomen because, FINE MOTOR Puts small pellets into small bottles
although they are walking well, their abdominal muscles DEVELOPMENT Scribbles voluntarily with a pencil/crayon
are not yet strong enough to support abdominal contents. Holds a spoon well but may still turn it
They also have a forward curve of the spine at the sacral upside down on the way to the mouth
area (lordosis). PLAY Can stack 2 blocks; Enjoys being read to
Drop toys for adult to recover (exploring
sense of permanence)
SOCIALIZATION 4 to 6 words
& LANGUAGE

18 MONTHS
GROSS MOTOR Can run and jump in place
DEVELOPMENT Can walk up & downstairs holding onto a
person’s hand or railing
Places both feet on one step before
advancing
FINE MOTOR No longer rotates a spoon to bring it to
DEVELOPMENT mouth
PLAY Imitates household chores (e.g., dusting)
Begins parallel play (playing besides, not
with, another child)
Walks securely enough to enjoy pull toys

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 SOCIALIZATION 7-20 words; uses jargoning Nursing Significance
& LANGUAGE Names 1 body part ▬ Instruct parents not to offer snacks within an hour of meals
Bowel control is achieved ▬ Avoid small food items (peanuts, carrots, celery, hotdogs)
▬ Remind parents not to use food as a reward or a
24 MONTHS punishment
GROSS MOTOR Walks upstairs alone, still using both feet ▬ Parents should encourage the use of utensils
DEVELOPMENT on same step at same time
FINE MOTOR Can open doors by turning doorknobs; Promoting Toddler Safety
DEVELOPMENT unscrew lids Aspiration and Poisoning
PLAY Parallel play is evident → Urge parents to lock all toxic substances away from the
Wrapping a doll and putting it to bed or child’s reach, secure safety caps on medications, and
“driving the car,” they begin to use fewer remove small easily aspirated objects from the child’s
toys than before. environment
The act of imitating has become their
play. Falls
SOCIALIZATION 50 words → Instruct to keep crib rails up, place gates across stairways,
& LANGUAGE 50 words; two-word sentences (noun or secure screens on all open windows
pronoun and verb), such as “Daddy go,” → Supervise the toddler at play
“Dog talks”
Burns
30 MONTHS → Advise parents to avoid using tablecloths
GROSS MOTOR Can jump down from chairs → Teach the toddler what “hot” means
DEVELOPMENT → Store matches and lighters in locked cabinets out of reach
FINE MOTOR Makes simple lines or strokes for crosses → Secure safety plugs in all unused electrical outlets
DEVELOPMENT with a pencil; copies a circle
PLAY Spends time playing house, imitating Motor Vehicle and other Accidents
parents’ actions → Instruct parents to continue always using an appropriate-
Play is “rough housing” or active sized car seat
SOCIALIZATION Verbal language increasing steadily → Advise parents to lock cabinets & drawers that contain
& LANGUAGE Knows full name; can name one color hazardous items (knives, firearms)
and holds up fingers to show age → Encourage parents to teach a toddler how to cross a street
safely – by holding parent’s hand
36 MONTHS → Urge parents to supervise tricycle riding & outdoor play
GROSS MOTOR Rides a tricycle; Can do toothbrushing
DEVELOPMENT with little supervision Parental Concerns Associated with the Toddler
FINE MOTOR Unbutton buttons; draws a cross Period
DEVELOPMENT Toilet Training
PLAY Learns how to share ▬ One of the biggest tasks
SOCIALIZATION 300-900 words; Speaks fluently ▬ Parents should remember that this is an individualized task
& LANGUAGE Knows full name and sex for each child: it should begin & be completed according to
Nighttime bladder control achieved the child’s ability to accomplish it
▬ Bowel training is accomplished before bladder
Promoting Achievement of the Developmental Task: ▬ Complete night bladder training usually does not occur
Autonomy Versus Shame or Doubt until age 4 or 5
To develop a sense of autonomy is to develop a sense of ▬ They must have control of rectal and urethral sphincters,
independence. usually achieved by the time they walk well.
▬ They must have a cognitive understanding of what it means
to hold urine and stools until they can release them at a
Nutritional Requirements certain place and time.
✓ Growth rate slows – decrease in the child’s need for ▬ They must have a desire to delay immediate gratification
calories, protein, and fluid for a more socially accepted action
✓ Calorie requirement: 102 kcal/kg/d
✓ Protein requirement: 1.2 g/kg/d Signs of Toddler’s Readiness for Toilet Training
✓ Milk should be limited to no more than 1qt (1 liter) per day ✓ Stays dry for 2 hours, with regular bowel movements
✓ Can sit, walk, and squat
✓ Can verbalize the desire to void or defecate
Food Preferences
✓ Exhibits willingness to please parents
✓ Wants to have soiled diapers changed immediately
✓ 12 months: most eat the same food as the rest of the family
✓ 18 months: physiologic anorexia (picky eaters); may
Ritualistic Behavior
experience food jags
▬ They will use only “their” spoon at mealtime or only “their”
✓ Prefer to feed themselves & prefer small portions of
blanket at bedtime.
appetizing food
▬ They will not go outside unless a mother or father locates
✓ Prefer single foods instead of mixtures
their favorite cap.

