PEDIATRIC NURSING

PEDIATRIC NURSING GENERAL PRINCIPLES Definition of Terms A. Growth: increase in size of a structure. Human growth is orderly and predictable, but not even; it follows a cyclical pattern. B. Development: Development: maturation of physiologic and psychosocial systems to more complex state. C. Cephalocaudal: head-to-toe progression of growth and development GENERAL PRINCIPLES Definition of Terms D. Proximodistal: trunk-to-periphery (fingers and toes) progression of growth and development E. Phylogeny: development or evolution of a species or group; group; a pattern of development for a species F. Ontogeny: development of an individual within a species Rates of Development A. Fetal period and infancy: infancy: the head and neurologic tissue grow faster than other tissues. B. Infancy and adolescence: adolescence: fast growth periods C. Toddler through school-age: school-age: slow growth periods D. Toddler and preschool periods: periods: the trunk grows more rapidly than other tissue. E. The limbs grow most during school-age period. F. The trunk grows faster than other tissue during adolescence. adolescence. NEONATAL ASSESSMENT Initial assessment Ongoing assessment Physical assessment Sensory assessment Behavioral assessment

Apgar scoring Cord clamp  bleeding, AVA Voiding and meconium Footprints and fingerprints Identification bands Mother infant bonding APGAR SCORING Heart rate Respiratory effort Muscle tone Reflex irritability Skin color 1 minute  initial adaptation to extrauterine life 5 minutes  overall status APGAR SCORING INTERPRETATION 7 to 10  Good condition 4 to 6  Fair condition 0 to 3  In danger  resuscitation Ongoing Physical Assessment Vital Signs Vital statistics Gestational age assessment Administer medications Perform laboratory tests

Initial Assessment Airway  suctioning and O2 if needed Body temperature Positioning  head lower than the trunk

Ongoing Physical Assessment Vital signs: RR 30 to 60 bpm Apical Pulse 110  sleeping 120 – 160  awake 180  crying Temperature 36  36.8 Blood Pressure 80/46 mmHg Vital Statistics:

Weight 2,500 – 4,000 g Length 18 – 21 inches Head Circumference 13 – 14 inches Chest Circumference 12 – 13 inches Ongoing Physical Assessment Gestational Age Preterm Term Postterm Laboratory Test Mother  Rh neg or blood type O Blood type Bilirubin level Direct coomb’s test Reticulocyte count Hct Administer Medications Vit K (Aquamephyton) .5 to 1 mg IM Prevent transient deficiency of coagulation factors Erythromycin ointment .5% 1 to 2 cm Neisseria gonorrhea, chlamydia PHYSICAL ASSESSMENT Skin Head Eyes Ears Nose Mouth and throat Neck Chest Genitalia Extremities HEAD Eyes Normal Color  gray Absence of tears Searching nystagmus Abnormal Yellow sclera Blue eyes

Purulent discharge Congenital cataracts Ears Normal Pinna  top is horizontal line with outer cantus of the eye, flexible, cartilage present Abnormal Low placement of ears Absent of startle reflex in response to loud noise

MOUTH AND THROAT Epstein pearl Reflexes Sucking Gag Extrusion Candidiasis (thrush) Inability to pass NGT High pitch cry or absent Neck Normal Short, thick, usually surrounded by skin folds Tonic neck reflex Abnormal Resistance to flexion Fractured clavicle No tonic neck reflex Chest Normal APD = TD Slight sternal retractions evident during inspiration Abnormal Asymmetry of the chest Depressed sternum GENITALIA MALE Normal Urethral opening at tip of glans penis Palpable tetes Abnormal

Hypospadias Epispadias FEMALE Normal Labia and clitoris usually edematous Urethral meatus behind clitoris Pseudomenstruation Abnormal Fused labia Meconium in the vaginal area Absence of vaginal opening EXTREMITIES NORMAL Ten fingers and toes Full range of motion Nail beds are pink, with transient cyanosis immediately after birth Equal brachial pulses Sole usually flat ABNORMAL Polydactyly Syndactyly  fused or webbed digits Yellowing of nail beds Unequal gluteal folds Sole covered with creases SENSORY ASSESSMENT Tactile Behaviors Sensation to touch, pain and pressure Olfactory behaviors Vision Behaviors Can see  7 to 12 inches Auditory Behaviors Taste Behaviors BEHAVIORAL ASSESSMENT Period of Reactivity 30 minutes after birth Awake and active VS are increased Mother infant bonding  breastfeeding Resting Period 2 to 4 hours VS returning to baseline 1 ½ sleep and difficult to be aroused Second Period of Reactivity 4 to 6 hours

Gain of 28g /day  1st 6 months Gain of 14g/day  2nd 6 months Weight gain 2x  6 months 3x  1 year 4x  2 ½ year DAILY NUTRIONAL REQUIREMENTS Calories  100 to 200 kcal/kg Fluid  150 to 180ml/kg CHON  2.2g/Kg  1.6g/Kg Fat  30 to 60% of daily calories HIGH RISK INFANTS According to size LBW  < 2500g ELBW  < 1000g MLBW  < 1500g SGA Birth weight falls below 10th percentile on intrauterine growth curve LGA  above 90th % According to age Premature Full term Postmature DEVELOPMENTAL THEORIES Psychosexual model (Freud) 1. Oral a. 0-18 months b. Pleasure and gratification through mouth c. Behaviors: Behaviors: dependency, eating, eating, crying, crying, biting d. Distinguishes between self and mother e. Develops body image, aggressive drives Psychosexual model (Freud) 2. Anal a. 18 months - 3 years b. Pleasure through elimination or retention of feces c. Behaviors: Behaviors: control of holding on or letting go d. Develops concept of power, power, punishment, ambivalence, concern with cleanliness or being dirty Psychosexual model (Freud) 3. Phallic/Oedipal a. 3 - 6 years b. Pleasure through genitals

