s.

Musculoskeletal – muscle size, strength, posture, body

Growth and Develiopment alignment, symmetry, ROM, gait, joint mvmt, swelling,
Dr Daphne Miranda redness, tenderness
PEDIATRIC NURSING HEALTH ASSESSMENT t. Neurologic – cerebral function, cranial nerve function,
DTR’s, balance and coordination
General considerations
1. Child DEFINITION
- maintain eye contact, bend to child’s level Growth
- Use appropriate language - size, cm, kg
- Allow child some warm up time Development
- Respect child’s response, need for privacy - skill
- Incorporate play - complexity of function
2. Family Considerations
- encourage parents participation IMPORTANCE OF KNOWLEDGE OF GROWTH AND
- choose quiet environment for teaching and assessment DEVELOPMENT
- ask open ended questions 1. Health promotion and Illness prevention
- Focus on information needed or problem 2. Health restoration and maintenance
- Listen attentively, respect response, provide feedback
- encourage questions STAGES OF GROWTH and DEVELOPMENT
Health History A. 1st
Biographical data Prenatal – conception – birth
Chief complaint B. 2nd
Current or health status Neonate - birth - 28 days
Past health Infant - 1 month - 1 yo
Review of systems C. 3rd
Family history Toddler - 1 - 3 yo 1-6 yo (early childhood)
Nutritional history Preschool - 3 - 6 yo
Psychosocial history – home and family structure, school and D. 4th
work, activity and discipline assessment, sexual and School age - 6 - 12 yo (middle childhood)
substance abuse assessment of adolescents Adolescence - 13 - 18 yo
Age related interview techniques
Infant: speak softly, allow infant to identify you w/ a parent, PRINCIPLES OF GROWTH and DEVELOPMENT
use touch 1. Continuous
Toddler: allow toddler to stay close to parent, focus on 2. Orderly and sequential
favorite toy or unique characteristics of child 3. Highly individualized
Preschooler: use simple questions and words, 4. Different rates
allow child to manipulate equipment, use puppets 5.Cephalocaudal
and play 6. Proximodistal
School age: offer explanations, teach about health, provide 7. Simple to complex
demonstrations Adolescents: maintain confidentiality, 8. Sensitive periods
facilitate trust, open and honest communication, 9. Practice
nonjudgmental
Physical Assessment FACTORS THAT AFFECT GROWTH and DEVELOPMENT
- Complete less threatening and less intrusive procedure first
to secure child’s trust Explain actions, what child should I. Genetics
expect and let child manipulate equipment a. Gender
Developmental Approaches b. Health
a. Infant: allow infant to sit on parent’s lap, encourage c. Intelligence
parents to hold infant, use distraction, enlist parent’s help d. Temperament
b. Toddler: allow toddler to sit on parent’s lap, enlist parent’s
assistance, use play, praise cooperation Types of temperament
c. Preschooler: use storytelling, doll, and puppet Easy children – even tempered, regular and predictable;
d. School age: maintain privacy, explain procedure and react to stimuli positively
teach child about body Difficult children – irritable, highly active and intense; react w/
e. Adolescent: provide privacy and confidentiality, provide negative withdrawal
options Slow to warm up – moody, inactive and moderately irregular;
Head to toe assessment react w/ mild but passive resistance
a. Measurements
- height and weight, head circumference < 2 yo Nursing Management
b. General Appearance – alertness, LOC, physical Understand variations
appearance, nutritional state, hygiene, behavior, Provide parents information
interaction w/ parent and nurse, overall development Provide health education esp for families of children w/
