III – Nursing Care of a Family with a Toddler

Toddler period - spans from 1 to 3 years. A lot of changes take place in a child and then
eventually in a family. During this stage, children develop sense of autonomy (independence).
As a counterpart for this development, parents must also change their approach during this
period. The role of the parents during this time is to support their child’s growing autonomy Page | 52
with patience and sensitivity and to learn techniques when dealing with the child’s frustrations
that arise from searching independence.

Target outcomes of this learning module:

a. Describe the normal characteristics of

a toddler as well as common parental Key Terms
concerns.
b. Use critical thinking to analyze ways • Assimilation
to care for a toddler. • Autonomy
c. Assess a toddler for normal growth • Deferred Imitation
and development milestones. • Discipline
d. Create a nursing care plan for a • Lordosis
normal toddler that will include the • Parallel Play
family. • Preoperational Thought
e. Integrate knowledge on toddlers’ • Punishment
physical, cognitive, social • Tertiary Circular Reaction
development in formulating nursing Stage
care interventions for the newborn.
f. Integrate knowledge of toddler growth
and development with nursing process to achieve quality maternal and child health
nursing care.

A. Physical Assessment
A typical toddler appearance can be seen in Box 30.2.

Weight, Height, and Head Circumference

A child gains only about 5 to 6 lb (2.5 kg) and

5 in (12 cm) a year during the toddler period,
lesser than the rate during the period of
growth in infancy.

Subcutaneous tissue, or baby fat, begins

to disappear toward the end of the second
year. (From a plump baby into a leaner, more
muscular little girl or boy).

Appetite decreases accordingly, yet

adequate intake of all nutrients is still
essential to meet energy needs (Rolfes,
Pinna, & Whitney, 2009).
Head circumference increases only about 2 cm during the second year compared to about 12
cm during the first year. Head circumference equals chest circumference at 6 months to 1 year
of age. By 2 years, chest circumference has grown greater than that of the head.
G&D Module 3: Toddler, Prepared by:
Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
Body Contour

Toddlers tend to
have a prominent
abdomen because
although they are
Page | 53
walking well, their
abdominal muscles
are not yet strong
enough to support
abdominal contents
as well as they will
later. They also have
a forward curve of
the spine at the
sacral area
(lordosis). As they become more experienced at walking, this will correct itself naturally. Many
toddlers, in addition, waddle or walk with a wide stance. This stance seems to increase the
lordotic curve, but it keeps them on their feet.

Teeth

Eight new teeth (the canines and the first molars) erupt during the second year. All 20
deciduous teeth are generally present by 2.5 to 3 years of age (Gonsalves, 2008).

Body Systems

Body systems continue to mature during this time:

 Respirations slow slightly but continue to be mainly abdominal.

 The heart rate slows from 110 to 90 beats per minute; blood pressure increases to
about 99/64 mm Hg.
 The brain develops to about 90% of its adult size.
 In the respiratory system, the lumens of vessels enlarge progressively so the threat of
lower respiratory infection becomes less.
 Stomach secretions become more acid; therefore, gastrointestinal infections also
become less common. Stomach capacity increases to the point a child can eat three
meals a day.
 Control of the urinary and anal sphincters becomes possible with complete myelination
of the spinal cord so toilet training is possible.
 IgG and IgM antibody production becomes mature at 2 years of age. The passive
immunity obtained during intrauterine life is no longer operative.

Growth and Developmental Milestones

DIMENSION CHARACTERISTICS
SENSORY ABILITIES  Visual acuity is fairly well established at 1 year;
Accommodation to near and far objects is fairly well
developed by 18 months and continues to mature with
age. At 3 years of age, the toddler can look away from
a toy prior to reaching out and picking it up. This
G&D Module 3: Toddler, Prepared by:
Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
 ability requires the integration of visual and
neuromuscular mechanisms.
 Senses of hearing, taste, smell, and touch become
increasingly developed and associated with each
other.
 Hearing in the 3-year-old is at adult levels.
 Taste buds are sensitive to natural flavors of food, Page | 54
and the 3-year-old prefers familiar odors and tastes.
 Touch is a very important sense and a distressed
toddler is often soothed by tactile sensations.
MOTOR ABILITIES  Fine muscle coordination and gross motor skills
improve during toddler years.