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▬ The child who seems to need an excessive number of Management:
objects to cling to or an excessive number of routines, ✓ Schedule an earlier bedtime or afternoon nap
however, may be trying to say, “I need more guidelines, ✓ Schedule two shorter trips each week rather than one
more rules. Don’t let me be quite so independent.” long one
✓ Limit the number of choices asked of the child
Negativism
▬ Common; part of establishing their own identities as
separate individuals
▬ They do not want to do anything a parent wants them to
do. KEY POINTS FOR REVIEW
▬ Their reply to every request is a very definite “no.”

How to manage? ● Erikson’s developmental task for the toddler period is to

✓ Decrease the number of questions form a sense of autonomy or independence versus shame or
✓ Make statement instead of asking doubt.
✓ Offer options
● Toddlers make great strides forward in development, but
Discipline their physical growth slows.
▬ Discipline means setting rules or road signs, so children
know what is expected of them. ● A critical milestone of toddler development is being able to
▬ Punishment is a consequence that results from a form two-word sentences (a noun and a verb) by 2 years of
breakdown in discipline or the child’s disregard of the rules age.
that were learned.
● Toddlers are capable of preoperational thought or can deal
Measures: much more constructively with symbols than they could while
✓ Consistent infants.
✓ Initiated after a misbehavior
✓ Planned in advance ● Important aspects of toddler care are promoting safety,
✓ Oriented to the behavior, not the child toddler development, and healthy family functioning because
✓ Private and not shame-inducing all three of these facets help in planning nursing care that not
only meets QSEN competencies but that also best meets a
▬ Rules are learned best if correct behavior is praised rather family’s total needs.
than wrong behavior punished.
▬ A “time-out” is a technique to help children learn that ● Toddler appetites decrease from those of the infant, so
actions have consequences. children eat proportionally less than they did as infants.
▬ Parents should carry them out in a safe, non-stimulating
area ● Common concerns of parents during the toddler period are
▬ Duration should be 1 minute per year of age toilet training, ritualistic behavior, negativism, temper
tantrums, discipline, and separation anxiety.
Separation Anxiety
▬ Fear of being separated from parents begins at about 6 ● Promoting autonomy in the child who is physically
months of age and persists throughout the preschool challenged or chronically ill calls for creative planning because
period. there may be many tasks that must be done for the child to be
▬ Peaks at 18 months certain they are done safely

3 Distinct Phases:
a. Protest – characterized by anger; may scream & call the
mother to come back
b. Despair – characterized by being withdrawn and does
not want to talk
c. Denial – exhibiting by ignoring the parents

How to prevent separation anxiety?

