Zandrea Hart

January 16, 2011

LP 1 Assignment

INFANT (birth-1 year)-Perry Ch. 36

Biological Development

Proportion changes

Growth is very rapid during the first year, especially the first 6 months. Infants gain 5-7oz weekly
until approx. 5- 6 months and then slows. (avg. wt. at 6 months is 16lb and at 1 year is 21.5lb). Height
increases by 1 inch a month during the first 6 months and then slows. Increases in length occur in spurts
rather then gradually (avg. ht. is 25 ½ inches at 6 months and 29 inches at 1 year). The increase occurs
mainly in the trunk. The Standardized National Center for Health Statistics growth charts should be used
to monitor infant’s growth.

Head growth is also rapid. During the first 6 months head circumference increases 3/5 an inch a
month and then 1/5 inch a month until 12 months (avg. size is 17 inches at 6 months and 18 inch at 12
months). Closure of the cranial sutures occurs, with the posterior frontal closing by 6-8 weeks and the
anterior frontal closing by 12-18 months.

Expanding head size reflects the growth and differentiation of the nervous system. Maturation
of the brain is exhibited in the dramatic developmental achievements of infancy. By the end of the first
year the brain has increased in wt. by 2 ½ times. Primitive reflexes are replaced by voluntary, purposeful
movement, and new reflexes that influence motor development appear.

The chest assumes a more adult contour, with the lateral diameter becoming larger than the
anteroposterior diameter. The chest circumference approx. equals the head circumference by the end
of the first year. The heart grows less rapidly than any other part of the body and its wt. is doubled by 1
year while body wt. triples. However, the size of the heart is large in comparison to the chest cavity.

Maturation of Systems

The respiratory rate slows and is relatively stable. Respiratory movements continue to be
abdominal. The factors predispose infants to acute/sever resp. problems. The close proximity of the
trachea to the bronchi and its branching structures rapidly transmits infectious agents from one
anatomic location to another, the short, straight Eustachian tube closely communicates with the ear,
allowing infection to ascend from the pharynx to the middle ear, and the inability of the immune system
to produce sufficient immune globulin A (IgA) in the mucosal lining provides less protection against
infection during later childhood.

The heart rate slows and the rhythm is often sinus arrhythmia (rate increases with inspiration
and decreases with expiration). Systolic BP rises during first 2 months as a result of increasing ability of
the left ventricle to pump blood into systemic circulation. Diastolic pressure decreases during the first 3
months, and then gradually rises to values close to those at birth.

Significant hematopoietic changes occur during the first year. Fetal hemoglobin (HgbF) is
present in large quantities for the first 5 months, with adult hemoglobin steadily increasing through first
half of infancy. Fetal hemoglobin has a shorter life span than adult hemoglobin; therefor increased
turnover. This process results in physiologic anemia around 3 to 6 months of age. High levels of HgbF
depress the production of erythropoietin, a hormone released by the kidney that stimulates RBC
production. Hemoglobin levels decrease to a certain pt. At which tissue oxygenation needs stimulate
erythropoietin, and erythropoiesis resumes, forming new RBC’s.

Maternal iron stores are present for the first 5 to 6 months and gradually diminish, which also
accounts for lowered hemoglobin toward end of the first 6 months. The occurrence of physiologic
anemia is not affected by an adequate supply of iron. However, when erythropoiesis is stimulated, iron
supplies are necessary for the formation of hemoglobin.

The digestive process is immature at birth. Saliva is excreted in small amounts, but the majority
of digestive processes do not begin until age 3 months when drooling is common because of poorly
coordinated swallow reflex. The enzyme amylase is present in small amounts but usually has little effect
on the foodstuffs because of the small amount of time the food stays in the mouth. Gastric digestion in
the stomach consists primarily of the action of HCL and renin, an enzyme that acts specifically on the
casein in milk to cause formation of curds. The curds cause the milk to be retained in the stomach long
enough for digestion to occur.

Digestion also takes place in the duodenum, where pancreatic enzymes and bile begin to break
down protein and fat. Secretion of the pancreatic enzyme amylase, which is needed for digestion of
complex carbs, is deficient until the 4 to 6 months. Lipase is also limited, and infants don’t achieve adult
levels of fat absorption until 4 to 5 months. Trypsin is secreted in sufficient quantities to catabolize
protein into polypeptides and some amino acids.

The immaturity of the digestive processes is evident in the appearance of stools. During infancy
solid foods are passed incompletely broken down in feces. An excess quantity of fiber easily disposes
the child to loose, bulky stools. The stomach also enlarges to accommodate greater volume of food. By
the end of the first year the infant can tolerate 3 meals a day and evening bottle and may have 1 to 2
bowel movements. . With any type of gastric irritation, they are vulnerable to diarrhea, vomiting and
dehydration.

The liver is the most immature of all the GI organs. The ability to conjugate bilirubin and secrete
bile is achieved after the first weeks of life. However, the capacities for glucogenesis formation of
plasma protein and ketones, storage of vitamins and deaminazation of amino acids remain immature for
the first year.

Maturation of the suckling, sucking and swallowing reflexes and eruption of teeth parallel the
changes in the GI tract and prepare the infant for solid foods.
 IgA is present in large amounts in colostrum; this is believed to have a protective role in the GI
tract against bacteria. The function and quality of T-lympocytes, lymphokines, and complement are
reduced in early infancy, thus pre\venting optimal response to certain bacteria and viruses.

The full-term newborn receives significant amounts of IgG, which for 3 months confers
immunity against antigens to which the mother was exposed. During this time infant synthesizes IgG and
40% of adult levels reached by 1 year. Significant amounts of IgM are produced at birth and adult levels
reached by 9 months. The production of igA, IgD and IgE is more gradual, max levels reached in early
childhood.

Thermoregulation becomes more efficient; ability to shiver and muscles to contract increases.
The peripheral capillaries respond to changes in temperature and regulate heat loss. In cold they
constrict and they dilate in heat. Increased adipose tissue during first 6 mo. insulates the body against
heat loss.

A shift in total body fluid occurs. At birth 75% of body wt. is water and there is an excess of ECF.
As % of body water decreases so does ECF from 40% at term to 20% at childhood. The high production
of ECF, composed of plasma, interstitial fluid and lymph predisposed them to rapid loss of total body
fluid and dehydration.

Immature renal structures predispose them to dehydration also. Maturity of the kidney occurs
the latter half of second year. when the cuboidal epithelium of the glomeruli becomes flattened. Before
this time the glomeruli’s filtration capacity is reduced. Urine voided has a specific gravity of 1.000-1.010)

Auditory acuity is at adult levels during infancy, visual acuity begins to improve and binocular
fixation is established. Binocularity, fixation of two ocular images into one picture (fusion), begins to
develop by 6 weeks and is well established by 4 mo. Depth perception begins to develop by 7 to 9
months but may exist earlier as an innate safety mechanism against accidental falling.

Fine Motor Development-Reflex Behaviors

This is the use of hands and fingers in the prehension (grasp) of an object. Grasping occurs
during the first 2-3 months as a reflex and gradually becomes voluntary. At 1 month, the hands are
predominantly closed, and by 3 mo. are mostly open. By this time they can demonstrate desire to grasp,
but they grasp more with the eyes. By 4 months, they can look at the object and back again. By 5
months they can grasp the object. Gradually the palmar grasp( using whole hand) is replaced with the
pincer grasp (use of thumb and index finger) Crude pincer grasp is at 8 to 9 months and then goes to a
neat pincer grasp at 11 months.

By 6 months they can hold their bottle, grasp feet and pull them to their mouth, and feed
themselves a cracker. By 7 months they can transfer objects from one hand to the other, use one hand
for grasping and hold a cube in each hand simultaneously. They also enjoy banging objects. By 10
months the pincer grasp is established, they can deliberately go for and object and offer it to someone.
By 11 months they put objects into containers and remove them. By 1 year they try to build a tower
with block but fail.

Gross Motor Development

Full-term newborns can momentarily hold their head in midline and parallel when the body is
suspended ventrally and can lift and turn head side to side when prone. Marked head lag is evident
when the infant is pulled from a lying to sitting position. By 3 months they can hold their head well
beyond the plane of the body. By 4 months they can lift the head and front portion of the chest approx.
90 degrees above the table, bearing wt. on forearms. Only slight head lag is evident when pulled from
lying to sitting. By 4 to 6 months head control is well established. I there is head lag at 6 months they
should have a dev. and neurological evaluation.

Many infants roll over on accident because of rounded back. They can turn from abdomen to
back at 5 months and they can turn from back to abdomen by 6 months. If put to sleep on sides they can
roll over to prone and have risk for SIDS. Place infants in supine position for sleep. If awake prone is
acceptable to achieve head control, crawling, creeping and turning over. Parachute reflex, protective
response to falling, begins at 7 months.

When sitting for the first 2 to 3 months, the back is uniformly rounded. The convex cervical
curve forms at approx. 3 to 4 months when head control is established. The convex lumbar curve
appears when the child begins to sit at 4 months as the spinal column straightens, the infant can be
propped in a sitting position. By 7 months they can sit alone, leaning forward on hands for support. By 8
months they can sit well while supported and explore surroundings in this position. By 10 months they
can maneuver from prone to sitting.

Locomotion involves ability to bear wt., propel forward on 4 extremities, stand upright with
support and walk alone. At 4 to 6 months they have increasing coordination in arms. Initial locomotion
results in propelling themselves backward by pushing with arms. By 6 to7 months they can bear all wt.
on legs with assistance. Crawling (propelling forward with belly on the floor) progresses to creeping (on
hands and knees with belly on floor) by 9 months. At this time they stand while holding onto furniture
and pull themselves to standing, but cannot maneuver back down except by falling. By 11 months they
walk while holding furniture or with both hands held. By 1 year they can walk with one hand held. If not
pulled to standing by 11 to 12 months they should be further evaluated for dev. dysplasia of the hip.

First Words

At 10 months, the infant can say “mama” and “dad” and may also say “hi,” “bye,” or “no”. By 1
years of age, the infant may be able to say 3 to 5 words.
Psychosocial Development

Erikson-trust versus mistrust

Birth to 1 year is concerned with acquiring a sense of trust while overcoming a sense of mistrust.
The crucial element for the achievement of this task is the quality the parent-child relationship and the
care they receive. The provision of food, warmth and shelter is adequate for strong sense of self.
Mistrust develops when these fail to develop. Failure to learn delayed gratification leads to mistrust.
This can result from too much or too little frustration. Consistency of care is essential.

The trust acquired provides foundation for all succeeding phases. Trust allows the feeling of
comfort and security, which assists them in experiencing unfamiliar situations with a minimum of fear.
Erikson divided the first year of life into two oral/social stages. During the first 3-4 months, food intake is
the most important social activity. Primary narcissism (total concern for one’s self) is at its height. As
vision, motor movements, and vocalization become controlled, they use more advanced behaviors to
interact. (ex. Putting hands up instead of crying to be held)

Grasping is initially reflexive. The reciprocal response is the parents holding on and touching.
There is pleasurable tactile stimulation for the parent and child. Tactile stimulation is important in
acquiring trust. The degree of mothering skill, quality of food, and length of sucking doesn’t. It is the
overall quality of the relationship that forms trust.

During the second stage the more active and aggressive modality of biting occurs. Infants learn
they can hold on to what is their own and more fully control their environment. If breastfeeding they
quickly learn that biting causes their mother to be upset and withdraw breast. Yet biting relieves
teething discomfort and sense of power for the infant.

This conflict may be solved in a few ways. The mother can wean the infant from breast milk and
begin bottle feeding, or the infant may learn to bite substitute nipples such as a pacifier. The successful
resolution of this conflict strengthens the mother-child relationship because it occurs when the infant is
recognizing their mother is most significant person in their life.

Cognitive Development

Piaget-sensorimotor phase

Birth to 24 months is the sensorimotor phase and has 6 stages, but only the first 4 are discussed
for infants. Infants progress from reflex to simple repetitive acts to imitate activity; three events take
place during this stage. The first involves separation, in which infants learn to separate themselves from
other objects in the environment. The second major accomplishment is achieving the concept of object
permanence, or the realization that objects that leave the visual field still exist (ex. Infants able to
pursue objects they observe hidden under pillow or behind a chair). This develops at 9-10 months.
 The last major intellectual achievement of this period is the ability to use symbols, or mental
representation. The use of symbols allows the infant to think of an object or situation without
experiencing it. The recognition of symbols is the beginning of the understanding of time and space.

Piaget’s first stage, birth to 1 month is identified by the infant’s use of reflexes. At birth the
infant’s individuality and temperament are expressed through the physiologic reflexes of sucking,
rooting, grasping and crying. The repetitious nature of the reflexes is the beginning of associations
between an act and a sequential response.

The second stage, primary circular reactions, marks the beginning of the replacement of
reflexive behavior with voluntary acts. From 1 to 4 months sucking and grasping become deliberate. The
beginning of accommodation is evident. They are realizing that this happened before and they recognize
the sequence of events. (ex. Used to cry to receive the nipple but now when they hear the mothers
voice they know that they will receive the nipple so they don’t cry)

The secondary circular reactions stage is a continuation of primary circular reactions and lasts
until 8 mo. of age. Grasping and holding bow become shaking, banging and pulling. Shaking is performed
to hear a noise, not for pleasure. The quality and quantity of an act become evident. Understanding of
causality, time, deliberate intention and separateness from environment develops. In this stage they
learn from the type of interaction between objects or individuals.

Imitation requires the differentiation of selected acts from several events. By second half of 1st
year they can imitate sounds and gestures. Play becomes evident as they take pleasure after mastering
it. Affect (the outward manifestation of emotion and feeling) is seen as infants begin to dev. a sense of
permanency. During the first 6 months they believe an object exists only as long as they see it. Object
permanence is a critical component to parent-child attachment and is seen in the dev. of separation
anxiety at 6-8 months.

During the fourth stage, coordination of secondary schemata’s and their application to new
situations, infants use previous behavioral achievements primarily as the foundation for adding more
sills. This stage is largely transitional. They realize hiding an object doesn’t mean it is gone. In this stage
they learn from the object itself. If something is in their way they attempt to climb over it or push it
away.

Body Image

This parallels sensorimotor development. Infant’s kinesthetic and tactile experiences are the
first perceptions of their body and the mouth is the principal area of pleasurable sensations. Achieving
the concept of permanence is the basic development of self-image. As motor skills develop, they learn
that parts of the body are useful.
Social Development

This is initially influenced by their reflexive behavior, such as grasp, and eventually depends on
the interaction between them and the principal caregivers. Attachment to the parent is evident during
the second half of the first year. By 4 mo. infants laugh out loud.

Concerns Related to Normal Growth and Development

The fear that causes the most concern is the fear related to strangers and separation. Stranger
fear and separation anxiety are important components of a strong, healthy parent child attachment. To
accustom the child to people, parents are encouraged to have family and friends visit often. Infants also
need opportunities to safely experience strangers. The best approach for a stranger is to talk softly,
meet the child at eye level and maintain a safe distance and avoid sudden gestures. Parents need to be
reassured that spoiling is healthy, desirable and necessary for the child’s optimum emotional
development. Talking to infants when leaving the room, allowing them to hear ones voice on the phone
and using transitional objects, such as a toy, reassures them of the parents continued presence.

Teething

One of the more difficult periods in the infant’s life is teething. The order of their teeth is fairly
regular and predictable. The first primary teeth to erupt are the lower central incisors, which appear at
approx. 6- 10 months. These are followed by upper central incisors. Age of child in months minus 6 =
number of teeth

Some children show minimum evidence of teething such as drooling, increased finger sucking or
biting of hard objects. Others are very irritable, have trouble sleeping and refuse to eat. Fever, vomiting,
diarrhea and frequent waking periods are generally signs of illness or developmental changes. If the
temperature is over 100.4 the infant should be evaluated by a practitioner. Teething pain is a result of
inflammation and cold is soothing. In the event of persistent irritability that affects sleeping and feeding,
systemic analgesics can be given for no more than 3 days.

Nutrition

Discussion of optimum nutrition should begin prenatally with the decision to breastfeed. Or
bottle-feed. Certain chronic health illnesses have been linked to feeding practices in infancy. One
concern is the children’s intake of megavitamins and herb. Parents need to be aware that the word
natural doesn’t always mean safe.