NUTRITION GENERAL INFORMATION Loses 5 to 10% and regain within 10 days

c. Behaviors: Behaviors: touching of genitals, genitals, erotic attachment to parent of opposite sex d. Develops fear of punishment by parent of same sex, sex, guilt, guilt, sexual identity Psychosexual model (Freud) 4. Latency a. 6 - 12 years b. Energy used to gain new skills in social relationships and knowledge c. Behaviors: Behaviors: sense of industry and mastery d. Learns control over aggressive, destructive impulses e Acquires friends Psychosexual model (Freud) 5. Genital a. 12 - 20 years b. Sexual pleasure through genitals c. Behaviors: Behaviors: becomes independent of parents, parents, responsible for self d. Develops sexual identity, ability to love and work Psychosocial Model (Erikson) 1. Trust vs mistrust a. 0 - 18 months b. Significant relations: mother c. Psychosocial virtues: hope, hope, faith d. Maladaptations & malignancies: sensory distortion- withdrawal Psychosocial Model (Erikson) 2. Autonomy vs shame and doubt a. 18 months - 3 years b. Significant relations: parents c. Psychosocial virtues: will, determination d. Maladaptations & malignancies: impulsivity -- compulsion Psychosocial Model (Erikson) 3. Initiative vs guilt a. 3 - 5 years b. Significant relations: family c. Psychosocial virtues: purpose, courage d. Maladaptations & malignancies: ruthlessness -- inhibition Psychosocial Model (Erikson) 4. Industry vs inferiority a. 6 - 12 years b. Significant relations: neighborhood and school c. Psychosocial virtues: competence d. Maladaptations & malignancies: narrow virtuosity -- inertia

Psychosocial Model (Erikson) 5. Identity vs role confusion a. 12 - 20 years b. Significant relations: peer groups, groups, role models c. Psychosocial virtues: fidelity, loyalty d. Maladaptations & malignancies: fanaticism -- repudiation Psychosocial Model (Erikson) 6. Intimacy vs isolation a. 20 - 25 years b. Significant relations: partners, partners, friends c. Psychosocial virtues: love d. Maladaptations & malignancies: promiscuity -- exclusivity Psychosocial Model (Erikson) 7. Generativity vs stagnation a. 25 - 45 years b. Significant relations: household, workmates c. Psychosocial virtues: care d. Maladaptations & malignancies: overextension -- rejectivity Psychosocial Model (Erikson) 8. Integrity vs despair a. 45 years to end of life b. Significant relations: mankind or “my kind” c. Psychosocial virtues: wisdom d. Maladaptations & malignancies: presumption -- despair Interpersonal Model (Sullivan) 1. Infancy a. 0 - 18 months b. Others will satisfy needs 2. Childhood a. 18 months - 6 years b. Learn to delay need gratification 3. Juvenile a. 6 - 9 years b. Learn to relate to peers Interpersonal Model (Sullivan) 4. Preadolescence a. 9-12 years b. Learn to relate to friends of same sex 5. Early adolescence a. 12-14 years

b. Learn independence and how to relate to opposite sex 6. Late adolescence a. 14-21 years b. Develop intimate relationship with person of opposite sex Cognitive Theory (Piaget) A. 0 - 2 years: sensorimotor -reflexes, reflexes, repetition of acts B. 2 - 4 years: preoperational -no cause and effect reasoning; egocentrism; use of symbols; symbols; magical thinking C. 4 - 7 years: intuitive -beginning of causation Cognitive Theory (Piaget) D. 7 - 11 years: concrete operations - uses memory to learn aware of reversibility E. 11 - 15 years: formal operations -reality, abstract thought -can deal with the past, present and future KOHLBERG’S STAGES OF MORAL DEVELOPMENT PRECONVENTIONAL LEVEL Stage 1 Age: 2-3 Description: Punishment or obedience (heteronomous morality) A child does the right things because a parent tells him or her to avoid punishment PRECONVENTIONAL LEVEL Stage 2 Age : 4-7 Description: Individualism, Instrumentalism, and Exchange Child carries out actions to satisfy own needs rather than society’s. The child does something for another if that person does something for him in return

CONVENTIONAL LEVEL level 2 Stage 3 Age : 7-10 Description: "Good boy/girl" Orientation to interpersonal relations of mutuality A child follows rules because of a need to be a good person in own eyes and in the eyes of others CONVENTIONAL LEVEL level 2 Stage 4 Age : 10-12 Description: Law and Order Maintenance of social order, fixed rules and authority Child follows rules of authority figures as well as parents to keep the system working POSTCONVENTIONAL LEVEL level 3 Stage 5 Age :older :older than 12 Description: social contract, contract, utilitarian law making perspective child follows standards of society for the good of all people POSTCONVENTIONAL LEVEL level 3 Stage 6 Age :older :older than 12 Descriptions: Principled Conscience universal ethical principle orientation child follows internalized standards of conduct NEONATAL REFLEXES Reflex: Reflex: Symmetric tonic neck Stimulus: Stimulus: neck flexion, neck extension Response:arm Response:arm flexion, leg extension, arm extension, leg flexion Onset: Onset: birth-1month Suppression: Suppression: 4 mos NEONATAL REFLEXES Reflex: Reflex: positive supporting Stimulus: Stimulus: tactile contact and weight bearing on sole Response:leg Response:leg extension for supporting partial body weight Onset: Onset: 2 months