At the age of 18 months:

Can pick up raisins or cereal pieces and place them in
a receptacle.
Can also hold a spoon and a cup and can walk
upstairs with assistance.
Will probably crawl down the stairs.

At 2 years, toddlers:
Can hold a spoon and put it into the mouth correctly.
Able to run, their gait is steady, and they can balance
on one foot and ride a tricycle (Figure 21–6 •).

In the third year most children are toilet trained,

although they still may have the occasional accident
when playing or during the night.

Psychosocial  Freud: Ages of 2 and 3 years represent the anal

Development phase of development, when the rectum and anus
are the especially significant areas of the body.
 Erikson: viewed the period from 18 months to 3 years
as the time when the central developmental task is
autonomy versus shame and doubt.
Toddlers begin to develop their sense of autonomy by
asserting themselves with frequent use of the word
“no.”,Often frustrated by restraints to their behavior
Ages 1 and 3 may have temper tantrums. With the
guidance of their caregivers they slowly gain control
over their emotions. Parents need to have a great

G&D Module 3: Toddler, Prepared by:

Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
 deal of patience coupled with an understanding of the
importance of this developmental milestone.

 Self-concept refers to an individual’s perception of

their identity.

A child’s self-concept is formed by interpersonal Page | 55

experiences.

It is formed in accordance with the child’s ability to

perform tasks, academic performance, social
acceptance, and physical appearance.

Children learn to develop a sense of self-concept

through their immediate social environment, in which
their parents play a significant role. If the children’s
social interactions with their parents are negative
(e.g., constant disapproval regarding eating, toilet
training, or other behavior), the children may begin to
see themselves as bad. This perception is the basis
of a negative self-concept.

 Parents need to give toddlers positive input so

they can develop a positive and healthy self-
concept. With a healthy self-concept, the
toddler is better able to deal with periodic
failures later in life.

Although toddlers like to explore the environment,

they always need to have a significant person nearby.
Parents need to know that young children experience
acute separation anxiety, the fear and frustration that
come with parental absences (will be discussed later
in this module).

For example, toddlers may become highly anxious

when separated from their parents and admitted to a
hospital.

Regression or reverting to an earlier development

stage may be indicated by bed-wetting or using baby
talk. Nurses can assist parents by helping them
understand that this behavior is normal and indicates
that these toddlers are trying to establish their position
in the family.

 Experience with separation helps the child

cope with parental absences. Children need
room for exploration and interaction with other
children and adults. At the same time, they
need to know that the parental bond of a
loving and close relationship remains secure.
Cognitive  Piaget: Toddler completes the fifth and sixth stages of
Development the sensorimotor phase and starts the pre conceptual
phase at about 2 years of age.
G&D Module 3: Toddler, Prepared by:
Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
 In the fifth stage, the toddler solves problems by a
trial-and-error process.
By stage 6, toddlers can solve problems mentally.
For example, when given a new toy the toddler will
not immediately handle the toy to see how it works,
but will instead look at it carefully to think about how it Page | 56
works.

Preconceptual phase, toddlers develop considerable

cognitive and intellectual skills. They learn about the
sequence of time. They have some symbolic thought;
for example, a chair may represent a place of safety,
and a blanket may symbolize comfort.