The first 6 months- Human milk is the most desirable complete diet for the infant at this time. A
healthy infant who is drinking adequate amounts of milk require no vitamins or minerals, with a few
exceptions. Vitamin D supplementation should occur until the infant is consuming at least 1L/day.
Infants, whether breastfed or bottle fed, don’t require additional fluids during the first 4 months.
Excessive water may result in water intoxication. Mothers who are working should pump milk for their
baby. Expressed breast milk may be stored in the refrigerator for up to 5 days in an appropriate air tight
container. Expressed breast milk may be frozen for up to 12 months. Breastfeeding mothers should
have proper nutrition and rest for adequate lactation. Maternal fatigue is the biggest threat to
successful breastfeeding. Warming expressed milk in the microwave decreases availability of anti-
infective properties and vitamin C and causes separation of layers, which effects fat content. Breast milk
should never be thawed or rewarmed in the microwave oven.

Unmodified cow’s milk, low fat cow’s milk, skim milk, and imitation milks are not acceptable as a
major source of nutrition because of their limited ability to be digested. Dietary fat should not be
restricted. Amount of formula per feeding and the number of feedings a day vary from infant to infant.
Bottled water for mixing powdered or concentrated formula is a relatively safe practice. The addition of
solid foods before 4 to 6 months is not recommended. This may lead to excessive wt. gain. Fruit juices
are not recommended in the first 6 months.

The second 6 months- Human milk or formula is the primary source of nutrition. Fluoride
supplementation should begin and breastfeeding is discontinued. At 4 to 6 months they are in the
transition period.

Selection and preparation of solid foods- Rice is suggested because it is easily digested. Infant
cereal is mixed with formula until whole milk is given. Fruit juice can be given for its rich source of
vitamin C as a substitute for milk for one meal a day (no more than 4-6oz for infants less than 6 months).
White grape juice is said to be the best for infants at this age because it doesn’t cause GI distress. Citrus
fruits, meats and eggs are delayed until after 6 mo. of age. By 8 to 9 months finger foods can be given
and then by 1 year well-cooked table foods are served. Low calorie foods should be avoided unless
strictly told by the PCP.

Introduction to solid foods- Spoon feeding should be attempted after ingestion of some breast
milk or formula to associate this activity with a pleasurable one, however, after entire milk feeding it is
useless. Introduce a food at intervals of 4-7 days to allow for food allergy identification.

Sleep Problems

One of the two major categories is dyssomnia; the child has trouble falling asleep or staying
asleep or difficulty staying awake during the day. The second are parasomnias, which are confusional
arousals, sleepwalking, sleep terrors, nightmares, and rhythmic movement disorders. These usually
occur in 3 to 8 month olds. Sleep problems are common during infancy. Infant sleep problems have
been linked with maternal depression and overall mental or general health of the mother or father. An
atraumatic approach to night crying is known as gradual extinction, this is where you let the child cry for
progressively longer times. Also, those who fall asleep on their own usually sleep longer than those who
must sleep with the parent in the room. Feeding them during wake up intervals at night is associated
with poor sleep habits. To prevent sleep problems, place the infant awake in their own crib to fall
asleep. The crib should be used as a bed only not a playpen.
Immunizations

Immunizations are perhaps one of the greatest and most useful inventions and caused a
dramatic decline in infectious diseases. However, vaccines have been widely criticized and believed to
be no longer necessary. The recommendation is to start vaccines at infancy. These are some of the
vaccines that should be given:

*Hepatitis A- fecal-oral and person-person or contaminated water. However, rarely by blood.

Has abrupt onset, fever, malaise, anorexia, nausea, abdominal discomfort, dark urine, jaundice.
Vaccine recommended at 1 yr. and second dose 6 mo. later.

*Hepatitis B- Newborns should get this vaccine before discharge if the mother has hepatitis B
antigen negative. If positive or unknown, they should get the vaccine within 12 hours of birth at
2 different sites and should be given the full series at 1, 2 and 6 mo. of age.

*Diphtheria-Usually in combination with tetanus

*Tetanus- Recommended for children 11-12 years

*Polio-All children should receive 4 doses at 2 mo., 4 mo. 6-18 mo. and 4-6 yr.

*Measles- (rubella)-given at 12-15 mo. and a second at 4-6 yr., then reactivation at 11-12 yr.

*Mumps- recommended for children at 12-15 mo. and usually given with measles and rubella.

*Rubella- recommended for children at 12-15 mo.

*Pneumococcal- Administered at 2, 4 and 6 mo. with a dose at 12-15 mo.

*Varicella-For ages 7 and older

*Haemophilus influenza type B

*Meningococcal- Administered at age 11 or 12 yr. or to college freshman

Injury Prevention

The top leading causes of injury to infants were falls, ingestion injuries and burns. . The leading
causes of death were suffocation, motor vehicle accidents and drowning.

Aspiration of foreign objects such as clothes and food items are common causes of aspiration.
Pacifiers can also be dangerous because the entire object can be aspirated if it is small enough. A
syringe is accurately used to measure and administer medications; however, the syringe cap is an
aspiration hazard. Another hazard is baby powder.

Suffocation of nonfood items causes the majority of deaths in young children. Latex balloons
are the leading cause of choking deaths. The bed or crib also has many hazards. Infants can be
suffocated if tucked in to tightly into bed. Baby pillows filled with beads are also a hazard. Also, the
infants head can be lodged between the crib slats and shouldn’t be more than 2 3/8 inches apart. Plastic
bags can easily be wrapped around the head and cause suffocation so there should be no plastic
wrapped around the mattress or near the bed. Cords can cause strangulation. Bibs should be removed
and pacifiers shouldn’t be hung around their neck. Toys with strings attached should be taken away.

Automobile injuries are the leading cause of accidental death in children between the ages of 1
and 9 years of age. A rear facing seat provides the best protection for the heavy head and weak neck of
the child. A recent study indicated that children 0 to 3 years riding properly restrained in the middle of
the back seat has a 43% lower risk of injury than children riding window seat in a crash. The five point
harness system is the most effective restraint for infants should ride rear facing car seats from birth until
20lb and as close to 1 year of age as possible. Sever injuries and deaths have occurred from the air bags
deploying on impact. Keep infants in the back seat facing rear to prevent this from happening. If no rear
seat, place them facing the rear with the seat as far back as possible and the air bags turned off.
Another hazard is overheating (hyperthermia) when the vehicle is over 80 degrees Fahrenheit. Death
may occur in a few hours. Don’t leave infants in a car alone for any reason.

Falls are the most common after 4 months of age. Never place a child unattended on a raised
surface. Changing tables are also dangerous so never leave them unattended. Infant seats, high chairs,
walkers and swings are opportunities for falling. Once the infants are mobile they shouldn’t be allowed
to mobilize alone, be near stairs or water. Gates should be used at the top and bottom of stairs. Heavy
objects such as unsturdy furniture or freestanding item can be dangerous f they fall on the child.
Children often trip over their own feet from clothing so be sure that their clothes fit them properly.

Poisoning is at its highest incidence is in those that are 2 years old. The major reason for
ingestion of poisons is improper storage. Plants are another source of poisoning for infants. Button
sized batteries are also dangerous and are attractive to infants because they are bright and shiny.
Inhalation is another possible route, for example chemicals or drugs. Parents should know the
telephone number of the local poison control center. 1-800-222-1222.

Burns can occurs from scalding of water, excessive sunburn, and burns from house fires,
electrical wires, sockets, and heating elements cause many deaths and injuries in infants. Their
temperature perception is not fully developed making it easier to burn. Lowering the water heater to
120 degrees Fahrenheit can help prevent scalding the child. Also, the bathwater should be checked
before putting the child in the tub. Avoid bathing children in the kitchen sink when the dishwasher is
running because this can cause the water to come up through the garbage disposal. Check any
microwave foods before giving to the infant. Sunburn is also a concern for infants. Direct sunlight should
be avoided for the first 6 months. When in the sun the body, especially the face and the head should be
covered. Sunscreen is used only sparingly in those under 6 months. Electrical outlets should be covered.
Children shouldn’t be allowed to play near the TV, stereo or other appliances. Any heat producing
element should have a guard placed in front of it.
 Drowning can occur in just an inch or two of water at this age. Most infants younger than 1 year
drown in a toilet, bathtub or bucket. Organized swimming instruction is not recommended until 4 years
of age because it may lead to a false sense of security.

Any long, pointed, sharp-edged objects can be harmful to infants and cause bodily damage.
Forks are best avoided until the child has mastered the spoon, around 18 months. A high rate of
battering infants has been shown in 0 to 5 months. Animal attacks are also important to be aware of.

Hospitalized Infant

Infants are developing trust. Trust is established through loving care by a nurturing person.
Infants attempt to control their surroundings through environmental expressions, such as crying or
smiling. Routines may be established to meet the hospitals needs rather than the infants, which may
lead to mistrust and a decreased sense of control.
 TODDLER (12-36 months of age)-Perry Ch. 37

Biological Development

Proportion Changes

Growth slows considerably during toddlerhood (the avg. wt. gain is 4-6lb). The birthrate is
quadrupled by 2 ½ years. The rate of increase in height also slows (usually 3 inches per year and occurs
mainly in elongation of the legs). The average ht. of a 2 year old is 34 inches.

The rate of increase in head circumference slows somewhat by the end of infancy. Head
circumference is usually equal to chest circumference. The rate of increase is approx. 1 inch per year.
The anterior frontal closes between 12 and 18 months. Chest circumference continues to increase in size
and exceeds head circumference during toddler years. Its shape also changes as the transverse, or
lateral, diameter exceeds the abdominal measurement.

Sensory Changes

Visual acuity of 20/40 is acceptable during toddler years. Full binocular vision is well developed.
Depth perception continues to develop but due to the child lack of coordination, falls from heights are a
persistent danger. The senses of hearing, smell, taste and touch become increasingly well developed.
The toddler may visually inspect something before turning it over. They will also shake it to see if it
makes noise. Taste preferences are also an integrated function. Toddlers are less likely to try something
new in appearance, texture or smell.

Maturation of Systems

Most of the physiologic systems are mature by the end of toddlerhood. Volume of the
respiratory tract and growth of associated structures continue to increase into early childhood. The
internal structures of the ear and throat continue to be short and straight, and the lymphoid tissue of
the tonsils and adenoids continue to be large. As a result, otitis media, tonsillitis and upper respiratory
tract infections are common. . The respiratory and heart rates slow, and the BP increases. Respirations
continue to be abnormal.

The toddler rarely has difficulties of the young infant in maintaining body temperature. The
mature functioning of the renal system serves to conserve fluid under times of stress, decreasing the risk
of dehydration.

The digestive process is fairly complete by the beginning of toddlerhood. The acidity of gastric
contents continues to increase and has a protective function, since it is capable of destroying many
types of bacteria. Stomach capacity increases to allow for the usual schedule of 3 meals a day.

One of the more prominent changes of the GI system is the voluntary control on elimination.
With complete myelination of the spinal cord, control of the anal and urethral sphincters is gradually
achieved. The physiologic ability to control the sphincters occurs somewhere between 18 and 24
months. Bladder capacity also increases considerably, and by 14-18 months the child is able to retain
urine for up to 2 hours or longer.

The defense mechanism of the skin and blood, phagocytosis, is much more efficient in toddlers
than infants. The production of antibodies is well established. However, young children have an
increase in infections when they enter preschool.

Gross Motor Development

The development of locomotion is the major skill learned during toddlerhood. By 12 to 13

months toddlers can walk alone and by 18 months they try to run but fall easily. Between 2 to 3 years of
age, refinement of the upright position is improved. By 2 years toddlers can walk up and down the stairs
and by 2 ½ they can jump, stand on one foot and tiptoe. At 15 months they can also kneel without
support. They cannot walk around corners or stop suddenly without losing balance or throw a ball
without falling.

Fine Motor Development

This is demonstrated in increasingly skillful manual dexterity. By 1 year, toddlers are able to
grasp a very small object but unable to release it at will. At 15 months they can drop a pellet in a
narrow-necked bottle. Casting or throwing objects and retrieving them become obsessive activities by
15 months. By 18 months they can throw a ball over hand without losing balance.

Psychosocial Development

Erikson-autonomy versus shame and doubt

He believed that the developmental task of toddlerhood is acquiring a sense of autonomy while
overcoming a sense of doubt and shame. Just as the infant has the newly gained grasping a biting, the
toddler has gained holding on and letting go. Several characteristics, especially negativism and ritualism
are typical for toddlers. Emotions are strongly expressed, usually with rapid mood swings. Ritualism, the
need to maintain sameness and reliability, provides a sense of comfort. Erikson focuses on the
development of ego during this phase of development. There is also a rudimentary beginning of the
superego, or conscience, which is the incorporation of the morals of society and the process of
acculturation.

Cognitive Development

Piaget-sensorimotor phase

The period from 12-24 months is a continuation of the final 2 stages of the sensorimotor phase.
During this time the cognitive processes develop rapidly and at times seem similar to those of mature
thinking.

Tertiary Circular Reactions- In the 5th stage o f the sensorimotor phase (13-18 months), the child
uses active experimentation to achieve goals. Newly acquired skills are increasingly important for the
function they serve. During this stage there is further differentiation of one’s self from objects. This is
evident in the child’s increasing ability to venture away from the parent and tolerate longer periods of
separation. Awareness of casual relationship between 2 events is apparent. Because classification of
objects is still rudimentary, the appearance of an object denotes its function. The toddler is not able to
differentiate which objects are safe and which are unsafe. Children are able to recognize different
shapes and their relationship to each other. Children are also aware of space and the relationship of
their body to dimensions such as height. Object permanence has also advanced. They still cannot see
things that are hidden but may be aware that the objects to exist behind them.

From ages 19-24 months the child is in the final sensorimotor phase. During this stage the child
completes the more primitive, autistic-like thought processes of infancy and is prepared for more
complex mental operations. One of the most dramatic achievements of this stage is in the area of object
permanence. Children will now actively search for an object in hiding places. Imitation displays deeper
meaning and understanding. There is greater symbolization to imitation. Domestic mimicry, imitation
household activities, and gender role behavior become common especially during the second year.
Identification of the parent of the same gender becomes evident. The concept of time is still immature,
but children have some sense of timing in terms of anticipation, 1 minute can seem like an hour.

Preoperational phase- At approx. 2 year the child enters the pre-conceptual phase of cognitive
development, which lasts until about 4 years of age. The pre-conceptual phase is a subdivision of the
preoperational phase, which spans ages 2 to 7 years. The pre-conceptual phase is primarily one of
transition that bridges the purely self-satisfying behavior. Preoperational thought implies that children
cannot think in terms of operations. Toddlers think primarily on the basis of their perception of an
event. Problem solving is based on what they see or hear directly rather than what they recall. Within
the second year the child increasingly uses language symbolically and is concerned with why and how.

Spiritual Development

The child’s developmental level often parallels cognitive development. Family values, beliefs,
customs and expressions influence the child’s perception of his/her spiritual self. In the past two
decades there has been an increased interest in and focus on the spiritual care in adults and children.

Toddlers learn about God through the words and actions of those closest to them. If God is
spoken about with reverence, they associate God with something special. Toddlers begin to assimilate
behaviors associated with the divine. Routines such as saying prayers before meals and at bedtime can
be important and comforting. Near the end of toddlerhood, there is some advancement in their
understanding of God.

Development of Body Image

The development of body image closely parallels cognitive development. Developing

psychological understanding provides greater self-awareness. During the second year, they recognize
themselves in the mirror and make references to themselves. They recognize the usefulness of body
parts and gradually learn their names. By 2 years there is recognition of gender differences and
reference to self by name and then pronoun. Gender identity developed by age 3. Once they begin
preoperational thought, toddlers can use symbols to represent objects, but their thinking may lead to
inaccuracies.

It is evident that the body integrity is poorly understood. Toddlers also have unclear body boundaries
and may associate nonviable parts, such as feces, with essential body parts. Nurses can assist parents in
fostering a positive body image in their child by encouraging them to avoid negative labels. Body parts
should be called by their correct names.