Suppression: Suppression: 3-7 mos, replaced by volitional standing NEONATAL REFLEXES Reflex: Reflex: rooting Stimulus: Stimulus: stroking the corner of the mouth,upper or lower lip Response:moving Response:moving the tongue, mouth and head towards the site of stimulus Onset: Onset: birth Suppression: Suppression: 4 mos NEONATAL REFLEXES Reflex: Reflex: palmar grasp Stimulus: Stimulus: pressure or touch on the palm, stretch of finger flexors Response:flexion Response:flexion of fingers Onset: Onset: birth Suppression: Suppression: 4-6 mos NEONATAL REFLEXES Reflex: Reflex: Plantar grasp Stimulus: Stimulus: pressure on the sole just distal to the metatarsal heads Response:flexion Response:flexion of toes Onset: Onset: birth Suppression: Suppression: 12-18 mos NEONATAL REFLEXES Reflex: Reflex: Automatic neonatal walking Stimulus: Stimulus: contact of the sole in vertical position tilting the body forward and from side to side Response: Response: automatic alternating steps Onset: Onset: birth Suppression: Suppression: 3-4 mos REFLEXES Blinking or corneal reflex Pupillary reflex Doll’s eye  fixation develops Sneeze reflex Sucking reflex Gag reflex Rooting reflex  3 to 4 months REFLEXES Extrusion reflex  4 months Cough reflex Babinski reflex Moro reflex  3 to 4 months Dance or step reflex  3 to 4 weeks HEARING: NEONATAL SENSES

able to hear in the utero within hrs after birth, hearing in NB becomes acute VISION: focus on black and white objects distance of 9-12 inches pupillary reflex present at birth NEONATAL SENSES TASTE: developed before birth TOUCH: well developed at birth react to painful stimuli SMELL: present as soon as the nose is cleared of mucus ability to respond to odors can be used to document alertness Infant A. Physical tasks 1. Neonate (Birth to 1 month) a. Weight: Weight: 6 - 8 lb (2750 - 3629 g); gains 5 - 7 oz (142 - 198 g) weekly for first 6 months b. Length: Length: 20 inches (50 cm); grows 1 inch (2.5 cm) monthly for first 6 months Infant A. Physical tasks 1. Neonate (Birth to 1 month) c. Head growth 1) head circumference 33 - 35.5 cm (13 - 14 inches) 2) head circumference equal to or slightly larger than chest 3) increases by 1/2 inch (1.25 cm) monthly for first 6 months Infant A. Physical tasks 1. Neonate (Birth to 1 month) d. Vital signs 1) pulse: 110 - 160 and irregular; count for a full minute apically 2) respirations: 32 - 60 and irregular; neonates are abdominal breathers, breathers, obligate nose breathers 3) blood pressure: 75/49 mm Hg Infant A. Physical tasks 1. Neonate (Birth to 1 month)

e. Motor development 1) behavior is reflex controlled 2) flexed extremities Infant A. Physical tasks 1. Neonate (Birth to 1 month) f. Sensory development 1) hearing and touch well developed at birth 2) sight not fully developed until 6 years a) differentiates light and dark at birth b) rapidly develops clarity of vision within 1 foot c) fixates on moving objects d) strabismus due to lack of binocular vision Infant A. Physical tasks 2. 1 - 4 months a. Head growth: growth: posterior fontanel closes b. Motor development 1) reflexes begin to fade (e.g., Moro, tonic neck) 2) gains head control; control; balances head in sitting position 3) rolls from back to side 4) begins voluntary hand-to-mouth activity Infant A. Physical tasks 2. 1 - 4 months c. Sensory development 1) begins to be able to coordinate stimuli from various sense organs 2) hearing: locates sounds by turning head and visually searching 3) vision: follows objects 180° 180° Infant A. Physical tasks 3. 5 - 6 months a. Weight: Weight: birth weight doubles; doubles; gains 35 oz (84-140 g) weekly for next 6 months b. Length: Length: gains 1/2 inch (1.25 cm) for next 6 months Infant A. Physical tasks

3. 5 - 6 months c. Eruption of teeth begins 1) lower incisors first 2) causes increased saliva and drooling 3) enzyme released with teething causes mild diarrhea, diarrhea, facial skin irritation 4) slight fever may be associated with teething, but not a high fever or seizures Infant A. Physical tasks 3. 5 - 6 months d. Motor development 1) supports weight on arms 2) sits with support Infant A. Physical tasks 3. 5 - 6 months e. Sensory development 1) hearing: can localize sounds above and below ear 2) vision: smiles at own mirror image and responds to facial expressions of others 3) taste: sucking needs have decreased and cup weaning can begin; chewing, chewing, biting, biting, and taste preferences begin to develop Infant A. Physical tasks 4. 7 - 9 months a. Teething continues 1) 7 months: upper central incisors 2) 9 months: upper lateral incisors b. Motor development 1) crawls; crawls; may go backwards initially 2) pulls self to standing position 3) develops finger-thumb opposition (pincer grasp) Infant A. Physical tasks 5. 10-12 months a. Weight: Weight: birth weight tripled b. Length: Length: 50% increase over birth length c. Head and chest circumference equal d. Teething 1) lower lateral incisors erupt 2) average of eight deciduous teeth Infant A. Physical tasks