✓ Do not prolong goodbyes
✓ Say goodbye firmly
✓ Transitional objects are important especially during
periods of separation

Temper Tantrums
▬ Occurs as a natural consequence of toddler’s development

Reasons:
✓ Response to unrealistic request by a parent
✓ Parents saying “NO” too frequently
✓ Difficulty making choices or decisions

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 Chapter 30: NURSING CARE OF A FAMILY WITH A PRESCHOOL CHILD
Age 3 to 5 years 3 YEARS OLD
Although physical growth slows considerably during this GROSS MOTOR Runs, rides tricycle
period, personality and cognitive growth continue at a DEVELOPMENT Alternates feet on stairs
rapid rate. Stands on one foot
Most children of this age want to do things for FINE MOTOR Undresses self; stacks tower of blocks;
themselves—choose their own clothing and dress DEVELOPMENT draws a cross
themselves, feed themselves completely, wash their own PLAY Able to take turns; very imaginative
hair, and so forth. SOCIALIZATION Vocabulary of 900 words
Preschoolers are egocentric, so they define objects in & LANGUAGE Using 3- or 4-word sentences
relation to themselves (e.g., a key is not a metal object but Give own first name & age
“what I use to open a door”, a car is not a means of
transportation but “what Mom uses to take me to school”).

Physical Growth
Contour changes are so definite that future body type—
ectomorphic body build (slim body build) or endomorphic
body build (large body build)—becomes apparent.

Weight
Average weight gain is 4.5 lbs (2 kg) a year
Appetite remains the same as it was during the toddler
years, a level perhaps considerably less than some parents
would like or expect. 4 YEARS OLD
FURIOUS F OURS (NOISY , AGGRESSIVE & STORMY)
Height GROSS MOTOR Jumps or skips
Gain is 2 to 3.5 inches (6-8 cm) a year DEVELOPMENT Always in motion
Head circumference is not routinely measured at physical FINE MOTOR Button buttons; Laces shoes
assessments on children over 2 years of age because it DEVELOPMENT Copies square; draws a person w/ 3 parts
changes little after this time. PLAY Pretending is a major activity
SOCIALIZATION Vocabulary of 1,500 words
Physiologic Status & LANGUAGE Knows four basic colors
Body Systems Singing a song
Lymphatic tissue begins to increase in size (tonsils)
Levels of IgA and IgG increase 5 YEARS OLD
Pulse Rate decreases to about 85 bpm GROSS MOTOR Throws & catch a ball; jump ropes
Blood Pressure holds at about 100/60 mmHg DEVELOPMENT Skip on alternate feet; Balance on
Bladder is palpable above symphysis pubis; voiding is alternate feet with eyes closed
frequent (9 or 10 times a day) FINE MOTOR Can draw a six-part figure (head, body,
Muscles of lower extremities are much stronger DEVELOPMENT arms & legs)
Handedness becomes obvious Tie shoelaces; Use scissors well
A child who earlier in life had an indeterminate longitudinal Copy a diamond and triangle
arch in the foot generally demonstrates a well-formed arch Print a few letters & numbers and her
now. first name
Muscles are noticeably stronger, so activities such as PLAY Count using fingers
gymnastics become possible. Recognize most alphabet letters
Many children at the beginning of the period exhibit genu Group games or reciting songs they have
valgus (knock-knees); this disappears with increased learned in kindergarten or preschool
skeletal growth at the end of the preschool period. SOCIALIZATION Vocabulary of 2,100 words
& LANGUAGE Likes games with numbers or letters
Dentition Follow rules of interactive peer games
Teeth Children generally have all 20 of their deciduous
teeth by 3 years of age; permanent teeth don’t replace
these until school age. Promoting Achievement of the Developmental Task:
Preserving these teeth is important because they hold the Initiative versus Guilt
position for the permanent teeth as the child’s jaw grows Children with a well-developed sense of initiative like to
larger. explore because they have discovered that learning new things
is fun.
Developmental Milestones
Play activities change focus dramatically as the preschooler
learns new skills and understands more about the world.

Hsci 102: Care of Infants and Children Prepared by: llal

 ✓ Prevent burns: store matches in closed containers
✓ To teach community safety:
→ Teach preschoolers that not all people are friends

Common Fears
✓ Fear of the Dark
→ Parents should monitor the number of stimuli children
are exposed to especially at bedtime
→ A dim light at the child’s room may be helpful
→ Reassure children that they are safe especially if they
are having nightmares
✓ Fear of Mutilation
→ Need a good explanation of the limits of health care
procedures in order to feel safe
✓ Fear of Separation
✓ Fear of Animals
✓ Fear of Ghosts