Concepts start to form in late toddlerhood. A

concept develops when the child learns words to
represent classes of objects or thoughts. An example
of a concrete concept is table, representing a number
of articles of furniture that are all different but all
tables.
Moral Development  Kohlberg: The first level of moral development is the
pre conventional when children respond to
punishment and reward. During the second year of
life, children begin to know that some activities elicit
affection and approval. They also recognize that
certain rituals, such as repeating phrases from
prayers, also elicit approval. This provides children
with feelings of security. By 2 years of age, toddlers
are learning what attitudes their parents hold
about moral matters.
Spiritual  According to Fowler (1981), the toddler’s stage of
Development spiritual development is undifferentiated. Toddlers
may be aware of some religious practices, but they
are primarily involved in learning knowledge and
emotional reactions rather than establishing spiritual
beliefs. A toddler may repeat short prayers at
bedtime, conforming to a ritual, because praise and
affection result. This parental or caregiver response
enhances the toddler’s sense of security.
Reference: Kozier and Erb’s Fundamentals of Nursing, 10th Ed., Ch. 21 pp. 336 - 337

Language Development

Toddlerhood is a critical time for language development. This varies among children because
in mastering language, children need practice time. A child who is 2 years old and does not
talk in two-word, noun–verb simple sentences needs a careful assessment to determine the
cause.
A word that is used frequently by toddlers and that is a manifestation of their developing
autonomy is “no.”

 To learn other words, children need exposure to conversation and need to be

read too often. Language develops most quickly if parents respect what
toddlers have to say so children grasp the use and purpose of language.
G&D Module 3: Toddler, Prepared by:
Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
  Urge parents to encourage language development by naming objects as they
play with their child (“ball,” “block,” “music box,” “doll”) or when they give their
toddler something (“Here is your drink of water,” “Let’s put on these pajamas,”
and so on). This helps children grasp the fact that words are not meaningless
sounds; they apply to people and objects and have uses. Always answering a
child’s questions is another good way to do this. Be sure answers for toddlers
Page | 57
are simple and brief because they have such a short attention span.
 Children learn language from imitating what they hear, they will speak like those
around them. If they are spoken to in baby talk, their enunciation of words can
be poor; if they hear examples of bad grammar, they will not use good
grammar.
 Remind parents that pronouns are difficult for children to use correctly; many
children are 4 years of age before they can separate the different uses of “I,”
“me,” “him,” and “her.” Bilingual children interchange words from both
languages.

B. Nursing Diagnosis

• Health-seeking behaviors related to normal toddler development

• Deficient knowledge related to best method of toilet training
• Risk for injury related to impulsiveness of toddler
• Interrupted family process related to need for close supervision of 2-year-old
• Readiness for enhanced family coping related to parents’ ability to adjust to new
needs of child
• Readiness for enhanced parenting related to increased awareness for poison
prevention
• Disturbed sleep pattern related to lack of bedtime routine

C. Planning and Implementation of Nursing Interventions

for Toddlers

Health Promotion for a toddler and a family

Promoting Toddler Safety

 Accidents are the major cause of death in children of all ages.
 Accidental ingestions (poisoning) are the type of accident that occurs most
frequently in toddlers (Dart & Rumack, 2008). It most often occurs from
ingestion of cleaning products.
 Aspiration or ingestion of small objects such as watch or hearing aid batteries,
pencil erasers, or crayons is also a major danger for children of this age (Dutta
& Barzin, 2008).

 Urge parents to childproof their home by putting all poisonous products,

drugs, and small objects out of reach by the time their infant is crawling,
and certainly by the time their infant is walking (Myers, Li, & Shaheen,
2007).

G&D Module 3: Toddler, Prepared by:

Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
 Other accidents that occur frequently in toddlers include motor vehicle
accidents, burns, falls, drowning, and playground injuries.

 To prevent serious injury, a toddler must be supervised at all times.

 They should be placed in the back seat if the car has a passenger seat
airbag (American Academy of Pediatrics [AAP], 2009).
Page | 58
 They need to wear a helmet as soon as they begin riding a tricycle.
 Parents might have to move their child to a regular bed with a side rail
as early as this time to keep the child from falling when climbing out of
a crib.
 A safety gate on the door of the room is another way to keep a toddler
contained and safe.
 As the child reaches 2 years of age and begins to imitate housework or
repairing a car, parents must be sure the child does not use real
cleaning compounds or sharp tools.

 LEAD SCREENING

The Centers for Disease Control and Prevention (CDC) has set as a goal the
elimination of elevated blood lead levels in children (CDC, 2008).