5. 10-12 months e. Motor development 1) walks with help or cruises 2) may attempt to stand alone Infant B. Psychosocial tasks 1. Neonatal period a. Cries to express displeasure b. Smiles indiscriminately c. Receives gratification through sucking d. Makes throaty sounds Infant B. Psychosocial tasks 2. 1 - 4 months a. Crying becomes differentiated at 1 month 1) decreases during awake periods 2) ceases when parent in view b. Vocalization distinct from crying at 1 month 1) coos, coos, babbles, babbles, laughs; laughs; vocalizes when smiling Infant B. Psychosocial tasks 2. 1 - 4 months c. Socialization 1) stares at parents’ parents’ faces when talking at 1 month 2) smiles socially at 2 months 3) shows excitement when happy at 4 months 4) demands attention, enjoys social interaction with people at 4 months Infant B. Psychosocial tasks 3. 5 - 6 months a. Vocalization: begins to imitate sounds b. Socialization: recognizes parents, stranger anxiety begins to develop; comfort habits begin Infant B. Psychosocial tasks 4. 7 - 9 months a. Vocalization: verbalizes all vowels and most consonants b. Socialization 1) shows increased stranger anxiety and anxiety over separation from parent

2) exhibits aggressiveness by biting at times 3) understands the word “no ” “no” Infant B. Psychosocial tasks 5. 10 - 12 months a. Vocalization: imitates animal sounds, can say only 4 - 5 words but understands many more (ma, da) b. Socialization 1) begins to explore surroundings 2) plays games such as pat-a-cake, pat-a-cake, peek-a-boo 3) shows emotions such as jealousy, affection, anger, fear (especially in new situations) Infant C. Cognitive tasks 1. Neonatal period: reflexive behavior only 2. 1 - 4 months a. Recognizes familiar faces b. Is interested in surroundings c. Discovers own body parts Infant C. Cognitive tasks 3. 5 - 6 months a. Begins to imitate b. Can find partially hidden objects 4. 7 - 9 months a. Begins to understand object permanence; permanence; searches for dropped objects b. Reacts to adult anger; cries when scolded c. Imitates simple acts and noises d. Responds to simple commands Infant C. Cognitive tasks 5. 10-12 months a. Recognizes objects by name b. Looks at and follow pictures in book c. Shows more goal-directed actions Infant D. Nutrition 1. Birth to 6 months a. Breast milk is a complete and healthful diet; supplementation may include 0.25 mg fluoride, 400 IU vitamin D, and iron after 4 months. months. b. Commercial iron-fortified formula is acceptable alternative;

supplementation may include 0.25 mg fluoride if water supply is not fluoridated. c. Juices may be introduced at 5-6 months, diluted 1:1 and preferably given by cup. Infant D. Nutrition 2. 6 - 12 months a. Breast milk or formula continues to be primary source of nutrition. b. Introduction of solid foods starts with cereal (usually rice cereal), which is continued until 18 months. Infant D. Nutrition 2. 6 - 12 months c. Introduction of other food is arbitrary; most common sequence is fruits, vegetables, meats. 1) introduce one new food a week. week. 2) decrease amount of formula to about 30 oz. as foods are added. d. Iron supplementation can be stopped. Infant D. Nutrition 2. 6 - 12 months e. Finger foods such as cheese, meat, carrots can be started around 10 months. months. f. Chopped table food or junior food can be introduced by 12 months g. Weaning from breast or bottle to cup should be gradual during second 6 months. months. Infant E. Play (Solitary) 1. Birth to 4 months a. Provide variety of brightly colored objects, different sizes and textures. b. Hang mobiles within 8-10 inches of infant’s face. Infant E. Play (Solitary) 2. 5 - 7 months a. Provide brightly colored toys to hold and squeeze. squeeze. b. Allow infant to splash in bath. c. Provide crib mirror. 3. 8 - 12 months

a. Provide toys with movable parts and noisemakers; noisemakers; stack toys, blocks; pots, pans, drums to bang on; walker and push-pull toys. toys. b. Plays games: hide and seek, seek, pat-acake. cake. Infant F. Fears 1. Separation from parents a. Searches for parents with eyes. b. Shows preference for parents. c. Develops stranger anxiety around 6 months (peaks at 8 months). 2. Pain Toddler (12 months to 3 years) A. Physical tasks: this is a period of slow growth 1. Weight: Weight: gain of approximately 11 lb (5 kg) during this time; birth weight quadrupled by 2 1/2 years 2. Height: Height: grows 20.3 cm (8 inches); 3. Head circumference: circumference: 19½ - 20 inches (49 - 50 cm) by 2 years; anterior fontanel closes by 18 months Toddler (12 months to 3 years) A. Physical tasks: this is a period of slow growth 4. Pulse 110; respirations 26; blood pressure 99/64 5. Primary dentition (20 (20 teeth) teeth) completed by 2 1/2 years 6. Develops sphincter control necessary for bowel and bladder control Toddler (12 months to 3 years) B. Psychosocial tasks 1. Increases independence; independence; better able to tolerate separation from primary caregiver. 2. Less likely to fear strangers. strangers. 3. Able to help with dressing/undressing at 18 months; dresses self at 24 months. months. 4. Has sustained attention span. 5. May have temper tantrums during this period; should decrease by 2 1/2 years. 6. Vocabulary increases from about 10 - 20 words to over 900 words by 3 years. Toddler (12 months to 3 years) B. Psychosocial tasks