Social Development

A major task of the toddler period is differentiation of self from significant others. The
differentiation process consists of 2 phases: separation, the child’s emergence from symbiotic fusion
with the mother and individuation, those achievements that mark the child’s expressions of his or her
individual characteristics. This process begins in infancy but the major achievements occur in the toddler
years.

Toddlers have an increased understanding of object permanence and some ability to withstand
delayed gratification and tolerate moderate frustration. Therefore, toddlers react differently to
strangers than infants. They learn that parents still exist when [physically absent. Toddlers know from
repetition that if they go to sleep without their parents there, when they wake up they will be there.

According to Harpaz-Rotem and Bergman, the separation-individualization phase encompasses

the phenomenon rapprochement; as the toddler separates from the mother and begins to make sense
of the experiences. Developmentally this term means the child moves away and returns for reassurance.

Transitional objects provide security for children when they are away from their parents.
Toddlers may become so attached that they refuse to let them go, this is normal. During overnight stays
these objects should be given for comfort.

Learning to tolerate brief separation is an important developmental task of this stage. It is

necessary for not only the child but the parent as well in order to rest and regain their energy.

Language

Toddlers begin to have an increasing level of comprehension. Although the number of words
acquired at one year is 4 and at 2 years is 300, the ability to comprehend and understand speech is
much greater than the number of words the child can say. At 1 year, the child uses one word sentences
or holophrases. At this age 25% of the vocalizations are intelligible. By 2 year the child uses multiword
sentences by stringing together 2 or 3 words and approx. 65% of speech is understandable. By 3 years
the child puts words together into simple sentences, begins to master grammatical rules and acquires 5
or 6 new words daily. Gestures precede or accompany each of the language milestones up to 30 months
of age.Once language are mastered, gestures phase out and the pace of word learning increases.
Social Behavior

Play

Play magnifies the toddler’s physical and psychosocial development. The solitary play of infancy
progresses to parallel play, where the toddler plays alongside, but not with, other children. The toddler
inspects the toys, talks to the toy, tests its strength and durability and invents uses for it. Imitation is one
of the most distinguishing characteristics of play. Increased locomotive skills make push-pull toys,
straddle trucks or cycles, a small gym and slide, balls, and rocking horses appropriate for energetic
toddlers. Finger paints, crayons and puzzles use the child’s fine motor skills. Toys are never substitutes
for the attention of devoted caregivers. Certain aspects of play are related to linguistic abilities.
Appropriate TV programs help the child learn to associate words with visual images.Total media time
should be limited to 1-2 hours a day. Toddlers also enjoy reading from picture books. Tactile play is also
important for the toddler. These types of unstructured activities are as important as educational play to
allow children freedom of expression.

Concerns Related to Normal Growth and Development

Toilet Training

Voluntary control of anal and urethral sphincters is achieved sometime after the child can walk, usually
between 18 and 24 months. The child must be able to recognize the urge and hold it and communicate
the sensation to the parent. Five markers signal a child’s readiness: bladder readiness, bowel readiness,
cognitive readiness, motor readiness, and psychologic readiness.

According to some experts psychologic and psychological readiness isn’t complete until 22-30
months; however, you should prepare the child for toilet training earlier than 30 months. There is no
universal age to begin toilet training. On average, girls are developmentally ready to being training 2 to 2
½ months before boys. Nighttime bladder control takes months to years. This is because the sleep cycle
needs to mature so they can awake to urinate. Children who do not have nighttime dryness by 6 yr are
likely to need intervention. Bowel training is usually accomplished before bladder training because of
greater regularity and predictability. There is a stronger sensation for defecation. A number of
techniques can be helpful when staring training.

Parents should begin the readiness phase by teaching the child how the body functions. A
freestanding potty chair allows children a feeling of security and planting feet on the floor also facilitates
defecation. Practice sessions should be limited to 5-8 minutes and a parent should stay with the child.
Children should be praised for cooperative behavior and successful evacuation. When they begin to
have daytime dryness, parents can experiment with underwear. Parents should remind the child
frequently to try to go to the bathroom in case they forget or are too excited to think about going. If the
parent-child relationship becomes strained the parent may need to regress, but this doesn’t mean
failure.
Sibling Rivalry

The natural jealousy and resentment of children to a new child in the family is normal. The
arrival of a new infant represents a crisis for the toddlers. This is usually pronounced in the first born
child, who experiences dethronement, loss of sole parental attention. Preparing the toddler for the birth
is individual; however, if you tell them too early their interest may be decreased. A good time to talk to
the toddler is when the toddler is aware of the pregnancy. Toddlers need a realistic idea of what the
newborn will be like. Parents should stress the activities that will take place once the baby arrives.
However, parents should emphasize the things that will stay the same. It may be helpful for the father
to spend more time with the toddler in the evening to anticipate mother’s time being with the newborn.
It is a good idea to introduce the toddler to an infant if the toddler hasn’t been around one before. Any
other stresses should be avoided at the time of a new baby, such as moving them to a new bed or
different room. Seeing sample pictures of the fetus and uterus can help the toddler feel more involved.
Parents can include the toddler in the visits with the baby as much as possible so the toddler doesn’t
feel left out. The toddler can also help with the care of the newborn.

Temper Tantrums

Tantrums are indications of the child’s inability to control emotions. The best approach toward
tapering temper tantrums requires consistency and developmentally appropriate expectations and
rewards. During tantrums, ignore the behavior, provided the behavior is not injurious. Continue to be
present to provide a feeling of control and security to the child once the tantrum is over. Also, offer the
child options, instead of all or nothing, ignore small skirmishes over unimportant issues, and give
comfort once the child is able to control emotions.

Negativism

Toddlers have a persistent no response. This negativism is not stubbornness but assertion of
self-control. One way to reduce this is to reduce opportunities to say no; Instead of asking them to do
something tell them to do it.

Regression

Regression is the retreat from one’s present pattern of functioning to past levels of behavior. It
usually occurs in instances of discomfort or distress. Regression is common in toddlers because almost
any additional stress hinders their ability to master tasks. At first, such regression appears acceptable
and comfortable for children, but the loss of newly required achievements is frightening and
threatening. When regression does occur, the best approach is to ignore it while praising existing
patterns of appropriate behavior. It is advisable not to attempt new areas of learning when additional
crisis is present or expected.
Nutrition

From 12-18 months, the growth rate slows, decreasing the need for calories, protein and fluid.
However, the protein and energy requirements are still high. The need for minerals such as iron,
calcium, and phosphorous may be difficult to meet. At approx. 18 months, most toddlers manifest this
decreased nutritional need with a decrease in appetite, a phenomenon known as physiologic anorexia.
They become picky, fussy eaters with strong taste preferences. Toddlers are increasingly aware of
nonnutritive function of food. They are influenced by factors other than taste when choosing food.
Ritualism also dictates certain principals in feeding practices. Toddlers like to use the same dish or cup
every time they eat. By 12 months most children are eating the same food prepared for the rest of the
family. Some may have mastered using a cup with occasional spilling, although most cannot adeptly use
a spoon until 18 months.

Dental Health

Regular dental exams are recommended by the age of 12 months. Poor oral hygiene and poor
dietary habits are associated with the development of caries in children. A method suitable for cleaning
is brushing and flossing. For effective cleaning, a small toothbrush with soft, rounded, multi-tufted nylon
bristles that are short and uniform in length is recommended. Toothbrushes are replaced as soon as the
bristles are frayed or bent.

Fluoride supplementation should be considered for any child over the age of 6 months whose
drinking water is deficient in fluoride. Supplementation based on a fluoride concentration of water
supply at less than 0.3 parts per million is 0.25 mg for a child 6 months to 3 years. Supplements should
remain in the mouth for 30 seconds before swallowing and be taken on an empty stomach. Afterward,
you shouldn’t eat or drink for 30 minutes.

Diet is critical because carious development depends primarily on fermentable sugars,

especially sucrose. The frequency with which sugar is consumed is more important than the total
amount eaten. A special form of tooth decay in infants and toddlers is nursing caries, which occurs when
they are routinely given a bottle at naptime or bedtime. Prevention includes eliminating the bottle
completely, feeding the last bottle before bedtime, substituting a bottle of water for milk o juice, not
using the bottle as a pacifier and never coating pacifiers in sweet substances. Juice should always be
given in a cup to avoid bottle habits. Toddlers should be encouraged to drink from a cup by their first
birthday and weaned from a bottle by 14 months.

Injury Prevention

Injuries cause more deaths in children between the ages on 1 and 4 years than any other
childhood age group except adolescence. Some say that the highest rate of childhood injury was in
children ages 15 to 17 months. The next highest rate was in children 15 years and older. Traumatic injury
is the leading cause of childhood hospitalization, and infants and young children are at higher risk
because of their small size and their inability to protect themselves. Child protection and parent and
child education are key determinants in injury prevention.
 Motor vehicle injuries cause more accidental deaths in all pediatric age groups after age 1 than
any other type of injury or disease and are responsible for almost half of all accidental deaths among
children ages 1-4 yr. Many of the deaths are caused by injuries within the car when restraints haven’t
been used or have been used improperly. Unrestrained children in the front seat are at the highest risk
of injury.

Nurses have a responsibility to educate parents on proper motor vehicle safety and restraints.
The transition point for switching to the forward facing position is defined by the manufacturer but is
generally at a body weight of at least 9 kg (20lb) and 1 year of age. Infants who weigh 20lb before 1 year
should still sit rear-facing. Do not place padding in between the child and the restraint straps because
these add-ons create spaces of air that decrease support for the back, head and neck.

Booster seats are not restraint systems like the convertible devices because they depend on the
vehicle belts to hold the Booster seat in. Children should use car restraints until they are 145cm in
height or 8 to 12 years old. Injuries can also occur during sudden stops when objects are left
unrestrained. A loose toy may become a projectile missile; therefore, all items should be stored in the
trunk. Children over 3 years of age are often involved in pedestrian motor vehicle injuries and when
children climb into the trunk of the car and lock themselves in.

Preventing these injuries requires educating the children and the parents about the dangers of
moving or parked cars. Also, never leave a child in the car unsupervised. The child may accidentally hit
the accelerator or pull the e-brake. Overheating is also a big problem for toddlers. The vehicle
temperature increases 19-20 degrees Fahrenheit every 10 minutes, even with the window cracked.

Drowning ranks second among boys and third among girls ages 1 to 4 years as a cause of
accidental death. Adult supervision is essential and teaching swimming and water safety can be helpful
but cannot be sufficient protection.

Burns rank second among girls and third among boys in this age group as a cause of accidental
death. Pot handles should be turned toward the back of the stove. Knobs for ranges should be out of
reach. Oven doors should be closed whenever the oven is on or cooling. Any other heaters or sources of
heat should have a guard placed in front of them. All homes also need smoke detectors in case of fires.
Outlets should have protected guards in them. Scald burns are the most common type of thermal injury
in small children. Always supervise children when near water. Limiting water temperature to less than
120 degrees is also recommended. At this temperature it takes 10 minutes of exposure to cause a full
thickness burn. However, water temperatures of 130 degrees can cause a full thickness burn within 30
seconds.

Toddlers are at the highest risk of poisoning. The major reason for poisoning is improper
storage, only a locked cabinet is safe. Parent should always have the poison control number on hand
and ready for an emergency.

Children need to be taught safety at play areas, such as no horseplay and staying away from
swings. Gates need to be placed at both ends of stairs. Never leave windows open where it is possible
for the child to climb out. Crib rails should be fully raised all the time and the mattress at the lowest
position. Once they reach 25 inches they should sleep in a bed rather than a crib. Children who sleep on
the top bunk should be 6 or older. Proper restraint and adequate supervision are essential when the
child is in any high area.

Foreign body aspiration is most common during the second year of life. Parents should be
taught the emergency procedures for choking. Also, keep children away from sharp objects and avoid
having them around the child. Teach children the importance of safety at home.

Hospitalized Toddler

Toddlers are striving for autonomy. When their pleasures meet with obstacles, toddlers react
with negativism, especially when having a temper tantrum. Any limitation can cause forceful resistance
and noncompliance. Altered routines can cause loss of control. Toddlers rely on consistency to provide
stability and control. Hospitalization or illness limits their sense of expectation and predictability
because it is very different from their routine at home. Their main ritual areas include eating, sleeping,
bathing, toileting and play. The reaction to such change is regression, which is threatening for them to
relinquish their most recently acquired achievements.

Enforced dependency is a chief characteristic of the sick role and accounts for the numerous
instances of toddler negativism. Although most toddlers initially react negatively and aggressively to
dependency, prolonged loss of autonomy may result in passive withdrawal from interpersonal
relationships and regression in all areas of development. The effects of the sick role are most severe in
instances of chronic, long-term illnesses or in those families that foster the sick role despite the child’s
improved health.
 PRESCHOOL (3-5 years of age)-Perry Ch. 38

Biologic Development

The rate of physical growth slows and stabilizes during the preschool years. The average weight
is 14.5kg (32lb) at 3 years, 16.7kg (46 4/5 lb) at 4 years and 18.8kg (41 ½ lb) at 5 years. The average
weight gain per year remains approx. 2-3kg (4 ½ to 6 ½ lbs). Growth in height also remains steady, with a
yearly increase of 6.5-9cm (2 ½ to 3 ½ inches), and generally occurs by elongation of the legs rather than
of the trunk. The average height is 95cm (37 ½ inches) at 3 years, 103cm (40 ½ inches) at 4 years, and
110 cm (43 ½ inches) at 5 years.

Proportion Changes

Physical proportions no longer resemble those of the squat, pot bellied toddler. The
preschooler is slender but sturdy, graceful, agile, and posturally erect. There is little difference in
physical characteristics according to gender, except as dictated by such factors as dress and hairstyle.

Sensory

Preschool children are generally hyperopic (farsighted), that is, unable to focus on near objects.
As the eye grows in length, it becomes emmetropic (it refracts light normally). If the eyes become too
long, the child becomes myopic (nearsighted), that is unable to focus on objects far away. In severe
cases of hyperopia or myopia, glasses may be prescribed. By the end of the preschool years, visual
ability has improved; normal vision for a 5 year old is approximately 20/30. The Snellen E chart can be
used to assess the preschooler’s vision.

In strabismus, or cross-eye, one eye deviates from the point of fixation. If the misalignment is
constant, the weak eye becomes “lazy,” and the brain eventually suppresses the image produced by that
eye. If strabismus is not detected and corrected by ages 4 to 6 years, blindness from disuse, called
amblyopia, may result; at 4 years, there is a maximum potential for development of amblyopia.

The hearing abilities of the preschool child have reached optimal levels, and the ability to listen
has matured since the toddler age. As for the sense of taste, preschoolers show their preferences by
asking for something “yummy” and may refuse something they consider “yucky.” At about age 3,
children display food “jags,” refusing to eat some foods or only eating a few particular foods.

Maturation of Systems

Fine Motor Development

Fine motor development is evident in the child’s increasingly skillful manipulation, such as
drawing and dressing. These skills provide readiness for learning and independence for entry into
school.
Gross Motor Development

Walking, running, climbing, and jumping are well established by 36 months. Refinement in eye-
hand and muscle coordination is evident in several areas. At age 3 the preschooler rides a tricycle, walks
on tiptoe, balances on one foot for a few seconds, and broad jumps. By age 4, the child skips and hops
proficiently on one foot and catches a ball reliably. By age 5, the child skips on alternate feet, jumps rope
and begins to skate and swim.

Psychosocial Development

Erikson-initiative versus guilt

He maintained that the chief psychosocial task of this period is acquiring a sense of initiative.
Children are in a stage of energetic learning. Conflict arises when children overstep the limits of their
ability and experience a sense of guilt for not behaving appropriately. Clarifying that wishes don’t make
events occur is essential in making them overcome their guilt and anxiety for having certain thoughts.
Development of a superego or conscience begins toward the end of the toddler years and is a major task
for preschoolers. Learning right from wrong is the beginning of morality.

Cognitive Development

Piaget-preconceptual phase and intuitive thought phase

Piaget’s cognitive theory does not include a period specifically for children who are 3 to 5 years
old. The preoperational phase covers the age span from 2 to 7 years and is divided into 2 stages, the
preconceptual phase, ages 2 to 4, and the phase of intuitive thought, ages 4 to 7. One of the main
transitions during these two phases is the shift from totally egocentric thought to social awareness and
the ability to consider viewpoints. Language continues to develop during the preschool period. You want
to understand what your child is thinking through nonverbal approaches.