All children between the ages of 6 months and 6 years who live in communities
with buildings built before 1950 should be tested periodically for the presence
of too much lead in their body (lead poisoning).

Elevated lead levels are caused by eating, chewing, or sucking on objects

(such as windowsills, paint chips, or furniture) that are covered with lead-based
paint. Although federal law has prohibited the use of lead in the manufacture of
interior and exterior paints since the mid-1970s, many older houses still contain
lead paint (Brown, 2008).

Additional sources of lead poisoning can include:

o Soil around the exterior of the house and potentially contaminated food grown
there
o Dust or fumes created by home renovation
o Pottery made with lead glazes
o Jewelry made from lead or lead alloys
o Colored print in newspapers
o Old water pipes
o Lead-based gasoline—children who live in high-traffic areas are at high risk for
contamination by lead fumes
o Lead dust brought home on the clothing of parents who work with lead products
such as batteries
o Toys or cribs that were painted with lead-based paint
o Sources in other countries (pertains to immigrant children)

Lead is toxic to body tissue, ingestion of it leads to serious damage in

the brain and nervous system, kidneys, and red blood cells. Levels as low
as 10 _g/dL can cause learning and behavioral problems (Keefe, 2007).
High levels may result in seizures, cognitive challenges, coma, and even
death.

G&D Module 3: Toddler, Prepared by:

Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
Promoting Nutritional Health of a Toddler

 Growth slows abruptly after the first year of life. Toddler’s appetite is smaller
than an infant’s.
 If feeding problems begin at this time, it is often because parents are unaware
their toddler’s appetite has decreased so food consumption will be less. Page | 59
 Actual amount of food eaten daily varies from one child to another, teach
parents to place a small amount of food on a plate and allow their child to eat
it and ask for more rather than serve a large portion the child cannot finish.

 It is important to educate parents while the child is still an infant that this
decline in food intake will occur so they will not be concerned when it
happens.
 Allowing self-feeding. This is a major way to strengthen independence
in a toddler.
 Offering finger foods and allowing a choice between two types of food.
This helps promote independence while exposing children to varied
foods (Williamson, 2007).
o Nutritious finger foods that toddlers enjoy include pieces of
chicken, slices of banana, pieces of cheese, and crackers.
o Most toddlers insist on feeding themselves and generally will
resist eating if a parent insists on feeding them. An individual
child may react to repeated attempts at being fed by refusing to
eat at all.
o Many toddlers prefer to eat the same type of food over and over
because of the sense of security this offers.

 Toddlers usually do not like food that is “mixed up”. They often prefer
that different foods do not touch one another on their plate. Frequently
they eat all of one item before going on to another. They often prefer
brightly colored foods to bland colors.

Toddler Nutrition

Parents may become frustrated when trying to provide adequate nutrition for their
toddler because of a toddler’s varying and unpredictable appetite and food
preferences.

 Energy needs are generally met when sufficient food is supplied in a

positive environment. Calories are best supplied by a variety of foods
spaced into three meals a day (Krebs & Primak, 2008).
 Protein and carbohydrate needs are often those most easily met during
the toddler period;
 Diets high in sugar should be avoided.
 Fats should generally not be restricted for children under 2 years old;
however, children over 2 years old should have a total fat intake
between 30% and 35% of calories, with most fat coming from sources
of polyunsaturated and monounsaturated fatty acids, such as fish, nuts,
and vegetable oils—the same as for adults. Trans–fatty acids should be
kept to a minimum.

G&D Module 3: Toddler, Prepared by:

Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
  Adequate calcium and phosphorus intake is important for bone
mineralization. Milk should be whole milk until age 2 years, after which
2% milk can be introduced (Rolfes, Pinna, & Whitney, 2009).

Why diets high in sugar should be avoided during toddler stage?