Behavior Variations
✓ Telling Tall Tales
Character Traits
→ Stretching stories to make them seem more interesting
▬ Curious, creative, imaginative, and imitative → Caution parents not to encourage this behavior, help
▬ Presence of complexes child separate fact from fiction
✓ Imaginary Friends
➢ Oedipal Complex – identification of the preschool boy → Expose the child to real playmates
to his father and attachment to his mother → Parents can help their children separate fact from
fantasy
➢ Electra Complex – identification of the preschool girl to ✓ Difficulty Sharing
her mother and attachment to her father → Assure parents that sharing is a difficult concept to
grasp, preschoolers need practice to understand & learn
it
Nutritional Requirements → Define limits and expose children to these categories:
✓ Similar to toddlers mine, yours, ours
✓ Calorie requirement: decreases to 90 kcal/kg/day ✓ Regression
✓ Protein requirement: 1.2 g/kg/day → Related to stress
✓ Fluid requirement: 100 mL/kg/day → Help parents understand that regression in some
circumstances is normal
Food Preferences → Assure children that although situations are changing,
the important aspect of their life is not
✓ May reject vegetables, mixed dishes & liver
→ Thumb sucking or other manifestation of stress are best
✓ Favorite foods: cereal, meat, baked potatoes, fruits, sweets
ignored
✓ Many (3-4 y/o) are still restless or fussy with meals with the
✓ Siblings Rivalry
family and they may struggle with utensils
→ Supply preschoolers with a private drawer or box for
✓ Food habits of others influence 5 years old:
their things that parents, or other children do not touch.
→ Tends to focus on “social” aspects of eating, including
conversation, manners, and willingness to try new
foods; help with meal preparation and clean up Sex Education
→ Older preschooler can manage a spoon and fork ✓ Adults should answer questions about sex simply and
honestly.
Promoting Safety ✓ Parents should explain to preschoolers that certain things
are done in some places but not in others.
Setting Limits
✓ Teach preschoolers to avoid sexual abuse: do not allow
✓ Parents and adults should emphasize safety measures; anyone to touch their body.
preschoolers listen to adults and can understand and heed
precautions.
Broken Fluency

Related Safety Concerns ✓ Repetition and prolongation of sounds, syllables, and

words
✓ To prevent motor vehicle accidents, teach the preschooler:
✓ Part of normal development and it will come to pass
→ Safety with tricycle
✓ How to reduce stuttering:
→ Always hold hands with grownup before crossing a
→ Listen to what the child is saying with patience
street
→ Talk to the child in a calm, simple way
→ Not to run behind cars that are backing up
→ Protect space for the child to talk
✓ Prevent drowning: teach beginning swimming
→ Do not force the child to speak
✓ To prevent poisoning, parents should:
→ Never present medication as candy
→ Never take medication in front of a child

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 KEY POINTS FOR REVIEW ● Preschoolers are still operating at a cognitive level that
prevents them from understanding conservation (objects have
not changed substance even if they have changed
● Although preschoolers grow only slightly and gain just a little appearance).
weight, they seem much taller than when they were toddlers
because their contour changes to more childlike proportions. ● Preschoolers are self-centered (egocentric) so it is difficult
for them to share and view someone else’s side of a problem.
● Erikson’s developmental task for the preschool period is to They need good explanations of how a procedure will benefit
gain a sense of initiative versus guilt, or to learn how to do them before they can agree to it.
things. Play materials ideal for this age group are those that
stimulate creativity, such as modeling clay or colored markers. ● Many preschoolers begin preschool programs or childcare.
Late in the preschool period, they may be enrolled in
● Promoting childhood safety is a major role because kindergarten. Parents often appreciate guidance on how to
preschoolers’ active imaginations can lead them into prepare their children for these new experiences.
dangerous situations; stressing this helps in planning nursing
care that not only meets QSEN competencies but that also ● Preschoolers who have special needs may have difficulty
best meets a family’s total needs. achieving a sense of initiative because they may be limited in
their ability to participate in activities that stimulate initiative.
● Common parental concerns during the preschool period are They may need special playtimes set aside for stimulation and
broken fluency, imaginary friends, difficulty sharing, and learning.
sibling rivalry. Preschoolers may develop several universal
fears, such as fear of the dark, mutilation, and abandonment.