c. Skin – color, texture, turgor, temperature, lesions, scars, illness
edema, tatoos Assess development
d. Hair – distribution, characteristics, lice
e. Nails – texture, shape, color, condition FACTORS THAT INFLUENCE GROWTH AND
f. Lymph nodes – swelling. Mobility, temperature, DEVELOPMENT
tenderness II. Environment
g. Head – size, shape, symmetry, fontanelles a. Socioeconomic level
h. Eyes – visual acuity b. Parent-Child Relationship
i. Ears – hearing acuity c. Ordinal position in the family
j. Nose and sinuses – discharge, tenderness d. Health
k. Mouth – tooth eruption, condition of hums, lips, teeth,
palates, tonsils, tongue, buccal mucosa THEORIES OF GROWTH AND DEVELOPMENT
l. Neck – suppleness and range of motion Developmental task
m. Chest – shape, breasts, discharge, lesions
n. Lungs – breath sounds - skill or growth responsibility arising at a particular time
o. Heart – sounds, murmurs, rubs in an individual’s life
p. Abdomen – umbilicus, sape, bowel sounds, hernias, liver, - foundation of accomplishment of future tasks
spleen, kidneys, masses/tenderness
q. Genitalia Erickson’s Theory of Psychosocial Development
female – stage of sexual devt, vulva, meatus, ext Trust vs Mistrust -infant
genitalia, discharge, lesions T: safe environment; dependable people
male – sexual devt stage, penis, scrotum, testes, urinary M: suspicious, fearful, shun emotional involvement
meatus, discharge, lesions NI: provide primary caregiver and visual stimulation
r. Anus – fissures, bleeding
Autonomy vs Shame and Doubt – toddler Postconventional (level III)
A: build on new motor and mental abilities, take pride in Stage 5 & 6 - >12
accomplishments following standards for everyone’s good
S: doubt and stop trying
NI: provide opportunities for decision making and give “Social Contract”
praises “Principled conscience”
Initiative vs Guilt – preschool
I: how to do things Harry Sullivan
G: limited brainstorming and problem-solving skills Prototaxic mode – infancy – need for bodily contact and
NI: provide opportunities for exploration, answer questions love; anxiety d/t unmet needs
and do not inhibit fantasy Parataxic mode – 2-5 yo - parents viewed as source of
Industry vs Inferiority - school age praise and acceptance
Ind: how to do things well Syntaxic mode – 5-8 yo - logical, rational and most mature
Inf: always worried about poor or incorrect performance type of cognitive functioning; need for peers and how to deal
NI: provide opportunities for completing short projects, give w/ them
praise and rewards
Identity vs Role Confusion – adolescent DEVELOPMENTAL AGE PERIODS
I: integrate image into a whole
R: unsure of who they are or who they can become, may Characteristics
rebel Growth and Development Milestones
NI: provide opportunities to discuss feelings and support and Reaction to Illness
praise for decision-making
INFANCY – 0-1 yo
Freud’s Psychoanalytic Theory 4-6 mos -2x birthweight
Oral – infant - 1ST 6 mos – 2 lb/mo; 2nd - 6 mos – 1 lb/mo
- oral stimulation for nutrition, enjoyment and release of 1 yo - 3x birthweight
tension HC=CC 6-12 mos
NI: provide oral stimulation – pacifiers, breastfeeding, 50% inc in height;
thumbsucking - 1st 6 mos – trunk; 1 in
Anal - toddler - 2nd 6 mos – legs
- elimination is a way of discovery and exerting 2/3 brain growth
independence HR 100-120 bpm
NI: achieve bowel and bladder control even if RR 20-30
hospitalized 12-18 mos - Ant fontanel
Phallic – preschool · 2 mos - Post fontanel
- increased knowledge of 2 sexes - Immune system
NI: accept sexual interest and answer questions about birth · 4 mos - Liquids to solids
or sexual difference · 6 mos - Shivering
Latent - school age - Tooth eruption
- libido diverted to school · ECF 35%, ICF 40%