Why fats should not be restricted? Page | 60

Promoting Adequate Intake with a Vegetarian Diet

Vegetarian diets are adequate for toddlers if parents are well informed about needed
vitamins and minerals (Theobald, 2007). A vegetarian diet can be easily designed for
a toddler who prefers finger foods, because many vegetables, fruits, and grains such
as pieces of oranges, peaches, raisins, chickpeas, tomatoes, and crackers are easily
eaten this way. The use of fortified soy milk prevents fluid, protein, B12, and calcium
deficiencies. Tofu or Quom should be part of every meal to supply protein.

Promoting Toddler Development in Daily Activities

A toddler’s new independence and developing abilities in self-care, such as dressing,

eating, and, to a limited extent, hygiene, present special challenges for parents.
Learning how to promote autonomy yet maintain a safe, healthful environment should
be a major goal for the family.

 DRESSING

 By the end of the toddler

period, most children can put
on their own socks,
underpants, and undershirt
(Fig. 30.6).

 Some may also be able to pull

on slacks, pullover shirts (the
sleeves of a shirt often
confuse a toddler), or simple
dresses.

Parents may be reluctant to encourage toddlers to dress themselves as

it is often easier and quicker to put their clothes on for them because a
toddler who is dressed by parents will (usually) be wearing clothes in
the correct way. When toddlers dress themselves, they invariably put
shoes on the wrong feet and shirt and pants on backward.

Encourage parents to give up perfection for the benefit of the child’s

developing sense of autonomy. If children end up with underpants or
shirt on backward, in most instances it does not make that much
difference, and toddlers are not likely to feel independent and confident
if their attempts at dressing are criticized. If parents feel they must
change the child’s clothes, they should begin with a positive statement,
such as “You did a good job,” before making the switch.

G&D Module 3: Toddler, Prepared by:

Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
  Sneakers are an ideal toddler shoe because the soles are hard enough
for rough surfaces and arch support is limited.

 SLEEP

The amount of sleep children need gradually decreases as they grow older
Page | 61
(Goldson & Reynolds, 2008). They may begin the toddler period napping twice
a day and sleeping 12 hours each night, and end it with one nap a day and only
8 hours’ sleep at night. Parents who are not aware that the need for sleep
declines at this time may view a child’s disinterest in sleeping as a problem. A
parent’s insistence that a child get more sleep may lead to sleeping problems
or refusal to sleep at all.

 If a child cannot fall asleep at night, maybe it is time to omit or shorten

an afternoon nap. If a child is so short-tempered at dinnertime that
eating is impossible, perhaps the child needs two naps a day. Some
toddlers begin having night terrors or wake crying from a bad dream so
they receive little sleep as they are reluctant to fall back asleep (Petit et
al., 2007).
Toddlers may begin to resist naps, however, as well as nighttime sleep
when they become aware for the first time that activities go on while
they sleep, so they do not want to miss anything.

 Caution parents that when they say, “We’ll do this after naptime,” they
wait until then to do it. Otherwise, a child may be reluctant to nap the
next day for fear of missing another activity.
 Also, parents must be sure older siblings do not point out to a toddler
all the exciting things a toddler missed while napping.

Other toddlers resist naptime as part of their developing negativism.

 Parents might minimize this by including a nap as part of lunchtime

routine, not as a separate activity: the child always goes from the table
directly to bed. The parent can state simply, “It’s naptime now,” and then
give a secondary choice: “Do you want to sleep with your teddy bear or
your rag doll?” Toward the end of the toddler period, when children are
ready to omit their afternoon naps, they may still be agreeable to a
“shoes-off” or quiet-play period until they begin to attend school full time.

As with any other activity of this period, a toddler loves a bedtime

routine: bath, pajamas, a story, brushing teeth, being tucked into bed,
having a drink of water, choosing a toy to sleep with, and turning out
the lights.

 Parents must be careful, however, not to let a child maneuver them into
such a long procedure that sleep is delayed considerably past the time
initially set. Although toddlers need to be independent, they also need
a feeling of security. Toddlers, especially when they are tired, like to see
parents as firm, consistent people who can be counted on to be reliable
over and over (Ward, Rankin, & Lee, 2007).