For children in this age group, the most enlightening and effective method is play. Preschoolers
increasingly use language without comprehending the meaning of words. Causality resembles logical
thought. Preschoolers’ thinking is described as magical thinking. Their inability to logically reason the
cause and effect of an illness or injury makes it especially difficult for them to understand events.
Preschoolers believe in the power of words. If you call them “bad” they think they are a bad child,
therefore say “that was a bad thing to do” instead.

Moral Development

Kohlberg

Pre-conventional or pre-moral level is the phase in which their development of morals is at the
most basic level. They have little concern at why something is wrong. In the punishment and obedience
orientation, children (2-4 yr.) judge whether an action is good or bad on whether they are rewarded or
punished. From 4-7 years of age, children are in the stage of naive instrumental orientation, in which
actions are directed toward satisfying their needs and needs of others.

Spiritual Development

Children’s knowledge of faith and religion is learned from significant others in their
environment, usually from parents and their religious beliefs and practices, but their understanding of
spirituality are influenced by their cognitive level. Development of the conscience is strongly linked to
spiritual development.

Development of Sexuality

Preschoolers form strong attachments to the opposite-sex parent while identifying with the
same-sex parent. Sex typing (the process where an individual develops the behavior, personality,
attitudes, and beliefs appropriate for his and her culture and sex) occurs during this period. The most
powerful examples of sex typing are childbearing practices and imitation. Most children are aware of
their gender and the expected sets of related behaviors by 11/2 to 21/2 years of age. Sex-role imitation
and “dressing up” like Mommy or Daddy are important activities. Sexual exploration may be more
pronounced now than ever before. Exploring and manipulating the genitalia are common. Questions
about sexual reproduction may come up in the search for understanding.

Social Development

Language

Language becomes more sophisticated and complex. Vocabulary increases dramatically, from
300 words at age 2 to more than 2100 words at the end of age 5. Sentence structure, grammatical
usage, and intelligibility also advance to a more adult level.

3-year-old children form sentences of about three or four words and include only the most
essential words to convey a meaning (termed telegraphic for its brevity). They ask many questions and
use plurals, correct pronouns, and the past tense of verbs. The vocabulary consists of about 900 words.
They name familiar objects, such as animals, parts of the body, relatives, and friends. They can give and
follow simple commands. They talk incessantly even if no one is listening or answering. They enjoy
musical or talking toys or dolls and imitate new words.

At age 4-years-old preschoolers use longer sentences of four or five words. They have a
vocabulary of about 1500 words or more. The pattern of asking questions is at its peak, and children will
usually repeat a question until they receive an answer. Four year olds tell exaggerated stories and know
simple songs. They may be mildly profane if associated with other children. They can name one or more
colors, and comprehends analogies such as, “If ice is cold, fire is____.”

By age 5 years old preschoolers have a vocabulary of about 2100 words. They can name coins
and four or more colors. They can describe pictures with much comments and elaboration. They know
days of the week, months, and other time associated words. They can follow three commands in
succession.

By age 6 children can use all parts of speech correctly. They can give some opposites such as “If
mommy is a woman, then Daddy is a man.” They can also describe an object according to its
composition, such as “A spoon is made of metal.”

Social Personal Behavior

At age 3 children can dress self almost completely if helped with back buttons and told which
shoe is right or left. They can pull on shoes and can feel self completely. They have an increased
attention span and can prepare simple meals such as cold cereal and milk. Children can help set the
table and dry dishes without breaking any. Fears may be present, especially of the dark and going to
bed. At age 3 children know their own gender and the gender of others.

At age 4 children are very independent and tend to be selfish and impatient. They can be
aggressive physically and verbally. Children at this age take pride in accomplishments. They can have
mood swings. They show off dramatically and enjoy entertaining others. They tell family tales to others
with no restraint and still have many fears.

Preschoolers at age 5 are less rebellious and quarrelsome than at age 4. They are more settled
and eager to get down to business. They are not as open and accessible in thoughts and behavior as in
early years. Children at this age are independent but trustworthy, not foolhardy, and more responsible.
They have fewer fears; relies on outer authority to control world. They are eager to do things right and
to please; tries to “live by the rules”. Children here have better manners and can care for self totally,
occasionally needing supervision in dress or hygiene. They are not ready for concentrated close work or
small print because of slight farsightedness and still unrefined eye-hand coordination.

Play

Preschoolers especially enjoy associative play- group play in similar or identical activities but
without rigid organization or rules. Play should provide for physical, social, and mental development.

Play activities for physical growth and refinement of motor skills include jumping, running, and
climbing. Tricycles, wagons, gym and sports equipment, sandboxes, wading pools, and activities at
water parks can help develop muscles and coordination. Activities such as swimming and skating teach
safety as well as muscle development and coordination. They enjoy playing with common household
items such as a broom handle or even items adults consider junk. The preschoolers imaginative mind
enjoys playing for its own sake.

Manipulative, constructive, creative, and educational toys provide for quiet activities, fine motor
development, and self-expression. Electronic games and computer programs are especially valuable in
helping children learn basic skills, such as letters and simple words.
 The most characteristic and pervasive preschool activity is imitative, imaginative, and dramatic
play. At no other time is the reproduction of adult behavior so faithful and absorbing as in 4 and 5-year-
old children. Toward the end of the preschool period, children are less satisfied with make believe or
pretend objects and enjoy doing the actual activity, such as cooling and carpentry.

Parents and other caregivers should supervise the selection of television programs and videos
watched. They should schedule limited time for television viewing and set a good example of what to
watch. Television can become an interactive activity when adults view programs with children and
discuss program content. The content of TV viewing is more important than the amount viewed.

Play is so much a part of the young child’s life that reality and fantasy become blurred.
Imaginary playmates are so much a part of this age period. The appearance of imaginary companions
usually occurs between ages 2 ½ and 3 years, and, for the most part, such playmates are relinquished
when the child enters school. The birth order and number of siblings may influence the creation of
imaginary companions, with 1st born and only children being more likely to create imaginary playmates.

Imaginary companions serve many purposes: they become friends in times of loneliness, they
accomplish what the child is still attempting, and they experience what the child wants to forget or
remember. It is not unusual for the “friend” to have myriad vices and to be blamed for wrongdoing.
Sometimes the child hopes to escape punishment through the imaginary playmate. At other times, the
child may fantasize that the companion misbehaved and play the role of the parent. This becomes a
way of assuming control and authority in a safe situation. Parents need to be reassured that the child’s
fantasy is a sign of health that helps differentiate make-believe and reality. Parents can acknowledge
the imaginary companion by calling by name and agreeing to set an extra place at dinner, but they
should not use the playmate to avoid punishment.

Children also benefit from play that occurs between them and a parent. Mutual play fosters
development from birth through the school years and provides enriched opportunities for learning.
Through mutual play, parents can provide tactile and kinesthetic experiences, can maximize verbal and
language abilities, and can offer praise and encouragement for exploration of the world. In addition,
mutual play encourages positive interactions between the parent and child, strengthening their
relationship.

Age 3- play is parallel and associative; begins to learn simple games, but often follows own rules;
begins to share. Age 4- play is associative and imaginary playmates are common. Children use dramatic,
imaginative, and imitative devices. At this age sexual exploration and curiosity demonstrated through
play, such as being “doctor” or “nurse”. Age 5- play is associative; tries to follow rules but may cheat to
avoid losing.
Concerns Related to Normal Growth and Development

Preschool and Kindergarten Experience

In preschool or day care centers, children are exposed to opportunities for learning group
cooperation; adjusting to socio cultural differences; and coping with frustration, dissatisfaction, and
anger. Activities that provide mastery and achievement give children feelings of success, self-
confidence, and personal competence. Whether structured learning is imposed is less important than
the social climate, type of guidance, and attitude toward the children that is fostered by the teacher.
Preschool is particularly beneficial for children who lack a peer-group experience, such as an only child,
and for children from impoverished homes.

One of the issues parents face is the child’s readiness for preschool or kindergarten. There are
no absolute indicators for school readiness, but the child’s social maturity and attention span. Parents
should promote a positive attitude toward learning by reading to their children and encouraging
children to participate in activities to explore their talents.

Children in day care centers have more illnesses than children not in day care centers, especially
GI tract infections; respiratory tract infections; and hepatitis A, varicella-zoster virus, and
cytomegalovirus infections.

Children need preparation for the beginning of school. Parents should present the idea as
exciting and pleasurable. Children should be introduced to the teacher and possibly remain with the
child for at least the first part of the day until the child is comfortable. To improve separation anxiety,
provide the school with detailed information about the child’s home environment. Such information
helps the child feel familiar with the strange surroundings. Transitional objects, such as a favorite toy,
may also help the child bridge the gap from home to school.

Sex Education

There are two rules to answering sensitive questions about topics like sex to a child. The first is
to find out what children know and think. Parents can then give correct information and help children
understand why their explanation is incorrect. The second rule is to be honest. The preschooler may
forget or misunderstand much of the information, but the correct information can be restated until the
child absorbs and comprehends the facts. Honesty does not imply telling the child every fact. When the
child is ready he/she will ask about the other unfinished part of the story. It is best to wait until they
ask.

Regardless of sex education, children will engage in games of sexual curiosity and exploration.
At age 3 children are aware of the anatomic differences between the sexes and are concerned with how
the other “works”. Children are still unaware of the reproductive function, but their curiosity is for the
elimination function of the anatomy. (Little boys wonder how girls pee, so they watch them go to the
bathroom.) “Doctor Play” is often a game invented for such investigation. A positive approach to this
behavior is to neither condone nor condemn, but to express that is children have questions, they should
ask the parents. The parents should then encourage them to engage in another activity.

Another concern for parents is masturbation. This occurs at any age for a variety of reasons
and, if not excessive, is normal and healthy. It is most common at 4 years of age and in adolescence. It
is part of sexual curiosity and exploration.

Stress

Young children are especially vulnerable because of their limited capacity to cope. Expression of
frustration, fear, or anxiety is hampered by inadequate expressive language. The best approach to
dealing with stress is prevention—monitoring the amount of stress in children’s lives so that levels do
not exceed their coping ability. Structuring children’s schedules to allow rest and preparing them for
change, such as entering school, are good ways to help relieve stress.

Aggression

The term aggression refers to behavior that attempts to hurt a person or destroy property.
Hyper aggressive behavior in preschoolers is characterized by unprovoked physical attacks on other
children and adults, destruction of others property, frequent intense temper tantrums, extreme
impulsivity, disrespect, and noncompliance. Factors that tend to increase aggressive behavior are
gender, frustration, modeling, and reinforcement. Boys are more aggressive than girls.

Frustration, or the continual thwarting of self satisfaction by disapproval, humiliation,

punishment, or insults, can lead children to act out against others as a means of release. Modeling, or
imitating the behavior of significant others, is a powerful influencing force in preschoolers. Television is
a significant source of modeling at this age. Reinforcement can shape aggressive behavior. The
difference between “normal” and “problematic” behavior is it quantity, severity, distribution, and
duration (at least 4 weeks).

Speech Problems

The most critical period for speech development occurs between 2 and 4 years of age. Failure
to master sensorimotor integrations results in stuttering or stammering as children try to say the word
they are already thinking about. This is a normal characteristic of language development in children
ages 2-5 years, affecting boys more frequently than girls. When parents place undue emphasis on a
child’s dysfluency, an abnormal speech pattern may develop. Children who stutter are encouraged to
speak slowly and clearly, refrain from correcting or criticizing the child’s speech, resist temptation to
finish the child’s sentence, and take time to listen attentively. The best therapy for speech problems is
prevention and early detection. Children pressured into producing sounds ahead of their developmental
level may develop dyslalia (articulation problems) or revert to using infantile speech. The Denver
Articulation Screening Exam is an excellent tool for assessing articulation skills in the child and for
explaining the expected progression of sounds.
Nutrition

The requirement for calories per unit of body weight is 90kcal/kg, for an average daily intake of
1800 calories. Fluid requirements are 100ml/kg/day but depend on the activity level, climatic
conditions, and state of health. Protein requirements are 13-19g/ day.

The following fat intake levels for children over the age of 2 years: saturated fatty acid less than
10% of total caloric intake, total fat over several days should be between 20% and 30% of total caloric
intake. Preschoolers may have decreased fat intake with substitutes such as soy-enriched foods
without affecting overall food taste, energy, and nutrient value.

The recommendation for daily calcium intake for children 1-3 years is 500mg, and the
recommendation for children 4-8 years of age is 800mg. The intake of fruit juice should be limited to 4-6
oz/day for children ages 1-6.

When children reach 4 years of ages, they seem to enter another period of finicky eating. Small
portions should be offered of each item being served. The practice of having the child remain at the
table until “the plate is clean” should be avoided because this may contribute to overeating. By age 5
children are more agreeable to try new foods, especially if they are encouraged by an adult. Usually the
5 year old child is ready for the social side of eating, but the 3-or 4-year-old child still has difficulty sitting
quietly through a long family meal.

Sleep and Activity

The average preschooler sleeps about 12 hours a night and infrequently takes daytime naps.
Waking during the night is common throughout early childhood. Free play and a variety of physical
activities are encouraged; however, organized play is only encouraged when it is developmentally
appropriate and occurs in a nonthreatening, fun, and safe environment.

Dental Health

By the beginning of the preschool period, the eruption of the deciduous (primary) teeth is
complete. Dental care is essential to preserve these temporary teeth and to teach good dental habits.
Assistance and supervision is required with brushing, and parents should floss teeth. Professional care
and prophylaxis, especially fluoride supplements (if needed), should be continued. Trauma to teeth at
this age is not uncommon. Preservation of the space previously occupied by an avulsed tooth is
necessary for proper eruption of the secondary tooth.

Injury Prevention

Because of improved gross and fine motor skills, coordination, and balance, preschoolers are
less prone to falls than are toddlers. They tend to be less reckless; listen more to rules; and are aware of
potential dangers. Putting objects in the mouth has all but ceased, although accidental poisoning is still
a danger. Pedestrian motor vehicle injuries increase because of activities such as playing in the parking
lot. Emphasis is now on education concerning safety and is an excellent time to start enforcing the use
of safety items such as a bicycle helmet.

Immunizations

*Pneumonococcal vaccine: recommended for all children aged younger than 5 years and older
than 6 weeks.

*IPV: fifth dose at age 4-6 years.

*Influenze vaccine (seasonal): Administer annually to children aged 6 months through 18 years.

*MMR: Administer 2nd dose routinely at age 4-6 years.

*Varicella vaccine: Administer 2nd dose routinely at age 4-6 years.Meningococcal vaccine:
Administer MCV4 to children aged 2-10 years.

*Screenings for TB

Hospitalized Preschooler

Prolonged separation, such as that imposed by an illness and hospitalization, is difficult, but
preschoolers respond to anticipatory preparation and concrete explanation. They are able to work
through many of their unresolved fears and anxieties through play, especially if guided with appropriate
play objects that represent family members, health care professionals, and other children.

During assessment, the preschooler can often participate in answering questions with assistance
from parents or caregivers.
 SCHOOL AGE (6-12 years)-Perry Ch.39

Biologic Development

Proportion Changes

Body proportions take on a slimmer look with a lower center of gravity. Posture improves which
makes climbing, bicycle riding, and other activities easier. Both boys and girls double their physical
strength and physical capabilities. Although strength increases, muscles are still functionally immature
when compared to those of the adolescent, and they are more readily damaged by muscular injury
caused by overuse. The most pronounced changes that indicate increasing maturity in children are a
decrease in head circumference in relation to standing height, a decrease in waist circumference in
relation to height, and an increase in leg length in relation to height. These observations provide a clue
to a child’s degree of maturity and are useful in predicting the readiness for meeting the demands of
school.

The face grows faster in relation to the remainder of the cranium and the skull and brain grow
more slowly. Because all of the primary teeth are lost during this age span, middle childhood is known
as the age of the loose tooth. The early years of middle childhood, when the new secondary
(permanent) teeth appear too large for the face, are known as the ugly duckling stage.