NI: achieve positive experiences to promote self esteem Health visits – 2 weeks, 2 mos, 4 mos, 6 mos, 12 mos
Genital - Adolescent
- establish sexual aims and finding new love objects
NI: opportunities to relate w/ opposite sex; verbalization
about new feelings
GROWTH AND DEVELOPMENTAL MILESTONES
Piaget’s Theory of Cognitive development GROSS MOTOR
2 mos - 45 deg head ctrl
Sensorimotor 1 mon-24 mo 3 mos - 90 deg head ctrl
- relate through senses, separate from environment, 4 mos - lifts head & chest on prone
practical intelligence - rolls over
Preoperational Thought 2-7 yo 5 mos - 6 mos - good head ctrl
toddler: symbolic thought, simple abstractions, literal - sits w/ support
thinking, poor concept of time and distance, transductive 8 mos - sits w/o support
reasoning 9 mos - pulls self to stand
pre-schooler: centering, egocentric, no reversibility, no - creeps
cause and effect, assimilation, role fantasy 10-11 mos – cruises
Concrete Operational Thought 7-12 yo 12 mos – stands alone; walks with someone’s hands
- systematic reasoning
- memory to learn broad concepts and subgroups FINE MOTOR
- seriation and classification 1 mo - eyes to midline
- reversibility 3 mos – eyes past midline
- inductive reasoning (specific to general) 4 mos –bring hands together
- conservation (7 yo – numbers; 7-8 yo quantity; 9 yo – 5 mos – grasps/reaches obj
weight; 11 yo – volume) 6 mos – holds obj in 2 hands
Formal Operational Thought 12 yo 7 mos - hand to hand transfer
- solve hypothetical problems, causality, time 9-10 mos - pincer grasp
- talk time to sort attitudes and opinions - points at obj
11 mos - bangs objects together
12 mos - throws toys
- attempts 2 tower blocks
Kohlberg’s Theory of Moral Development LANGUAGE
Preconventional (Level I) 1 mo - throaty gurgling sound
Stage 1 - 2-3 yo 2 mos - differentiate a cry
“mother or father says so” 3 mos - squeals
punishment obedience orientation 4 mos - coos and gurgles
Stage 2 - 4-7 yo - moves head to sound
“mother says it’s wrong” 5 mos - simple vowel sounds
individualism/egocentrism 7-8 mos - “ma” when crying
Conventional (Level II) 9 mos - mama, dada; understands no-no
Stage 3 – 7-10 yo 10 mos - understands gestures
“nice girl, nice boy” - responds to name
12 mos - obeys commands
Stage 4 – 10-12 yo - one word other than mama, dada
following rules is satisfying PERSONAL SOCIAL
“Law and Order”
2 mos - social smile Separation anxiety
4 mos - plays with rattle; enjoys social interaction Disruption of routine
7 mos - feeds self w/ crackers NURSING CARE
- recognizes familiar faces Soothing stimulation
8 mos - peek-a-boo Toys from home
- stranger anxiety Human contact
9 mos – waves bye bye Provide/Anticipate needs
10 mos – nursery games
11 mos – holds arm or foot out in dressing TODDLER – 1 –3 yo
12 mos – attempts to use spoon; shows jealousy and TODDLER – holding on, letting go
affection Slowed growth
PLAY – solitary play Wt gain 5-6 lbs (2.5 kg)
1-3 mos BW quadruples 2.5 yo
Balloon mobiles 5 in (12 cm)
Mirror play Baby fat disappears
Stuffed animals brain 90 % adult size
rattles CC > HC; inc by 2 cm
Being held HR 90 bpm
4-6 mos BP 99/64
Squeeze toys TODDLER
Busy boxes Protruberant abdomen
Play gyms bowlegged
7-9 mos Stomach capacity increases
Block play Control of urinary and anal sphincters
Splashing bath toys IgG and IgM
Cloth textured toys 20 deciduous teeth
Large balls
10-12 mos GROWTH AND DEVELOPMENTAL MILESTONES
Picture books Gross
Large blocks 15 mos – walks alone well
Nesting cups 18 mos – run and jump in place
PLAY - walk up & down stairs holding on to railing
Peek-a-boo - seat self in chair
Rocking 24 mos – walks up & down stairs one step at a time