G&D Module 3: Toddler, Prepared by:

Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
 Many toddlers are ready to be moved out of a crib into a youth bed or
regular bed with protective side rails or a chair strategically placed
beside it by the end of the toddler period.

 Moving children to a more grown-up bed is usually preferable to forcing

them to sleep in a crib if they no longer feel they should be there. Either
Page | 62
children will not fall asleep in the crib or they will scale the side rail and
perhaps fall.
 Remind parents to stress that sleeping in a regular bed does not give
children the right to get in and out of bed as they choose.

When first moved to a bed without side rails, many children are found
sleeping on the floor of the room in the morning. There is no harm in
this unless it is cold or drafty. Dressing the child in warm pajamas or
putting a blanket on the floor might be solutions to help parents accept
this.

 BATHING
The time for a toddler’s bath should depend on the parents’ and the child’s
wishes and schedule. Some parents prefer to bathe a toddler before the
evening meal because it has a quieting effect and prepares a child for eating;
others prefer to give it at bedtime because it has a relaxing effect and helps a
child sleep.

Toddlers usually enjoy bath time, and parents should make an effort to make it
fun by providing a toy, such as a rubber duck, boat, or plastic fish. Bath time is
usually so enjoyable for toddlers that parents can use it as a recreational
activity or something to do on a rainy day when they can find nothing else to
interest their child.

 Remind parents that although toddlers can sit well in a bathtub, it

is still not safe to leave them alone unsupervised. They might slip
and get their head under water or reach and turn on the hot-water
faucet and scald themselves (Ring, 2007).

 CARE OF TEETH

 Toddlers often need between-meal snacks. Encourage parents to offer

fruit (bananas, pieces of apple, orange slices) or protein foods (cheese
or pieces of chicken) rather than high carbohydrate items for snacks
such as cookies not only for the nutrition involved but also because
protein snacks help prevent caries more than sugar snacks by limiting
exposure of the child’s teeth to carbohydrate.
 Calcium (found in large amounts in milk, cheese, and yogurt) is
especially important to the development of strong teeth and are good
for snacks. In addition, children should continue to drink fluoridated
water, if it is available, so that all new teeth form with cavity resistant
enamel (Armfield & Spencer, 2007).

G&D Module 3: Toddler, Prepared by:

Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
 FOR TOOTH CARE:

 Toddlers need to have a toothbrush they recognize as their own.

 Toward the end of the toddler period, they can begin to do the brushing
themselves under supervision (almost all children need some
supervision until about age 8).
Page | 63
 Remind parents it is better for a child to brush thoroughly once a day,
probably at bedtime, than to do it poorly many times a day.
 After brushing, parents can use dental floss to clean between the child’s
teeth and remove plaque.
 Urge parents to schedule a first visit to a dentist skilled in pediatric
dental care at about 12 months of age for assessment of dentition
(Mueller, 2008).
 Parents can prepare their child for this first and subsequent visits by
reading a story about a dentist visit, maintaining a positive attitude about
the visit, avoiding the use of frightening words like “drill” or “shot,” and
answering their child’s questions honestly without going into too much
detail. Because children rarely have cavities this early, the visit is
usually painless and sets a positive stage for future dental supervision
visits.

Promoting Healthy Family Functioning

Learning self-reliance is the primary goal of a child during the toddler period. Some
parents who enjoyed caring for their child as an infant may find it difficult to have their
authority challenged by a toddler.

Help parents to understand their responses to these attempts at independence are

crucial to the healthy development of their child. Although the child still needs firm limits
to feel secure, a child must be given some room to make independent decisions in
areas that the parents feel they do not need to control. An outside person, such as
a nurse, can provide an important perspective on this issue.

If parents punish children excessively at each move toward independence, they will
begin to feel guilty for wanting to do things independently.

At bedtime, naptime, or anytime they are tired, toddlers may become much more like
their old selves, wanting to sit on a parent’s lap and be rocked or picked up and carried.
This does not signal babyish behavior or regression in a toddler; it is a natural state
between infant and preschool ages.