Age 6- weight 16-26.3 kg, height 106.7-122 cm. Central mandibular incisors erupt and looses
first tooth. Vision reaches maturity.

Age 7- Begins to grow at least 5 cm in height per year. Weight 17.7-30 kg. Height 112-130 cm.
Maxillary central incisors and lateral mandibular incisors erupt. Jaw begins to expand to accommodate
permanent teeth.

Ages 8-9 year- continues to gain 5cm in height per year. Weight 19.5-39.5 kg. Height 117-142
cm. Lateral incisors (maxillary) and mandibular cuspids erupt.

Ages 10-12 years- Weight 24.5-58 kg. Height 127-162.5 cm. Posture is more similar to an adult;
will overcome lordosis. Remainder of teeth will erupt and tend toward full development (except
wisdom teeth). Girls- Pubescent changes may begin to appear; body lines soften and round out. Boys-
Slow growth in height and rapid weight gain; may become obese in this period.

Prepubescence

Preadolescence is the period of approximately 2 years that begins at the end of middle
childhood and ends with the 13th birthday. Prepubescence typically occurs during preadolescence.
There is a difference of 2 years between girls and boys in the age of onset of pubescence. This is a
period of rapid growth in height and weight, especially for girls. There is no universal age at which
children assume the characteristics of prepubescence. The first physiological signs appear at about 9
years of age (particularly in girls) and are usually clearly evident in 11-12-year-old children. Either early
or late appearance of these characteristics is a source of embarrassment and uneasiness to both sexes.
Generally, puberty begins at 10 years in girls and 12 years in boys, but can be as early as 8 years. Boys
experience little visible sexual maturation during preadolescence.

Fine Motor Development

At age 6 there is a gradual increase in dexterity and the child often returns to finger feeding. At
table, uses knife to spread butter on bread. At play cuts, folds, pastes paper; sews crudely if needle is
threaded.

At age 7 the child uses table knife for cutting meat; may need help with tough or difficult pieces.
The child brushes and combs hair acceptably without help.

At ages 8-9 years the child makes use of common tools such as hammer, saw, and screwdriver.
Uses household and sewing utensils and helps with routine household tasks such as dusting and
sweeping. The child has increased smoothness and speed in fine motor control; uses cursive writing. By
this age most children have sufficient fine motor control for such activities as drawing, building models,
or playing musical instruments.

At ages 10-12 years the child makes useful tools or does easy repair work. He/she can cook or
sew in small ways.

Gross Motor Development

Age 6- Active age; constant activity. The child likes to draw, print, and color.

Age 7- more cautious in approaches to new activities; repeats performances to master them.

Ages 8-9 years- movement fluid; often graceful and poised. Always on the go; jumps, chases,
skips. The child dresses self completely.

Psychosocial Development

Erikson: industry versus inferiority

A sense of industry, or a stage of accomplishment, is achieved somewhere between age 6 and

adolescence. School-age children are eager to develop skills and participate in meaningful and socially
useful work. Children want to engage in tasks that can be carried through completion. They gain
satisfaction from independent behavior and from interactions with their peers. Peer approval is a strong
motivating power. Children achieve a sense of industry when they have access to tasks that need to be
done and they are able to complete the tasks well despite individual differences in their capacities and
emotional development.

The danger in this period is the occurrence of situations that may result in a sense of inferiority.
Children with physical and mental limitations may be at a disadvantage in acquiring certain skills. When
the reward structure is based on evidence of mastery, children who are incapable of developing these
skills risk feeling inadequate and inferior. Children must be able to learn that they will not master every
skill they attempt. All children will feel some degree of inferiority when they encounter specific skills
they cannot master.

Cognitive Development

Piaget: concrete operations phase and formal operations phase

This is the stage of concrete operations, when children are able to use thought processes to
experience events and actions. Children can see things from another’s point of view. During this stage
children develop an understanding of relationships between things and ideas. They progress from
making judgments based on what they see (perceptual thinking) to making judgments based on what
they reason (conceptual thinking). They are able to master symbols and to use their memories of past
experiences to evaluate and interpret present.

One cognitive task of school-age children is mastering the concept of conservation. Each glass
contains the same amount of liquid is learned at age 5-7. Each object contains the same amount of
mass is learned at age 5-7. Each object weighs the same is attained at age 9-10. Each row contains the
same number of marbles at age 5-7. The two pencils are still of equal length at age 6-7. The amount of
uncovered area remains the same at age 9-10. Pieces of clay displace the same volume of liquid
attained at age 9-12.

School age children also develop classification skills. They become occupied with collections of
objects. They may even begin to order friends and relationships (best friend, second best friend). They
understand relational terms (bigger and smaller; darker and paler). They view family relationships in
terms of reciprocal roles (to be a brother, one must have a sibling).

School aged children learn the alphabet and the world of words. They learn to tell time, to se
history and geography, and astronomy. The ability to read is acquired during the school years and
becomes the most significant and valuable tool for independent inquiry.

Age 6- develops concept of numbers; can count 13 pennies. Knows whether it is morning or
afternoon; defines common objects such as fork and chair in terms of their use. Obeys three commands
in succession; knows right and left hands. Says which is pretty and which is ugly; describes the objects in
a picture rather than simply enumerating them; attends 1st grade.

Age 7- notices that certain items are missing from pictures. Can copy a diamond; repeats three
numbers backward. Develops concept of time; reads ordinary clock or watch correctly to nearest
quarter hour; uses clock for practical purposes; attends 2nd grad. More mechanical in reading; often
does not stop at the end of a sentence; skips words such as “it”, “the”, and “he”.

Ages 8-9 years- gives similarities and differences between two things from memory. Counts
backward from 20 to 1; understand concept of reversibility. Repeats days of the week and months in
order; knows the date. Describes common objects in detail, not merely their use. Makes change out of
a quarter; attends 3rd and 4th grade. Reads more; may plan to wake up early just to read (reads classic
book, but also enjoys comics). More aware of time; can be relied on to get to school on time. Can grasp
concepts of parts and whole fraction. Understands concepts of space, cause and effect, puzzles,
conservation. Classifies objects by more than one quality; has collections. Produces simple paintings or
drawings.

Ages 10-12- writes brief stories. Attends 5th to 7th grade. Writes occasional short letters to
friends or relatives on own initiative. Uses telephone for practical purposes. Responds to magazine,
radio, or other advertizing. Reads for practical information or own enjoyment- stories or library books of
adventure or romance, animal stories.

Spiritual Development

Children at his age picture God as human and use adjectives such as “loving” and “helping”.
They are fascinated by the concepts of heaven and hell. They may fear going to hell for misbehavior.
Children may view illness or injury as a punishment for a real or imagines misdeed. School-aged children
begin to learn the difference between the natural and the supernatural but have difficulty
understanding symbols. Religious concepts must be presented in concrete terms. Prayer comforts
them and their petitions to their God tend to be for tangible rewards. Although young children expect
their prayer to be answered, as they get older, they become less concerned when prayers are not
answered. They are able to discuss their feelings about their faith and how it relates to their lives.

Social Development

Relationships

For the first time, children join group activities with unrestrained enthusiasm and steady
participation. Children learn to appreciate the numerous and varied points of views that are
represented in the peer groups and learn the limits of their own point of view. Children learn to argue,
persuade, bargain, cooperate, and compromise to maintain friendships.

Children also become increasingly sensitive to the social norms and pressure of the peer group.
They may modify their behavior to be accepted by a group. A variety of roles, such as class joker or class
hero, may be assumed by individual children to gain approval from the group.

The interaction among peers leads to the formation of intimate friendships between same-sex
peers (best friends). These relationships where the child experiences love and closeness for a peer may
be important as a foundation for relationships in adulthood.

Age 6- can share and cooperate better; has great need for children of own age. Will cheat to
win; often engages in rough play. Often jealous of younger brother or sister; does what adults are seen
doing; may have occasional temper tantrums. Is a boaster; is more independent, probably influenced by
school. Has own way of doing things and increases socialization.

Age 7- is becoming a real member of the family group. Takes part in group play; boys prefer
playing with boys; girls prefer playing with girls. Spends a lot of time alone; does not require a lot of
companionship.
 Ages 8-9- is easy to get along with at home. Likes the reward system; dramatizes; is more
sociable; is better behaved. Is interested in boy-girl relationships, but will not admit to it. Goes about
home and community freely, alone, or with friends. Like to compete and play games; shows preference
in friends and groups. Plays mostly with groups of own sex, but is beginning to mix. Develops modesty;
compares self with others. Enjoys organizations, clubs, and group sports.

Ages 10-12- loves friends; talks about them constantly. Chooses friends more selectively; may
have a “best friend”. Enjoys conversation; develops beginning interest in opposite sex. Is more
diplomatic; likes family and family really has meaning. Likes mother and wants to please her in many
ways. Demonstrates affection and respects parents. Likes father, who is admired and may be idolized.

Clubs and Peer Groups

One of the outstanding characteristics of middle childhood is the formation of formalized groups
with rigid rules imposed on the members. There is exclusiveness in the selection of people who are
allowed to join. Acceptance is determined on a pass-or-fail basis according to social or behavioral
criteria. Conformity is the core of the group structure and conforming to the rules provides children
with feelings of security and relieves them of the responsibilities of making decisions. By merging their
identities of those with the peers, children are able to move from the family group to an outside group
as a step toward seeking further independence.

During the early school years, groups are usually small and loosely organized. In general girls
groups are less formalized than boys are, and although there may be a mixture of both sexes in the early
years, the groups are predominately composed of children of the same sex.

Poor relationships with peers and a lack of group identification can lead to bullying. Bullying is
any recurring activity that is intended to harm or bother someone where there is a perceived imbalance
of power between the aggressor and the victim. Bullies are generally defiant towards adults, antisocial,
and likely to break school rules. They have little anxiety, strong self-esteem, and dominant personalities;
may come from homes where parental involvement and nurturing are lacking; and may experience or
witness violence or abuse at home. Bullying by boys is more common than girls. Chronic bullies tend to
continue their behavior into adulthood, negatively influencing their ability to develop and maintain
relationships. Victims of bullying can feel socially rejected and can fear school, which can develop into
school phobia or long term problems of depression and low self-esteem. Peer pressure forces some
children to take risks or engage in behaviors that are against their better judgment.

Relationships with Families

Parents are the primary influence in shaping the child’s personality. Family values usually take
precedence over peer value systems. Although children may appear to reject parental values while
testing the new values of the peer group, ultimately they retain and incorporate into their own value
systems the parental values they have found to be of worth.
 In the middle school years, children want to spend more time in the company of peers and they
often prefer peer-group activities to family activities. They discover that parents can be wrong and they
begin to question the knowledge and authority of their parents. Children are not prepared to abandon
all parental control. They need and want restrictions placed on their behavior, and they are not
prepared to cope with all the problems of their expanding environment. They feel more secure knowing
there is an authority figure. Children may complain loudly about restrictions and try to break down
parental barriers, but they are uneasy if they succeed in doing so. They respect adults prevent them
from acting on every urge. Children view this behavior as an expression of love and concern for their
welfare. Children need the stable, secure strength provided by mature adults to whom they can turn
during troubled relationships with peers or stressful changes in their world.

Play

Play involves increased physical skill, intellectual ability, and fantasy. Children develop a sense
of belonging to a team or club by forming groups and cliques.

Children now begin to see the need for rules, and their games have fixed and unvarying rules
that may be bizarre and extraordinarily rigid. Part of the enjoyment of the game knows the rules
because knowing means belonging. Childhood is full of chants and taunts, such as “eeny, meeny, miney,
mo,” and “last one is a rotten egg.” Children derive a sense of power and pleasure from such sayings.

Team play teaches children to modify or exchange personal goals for goals of the group; it also
teaches them that division of labor is an effective strategy for attaining a goal. Children learn about
competition and the importance of winning. Team play can also contribute to children’s social,
intellectual, and skill growth. Children work hard to develop the skills needed to become team
members, to improve their contribution to the group, and to anticipate the consequences of their
behavior for the group. Team play helps stimulate cognitive growth because children are called on to
learn many complex rules, make judgments about those rules, plan strategies, and assess the strengths
and weakness of members of their own team and members of the opposite team.

School age children become fascinated with complex board. Card, or computer games that the
can play alone, with a best friend, or with a group. Disagreements over rules can cause much discussion
and argument, but are easily resolved by reading the rules of the game. School age children never tire
of stories and, as with preschool children, love to have storied read aloud. Sewing, cooking, carpentry,
gardening, and creative activities such as painting are other activities enjoyed. Many other skills such as
music, dancing, swimming, and skating are enjoyed.

Through play, children can feel as big, as powerful, and as skillful as their imaginations will allow.
Children need space in which to exercise large muscles and to deal with the tensions, frustrations, and
hostility.
Developing Self Concept

The term self-concept refers to a conscious awareness of self-perceptions, such as one’s physical
characteristics, abilities, values, self-ideals and expectations, and idea of self in relation to others. Each
small success a child experiences increases a child’s self-image. The more positive children feel about
themselves, the more confident they will be in trying for success in the future. A positive self-concept
makes children feel likable, worthwhile, and capable of significant contributions. These feelings lead to
self-respect, self-confidence, and happiness. Negative feelings lead to self-doubt.

Concerns Related to Normal Growth and Development

School Experience

After the family, schools are the second most important socializing agent in the lives of children.
Children want to go to school and usually adapt to the new conditions with little difficulty. Successful
adjustment is related to the child’s physical and emotional maturity and the parent’s readiness to accept
the separation associated with school entrance. Unfortunately, some parents express their unconscious
attempt to delay the child’s maturity by clinging behavior, particularly with the youngest child.

By the time they enter school, most children have a fairly realistic concept of what school
involves. Middle-class children have fewer adjustments to make and less to learn about expected
behavior, since school tends to reflect dominant middle-class customs and values. School is the first time
that some children become members of a large group of individuals their own age. Peer relationships
become increasingly important and influential as children proceed through school.

Latchkey Children

The term latchkey children is used to describe children in elementary school who are left to care
for themselves before or after school without the supervision of an adult. Inadequate adult supervision
after school leaves children at greater risk for injury and delinquent behavior. In some instances outside
activities are curtailed and relationships with peers may be significantly diminished. Latchkey children
may feel more lonely, isolated, and fearful than children who have someone to care for them. To cope
with their fears and anxieties while alone, these children may devise strategies such as hiding, playing
the TV at loud volume, or using pets for comfort.

Limit Setting and Discipline

When children develop an ability to see a situation from another’s point of view, they are also
able to understand the effects of the reactions on others and themselves. Discipline should take place in
a positive, supportive environment with the use of strategies to instruct and guide desired behaviors
and eliminate undesired behaviors. Reasoning is an effective technique for older school-age children.
Withholding privileges, requiring compensation, imposing penalties, and contracting can be used with
great success. Problem solving is the best approach to limit setting, and children themselves can be
included in the process of determining appropriate disciplinary measures.
Dishonest Behavior

During middle childhood, children may engage in what is considered to be antisocial behavior.
Previously well-behaved children may engage in lying, stealing, and cheating.

Lying can occur for a number of reasons. Young children may lie to escape punishment or to get
out of some difficulty even when their misbehavior is evident. Older children may lie to meet
expectations set by other to which they have been unable to measure up. However, most children know
that lying and cheating are wrong, and they are concerned when it is observed by their friends. They are
quick to tell on others when they detect cheating. Parents need to be reassured that all children lie
occasionally and that sometimes children may have difficulty separating fantasy from reality.

Cheating is most common in young children 5-6 years of age. They find it difficult to lose at a
game or contest, so they may cheat to win. They have not yet realized that this behavior is wrong, and
they do it almost automatically. This behavior usually disappears as they mature. When parents set
examples of honest, children are more likely to conform to these standards.

Stealing is not unexpected in the younger child. Between 5 and 8 years of age, children’s sense
of property right is limited, and they tend to take something simply because they are attracted to it or to
take money for what it will buy. They are equally likely to give away something valuable that belongs to
them. When young children are punished, they are penitent- they “didn’t mean to” and “promise to
never do it again”- but they are likely to repeat the performance the next day. Often they not only steal
but also lie about their behavior or attempt to justify it with excuses. It is seldom helpful to trap children
into admission by asking directly if they committed the offense. Children do not take responsibility until
the end of middle childhood.