Singing games 2 ½ yo – tiptoes, jumps
Squeaky toys 3 yo - throws balls, rides tricycles
Pat-a-cake - stands on 1 foot momentarily
Peek-a-boo Fine motor
Feet & toes games 15 mos - 2 tower blocks, scribbles
Fingers & hand games 18 mos – 3-4 tower blocks
Listening to stories 24 mos – vertical stroke
Making faces 30 months – 8 tower blocks
NUTRITION LANGUAGE
Lipase – dec until 1 yr 15 mos - vocalizes wants
Amylase – dec until 3 mos - jargon
Immature liver – inefficient storage and formation of nutrients - 3 words other than dada, mama
Extrusion reflex – until 4 mos 18 mos - uses phrases
Calories: 100-115 kcal/kg/day 2 yo - short sentences; 2-3 words; 300 words
0-3 mos - breastmilk - pronouns
4-6 mos - semi-solid food - points to one body part
Introduce one at a time 2 ½ - full name
Start with small quantities 3 yo - speaks fluently using longer sentences
Cereals, strained vegetables, meat - tells stories
7-9 mos - Finger food, fluids - plurals
10-12 mos – 3 meals w/ snacks PERSONAL/SOCIAL
Water – 125-150 ml/k/day from 0-6 mos 15 mos - pats pictures
- 135 ml/kg/day from 6-12 mos - imitates housework
DAILY CARE 18 mos - turns page 2-3 at a time
- bathing - uses spoon
- diaper care 2 yo - removes garments
- care of teeth - toilet trained by day (2-3 yrs old)
- dressing 3 yo - dry by night (3-4 yrs old)
- sleep – 10-12 hrs/day; 1 or more naps by 12 mos old - washes and dries hands
- exercise NUTRITION
Concerns Decrease in appetite/ Physiologic anorexia
- Constipation picky eaters, food jags
- Teething – cleanliness Milk – 1L/day
- thumb sucking – until school age 1, 300 kcal/day
- pacifiers – wean after 3 mos Single food instead of mixtures
- head banging – begin 2nd half of infancy to Allow self feeding
preschool, naptime, under 15 min Allow choice between 2 types of food
- sleep problems – breastfed infants wake up Offer finger food
sooner; Risk of aspiration
- spitting up PLAY - parallel play
- diaper dermatitis - imitation
- miliaria/prickly heat – papular, erythematous on neck, Babbling and talking
ear, face, trunk Ball games
- baby bottle syndrome Clay
- Loose stools – breastfed Listening to music
- Colic – paroxysmal abdominal pain, < 3 mos, inc in formula Listening to stories
fed Large blocks
- Obesity – 32 oz formula daily, add fiber and water to diet Making music and noise
- Stranger anxiety Push and Pull toys
REACTION TO ILLNESS Puppet play
Discomfort and pain Scribbling
Lack of stimulation Stack-and-dump toys
DAILY CARE 4 yo - exaggerates and boasts
- dressing – can put on socks, underpants, undershirt - 1, 500 words
- sleep – 8-12 hours sleep w/ 1 nap - why questions
- bathing 5 yo- talks constantly
- care of teeth - 2, 100 words
CONCERNS PERSONAL/SOCIAL
Toilet Training 3 ½ yo - dresses w/ supervision
bowel control – 18 mos - separates more easily from mother
daytime bladder ctrl – 2-3 yo yo – buttons up
nighttime bladder ctrl – 3-4 yo 4 ½ - dresses w/o supervision
CONDITIONS: 5 yo – uses a knife, spoon fork; focus on social aspects
1. control of sphincters of eating
2. cognitive understanding NUTRITION
3. delay immediate gratification Slow/Steady growth
4. mature nervous system Decreased appetite
* Should not be initiated during times of stress Reject vegetables, mixed dishes, liver
Negativism Offer small servings
Temper Tantrums – “extinction” Discourage “grazing” – eating small amounts of non
Accidents nutritious food
Rituals Healthy snack food
Egocentrism PLAY – associative play
Fears: loss of parents, loud noises, going to sleep, large Dress up clothes
animals Housekeeping toys
Dolls and other toys for pretending
Sibling rivalry Bikes and climbing toys
Discipline Paper and crayons