7. Has beginning awareness of ownership (my, mine) at 18 months; shows proper use of pronouns (I, me, you) by 3 years. 8. Moves from hoarding and possessiveness at 18 months to sharing with peers by 3 years. 9. Toilet training usually completed by 3 years. a. 18 months: bowel control b. 2 - 3 years: daytime bladder control c. 3 - 4 years: nighttime bladder control

E. Play 1. Predominantly- “parallel “parallel play” play” period. 2. Provide toys appropriate for increased locomotive skills: push toys, toys, rocking horse, horse, riding toys or tricycles; tricycles; swings and slide. 3. Give toys to provide outlet for aggressive feelings: feelings: work bench, toy hammer and nails, drums, pots, pans. 4. Provide toys to help develop fine motor skills, skills, problem-solving abilities: puzzles, puzzles, blocks; blocks; finger paints, crayons. crayons. Toddler (12 months to 3 years) G. Fears: separation anxiety 1. Learning to tolerate and master brief periods of separation is important developmental task. 2. Increasing understanding of object permanence helps toddler overcome this fear. Toddler (12 months to 3 years) G. Fears: separation anxiety 3. Potential patterns of response to separation a. Protest: Protest: screams and cries when mother leaves; attempts to call her back. b. Despair: Despair: whimpers, clutches transitional object, curls up in bed, decreased activity, rocking. c. Denial: Denial: resumes normal activity but does not form psychosocial relationships; when mother returns, child ignores her Preschooler (3 to 5 years) A. Physical tasks 1. Slower growth rate continues a. Weight: increases 4 - 6 lb (1.8 - 2.7 kg) a year b. Height: increases 2 1/2 inches (5-6.25 cm) a year c. Birth length doubled by 4 years 2. Vital signs decrease slightly a. Pulse: 90-100 b. Respirations: 24-25/minute c. Blood pressure: systolic 85-100 mm Hg diastolic 6090 mm Hg Preschooler (3 to 5 years) A. Physical tasks

Toddler (12 months to 3 years) C. Cognitive tasks 1. Follows simple directions by 2 years. 2. Begins to use short sentences at 18 months to 2 years. 3. Can remember and repeat 3 numbers by 3 years. 4. Knows own name by 12 months; refers to self, gives first name by 24 months; gives full name by 3 years. 5. Able to identify geometric forms by 18 months. Toddler (12 months to 3 years) C. Cognitive tasks 6. Achieves object permanence; permanence; is aware that objects exist even if not in view. 7. Uses “magical” “magical” thinking; thinking; believes own feelings affect events (e.g., anger causes rain). 8. Uses ritualistic behavior; behavior; repeats skills to master them and to decrease anxiety. 9. May develop dependency on “transitional object” such as blanket or stuffed animal. Toddler (12 months to 3 years) D. Nutrition 1. Caloric requirement is approximately 100 calories/kg/day. 2. Increased need for calcium, iron, and phosphorus. 3. Needs 16 - 24 oz milk/day. 4. Appetite decreases. 5. Able to feed self. 6. Negativism may interfere with eating. 7. Initial dental examination at 3 years. Toddler (12 months to 3 years)

3. Permanent teeth may appear late in preschool period; first permanent teeth are molars, molars, behind last temporary teeth. 4. Gross motor development a. Walks up stairs using alternate feet by 3 years. b. Walks down stairs using alternate feet by 4 years. c. Rides tricycle by 3 years. d. Stands on 1 foot by 3 years.

1. Focuses on one idea at a time; time; cannot look at entire perspective. 2. Awareness of racial and sexual differences begins. a. Prejudice may develop based on values of parents. b. Manifests sexual curiosity. curiosity. c. Sexual education begins. d. Beginning body awareness. awareness. Preschooler (3 to 5 years) C. Cognitive development 3. Has beginning concept of causality. 4. Understanding of time develops during this period. a. Learns sequence of daily events. events. b. Is able to understand meaning of some time-oriented words (day of week, month, etc.) by 5 years. 5. Has 2000-word vocabulary by 5 years. 6. Can name 4 or more colors by 5 years. 7. Is very inquisitive (why?, why? why?). why?). Preschooler (3 to 5 years) D. Nutrition 1. Caloric requirement is approximately 90 calories/kg/day. 2. May demonstrate strong taste preferences. preferences. 3. More likely to taste new foods if child can assist in the preparation. Preschooler (3 to 5 years) F. Play 1.Predominantly associative play 2. Enjoys imitative and dramatic play. play. a. Imitates same-sex role functions in play. b. Enjoys dressing up, dollhouses, trucks, cars, telephones, doctor and nurse kits. 3. Provide toys to help develop gross motor skills: tricycles, tricycles, wagons, wagons, outdoor gym; gym; sandbox, wading pool. Preschooler (3 to 5 years) F. Play 4. Provide toys to encourage fine motor skills, skills, self-expression, and cognitive development: construction sets, blocks, carpentry tools; flash cards, illustrated books, puzzles; puzzles; paints, paints, crayons, crayons, clay, clay, simple sewing sets.