● The preschool age is often the time when a new sibling is

born. Helping parents offer good preparation for this is
necessary to prevent intense sibling rivalry.

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 Chapter 32: NURSING CARE OF A FAMILY WITH A SCHOOL-AGE CHILD
Age 6-12 years old
Time of slow physical growth; cognitive growth and Developmental Milestones
development proceed at a rapid rate.
The school-age period is a relatively long-time span, and
Development is more subtle and marked by mood swings;
even though growth is slow, children grow and develop
what the child enjoys on one occasion may not be
extensively during this time period.
acceptable on the next.

Physical Growth 6 YEARS OLD

Weight PHYSICAL A year of constant motion; skipping is a
Average weight gain is DEVELOPMENT new skill; first molars erupt.
approximately 3 to 5 lb (1.3 - PSYCHOSOCIAL First-grade teacher becomes authority
2.2 kg) & COGNITIVE figure
DEVELOPMENT Adjustment to all-day school may be
Height difficult and may lead to nervous
Increase is 1 to inches manifestations of fingernail biting, etc.
Defines words by their use (e.g., a key is
Dentition to unlock a door, not a metal object).
Deciduous teeth are lost & Beginning interest in God
permanent teeth erupt GROSS MOTOR A year of constant motion; skipping is a
Gains 28 teeth between 6 DEVELOPMENT new skill; Walk a straight line
and 12 years FINE MOTOR Easily tie shoelaces. Cut & paste well.
DEVELOPMENT Draw a person with good detail
Physiologic Status Can print but may routinely reverse
letters
Posture becomes more erect
PLAY Continues to be rough
By 10 years of age, brain growth is complete; fine motor
Spends quiet time with books
coordination becomes refined
Discover reading as an enjoyable activity
Have normal vision
Play in groups, but when they are tired
IgG and IgA have reach adult levels & lymphatic tissue
or under stress, they usually prefer one-
continues to grow until 9
to-one contact.
Innocent heart murmurs may be apparent
SOCIALIZATION Talk in full sentences
Pulse Rate decreases to 70-80 bpm
& LANGUAGE Use language easily and with meaning
Blood Pressure rises to 112/60 mmHg
Define objects by their use
Maturation of the respiratory system leads to increased
O2-CO2 exchange
Time of onset of puberty: 10 to 14 years 7 YEARS OLD
PHYSICAL Central incisors erupt; difference
DEVELOPMENT between sexes becomes apparent in play
Chronologic Development of Secondary Sex
(e.g., video games vs. dolls); spends time in
Characteristics
quiet play.
BOYS PSYCHOSOCIAL Learns conservation (e.g., water poured
9-11 Prepubertal weight gain occurs. & COGNITIVE from tall container to a wide, flat one is the
11-12 Sparse growth of straight, downy, slightly DEVELOPMENT same amount of water); make simple change
pigmented hair at base of penis. They set too high a standard for
Scrotum becomes textured; growth of penis and themselves and then have difficulty
testes begins. performing at that level.
Sebaceous gland secretion increases. GROSS MOTOR Appears quiet (a quiet year)
Perspiration increases. DEVELOPMENT Gender differences appear in play
12-13 Pubic hair present across pubis. Penis lengthens. FINE MOTOR Striving for perfection – “eraser year”
Dramatic linear growth spurt. DEVELOPMENT
Breast enlargement may occur PLAY Require more props for play than when
they were younger
GIRLS Start of a decline in imaginative play
9-11 Breasts: Elevation of papilla with breast bud Develop interest in collecting items
formation; areolar diameter enlarges. SOCIALIZATION Can tell time in hours
11-12 Straight hair along the labia. Vaginal epithelium & LANGUAGE Can add and subtract
becomes cornified. pH of vaginal secretions Know the months of the year
becomes acidic; slight mucous vaginal discharge May have trouble with concepts such as
is present. Sebaceous gland secretion increases. “half past” and “quarter to,”
Perspiration increases. Dramatic growth spurt. Aware of family roles and responsibility.
12-13 Pubic hair grows darker; spreads over entire Promises must be kept
pubis. They tattle because they have such a
Breasts enlarge, still no protrusion of nipples. strong sense of justice
Axillary hair present. Menarche occurs.