Parental Concerns Associated With the Toddler Period

TOILET TRAINING

Toilet training is one of the biggest tasks a toddler tries to achieve.

o Toilet training is an individualized task for each child. It should begin and be completed
according to a child’s ability to accomplish it, not according to a set schedule.
o The time when parents begin these activities is culturally determined.

G&D Module 3: Toddler, Prepared by:

Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
 o Being aware that childrearing practices are not consistent across the world is a help in
understanding why parents approach childrearing problems differently and why
childrearing advice must be individualized.

Before children can begin toilet training, they must have reached three
important developmental levels, one physiologic and the other two cognitive: Page | 64

 They must have control of rectal and urethral sphincters, usually achieved at the time
they walk well.
 They must have a cognitive understanding of what it means to hold urine and stools
until they can release them at a certain place and time.
 They must have a desire to delay immediate gratification for a more socially accepted
action.

Some toddlers smear or play with feces, often at about the same time that toilet training is
started. This occurs because they have become aware of body excretions but have no adult
values toward them; stools seem little different from the modeling clay they play with. This
activity can be minimized by providing toddlers with play substances of similar texture and by
changing diapers immediately after defecation. Teach parents to accept this behavior for what
it is: enjoyment of the body and of the self, and the discovery of a new substance. After a child
is fully toilet trained, this activity rarely persists.

Specific tips on how to potty train a toddler, refer below:

G&D Module 3: Toddler, Prepared by:

Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
RITUALISTIC BEHAVIOR

Although toddlers spend a great deal of time every day investigating new ways to do things
and doing things they have never done before, they also enjoy ritualistic patterns. They will
use only “their” spoon at mealtime, only “their” wash cloth at bath time. They will not go outside
unless mother or father locates their favorite cap.
Page | 65
NEGATIVISM

As part of establishing their identities as separate individuals, toddlers typically go through a

period of extreme negativism. They do not want to do anything a parent wants them to do.
Their reply to every request is a very definite “no.”

Parents may need some help to realize this is not only a normal phenomenon of toddlerhood
but also a positive stage in development. This change indicates that toddlers have learned
they are separate individuals with separate needs. It is important that toddlers do this if they
are to grow up to be persons who are independent and able to take care of their own needs
and desires.
Once extreme negativisms runs its course, it passes. In the meantime, the more parents try
to make children obey them, the more children are likely to resist. Some long-term parent–
child interaction problems begin during this period because parents insist on being obeyed
totally or are inconsistent in their approach.

 A toddler’s “no” can best be eliminated by limiting the number of questions asked of
the child. Make a statement instead of asking a question can avoid a great many
negative responses.

Examples:
Instead of, “Are you ready for dinner?” = “Come to the table. It’s dinnertime.”
“Will you come take a bath now?” = “It’s time for your bath.”

 Give toddlers the experience to make choices. To provide the opportunity to do this, a
parent could give a secondary choice. “No” is not allowed for the major task, so the
parent states, “It’s bath time now” but then says, “Do you want to take your duck or
your toy boat into the tub with you?” Other examples are, “It’s lunchtime. Do you want
to use a big or little plate?” or “It’s time to go shopping. Do you want to wear your jacket
or your sweater?”

DISCIPLINE

 Remind parents that “discipline” and “punishment” are not interchangeable terms.
Discipline means setting rules or road signs so children know what is expected of them.
Punishment is a consequence that results from a breakdown in discipline, from the
child’s disregard of the rules that were learned.
 Parents should begin to instill some sense of discipline early in life because part of it
involves setting safety limits and protecting others or property: for example, a child
must stay away from the fireplace or heater; she must not go into the street; she must
not hit other children.
 “Timeout” is a technique to help children learn that actions have consequences. To
use “timeout” effectively, parents first need to be certain their child understands the
rule they are trying to enforce: for instance, “If you hit your brother, you’ll have timeout.”
Parents should give one warning.
 If the child repeats the behavior, parents select an area that is non stimulating, such
as a corner of a room or a hallway. The child is directed to go immediately to the
G&D Module 3: Toddler, Prepared by:
Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
 “timeout” space. The child then sits there for a specified period of time. If the child cries
or shows any other disruptive behavior, the timeout period does not begin until there
is quiet. When the specified time period has passed, the child can return to the family.
A guide regarding how long children should remain in their “timeout” chair is 1 minute
per year of age. Using a timer that rings when time is up lets children know when they
can return to the family.
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SEPARATION ANXIETY