Preschooler (3 to 5 years) A. Physical tasks 4. Gross motor development e. Hops on 1 foot by 4 years. f. Skips and hops on alternate feet by 5 years. g. Balances on 1 foot with eyes closed by 5 years. h. Throws and catches ball by 5 years. i. Jumps off 1 step by 3 years. j. Jumps rope by 5 years. Preschooler (3 to 5 years) A. Physical tasks 5. Fine motor development a. Hand dominance is established by 5 years. b. Builds a tower of blocks by 3 years. c. Ties shoes by 5 years. d. Ability to draw changes over this time 1) copies circles, circles, may add facial features by 3 years. 2) copies a square, square, traces a diamond by 4 years. Preschooler (3 to 5 years) B. Psychosocial tasks 1. Becomes independent a. Feeds self completely. b. Dresses self. c. Takes increased responsibility for actions. 2. Aggressiveness and impatience peak at 4 years then abate. 3. Gender-specific behavior is evident by 5 years. years. 4. Egocentricity changes to awareness of others; rules become important; important; understands sharing. Preschooler (3 to 5 years) C. Cognitive development

5. Television, Television, when supervised, can provide a quiet activity; some programs have educational content. Preschooler (3 to 5 years) G. Fears 1. Greatest number of imagined and real fears of childhood during this period. 2. Fears concerning body integrity are common. a. Magical and animistic thinking allows children to develop many illogical fears (fear of inanimate objects, objects, the dark, dark, ghosts). ghosts). School-age (6 to 12 years) A. Physical tasks 1. Slow growth continues. a. Height: 2 inches (5 cm) per year b. Weight: doubles over this period c. At age 9, 9, both sexes same size; size; age 12, 12, girls bigger than boys 2. Dentition a. Loses first primary teeth at about 6 years. b. By 12 years, has all permanent teeth except final molars. School-age (6 to 12 years) A. Physical tasks 3. Bone growth faster than muscle and ligament development; very limber but susceptible to bone fractures during this time. 4. Vision is completely mature; mature; hand-eye coordination develops completely. 5. Gross motor skills: predominantly involving large muscles; children are very energetic, energetic, develop greater strength, strength, coordination, and stamina. 6. Develops smoothness and speed in fine motor control. School-age (6 to 12 years) B. Psychosocial tasks 1. School occupies half of waking hours; hours; has cognitive and social impact. a. Readiness includes emotional (attention span), physical (hearing and vision), and intellectual components. b. Teacher may be parent substitute, substitute, causing parents to lose some authority.

School-age (6 to 12 years) B. Psychosocial tasks 2. Morality develops a. Before age 9 moral realism predominates: strict superego, superego, rule dominance; things are black or white, right or wrong. wrong. b. After age 9 autonomous morality develops: recognizes differing points of view, sees “gray” areas.

School-age (6 to 12 years) B. Psychosocial tasks 3. Peer relationships a. Child makes first real friends during this period. b. Is able to understand concepts of cooperation and compromise (assist in acquiring attitudes and values); learns fair play vs competition. competition. c. Help child develop self-concept. d. Provide feeling of belonging. School-age (6 to 12 years) B. Psychosocial tasks 4. Enjoys family activities. 5. Has some ability to evaluate own strengths and weaknesses. 6. Has increased self-direction. self-direction. 7. Is aware of own body; compares self to others; others; modesty develops. School-age (6 to 12 years) C. Cognitive development 1. Period of industry a. Is interested in exploration and adventure. adventure. b. Likes to accomplish or produce. produce. c. Develops confidence. School-age (6 to 12 years) C. Cognitive development 2. Concept of time and space develops. a. Understands causality. b. Masters concept of conservation: permanence of mass and volume; concept of reversibility. reversibility. c. Develops classification skills: understands relational terms; may collect things.

d. Masters arithmetic and reading. School-age (6 to 12 years) D. Nutrition 1. Caloric needs diminish in relation to body size: 85 kcal/kg. 2. “Junk” “Junk” food may become a problem; excess sugar, starches, fat. 3. Obesity is a risk in this age group. 4. Nutrition education should be integrated into school program.

e. Apocrine glands cause increased body odor. odor. f. Increased production of sebum and plugging of sebaceous ducts causes acne. acne. Adolescent (12 to 19 years) A. Physical tasks 4. Sexual development: girls c. Development of secondary sex characteristics and sexual functioning under hormonal control d. Breast development is first sign of puberty. 1) bud stage: areola around nipple is protuberant. 2) breast development is complete around the time of first menses. Adolescent (12 to 19 years) A. Physical tasks 5. Sexual development: boys a. Development of secondary sex characteristics, characteristics, sex organs and function under hormonal control. b. Enlargement of testes is first sign of sexual maturation; occurs at approximately age 13, about 1 year before growth spurt. c. Scrotum and penis increase in size until age 18. d. Reaches reproductive maturity about age 17, with viable sperm. Adolescent (12 to 19 years) A. Physical tasks 5. Sexual development: boys e. Nocturnal emission: emission: a physiologic reflex to ejaculate buildup of semen; natural and normal; occurs during sleep (child should not be made to feel guilty; needs to understand that this is not enuresis). f. Masturbation increases (also a normal way to release semen). g. Pubic hair continues to grow and spread until mid 20s. h. Facial hair; hair; appears first on upper lip. Adolescent (12 to 19 years) A. Physical tasks 5. Sexual development: boys i. Voice changes due to growth of laryngeal, cartilage.