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 8 YEARS OLD
PHYSICAL Coordination definitely improved 11-12 YEARS OLD
DEVELOPMENT Eyesight fully develops; Expansive years PHYSICAL Pre-adolescent period
PSYCHOSOCIAL “Best friends” develop DEVELOPMENT Active, but awkward and ungainly
& COGNITIVE Understands concepts of past, present, PSYCHOSOCIAL Insecure with members of opposite sex;
DEVELOPMENT and future. & COGNITIVE repeats off-color jokes.
GROSS MOTOR Movements are more graceful DEVELOPMENT Secret language is common
DEVELOPMENT May stumble on furniture or spill milk A sense of humor is present
food. Rides a bicycle well. Sociable and cooperative.
FINE MOTOR Write script in addition to print GROSS MOTOR Plunge into activities with intensity and
DEVELOPMENT More involved in science projects and DEVELOPMENT concentration.
experiments FINE MOTOR “turned on” to reading
PLAY Playing with gang becomes important DEVELOPMENT Raking leaves or babysitting for money
Loves to collect objects (sorting, catalog) PLAY Enjoy dancing to popular music and
Enjoys helping in kitchen playing table games
like table games but hate to lose, so they Accommodating enough to play with
tend to avoid competitive games younger siblings
SOCIALIZATION Whispering and giggling begin SOCIALIZATION Sharing secrets with friends
& LANGUAGE Can count backwards & LANGUAGE Time with friends spent just talking
Can carry on adult conversation
9 YEARS OLD Both boys and girls seem to feel they are
PHYSICAL All activities done with friends/gang. on the verge of something great and
DEVELOPMENT Takes care of body needs completely anxiously wait to turn 13 years old and
Stealing lying are common become teenagers.
PSYCHOSOCIAL Friend or club age; a 9-year-old club is
& COGNITIVE formed to spite someone, has secret Emotional Development
DEVELOPMENT codes, is all boy or all girls; clubs disband Ideally, children enter the school-age period with the
and reform quickly; Hero worship ability to trust others and with a sense of respect for their own
Talent for music or art becomes evident worth. They can accomplish small tasks independently
GROSS MOTOR On the go constantly because they have gained a sense of autonomy. They should
DEVELOPMENT Have enough eye-hand coordination have practiced or mimicked adult roles, learned to share,
FINE MOTOR Writing begins to look mature and less discovered that learning is an adventure, and grasped the idea
DEVELOPMENT awkward that doing things is more important and more rewarding than
PLAY Play hard; not as interested in perfecting watching things being done (a sense of initiative).
their skills
May have difficulty going to bed at night Characteristic Traits
because they want to play another game Industrious
SOCIALIZATION Discover dirty jokes & swear words They love to collect objects
& LANGUAGE Tells time correctly They can’t bear to lose; they cheat
They use swear words to express anger They are modest
or just to show other children that they
are growing up
Nutrition Promotion
They may have a short period of intense
✓ Daily calorie requirements diminish in relation to body size
fascination with “bathroom language”
✓ Average of 2,400 calories per day
✓ Stress the need for balanced diet from the food pyramid
10 YEARS OLD
PSYCHOSOCIAL Ready for camp away from home;
Food Preferences
& COGNITIVE collecting age
DEVELOPMENT Ready for competitive games. ✓ Exposed to broader eating experiences in school
Age of special talents; joins organization ✓ At home, child should eat what the family eats
✓ Still dislike: vegetables, casseroles, liver, and spicy foods
GROSS MOTOR More interested in perfecting their skills
✓ May go on “food jags”
DEVELOPMENT Coordination improves
✓ Obesity could develop from overeating and underactivity –
FINE MOTOR Writes legibly; playing handheld or
play provides a significant role
DEVELOPMENT console games
PLAY Boys and girls play separately
Interest in the opposite sex is apparent Promoting Safety
Boys show off as girls pass their group; ✓ Learn to accept more responsibility for personal health care
girls talk loudly or giggle at the sight of a and injury prevention
familiar boy ✓ Children’s developing cognitive skills complement their
Girls become more interested in the way own judgements and assist in helping them avoid many
they look and dress types of injuries
Interested in rules and fairness ✓ Parents should continue to provide guidance for new
SOCIALIZATION Well-mannered with adults situations and threats to safety
& LANGUAGE Children talk, giggle, and roughhouse
into the middle of the night.