-consistent, planned, private, initiated after behavior simple crafts
Separation anxiety – 18 mos Large blocks
Transitional objects DAILY CARE
- accidents – bicycle safety, seat belts
REACTION TO ILLNESS and NURSING INTERVENTIONS - dressing – choose own clothes
- sleep – 11-13 h per day; resist taking naps
fear of separation - Assure of parents return - exercise – very active
phases: protest, despair, detachment - bathing – can wash and dry hands; need
Defense mech: Regressive behaviors - reassurance supervision
st
Nutrition – allow finger food - care of teeth – independent brushing; 1 dental visit
Dressing changes – allow to pull off tape CONCERNS
Medication – allow choices of “chaser” after oral medication - imitation
Hygiene – allow choice of bathtime toy, allow to put - Oedipus and electra complex
toothpaste - gender roles – need exposure to parents of opposite sex
Pain – allow to express pain - Socialization – capable of sharing
Stimulation - Discipline – “time out”
Elimination – continue potty training - Common fears – dark, mutilation/castration, separation,
Rest – allow choice of toy at bedtime animals, ghosts
- Telling tales
PRE SCHOOL 3-5 yo - Imaginary friends
PRE SCHOOL - sharing – define limits and teach property rights
Future body build apparent - Regression –reaction to stress
Increased skeletal growth - Sibling rivalry
Handedness - sex education
5 yo - may have permanent teeth - pre-school center
Tonsils inc in size - broken fluency
IgG and IgA increases - swearing
PRE SCHOOL - High energy level
- Curiosity
HR 85 bpm REACTIONS/CONCERNS IN ILLNESS AND NURSING
BP 100/60 INTERVENTIONS
3 - 5 kg/yr - nutrition – food in animal/alphabet shapes
2 - 3.5 in/yr - dressing change – allow to measure, cut tape, see
Frequent voiding incision site
- medication – allow to choose “chaser”
- hygiene – allow choice of toys, wash hands and face
GROWTH AND DEVELOPMENTAL MILESTONES - pain – allow pain expression, handle syringe, analgesic
Gross - stimulation
3 1/2 yo - stands on 1 foot 5 sec
- upstairs on 1 foot/step; down 2 feet /step School Age 7 – 11 yo
4 – 4 ½ - climbs stairs SCHOOL AGE
- hops on 1 foot, skip 3-5 lb/yr
- catch ball 1-2 in /yr
5 yo – heel to toe walk 10 yo – brain growth complete
- skips Alternate foot and runs Adult vision
- throw and catch a ball, jump rope, balance on Abundant tonsillar and adenoid tissue
alternate feet “innocent” heart murmurs
FINE MOTOR HR 70 bpm
3 yo – copies circle, imitates cross BP 112/60
4 –4 1/2 28 permanent teeth
- draws man w/ 3 parts Pubertal onset
- copies square, trace diamond SECONDARY SEX CHARACTERISTICS
- lace shoes Female breast devt
5 yo - copies triangle and diamond St 1 (prepubertal)
- writes alphabet, first name St 2 – breast buds
LANGUAGE St 3 – further enlargement of breasts and areola; no
3 ½ yo - knows sex separation of contours
- counts to 3 or more St 4 – breast mound
- 900 words St 5 – adult configuration
Male genitalia devt
St 1 – prepubertal ADOLESCENT
St 2 – enlargement of testes and scrotum; rugae, reddening Girls taller than boys 2-8 in, 15-55 lbs
of scrotum Growth stops 16-17 yo
St 3 – further enlargement, lengthening of penis Boys grow 4-12 in and gain 15-65 lbs
St 4 – increase length and width of penis, devt of glans, Growth stops 18-20 yo
darkening of scrotum Heart and lung size increase more slowly
St 5 – adult configuration HR 70 bpm
RR 20 breaths/min
GROWTH AND DEVELOPMENTAL MILESTONES BP 120/70
6 yo – skip, jump, tumble, hop, ride bicycle, walk a straight ADOLESCENT
line; first molars Androgen inc sebaceous gland activity resulting in acne
7 yo – central incisors; sexual differences seen in play; quiet Apocrine glands inc activity