School-age (6 to 12 years) E. Play 1. Rules and ritual dominate play; individuality not tolerated by peers; knowing rules provides sense of belonging; “cooperative “cooperative play.” play.” 2. Team play: games or sports a. Help learn value of individual skills and team accomplishments. b. Help learn nature of competition. competition. 3. Quiet games and activities: board games, collections, books, television, painting 4. Athletic activities: swimming, hiking, bicycling, skating School-age (6 to 12 years) G. Fears: more realistic fears than younger children; include death, death, disease or bodily injury, injury, punishment; punishment; school phobia may develop, resulting in psychosomatic illness. Adolescent (12 to 19 years) A. Physical tasks a. Girls: Girls: height increases approximately 3 inches/year; slows at menarche; stops around age 16. b. Boys: Boys: growth spurt starts around age 13; height increases 4 inches/year; slows in late teens. c. Boys double weight between 12 and 18, related to increased muscle mass. Adolescent (12 to 19 years) A. Physical tasks d. Body shape changes 1) boys become leaner with broader chest. 2) girls have fat deposited in thighs, hips, and breasts; pelvis broadens.

j. Gynecomastia: Gynecomastia: slight hypertrophy of breasts due to estrogen production; will pass within months but causes embarrassment. Adolescent (12 to 19 years) B. Psychosocial tasks 1. Early adolescence: adolescence: ages 12-14 years a. Starts with puberty. b. Physical body changes result in an altered self-concept. c. Tends to compare own body to others. d. Early and late developers have anxiety regarding fear of rejection. e. Fantasy life, daydreams, daydreams, crushes are all normal, help in role play of varying social situations. f. Is prone to mood swings. swings. g. Needs limits and consistent discipline. Adolescent (12 to 19 years) B. Psychosocial tasks 2. Middle adolescence: adolescence: ages 15-16 years a. Is separate from parents (except financially). b. Can identify own values. c. Can define self (self-concept, strengths and weaknesses). d. Partakes in peer group; conforms to values/fads. e. Has increased heterosexual interest; interest; communicates with opposite sex; may form “love” relationship. Adolescent (12 to 19 years) B. Psychosocial tasks 3. Late adolescence: adolescence: ages, 17-19 years a. Achieves greater independence. independence. b. Chooses a vocation. vocation. c. Participates in society. d. Finds an identity. e. Finds a mate. mate. f. Develops own morality. g. Completes physical and emotional maturity. Adolescent (12 to 19 years) C. Cognitive development 1. Develops abstract thinking abilities. 2. Is often unrealistic. 3. Is capable of scientific reasoning and formal logic. logic. 4. Enjoys intellectual abilities.

5. Is able to view problems comprehensively. Adolescent (12 to 19 years) D. Nutrition 1. Nutritional requirements peak during years of maximum growth: age 10-12 in girls, 2 years later in boys 2. Appetite increases. increases. 3. Inadequate diet can retard growth and delay sexual maturation. 4. Food intake needs to be balanced with energy expenditure. 5. Increased needs include calcium for skeletal growth; iron for increased muscle mass and blood cell development; zinc for development of skeletal and muscle tissue and sexual maturation. Adolescent (12 to 19 years) F. Activities: group activities predominate (sports are important); activities involving opposite sex by middle adolescence. G. Fears 1. Threats to body image: image: acne, obesity 2. Injury or death 3. The unknown Child’s Response to Death 1. toddlers - may insist on seeing a significant other long after that person’s death. 2. Preschoolers - See death as temporary; temporary; a type of sleep or separation. 3. School-age – See death as a period of immobility. - Feel death is punishment. punishment. 4. Adolescents - Have an accurate understanding of death. BREAST FEEDING ADVANTAGE Readily available Economical Promotes facial muscles, jaw and teeth Mother infant bonding Reduced incidence of allergies Reduced incidence of maternal breast cancer Transfer of maternal antibodies Ig A Lactoferrin Lysozyme

Leukocytes Macrophages DISADVANTAGE Prevents other from feeding the infant Limits paternal role in feeding Compels the mother to monitor her diet carefully Maybe difficult to a working mother Digest quickly  more feeding ADEQUATE ??? Wets 6 to 8 diapers a day Gaining weight BOTTLE FEEDING ADVANTAGE Permits the father to feed Mother  medications Fewer feedings Feeding  public  embarrassment DISADVANTAGE Cost Greater preparation and effort Hands  clean Requires refrigeration and storage No transfer of maternal antibodies Doesn’t benefit mother physiologically IMMUNIZATION BCG Infants .05 ml Intradermal Right deltoid School Entrants .1ml Intradermal Left deltoid DPT 6, 10 and 14 weeks .5ml Intramuscular Upper outer portion of the thigh IMMUNIZATION Hepatitis 6, 10, and 14 weeks .5ml Intramuscular Upper outer portion of the thigh OPV 6, 10 and 14 weeks 2 drops Mouth