Children steal for several reasons. Young children may lack a sense of property rights, attempt
to acquire a specific object to bribe favors from other children, have a strong desire to own a coveted
item, or have a desire for revenge to “get back at someone” (usually a parent for unfair treatment).
Older children may steal to supplement an inadequate allowance. Stealing can be an indication that
something is seriously wrong or lacking in the child’s life. Children may steal to make up for love or
another satisfaction that they feel is lacking. An appropriate and reasonable punishment, such as having
the older child pay back the money or return the stolen items takes care of most cases. If children’s
personal rights are respected, they are likely to respect the rights of others.

Stress and Fear

Children today experience significant amounts of stress, which can cause long-term adjustment
and health problems. Stress in childhood comes from a variety of sources such as conflict within the
family, interpersonal relationships, poverty, and chronic illness. The school environment and
participation in multiple organized activities can be additional sources of stress. The demands from
coaches and parents, in addition to school requirements and pressure from teachers to do well on
testing, can cause unrealistic expectations on the school-age child. In addition, with the increased
exposure to sexuality and provocative clothing and behaviors, children of this age group may feel
pressured to have a girlfriend or boyfriend, which their maturity level cannot handle and which causes
additional stress.

The increasing violence in society has also spilled over into the school setting. Today’s children
are often personally aware of violence in their families or communities. School-age children can be the
victims of teasing, bullying, and physical abuse in the school environment.

To help children cope with stress, parents, teachers, and health care providers need to
frequently reassure children that they are safe, have honest and open communication, encourage
children to express their feelings, and promote a daily routine. Children 7 to 12 years of age are capable
of identifying their own physiological responses to stress with terms that have meaning to them. These
words include: tight muscles, hot or red in the face, tingling, chills or goose bumps, shakiness, heart
beating fast, headache, and stomachache). Children can learn relaxation techniques such as deep
breathing exercises, progressive relaxation of muscle groups, and positive imagery.

In addition to stress, school-age children experience a wide variety of fears, including fear of the
dark, excessive worry about past behavior, self-consciousness, social withdrawal, and an excessive need
for reassurance. These fears are considered normal for this age. During the middle range of the school-
age years, children become less fearful of body safety than they were as preschoolers, but they still fear
being hurt, being kidnapped, or having to undergo surgery. They also fear death and are fascinated by
all the aspects of death and dying. The fears of noises, darkness, storms, and dogs lessen, but new fears
related predominantly to school and family bother children during this time.

Nutrition

Although caloric needs are diminished in relation to body size during middle childhood,
resources are being laid down at this time for the increased growth needs of adolescence. Parents and
children need to be aware of the value of a balanced diet to promote growth because children usually
eat what their family members eat. Children develop a taste for a variety of foods. The easy availability
of fast-food restaurants, the influence of the mass media, and the temptation of “junk food” make it
easy for children to fill up on empty calories. Foods that do not promote growth, such as sugars,
starches, and excess fats, are common in the school-age child’s diet. Parents are unable to monitor
what their children eat when they are away from home and the school cafeteria may not always provide
nutritious meals.

Sleep and Rest

The amount of sleep depends on the child’s age, activity level, and state of health. The growth
rate slows in the school-age years, and less energy is expended in growth than during preceding years.
School-age children usually do not require a nap, and they sleep during the night approximately 11
hours at age 5 and 91/4 hours at age 12. Fewer bedtime problems occur during these years, but
occasional difficulties are still associated with the bedtime ritual. Usually children 6 or 7 years old
exhibit fewer bedtime problems, and encouraging quiet activity before bedtime, such as coloring or
reading, facilitates the task of going to bed. However, most children in middle childhood must be
reminded frequently to go to bed; 8-9 year-old children and 11 year-old children are particularly
resistant. Often these children are unaware that they are tired; if they are allowed to remain up later
than usual; they are fatigued the next day. 12 year-old children usually offer no resistance and some
even retire early to read or listen to music.

Exercise and Activity

Longer, stronger muscles permit longer and increasingly strenuous play without exhaustion.
School-age children acquire the coordination, timing, and concentration that are required to participate
in the adult-type activities, but they may lack the strength, stamina, and control of the adolescent and
adult. Children may not be ready for strenuous competitive athletics.

Appropriate activities during the school-age years include running jumping rope, swimming,
roller skating, ice skating, dancing, and bicycle riding. Exercise is essential for muscle development and
tone, refinement of balance and coordination, increased strength and endurance, and stimulation of
body functions and metabolic processes. Most children have abundant energy and need little
encouragement to engage in physical activity. Children with disabling conditions or those who hesitate
to become involved in active play( such as obese children) require special assessment and help so that
activities appeal to them and are compatible with their limitations while also meeting their
developmental needs.

Dental Health

The first permanent (secondary) teeth erupt at about 6 years of age, beginning with the 6-year
molar, which erupts posterior to the deciduous molars. With the appearance of the second permanent
(12- year) molar, most permanent teeth are present. Permanent dentition is more advanced in girls
than in boys.

Correct brushing techniques should be taught or reinforced, and the role that fermentable
carbohydrates play in production of dental carries should be emphasized. It is important to be alert to
possible malocclusion problems that may result from irregular eruption of permanent teeth and that
may impair function. Regular dental supervision and continued fluoride supplementation are integral
parts of the health maintenance program.

The most effective means of preventing dental caries is proper oral hygiene. Teeth should be
brushed after meals, after snacks, and at bedtime. For the school-age child with mixed and permanent
dentition, the best toothbrush is one with soft nylon bristles and should be comfortable for the child to
hold and reach all teeth. Flossing follows brushing. Parents should perform the flossing until children
acquire the manual dexterity required (usually at about 8 or 9 years of age).

Sex Education

Many children experience some form of sex play during or before preadolescence as a response
to normal curiosity, not as a result of love or sexual urges. Initial curiosity about differences in body
structures between boys and girls and between children and adults arises in the preschool years.
Middle childhood is an ideal time for formal sex education, and many authorities believe that the topic is
best presented from a life span approach. Information about sexual maturation and the process of
reproduction minimizes the child’s uncertainty, embarrassment, and feelings of isolation that often
accompany puberty. An important component of ongoing sex education is effective communication
with parents. If parents either repress the child’s sexual curiosity or avoid dealing with it, the sexual
information that the child receives may be acquired almost entirely from peers. When peers are the
primary source of sexual information, it is transmitted and exchanged in secret conversation and
contains a large amount of misinformation.

When presenting sexual information nurses should treat sex as a normal part of growth and
development. They should answer questions honestly, matter-of-factly, and to the same extent as
questions about other topics. Answers should be at the child’s level of understanding. There may be
times boys and girls should be taught separately. Children need explanations of information that is
provided in the media. Information concerning pregnancy,; contraceptives; and sexually transmitted
infections should be presented in simple, accurate terms. Preadolescents need precise and concrete
information that will allow them to answer questions such as “What if I start my period in the middle of
class?” or “How can I keep people from telling I have an erection?” it is important to tell children what
they want to know and what they can expect to happen as they become mature sexually.

Injury Prevention

The number of injuries in middle childhood is diminished compared with the number in early
childhood. The most common cause of severe injury and death in school-age children is motor vehicle
accidents- either as a pedestrian or passenger. It is important that nurses continue o emphasize three
automobile safety measures that have been found to reduce the severity of injuries: effective care
restraint systems, door-lock mechanisms, and appropriate passenger-seating locations in the motor
vehicle. The rear vehicle seat is the safest place for children under the age of 13.

The school-age child’s desire for riding bicycles increases the risk of injury on streets. Other
serious injuries include accidents on skateboards, roller skates, in-line skates, scooters, and other sports
equipment. All-terrain vehicles (ATVs), popular with children younger than 16 years of age, are
unstable, difficult to handle, and responsible for an increasing number of childhood injuries.

Most injuries occur in or near the home or school. The most effective means of prevention is
education of the child and family regarding the hazards of risk taking and the improper use of
equipment. Safety helmets, protective eye and mouth shields, and protective padding are strongly
recommended for children engaging in active sports. Falls from bicycles, ATVs, and skating devices are
the cause of a significant number of head injuries in school-age children.

Physically active school-age children are also highly susceptible to cuts and abrasions, and the
incidence of childhood fractures, strains, and sprains is high. Trampoline injuries are highest in children
5-14 years and are not recommended for children of any age. Other possible injuries to the school- age
child are: drowning, burns, and poisoning.
Immunizations

*TDaP: (Minimum age: 10 years for Boostrix and 11 years for Adacel). Administer at age 11 or
12 years for those who have completed the recommended childhood DTP/DTap vaccination
series and have not received a tetanus and diphtheria toxoid (Td) booster dose.

*HPV: (Minimum age: 9 years). HPV4 1st dose to females at 11 or 12 years to prevent cervical,
vaginal and vuvlar precancers and cancers and genital warts.

*Meningococcal conjugate vaccine (MCV4): Administer at age 11 or 12, or at age 13-18 if not
previously vaccinated.

*Influenza vaccine (seasonal): Administer annually to children age 6 months- 18 years or for
healthy non pregnant persons age 7-18 years.

*Pneumococcal polysaccharide vaccine (PPSV): Administer to children with certain underlying

medical conditions.

*Hepatitis A vaccine (HepA): Administer 2 doses at least 6 months apart. Children older than 23
months.

*Hepatitis B vaccine (HepB): A 2-dose series (separated by at least 4 months) of adult

formulation Recombivax HB is licensed for children aged 11-15.

*IPV

*MMR

*Varicella vaccine: for persons aged 7 through 18 years with minimal interval between doses of
3 months.

*Screenings for TB

Hospitalized School Age Child

The school- age child is more independent and demonstrates concern for personal cleanliness
and appearance. The child may express a need for privacy. Any questions the child has should be
answered honestly and at the child’s level of understanding. Preadolescents need precise and concrete
information.
 ADOLESCENT (11-20 years old)-Perry Ch. 40

Biologic Development

Proportional Changes

Adolescence is a transition between childhood and adulthood in which the gradual appearance
of secondary sex characteristics occurs at age 11 or 12 years of age and ends with the cessation of body
growth at 18 or 20 years of age. There are 3 sub phases of adolescence: 1) early adolescence 11-14, 2)
middle adolescence 15-17, and 3) late adolescence 18-20.

The growth spurt begins earlier in girls usually between the age of 9 ½ and 14 ½ years old. The
average girl gains 2 to 8 inches in height and 15 ½ to 55 lbs in weight during adolescence. Growth in
height typically ceases 2 to 2 ½ years after menarche in girls. The hips in the female also become
broader during this time. This is due to epiphyseal unity under the potent effect of estrogen secretion
and the hormonal effect on female bone growth.

In males, the adolescent growth spurt usually begins at ages 10 ½ and 16 years of age. During
this time, the average boy gains 4 to 12 inches in height and 15 ½ to 66 lbs in weight. Shoulder width
and muscle mass also increase during adolescence. Growth in height typically ceases at age 18 to 20
years of age in boys.

Maturation of Systems

Puberty occurs when the reproductive organs begin to function and the secondary sex
characteristics develop. There are 3 stages of puberty: 1) prepubescence-2 years before puberty when
the child is developing preliminary physical changes that herald sexual maturity, 2) puberty-the point at
which sexual maturity is achieved, marked by the first menstrual flow in girls but less evident in boys,
and 3) postpubescence-1 to 2 years following puberty during which skeletal growth is completed and
reproductive functions become fairly well established.

The body changes during adolescence in response to different hormones being secreted. The
anterior pituitary (adenohypophysis) controls the release of certain hormones when stimulated by the
hypothalamus. The ovaries, testes, and adrenal cortex are responsible for secretion of sex hormones.
Estrogen, the feminizing hormone, is secreted slowly in increasing amount in both sexes until age 11. It
is at its maximum level in females 3 years after the onset of the maturation. Androgen, the masculinizing
hormones, are also secreted in both sexes slowly in increasing amounts up to age 7 or 9 years, but
especially in males at age 15. With the onset of testicular function, the level of androgen (particularly
testosterone) increases in males over that in females and is at its maximum level at maturity.

In females, the appearance of breast buds or thelarche to full maturity may be 1 ½ to 6 years
which is between the ages of 9 to 13 ½ years old. About 2 to 6 months following thelarche growth of
pubic hair on the mons pubis or adrenarche develops in females; however, pubic hair may precede
breast development. Normally 2 years following pubescent changes, the appearance of the
menstruation or menarche occurs. The normal age of menarche is usually 10 ½ to 15 years of age.
Menarche has been related to critical gain in body fat content. Girls may be considered to have pubertal
delay if breast development has not occurred by age 13 or if menarche has not occurred within 4 years
of the onset of breast development.

In males, the first pubescent changes are testicular enlargement accompanied by thinning,
reddening, and increased looseness of the scrotum between ages 9 ½ to 14. During this time,
hypertrophy of the laryngeal mucosa and enlargement of the larynx and vocal cords causes
uncontrollable voice shifts from deep to high tones in the middle of a sentence. By late puberty, there is
a definite increase in the length and width of the penis, testicular enlargement continues, and the first
ejaculation occurs; nocturnal emissions or “wet dreams” follow as well. Concerns about pubertal delay
should be considered for boys who exhibit no enlargement of the testes or scrotal changes by 13 ½ to 14
years of age, or if genital growth is not complete 4 years after testicular enlargement begins.

Both sexes, under the influence of gonadal and adrenal androgens, develop body hair that
coarsens, darkens, and lengthens at sights related to secondary sex characteristics including pubic and
axillary hair. Males in early puberty also develop beard, mustache, and body hair on the chest, upward
along the back and shoulders. Facial hair in males usually develops 2 years after appearance of pubic
hair. Both sexes are also affected by acne due to increasingly active sebaceous glands and body odor
under the axillae when the apocrine glands secrete a thick substance as a result of emotional stimulation
combined with bacteria.

Fine and Gross Motor Development

The practice of sports, games, and even dancing contributes significantly to growth and
development. During adolescence, football, baseball, basketball, gymnastics, soccer, and cheerleading
are just some of the activities that enhance physical and social development.

Psychosocial Development

Erikson-group identity versus alienation

Traditional psychosocial theory holds that the development of adolescent leads to the formation
of a sense of identity. During this time the adolescent is faced with the crisis of group identity versus
alienation. The individual strives to attain autonomy from the family and develop a sense of personal
identity as opposed to role diffusion.

Cognitive Development

Piaget-formal operations phase

Cognitive thinking culminates with the capacity for the abstract thinking. This stage, the period
of formal operations, is Piaget’s forth and last stage. Adolescents are no longer restricted to the real and
actual, which was typical of the period of concrete thought; they are also concerned with the possible.
They now think beyond the present. They consider consequences of their actions and how things may
affect their future. They also become more open minded to others views and thoughts.
Moral Development

Kohlberg-conventional level

Although younger children merely accept the decisions or points of view of adults, adolescents,
to gain autonomy from adults, must substitute their own set of morals and values. Their decisions
involving moral dilemmas must be based on an internalized set of moral principles that provides them
with the resources to evaluate the demands of the situation and to plan actions that are consistent with
their ideals. Late adolescence is characterized by serious questioning of existing moral values and their
relevance to society and the individual.

Spiritual Development

As adolescents move toward independence from parents and other authorities, some begin to
question their families’ values and ideals. Others cling to these values as a stable element in their lives as
they struggle with the conflicts of this turbulent period. Adolescents need to work out these conflicts for
themselves, but they also need support from authority figures and/or peers for their resolution.

Social Development

Relationships

Personal friendships of the one-on-one variety usually develop between same-sex adolescents.
Since a sense of intimacy grows within a permanent relationship, the stability of this same-gender
friendship is an important link in the process toward an intimate relationship in young adulthood.