Hsci 102: Care of Infants and Children Prepared by: llal

 Common Parental Concerns ● Common health problems during the school-age period
Common Fears and Anxieties include minor respiratory and gastrointestinal infections as
well as dental caries and malocclusion.
Anxiety r/t Beginning School:
✓ Parents need to alter their expectations of how much their
● Common parental concerns during this period are language
child should be achieving & conform to the child’s actual
development, fears and anxieties, and behavior problems such
ability
as stealing and exposure to recreational drugs. Treating
✓ Prepare the child for certain tasks (reading) beginning from
preventive strategies regarding these helps in planning nursing
infancy
care that not only meets QSEN competencies but that also
✓ Some children develop tics which occur when the child is
best meets a family’s total needs.
subjected to stress or anxiety
● As many as 90% of parents of school-age children are dual-
School Phobia
earner families. This means that many school-age children
Fear of attending school
return home before their parents. Counseling families on ways
Physical signs: vomiting, diarrhea, headache, abdominal pain
to turn this independent time into a positive experience is
on school days
helpful.
Management: Counseling may help
● Children in a concrete stage of operational thought are
SEX EDUCATION
limited to understanding concepts that they can actually see.
Topics to Teach: When health teaching, use concrete examples (actually let
✓ Reproductive organ function them hold a syringe, don’t just talk about it) to increase their
✓ Secondary sexual characteristics understanding.
✓ Physiology of reproduction
✓ Male sexual functioning ● School-age children thrive on rules. It is confusing for them
✓ Explanation of the physiology of pregnancy when rules are changed (e.g., medicine will now be taken four
✓ Social and moral implications of sexual maturity rather than three times a day) unless they have a clear
explanation of why the change is occurring.
Common Health Problems
Dental carries ● School-age children look for good adult role models; it is
hard for them to feel confidence in an adult who isn’t honest
✓ Defined as progressive, destructive lesions or
with them or who fails to live up to their expectations by not
decalcification of the tooth enamel and dentin
following through on promises.
✓ Management: Preventable with proper brushing and use of
fluoridated water. When carries occur, they should be
● School-age children with a family tendency toward obesity
treated quickly.
may become overweight. Helping the family learn a healthier
lifestyle is important.
DISCIPLINE
✓ Begin to internalize their own controls and need less
outside direction
✓ Regular household responsibilities help the feel that they
are important part of the family and increase their sense of
accomplishment
✓ Parents and caregivers should set reasonable concrete
limits and keep rules at a minimum

KEY POINTS FOR REVIEW

● School-age children mature slowly but steadily. Their

average annual weight gain is 3 to 5 lb; their increase in height
is 1 to 2 in.

● At about age 10 years, children begin to develop secondary

sex characteristics. Preparation for this helps them accept
these changes positively.

● Deciduous teeth are lost, and permanent teeth erupt during

the school-age period.

● Erikson’s developmental task for the school-age period is to

gain a sense of industry, or how to do things well.

Hsci 102: Care of Infants and Children Prepared by: llal

 Chapter 33: NURSING CARE OF A FAMILY WITH AN ADOLESCENT
Period between 13 and 18 to 20 years
Serves as a transition between childhood and adulthood Dentition
Divided into: Gain second molars at 13
Early (13-14 years old) Third molars between 18 and 21 years of age but may erupt
Middle (15-16 years old) as early as 14-15 years of age
Late (17-20 years old)
Physiologic Status
Physical Growth
Body System Changes
Weight Skeletal system grows faster than their muscles;
Physical growth is mostly in weight during prepubescence extremities elongate first before trunk growth
Gain about 30% to 50% of adult weight Heart and lungs increase in size more slowly
Average weight gain: PR and RR decrease slightly
Girls: between 15 and 55 lb (6.8-25 kg) Blood Pressure increases slight;y to 120/70 mmHg, reach
Boys: between 15 and 65 lb (6.8-29.5 kg) adult levels by late adolescence