IMMUNIZATION Measles 9 months .5ml Subcutaneous Left outer part of the upper arm Vitamin A Contraindication: Fever Compromise Immune system Seizure disorder must be controlled Never give gluteal INFANCY (0 to 1 yr) I – ron supplement (4 to 6 months), immunization N – o choking hazard F – ear of stranger peaks at 8 months A – llow to use a pacifier if NPO N – ote the weight changes T – rust V.S. mistrust S – olitary play TODDLER (1 to 3yr) T – alk to the child at simple terms O – ffer choices to the child to provide some control D – on’t leave alone near the bathtub or swimming pool D – oubt and shame V.S. Autonomy L – earns about death @ age 3 E – limination pattern R – rituals and routines TODDLER P – ush-pull toys (mobile), parallel play (forget sharing) R – rituals and routines (eyes and consistency), regression A – utnomy VS shame and doubt, accidents (death) I – nvolve parents S – eparation anxiety E – limination and explore COMMON ACCIDENTS P – revent further absorption O – ff, shower or wash off I - dentify S - upport O – ngoing safety education N – otify local poison control center PRESCHOOL (3 to 6 yr) P – lay is associative/cooperative

R – gression is common E – xplain procedures S – ame age group for room assignment C - urious H – ighly imaginative O – bserve for initiative VS guilt O – ff limits to the kitchen (risk for poisoning and burn) L – oss of body part is a common fear PRESCHOOL M - utilation A – associate play, abandonment G - uilt I – nitiative, imaginary playmate, imagination C – urious  “Y” SCHOOL AGE ( 6 to 12 yr) S – ame sex stage C – ompetitive play H – eroworship O – bserve for industry VS inferiority O – ff limits to vehicles L – oss of control is a common fear E – xplain procedurse R – egression is common SCHOOL AGE D – eath (bogeyman), honesty  funerals and burials I – ndustry VS inferiority (collections) M – odesty (privacy) P – eers (own sex) L – oss of control  hospitalization, encourage decision making E - xplaination of procedures ADOLESCENT (12 to 18 yr) P – eer group  activities, peer pressure A – ltered body image  don’t want to be seen different I – dentity – image  college or career R – ole diffusion S – eparation from peers SAMPLE QUESTIONS Two month old Kristin is brought to the health clinic for his first immunization against DPT. What route should the nurse use to administer the vaccine? Oral Intramuscular Intradermal

Subcutaneous The nurse should teach Kristin’s mother about the normal reaction an infant can experience approximately 12 to 24 hours after DPT. One of these reactions could be: Lethargy Mild fever Diarrhea Nasal congestion Mrs. Ortega brings her 4-month-old child Paula, to the clinic. She says, “The soft spot near the front of the Paula’s head is still big. When will it close?” The nurse’s response should be guided by knowledge that most often the anterior fontanel closes when the infant’s age is between about? 2 to 4 months 4 to 8 months 8 to 12 months 12 to 18 months Mrs. Ortigas brings her 4-month-old infant, Timmy, to the clinic. He appears well. Mrs. Ortigas asks the nurse when she should wean Timmy from breast-feeding and have him use a cup. The nurse should explain that Timmy will show readiness to be weaned when he is: Taking solid foods well Sleeping through the night Shortening his nursing time Eating on a regular schedule In counseling a teenage mother on the firstsolid food to introduce to her 5-month-old child, least allergenic foods are given. Which of the following should be recommended in the usual order in introducing solid foods? Eggs Pureed chicken Bananas Rice cereal A nurse is observing all of the following babies in the clinic. Which baby may be experiencing a developmental delay? A 1-month-old who does not coo A 3-month-old who does not crawl

An 8-month-old who does not walk A 10-month-old who does not sit A first-time mother is concerned that her 6month-old infant is not gaining enough weight. The best response for the nurse to make is which of the following? “Birth weight doubles by 6 months of age.’ “Birth weight doubles by 3 months of age.” “The baby will eat what he needs.” “You need to make sure the baby finishes each bottle.” The nurse discusses Lucy’s motor skill development with her mother. The nurse explains to Lucy’s mother that at about 7 months of age, Lucy will most likely to be able to Walk with support Feed herself with a spoon Stand holding onto furniture Sit alone using her hand with support A mother of an infant asks the nurse when she can expect her baby to sit up. The nurse informs the mother that an infant can generally sit up without support at: 4 months 6 months 8 months 10 months A mother of a 10-month-old baby asks a clinic nurse about appropriate and safe toys for the baby. The nurse tells the mother that the most appropriate toys for a 10-month-old is which of the following? cradle gym Teddy bears Low rocking horses Blocks Which is the best way to deal with a toddler who is having a temper tantrum? Reason with the child Threaten the child Spank the child Ignore the child’s outburst The nurse observes a group of 2-year-old children at play in the beach. The nurse would expect to see: Four children playing soft ball Three children playing tag

Two children playing sandbox building castles side by side One child digging a hole When assessing a 2-year-old child brought by his mother to the clinic for a routine check-up. The nurse would expect the child is able to do which of the following? Ride a tricycle Tie his shoelaces Kick a ball forward Use blunt scissors Mrs. Sara tells the nurse that her 4-year-old son, Charles does not seem to know the difference between right and wrong. She explains that he knows he should not push other children, but the only reason for not pushing them is that he avoids trouble. Mrs. Sara is describing typical behavior of a child who has reached with level of moral development as described by Kohlberg? Autonomous Conventional Preconventional Principles A mother brings her 5-year-old son to the pediatrician’s office for a complete health appraisal before he enters kindergarten next moth. The nurse should focus part of the assessment on the child’s achievement of psychosocial tasks. At this age, he should be trying to accomplish a sense of Autonomy Identity Mastery Initiative The mother of a 10-year-old student is concerned about her daughter’s compulsion for collecting things. The nurse explains that this behavior is related to the cognitive ability to perform: Concrete operations Formal operations Coordination of secondary schemas Tertiary circular reactions