Clubs and Peer Groups

The peer group has an intense influence on adolescent’ self-evaluation and behavior so to gain
acceptance, younger teenagers tend to conform completely in such things as mode of dress, hairstyle,
taste in music and vocabulary. Teenagers use the peer group as a yardstick of what is normal. The school
is psychologically important to adolescents as a focus of social life. Crowds of cliques of selected close
friends are formed during this time. Cliques are usually made up of one gender, and girls tend to be
more cliquish than boys and have a greater need for closer friendships. Within the intimacy of the
group, adolescents gain support in learning about themselves, consideration for the feelings of others,
and increased ego development and self-reliance. To belong is of utmost importance; thus adolescents
behave in a way to ensure their establishment in a group. To be ignored or criticized by peers creates
feelings of inferiority, inadequacy, and incompetence.

Relationships with Families

During adolescence the parent-child relationship changes from one of protection-dependency to

one of mutual affection and equality. The process of achieving independence often involves turmoil and
ambiguity as both parent and adolescent learn to play new roles and work toward this end while, at the
same time, resolving the often painful series of rifts essential to establishing the ultimate relationship.
 As teenagers assert their rights for grown-up privileges, they frequently create tensions within
the home. Favorite topics of dispute include use of the home phone, internet use, a personal cell phone,
manners, dress, chores, homework, disrespectful behavior, friendships, dating, money, cars, alcohol,
substance abuse, and time schedules. Parents should be guided toward an authoritative style of
parenting in which authority is used to guide the adolescent while allowing developmentally
appropriate.

Interests and Activities

Many adolescents must learn to juggle their time between school, activities, and the
responsibility of a job. It is generally recommended that adolescents limit their work hours to no more
than 20 hours per week while in school.

Development of Self Concept and Body Image

The sudden growth that takes place in early adolescence creates feelings of confusion. They
have lost the security of a familiar body and feel uncomfortable with their altered body. Experts have
determined that the body image established during adolescence is the one that individuals retain
throughout life. The self-concept becomes more differentiated as adolescents acquire a more complex
picture of themselves, one that takes situational factors into account. The self-concept gradually
becomes more individualized and more distinct from the concepts of others.

Nutrition

The rapid and extensive increase in height, weight, muscle mass, and sexual maturity during
adolescence is accompanied by increased nutritional requirements. The need for minerals, calcium, iron,
and zinc substantially increase during periods of rapid growth. Girls with heavy or frequent menses may
especially susceptible to iron deficiency due to blood loss.

Sleep and Activity

During growth spurts, the need for sleep is increased. Rapid physical growth, the tendency
toward overexertion, and the overall increased activity of this age contributes to fatigue in adolescence.
Adequate sleep and rest at this time are important to a total health regimen.

Adolescents spend more time and energy practicing and participating in sports than any other
age group. To improve health outcomes, school-aged children and adolescents should engage in 60
minutes or more of exercise daily.

Dental Health

Flossing and regular tooth brushing in adolescence serves to remove plaque and prevent
periodontal disease.
Personal Care

Body changes associated with puberty brings special needs for cleanliness. The hyperactive
sebaceous glands and newly functioning apocrine glands make frequent bathing or showering a
necessity and underarm deodorants and antiperspirants important.

Regular vision testing is an important part of healthcare and supervision during adolescence.
The increased demands of school work make adequate vision essential for academic success. It has been
documented that continuous exposure to loud sounds of music can cause cochlear damage; permanent
hearing loss can occur.

Scoliosis is a defect from the spine that occurs frequently in adolescence and is more common in
girls than in boys. The majority of these cases are idiopathic, and the defect manifests as a painless
curvature of the spine. All curvatures of the spine should be referred for further evaluation.

Piercing and tattooing is used to assist with adolescent identity formation. Although most cases
of piercing are accompanied by few if any serious side effects, there is always a danger of complications
such as infection, abscess formation, cyst, or keloid formation, bleeding, dermatitis, or metal allergy.
Using the same unsterilized needle to pierce body parts of multiple teenagers present the same risk of
human immunodeficiency virus (HIV), hepatitis C, and hepatitis B virus transmission as occurs with other
needle sharing activities. Amateur tattoo artists benefit from discussions about standard precautions
and the hepatitis B vaccination.

Low term effects of sunbathing and using tanning beds include premature aging of the skin,
increased risk of skin cancer, and, in susceptible individuals, phototoxic reactions. Those who insist on
using tanning equipment should be warned that goggles must be worn to prevent serious corneal
burning.

Stress Reduction

The multiple changes in adolescence can result in great stress. Adolescence is faced with great pressures
from peers that often involve flouting adult authority and taking serious health risks. Adolescents use
being alone as a method of coping with stress. Health professionals need to assess whether this
indicates clinical depression.

Injury Prevention

Physical injuries are the greatest single cause of death in the adolescent age group and claim
more loves than all other causes combined. The most vulnerable ages are 15 to 24, when accidental
injuries account for about 60% of death in boys and 40% in girls. Their propensity for risk taking behavior
plus feelings of indestructibility makes adolescents especially prone to injuries.

The major risk for death in a motor vehicle accident is failure to use a safely restraint, so
teenagers should be encouraged to always buckle-up. If riding a bike, adolescents should be taught to
wear safety apparel and to have a light on the bike at night.
 Adolescence is the peak age for being either a victim or an offender in an injury involving
firearm. Gun availability in the home is strongly linked to unintentional death and injury to children.
When guns are present in the home, families should be certain that they are never loaded, locked up in
a safe place, and ammunition is stored and locked up separately.

Every sport has some potential for injury, whether one participates in serious completion or for
pure enjoyment. A large number of severe or fatal injuries occur to youths who are not prepared for the
activity. Adolescence should be taught the proper instruction in sports and use of sports equipment.
They should also be taught to wear protective equipment.

Immunizations

*Adolescents 11 to 18 years of age should receive a single tetanue-diptheria-acellular pertussis

(Tdap) vaccine if they have received the recommended childhood series of DTap immunizations.
The adolescent who has received Td but not Tdap vaccine should also receive a single dose of
the Tdap vaccine, provided 5 years have elapsed between the Td and Tdap vaccination.

*Meningococcal vaccine (MCVA) should be given to adolescents 11 to 12 years old or at 15 years

old if previous immunization with MPSV4 occurred in childhood and at least 3 to 5 years have
passed since primary immunization.

*The human papillomavirus vaccine series is recommended for girls based on research at this
time. The series may start as early as 9 years of age with the second and third doses at months
and 6 months.

*Except for pregnant teenagers, all adolescents should receive a second measles-mumps-rubella
(MMR) vaccine unless they have documentation of 2 MMR vaccinations during childhood.

*All adolescents who have not previously received three doses of hepatitis B vaccine should be
vaccinated against hepatitis B virus. Hepatitis A vaccine should be given to all adolescents as
part of the two-dose series may be completed in childhood.

*Annual influenza vaccination with either a live attenuated influenza vaccine or trivalent
influenza vaccine is now encouraged for all children and adolescents.

*Varicella vaccine is recommended for those with no previous history of chicken pox. It may be
given in two doses 4 or more weeks apart for adolescents 13 years and older.

Hospitalized Adolescent

When hospitalized, adolescents may produce varied emotions, ranging from difficulty coping to
welcoming the event when separated from home and parents. However, loss of peer group contact may
pose an emotional threat because of loss of group status, inability to exert group control and leadership,
and loss of group acceptance. Ill adolescents may benefit from group associations with other
hospitalized teens.
 Adolescents struggle for independence, self-assertion, and liberation centers on the quest for
personal identity. Illness, which limits one’ s physical abilities, and hospitalization, which separates one
form one’s usual support systems, constitute major situational crises. The patient role fosters
dependency and depersonalization. Adolescents may react to dependency as rejection,
uncooperativeness, or withdrawal. They may respond to depersonalization with self-assertion, anger, or
frustration. Regardless of the response elicited, hospital personnel often regard them as difficult,
unmanageable patients. They may feel threatened by others who relay facts in a condescending
manner. The nurse should do a careful assessment of the adolescents’ intellectual abilities, previous
knowledge, and present needs.
 YOUNG ADULT (20 to 40 years old)-Kozier Ch. 22

Physical Development

People in their early 20s are in their prime physical years. The human body is at its most efficient
functioning at about age 25 years. The musculoskeletal system is well developed and coordinated. This
is when athletic endeavors reach their peak. All other body systems are also functioning at peak
efficiency. Emerging adults, however, tend to be high-risk takers, placing their high functioning bodies at
substantial risk of serious injury. Physical changes are minimal at this stage; weight and muscle mass
may change with diet and exercise.

Psychological Development

Common stressors among young adults include concerns about finances, divorce of parents,
worries about loyalty and disloyalty to others, occupational and educational choices, and all the new
roles they must take. They may have anxiety about making the right choices or even depression from all
the added responsibilities.

Psychosocial Development

Erikson-intimacy versus isolation

The young adult is in the intimacy versus isolation phase of Erikson’s stages of development.
Establishing a firm sense of self, and then reaching to others to develop loving, intimate relationship is
key. Choice of a lifelong partner and considerations of childbearing depend upon successful negotiation
of intimacy. Young adults face a number of new experiences and changes in lifestyle. They make choices
about education and employment, whether to marry or to be single, about starting a home, and about
rearing children. Some young adults choose not to marry and live with their partner, either same or
opposite sex. Some people who are gay or lesbian choose to marry their partner.

Cognitive Development

Piaget-formal operations phase

Piaget’s last phase of cognitive development, age 11 to 15 years, is the formal operations phase.
Even though technically it does not apply to young adults, young adults are able to use formal operation,
characterized by the ability to think abstractly and employ logic. For example, young adults are able to
generate hypotheses about what will happen, given a set of circumstances, and do not have to engage
in trial-and-error behavior.
Moral Development

Kohlberg-postconventional level

Young adults who have mastered the previous stages of Kohlberg’s theory of moral
development enter the post conventional level. At this time, the person is able to separate self from the
expectations and rules of others and to define morality in terms of personal principles.

Spiritual Development

According to Fowler, the individual enters the individuating-reflective period sometime after 18
years old. During this period a person focuses on reality. A 27 year old adult may ask philosophical
questions regarding spirituality and may be self-conscious about spiritual matters.

Health Problems

Young adulthood is generally a healthy time of life. Health risks that do occur are commonly
behaviors that possibly could be prevented. Unintentional injuries (primarily motor vehicle accidents)
are the 5th leading cause of death for the total population but the leading cause of death for people 1 to
44 years of age.

Suicide is the 3rd leading cause of death among adolescents and the leading cause of death
among young adults in the United States. Many suicides may actually be mistaken for accidental death
such as car accidents, combining alcohol and barbiturates, or discharging a gun while cleaning it.

Hypertension is a major concern for young African American adults, particularly men. In addition
to biologic inheritance, contributing factors may include smoking, obesity, a high-sodium diet, and high
stress levels.

Substance abuse is a major threat to the health of young adults. Prolonged use can lead to
physical and psychological dependency and subsequent health problems. For example, prolonged use of
alcohol can lead to cirrhosis of the liver and cancer of the esophagus.

STD’s such as genital herpes, AIDS, syphilis and gonorrhea are common infections in young
adults. Chlamydia is the most prevalent STD, and in fact is the most prevalent infectious disease in the
United States.

Many young adults battle with obesity. According to Healthy People 2010, 23% of adults age 20
and older are obese.

The youth are the perpetrators and victims of violence. For example, Health People 2010 reports
homicide is the second leading cause of death for young person’s 15 to 24 years of age and the leading
cause of death for African Americans in this age group.
 The problem of battered or abuse of women affects families of all socioeconomically levels.
Stressors that predispose families to abuse may include financial problems, separation from family and
community support, and physical as well as social isolation.

Testicular cancer is the most common neoplasm in men age 20 to 34 years of age. In women,
cancer of the breast is the leading cause of death. Breast cancer is rare under the age of 25, but the risk
increases after the age of 30.

Health Assessment and Promotions

Health Assessment Guidelines

In these 3 development areas, does the young adult do the following?

1) Physical Development

*Exhibit weight within normal range for age and sex

*Manifest vitals within normal range

*Demonstrate visual and hearing abilities within normal range

*Exhibit appropriate knowledge and attitudes about sexuality

2) Psychosocial

*Feel independent from parents

*Have a realistic self-concept

*Like self and direction life is going

*Interact well with family

*Cope with stresses of change and growth

*Have well-established bonds with significant others

*Have a meaningful social life

*Demonstrate emotional, social and economic responsibility of own life

*Have a set of values that guide behavior

3) Development of Activities of Daily Living

*Have a healthy lifestyle

Health Promotion Guidelines

1) Health Tests and Screenings

*Routine physical examination (every 1 to 3 years for females; every 5 years for males)

*Immunizations as recommended, such as tetanus-diphtheria booster every 10 years,

meningococcal vaccine if not given in early adolescence and hepatitis B vaccine.

*Regular dental assessment (every 6 months)

*Periodic vision and hearing screenings

*Professional breast examination every 1 to 3 years

*Papanicolaou smear annually within 3 years of onset of sexual activity

*Testicular examination every year

*Screening for cardiovascular disease (cholesterol test every 5 years if results are normal; blood

pressure to detect hypertension; baseline electrocardiogram at age 35)

*Tuberculosis skin test every 2 years

*Smoking history and counseling, if needed

2) Safety

*Motor vehicle reinforcement (using designated drivers when drinking; maintaining brakes and

tires)

*Sun protective measures

*Workplace safety measures

*Water safety reinforcement (no diving in shallow waters)

3) Nutrition and Exercise

*Importance of adequate iron intake in diet

*Nutritional and exercise factors that may lead to cardiovascular disease include obesity,

cholesterol and fat intake, and lack of vigorous exercise

4) Social Interactions
* Encourage personal relationships that promote discussion of feelings, concerns, and fears

* Setting short and long-term goals for work and career choices
 MIDDLE ADULT (40 to 65 years old)-Kozier Ch. 22

Physical Development

During middle adulthood many physical changes take place. For example, hair begins to thin and
gray hair appears; skin turgor and moisture decreases and subcutaneous fat decreases which cause
wrinkles. Fatty tissue is redistributed, resulting in fat deposits in abdominal area.

The skeletal muscle bulk decreases at age 60. Thinning of the intervertebral discs causes a
decrease in height of about 1 inch. Calcium loss from bone tissue is more common among
postmenopausal women. Muscle growth continues in proportional to use.

In the cardiovascular system, blood vessels lose elasticity and become thicker. Visual acuity
declines, often by the late 40s, especially for near vision (presbyopia). Auditory acuity for high-frequency
sounds also decreases (presbycusis), particularly in men. Taste sensations also diminish and metabolism
slows which may result in weight gain.

Gradual decrease in tone of large intestine may predispose the individual to constipation.
Neupron units are lost during this time and glomerular filtration rate decreases in the urinary system.

Hormonal changes take place in both men and women. Menopause occurs in women around 40
and 55 years of age; the average is 47 years of age. At this time, ovarian activity declines around until
ovulation ceases. Common symptoms related to a decline in estrogen include hot flashes, chilliness, a
tendency of the breasts to become smaller and less dense, and a decrease in metabolic rate that may
lead to weight gain; insomnia and headaches may also occur.

In men and women, sexual arousal takes longer in midlife. In men particularly, androgen levels
decrease very slowly; however, men can father children even in late life. Also, climacteric (andropause)
has been used to denote the change is sexual response in men, but there is no change comparable to
the menopause in women.

Psychological Development

Psychologically, the menopause can be an anxiety-producing time, especially if the ability to

bear children is an integral part of the women’s self concept. In men, anxiety can occur as well due to
difficulties in achieving sexual arousal.

Psychosocial Development

Erikson-generativity versus stagnation

Erikson viewed the middle aged adult as generativity versus stagnation. Generativity is defined
as the concern for establishing and guiding the next generation. In other words, the concern for
providing for the welfare of human kind is equal to the concern of proving for self. Generative middle-
aged persons are able to feel a sense of comfort in their lifestyle and receive gratification form
charitable endeavors.
 Erikson wrote that people who are unable to expand their interests at this time and who do not
assume the responsibilities of middle age suffer from a sense of boredom and impoverishment, that is,
stagnation. These people have difficulty accepting their aging bodies and become withdrawn and
isolated.

The “midlife crisis” occurs at this time when individuals recognize that they have reached the
halfway mark of life and youthfulness and physical strength can no longer be taken for granted. Some
may regress to younger patterns of behavior, for example, adolescent behavior.