play 13 yo – 2nd molars
8 yo – improved coordination; playing w/ gang important; PUBERTY – capable of sexual reproduction
eyes fully developed Secondary sexual characteristics
GROWTH AND DEVELOPMENTAL MILESTONES GROWTH AND DEVELOPMENTAL MILESTONES
8 yo – script writing 13 yo – sports
9 yo – all activities done w/ gang 15 yo - enjoys privacy
- hero worship; adult articulation; - stays in room
10 yo – more improved coordination 16 yo - part time job
- well mannered w/ adults - charitable causes
11 yo – active but awkward NUTRITION
- mixed sex activities - faddish diet
12 yo – coordination improves - give responsibility for food planning
- joins organizations - increased calories, Ca, protein
PERSONAL/SOCIAL/PLAY DAILY CARE
Competitive play and recreational activities - dressing and hygiene
Hobbies and personal interests - care of teeth
Arts and crafts - sleep – need more sleep
Biking - exercise – daily
Board games CONCERNS
Clubs - Socialization – falling in love
Collecting items - Obesity; Diseases – HPN
Chess - Acne
Comic Books – ability to read one of most significant skills - Body piercing
NUTRITION - Fatigue - emotional fatigue
Good appetite - Menstrual irregularities
May go on food jags - Sexuality and sexual activity
Food w/ high nutritional value - Poor posture
- more calories and nutrients - Stalking – educate girls
- hungry after school – give snacks and make mealtimes - Substance abuse
enjoyable - Suicide
DAILY CARE - runaways
- dressing – influenced by peers - discipline – firm, limit setting
- sleep – 8-12 hrs; no naps REACTION TO ILLNESS AND NURSING INTERVENTION
- exercise – games, bike riding, walking Defense mech: Denial and displacement
- hygiene – 8 yo – capable of bathing alone Main issue – body image – educate and Allow participation
- care of teeth – 2x yearly visit to the dentist; in tx decisions; compassionate understanding
brush daily Fears loss of control and independence - Respect privacy
* 6 yo – eruption of permanent teeth and confidentiality
- safety – bicycle, school bus safety, prevention of Fears injury and pain - Provide opportunities for self
falls and sports injuries expression
CONCERNS Separation from peers and lack of emotional support -
- problems w/ articulation – disappears 9 yo Approach w/ caring and understanding, age compatible
- Sex education roommate, Phone at bedside
- Stealing – 7 yo – importance of money - Nutrition – food preferences
- Violence/terrorism – education;reassurance - Dressing – final appearance of dressing, and time for
- School anxiety and phobia, bullying, intimidating changing
teachers, something bad happening to parents - Medicine – choice for injection site, teach name and
- Recreational drug and alcohol use action
- Obesity - Rest – time and length of rest periods
- nocturnal enuresis and encopresis (stool leakage; - Hygiene – respect modesty, extent of self care
boys > girls) - Pain – allow pain expression, ask for analgesics
REACTION TO ILLNESS AND NURSING - stimulation
INTERVENTIONS
Cause of illness – external forces; aware of significance of
different illnesses
Defense mech: reaction formation
- Death and disability, immobilization - Still need comfort
- Unknown events & procedures - Allow to
help
w/ care & treatment
- Loss of ctrl & independence - Give choices
- Loss of contact w/ peers - Allow visits
- Disruption of school - Talk about interests
- concerns over modesty
nutrition – allow choices
- dressing – ask opinions on bulk of dressing and
where to apply tape
- medicine – teach name and action, allow to
choose form if possible
- body injury, pain – allow expression of pain, explain
source and cause
- stimulation

ADOLESCENT 13-18 yo