Height Puberty
Achieve about 20% to 25% of adult height Period when primary and secondary sexual characteristics
Average height gain develop and mature
Girls: 2-8 inches (5-20 cm); growth ceases at about age 16 Onset:
or 17 Girls: Between 8 & 14 and ends within 3 years
Boys: 4-12 inches (10-30 cm); growth ceases between age Boys: Between 9 & 16 and ends by 18 or 19
18 or 20

TANNER SCALE MALE TANNER SCALE FEMALE

Hsci 102: Care of Infants and Children Prepared by: llal

 Significant Development Pre-marital Sex
✓ Experiences conflict between his need for sexual ✓ Adolescents engage in sexual activity for the ff reasons:
satisfaction and societal expectation → Pleasure
✓ Their core concern is the change in body image and → Satisfy drives and curiosity
acceptance of the opposite sex → Means of conquest or power
→ Express and receive affection
Personality Traits → Response to peer pressure
✓ Management:
✓ Idealistic – rebellious and reformers
→ Counselling may help improve adolescent’s perspective
✓ Very conscious of body image
and learn to say no
✓ Adventurous

Nutritional Requirement
✓ Daily intake should be balanced among the food groups KEY POINTS FOR REVIEW
✓ Average daily calorie requirement varies:
→ Girls (11-14) – 48 kcal/kg/day
→ Girls (15-18) – 48 kcal/kg/day
● The major milestones of development in the adolescent
→ Boys (11-14) – 60 kcal/kg/day
period are the onset of puberty and the cessation of body
→ Boys (15-18) – 42 kcal/kg/day
growth. Between these milestones, physical growth is rapid,
✓ Adolescents need milk and protein in sufficient quantity
although the development of adult coordination and thought
✓ Common dietary deficiencies: iron, folate, and zinc
processes is slow.

● The development of secondary sex characteristics is

completed during adolescence. These are rated according to
Tanner stages.
Food Preferences
● The developmental task of an adolescent according to
Maintaining adequate quality and quantity of daily intake may Erikson is to establish independence from parents by gaining a
be difficult because of busy schedule, influence of peers and sense of identity versus role confusion. Therefore, adolescents
easy availability of fast and fatty empty calories foods. usually respond best to health care personnel who respect
At least 50% of adolescents skip one meal a day their attempts at independence and who allow them as many
Family eating patterns continues to influence adolescent’s choices as possible in care.
food selection
Female adolescents are very prone to negative dieting ● Adolescents reach a point of cognitive development termed
behaviors formal operational thought. With this gained, they are able to
think in abstract terms and use rational thinking to arrive at
Safety Instructions for Adolescents conclusions.
Proper use and storage of firearms & other weapons
Swimming and diving safety ● Adolescents need to consume adequate calories and
Proper caution around gasoline, electricity, and fire especially protein, iron, calcium, and zinc to meet their
Ways to avoid sports injuries increased growth needs, but at the same time, be certain they
Use of sunscreen during sun exposure don’t become overweight.
Risks of tobacco, alcohol, and other drugs
Problem-solving techniques ● Being an adolescent is difficult in today’s world. Be aware
Safe sex that, to reduce stress, some adolescents may begin to abuse
substances. Asking about an adolescent’s drug experiences
Alcoholism during a health assessment is not intruding on privacy. Rather,
✓ Its use is correlated to motor vehicle accidents, homicide, it is a method of safe health interviewing and helps in planning
and suicide nursing care that not only meets QSEN competencies but also
✓ Linked to diseases such as cirrhosis, cognitive challenge, best meets a family’s total needs.
and destructive behaviors
✓ Management: ● Promoting adolescent safety is an important nursing role.
→ Remind parents that they have a responsibility to set as Motor vehicle accidents, homicide, and suicide are leading
role models. causes of death in this age group.
→ Help adolescents build self-esteem and coping abilities
● Common health problems in an adolescent are sometimes
Smoking minor and include poor posture, fatigue, or acne; they can also
be serious, such as beginning hypertension, substance abuse,
✓ Begin smoking because the habit conveys maturity,
and scoliosis. Identifying these problems and referring an
influenced by advertising
adolescent for help are important nursing actions.
✓ Management:
→ Help adolescents find other methods to demonstrate
maturity.
→ Use of nicotine gum and nicotine patches have been
both successful.

Hsci 102: Care of Infants and Children Prepared by: llal