Cognitive Development

Piaget-formal operations phase

Piaget’s formal operations phase may still apply to middle-adulthood but it is not discussed. The
middle-aged adult’s cognitive and intellectual abilities change very little. Cognitive processes include
reaction time, memory, perception, learning, problem solving, and creativity.

Reaction time stays the same or diminishes in later middle adulthood. Memory and problem
solving are maintained and learning continues to be enhanced by increased motivation at this time in
life. Problem solving and task completion may vary with different experiences in each individual.

Moral Development

Kohlberg-postconventional level

According to Kohlberg, the adult can move beyond the conventional level to the
postconventional level. He believed that extensive experience of personal moral choice and
responsibility is required before people can reach the postconventional level. Kohlberg found that few
of his subjects achieved stage 5, the highest level of moral reasoning.

Spiritual Development

In middle ages, people tend to be less dogmatic about religious belief, and religion often offers
more comfort to the middle-aged person than it previously did. People often rely on spiritual beliefs to
help them deal with illness, death, and tragedy.

Health Problems

Motor vehicle crashes are the most common cause of unintentional death in this age group.
Decreased reaction times and visual acuity may make the middle aged group prone to injury. Other
unintentional causes of death for middle aged adults includes falls, fires, burns, poisonings, and
drowning.

Cancer is the second leading cause of death among people between the ages of 25 and 64 in the
United States. Men have a higher incidence of cancer in the lung and bladder. In women, breast cancer
is highest in incidence, followed by cancer of the colon and rectum, uterus, and lung.
 Coronary heart disease (CHD) is the leading cause of death in the United States for the middle-
aged adult. Smoking, obesity, hypertension, hyperlipidemia, diabetes mellitus, sedentary lifestyle, a
family history of myocardial infarctions or death in a father less than 55 years old or in a mother less
than 65 years old are contributing factors to the risk of CHD.

Decreased metabolic activity and decreased physical activity mean a decrease in caloric need.
Clients should be educated that being overweight is a risk factor for chronic diseases such as diabetes
and hypertension and problems of mobility such as arthritis.

The excessive use of alcohol can result in unemployment, disrupt homes, injuries, and diseases.
It is estimated that 4 million people in the United States are dependent on alcohol and can be
considered alcoholics.

Developmental stressors, such as menopause, climacteric, aging, and impending retirement and
situational stressors such as divorce, unemployment, and death of a spouse, can precipitate increased
anxiety and depression in middle aged adults.

Health Assessment and Promotion

Health Assessment Guidelines

In these 3 areas of development, does the middle aged adult do the following?

1) Physical Development

*Exhibit weight within normal range for age and sex

*Manifest vital signs within normal range for age and sex

*Manifest visual and hearing abilities within normal range

*Exhibit appropriate knowledge and attitudes about sexuality

*Verbalize any changes in eating, elimination, or exercise

2) Psychosocial Development

*Accept aging body

*Feel comfortable and respect self

*Enjoy new freedom to be independent

*Accept changes in family roles

*Interact effectively and share companionable activities with life partner

*Expand and renew previous interests

 *Pursue charitable and altruistic activities

*Have a meaningful philosophy of life

3) Development in Activities of Daily Living

*Follow preventative health practice

Health Promotion Guidelines

1) Health Tests and Screening

*Physical examination (every 3 to 5 years until age 40, then annually)

*Immunizations as recommended, such as a tetanus booster every 10 years, and current

recommendations for influenza vaccine

*Regular dental assessments every 6 months

*Tonometry for signs of glaucoma and other eye diseases every 2 to 3 years or annually if

indicated

*Breast examination annually by primary care provider

*Testicular examination annually by primary care provider

*Screenings for cardiovascular disease

*Screenings for colorectal, breast, cervical, uterine, and prostate cancer

*Screenings for tuberculosis every 2 years

*Smoking history and counseling, if needed

2) Safety

*Motor vehicle safety reinforcement, especially when driving at night

*Workplace safety measures

*Home safety measures: keeping hallways and stairways lighted and uncluttered, using smoke

detectors, using nonskid mats and handrails in the bathrooms

3) Nutrition and Exercise

*Importance of adequate protein, calcium, and vitamin D in diet

 *Nutritional and exercise factors that may lead to cardiovascular disease

*An exercise program that emphasizes skill and coordination

4) Social Interactions

*The possibility of a midlife crisis: encourage discussion of feelings, concerns, and fears

*Retirement planning with partner if appropriate

 ELDER ADULT (65 and older)-Kozier Ch. 23

Physical Development

The skin becomes drier, less elastic, and more fragile, making the older person more susceptible
to skin tears and shearing injuries. The hair loses color, the fingernails and toenails become thickened
and brittle, and in women over 60, facial hair increases. Progressive wrinkling and sagging of the skin
occurs due to loss of elasticity, increased dryness, and decreased subcutaneous fat. Brown “age spots”
(lentigo senilis) on face, hands, and arms appear due to clustering of melanocytes.

Sarcopenia or a steady decrease is muscle fibers related to denervation of the muscle begins
around 50 years old leading to a wasted appearance. Loss of muscle strength leads to imbalance in the
elderly. Muscle endurance diminishes resulting in muscle fatigue after short periods of exercise.
Decreased muscle tone can result in delayed reaction time. Loss of overall statue occurs with age which
can be exaggerated by muscular weakness resulting in a stooping posture and kyphosis (humpback of
the upper spine).

Imbalance in rates of absorption and formation of bone tissue occurs with aging causing
osteoporosis and may lead to fractures called pathogenic fractures. Joint stiffness may also occur due to
drying and loss of elasticity in joint cartilage. Fewer cells in cerebral cortex may lead to greater difficulty
in complex learning and abstraction.

Each of the five senses becomes less efficient in older adulthood. Changes in vision associated
with aging include the shrunken appearance of the eyes due to loss of orbital fat, the slowed blinking
reflex, and the looseness of the eyelids, particularly the lower lid, due to poorer muscle tone. Other
changes resulting in loss of visual acuity are less power of adaptation to dark and dim light, a decrease in
accommodation to near and far objects, loss of peripheral vision, atrophy of lacrimal glands resulting in
dry eyes, and difficulty in discriminating similar colors, especially blues, greens, and purples.

Presbyopia, the inability to focus or accommodate due to loss of flexibility of the lens, causes a
decrease in near vision around 40. Cataracts or lens opacity occurs at age 80 which reduces visual acuity
and causes a glare to be a problem. Age related muscular degeneration (ARMD), glaucoma, and diabetic
retinopathy are other conditions that reduce visual acuity and blindness in the elderly.

Older people have a poorer sense of taste and smell and are less stimulated by food than the
young. Sweet sensations at the tip of the tongue are especially decreased. Taste sensations are
decreased due to decrease in number of taste buds in the tongue and because of tongue atrophy. Loss
of skin receptors takes place gradually, producing an increased threshold for sensations of pain, touch,
and temperature. This puts elders at a higher risk of injury.

Respiratory efficiency is reduced with age. Tidal volume (the amount of air moved in and out
during normal respirations) remains the same, but the older adult has a decreased vital capacity. This
means the older adult is unable to compensate for an increased oxygen need by significantly increasing
amount of air inspired, dyspnea occurs frequently. A greater volume of residual air is left in the lungs
after expiration, and the capacity to cough efficiently decreases because of weaker expiratory muscles.
Mucous secretions tend to collect making the elder susceptible to respiratory infections.

Reduced cardiac output and stroke volume, particularly during increased activity may result in
shortness of breath on exertion and pooling of blood in the extremities; this is due to increased rigidity
and thickness of heart valves and decreased contractile strength. Orthostatic hypertension (abrupt drop
in systolic blood pressure) may occur due to reduced arterial elasticity.

Periodontal disease occurs with age leading to tooth loss. Tooth enamel becomes hard and
more brittle causing fractures. The root of the tooth shrinks and the gingival reacts. Reduced saliva may
lead to xerostoma (dry mouth) and make the oral mucosa more susceptible to infection. Decreased
esophageal motility causes slowing of the esophageal emptying process. Decreased stomach motility,
emptying time, and a higher pH of the stomach contribute to increased incidence of gastric irritation.
Also, decreased production of intrinsic factor leads to pernicious anemia. There is also decreased
intestinal absorption, motility, and blood flow in the elderly.

The kidney’s filtering abilities may be impaired thus waste products may be filtered and
excreted more slowly due to decreased number of nephrons. More noticeable changes of the bladder
are urinary urgency and urinary frequency due to enlarged prostate in men and weakened muscles
supporting the bladder or weakness of the urinary sphincter in women. Decreased bladder capacity and
tone causes nocturnal frequency and retention of residual urine in the elderly.

In men, the prostate enlarges with age. Also, due to changes in blood supply, there is a decrease
in firmness of erection and increased refractory period. In women, there are multiple changes such as
shrinkage and atrophy of the vulva, cervix, uterus, fallopian tubes, and ovaries; reduction in secretions
and changes in the vaginal flora due to a decrease in estrogen and more alkaline vaginal pH. In both
sexes, the changes in blood supply to the penis and clitoris cause an increased time to sexual arousal.

With aging, t cells are less responsive to antigens and B cells produce fewer antibodies which
causes a decreased immune response and lower resistance to infections. Immune system changes may
precipitate insulin resistance causing poor response to immunizations. Decreased thyroid function and
increased insulin resistance is evident with age but the mechanism in unclear.

Psychological Development

Changes in appearance with age vary among individuals and cultures. For example, one person
may feel embarrassed or depressed, interpreting gray hair as a sign of losing one’s youth. The elderly
may also experience stress and anxiety when coping with the changes in their life such as relocation,
being a grandparent, retirement, or facing death.
Psychosocial Development

Erikson-ego integrity versus despair

According to Erikson, the developmental task at this time is ego integrity versus despair. People
who attain ego integrity view life with a sense of wholeness and derive satisfaction from past
accomplishments. They view death as an acceptable completion of life. People who develop integrity
accept “one’s one and only life cycle” (Erikson, 1963). By contrast, people who despair often believe
they have made poor choices during life and wish they could live life over.

Cognitive Development

Piaget-formal operations phase

Piaget’s phases of cognitive development end with the formal operation phase. However,
considerable research on cognitive abilities and aging is currently being conducted. Intellectual capacity
includes perception, cognitive ability, memory, and learning.

Perception, or the ability to interpret the environment, depends on the acuteness of the senses.
If the aging person’s senses are impaired, the ability to perceive the environment and react
appropriately is diminished. In elders, changes in cognitive abilities are more often a difference in speed
than in quality. Overall, the older adult maintains an intelligence, problem solving, judgment, creativity,
and other well practiced cognitive skills.

Memory is also a component of intellectual capacity that involves sensory memory, short term
memory, and long term memory. In elders, retrieval of information from long term memory can be
slower, especially if the information is not frequently used. Most age related differences, however, occur
in short term memory. Older adults need additional time for learning, largely because of the problem of
retrieving information.

Moral Development

Kohlberg-postconventional level

According to Kohlberg, moral development is completed in the elderly adult years. Kohlberg
hypothesized that an older person at the postconventional level obeys rules to avoid pain and the
displeasure of others. Elders at the conventional level follow society’s rules of conduct in response to
the expectations of others.

Spiritual Development

Elders can contemplate new religions and philosophical views and try to understand ideas
missed previously or interpreted differently. Many elders take their faith and religious practice very
seriously, and display a high level of spirituality. Many older people have strong religious convictions and
continue to attend religious meetings or services.
Health Problems

Healthy People 2010 reports that falls account for 87% of all fractures among adults 65 years
and older. Because vision is limited, reflexes are slower, and bones are brittle, caution is required when
climbing stairs, driving a car, and even walking. Fires are a hazard for the elder with a failing memory.
Elders may forget the stove is left on or may not extinguish a cigarette completely. Many elders suffer
and die each year from hypothermia (a body temperature below normal). A lowered metabolism and
loss of normal insulation from thinning subcutaneous tissue decrease the older client’s ability to retain
heat.

Arthritis, osteoporosis, heart disease, stroke, obstructive lung disease, hearing and visual
alterations and cognitive dysfunctions are some chronic illnesses that older adults suffer from. In
addition, acute illnesses such as pneumonia, fractures, and trauma from falls, motor vehicle crashes, or
other incidents may create chronic health problems.

The average elder in the United States takes 4 to 5 prescription drugs and 2 over-the-counter
medications every day. The complexities involved in the self administration of medication may lead to a
variety of misuse situations, including taking too much or too little medication, combining alcohol and
medication, combining prescription medications with OTC drugs, taking medication at the wrong time,
or taking someone else’s medication.

Chronic drinking has major effects on all the body systems, causes progressive liver and kidney
damage, damages the stomach and related organs, and slows mental response, frequently leading to
injuries and death. Also, for the older adult who has a chronic illness and takes many medications, the
combination of drugs and alcohol can lead to serious drug overdose. Dementia is a progressive loss of
cognitive function. It is critical that dementia be differentiated from delirium, an acute and reversible
syndrome.

Approximately 1 million to 2 million Americans over the age of 65 have been abused, neglected,
or exploited. Elder mistreatment may affect either sex; however, the victims most often are women over
75 years of age, physically or mentally impaired, and dependent for care on the abuser. The abuse may
be physical, psychological, or emotional abuse; sexual abuse; financial abuse; violation of human rights;
and active or passive neglect.

Health Assessment and Promotion

Health Assessment Guidelines

In these 3 areas, does the elder do the following?

1) Physical Development

*Adjust to physiologic changes

*Adapt lifestyle to diminishing energy and ability

 *Maintain vital signs within normal range for age and sex

2) Psychosocial Development

*Manage retirement in a satisfying manner

*Participate in social and leisure activities

*Have a social network of friends and support persons

*View life as worthwhile

*Have high self-esteem

*Gain support from value system and/or spiritual philosophy

*Accept and adjust to the death of significant others

3) Development in Activities of Daily Living

*Exhibit healthy practices in nutrition, exercise, recreation, sleep patterns, and personal habits

*Have the ability to care for self or to secure appropriate help with activities of daily living

*Have satisfactory living arrangements and income to meet changing needs

Health Promotion Guidelines

1) Health Tests and Screenings

*Total cholesterol and high-density lipid protein measurement every 3 to 5 years until age 75

*Aspirin, 81 mg daily, if in high risk group

*Diabetes mellitus screening every 3 years, if in high-risk group

*Smoking cessation

*Screening mammogram every 1 to 2 years

*Clinical breast examination annually

*Pap smear annually if there is a history of abnormal smears or previous hysterectomy for

malignancy; older women who have regular, normal Pap smears or hysterectomy for

nonmalignant causes do not need Pap smears beyond the age of 65

*Annual digital rectal exam

 *Annual prostate-specific antigen (PSA)

*Annual fecal occult blood test (FOBT)

*Sigmoidoscopy every 5 years; colonoscopy every 10 years

*Visual acuity screening annually

*Hearing screening annually

*Depression screen periodically

*Family violence screen periodically

*Height and weight measurements annually

*Sexual transmitted disease testing, if at high risk

*Annual flu vaccine if over 65 or in high risk group

*Pneumococcal vaccine at 65 and every 10 years thereafter

*Td vaccine every 10 years

2) Safety

*Home safety measures to prevent falls, fires, burns, scalds, and electrocution

*Working smoke detectors and carbon monoxide detectors in the home

*Motor vehicle safety reinforcement, especially when driving at night

*Elder driving skills evaluation

*Precautions to prevent pedestrian accidents

3) Nutrition and Exercise

*Importance of a well balanced diet with fewer calories to accommodate lower metabolic rate

and decreased physical activity

*Importance of sufficient amounts of vitamin D and calcium to prevent osteoporosis

*Nutritional and exercise factors that may lead to cardiovascular disease

*Importance of 30 minutes of moderate physical activity daily; 20 minutes of vigorous physical

activity 3 times per week

4) Elimination

*Importance of adequate roughage in the diet, adequate exercise, and at least 8-ounce glasses

of fluid daily to prevent constipation

5) Social Interactions

*Encouraging intellectual and recreational pursuits

*Encouraging personal relationships that promote discussion of feelings, concerns, and fears

*Assessment of risk factors for maltreatment

*Availability of social community centers and programs for seniors