As discussed in Chapter 29, fear of being separated from parents begins at about 6 months
of age and persists throughout the preschool period. This universal fear of this age group is
known as separation anxiety. For this reason, toddlers have difficulty accepting being
separated from their primary caregiver to spend the day at a day care center or if they or their
primary caregiver is hospitalized.
Parents may ask what they can do about this problem.

 Most toddlers react best to separation if a regular babysitter is employed or the day
care center is one with consistent caregivers. Many are more comfortable if they are
cared for in their own home. It helps if they have fair warning that they will have a
babysitter. For example, they could be told, “Mommy is fixing dinner early because
Mommy and Daddy are going to visit some friends tonight. Marsha is going to come
and babysit for you. She’ll put you to bed. When you wake up in the morning, Mommy
and Daddy will be here again.”
 No matter how well prepared toddlers are, they may cry when the babysitter actually
appears or may greet the babysitter warmly only to cry when the parents reach for their
coats. It helps if parents say goodbye firmly, repeat the explanation they will be there
when the child wakes in the morning, and then leave.

Prolonged goodbyes only lead to more crying. Sneaking out prevents crying and may
ease the parents’ guilt, but it can strengthen fear of abandonment so should be
discouraged. This applies to hospital visits as well.

TEMPER TANTRUMS
Almost every toddler has a temper tantrum at one time or another. The child may kick, scream,
stamp feet, shout “No, no, no,” lie on the floor, flail arms and legs, and bang the head against
the floor. Children may even hold their breath until they become cyanotic. If breath holding,
the child develops a distended chest (a halt after inspiration), often air-filled cheeks, and
increasing distress as the child’s body registers oxygen want. This is harmless breath holding;
ignoring it will make it ineffective and the child will give it up. True breath holding is a neurologic
problem in which children, under stress, appear to “forget” to breathe in or halt breathing after
expiration, usually at the peak of anger. They become so short of breath that they slump to
the floor. See guidelines in differentiating simple breath holding from neurologic disorders:

G&D Module 3: Toddler, Prepared by:

Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN
  Temper tantrums are a natural consequence of toddlers’ development (Taylor, 2007).
They occur because toddlers are independent enough to know what they want, but
they do not have the vocabulary or the wisdom to express their feelings in a more
socially acceptable way. For example, temper tantrums occur most often when children
are tired, just before naptime or bedtime, or during a long shopping trip or visit.
 Tantrums may be a response to an unrealistic request by a parent: asking children to
Page | 67
comb their hair before they are coordinated enough to do so, asking them to pick up
toys before they have a feeling of family responsibility, or asking them to share before
they can understand what that means.
 Tantrums may also occur if parents are saying “no” too frequently in regard to such
things as touching the coffee table, getting dirty, using a spoon, or running and jumping
so that children feel constantly thwarted.
 A tantrum may be a response to difficulty making choices or decisions or to pressure
from activities such as toilet training. Such children need to express feelings in some
way and do so with temper tantrums. These episodes are taxing for the parents; they
are also energy-consuming for children.

Probably the best approach is for parents to tell a child simply that they disapprove of
the tantrum and then ignore it. They might say, “I’ll be in the bedroom. When you’re
done kicking, you come into the bedroom, too.” Children who are left alone in a room
this way will usually not continue a tantrum but will stop after 1 or 2 minutes and rejoin
their parents. Parents should then accept the child warmly and proceed as if the
tantrum had not occurred. This same approach works well for nurses caring for
hospitalized toddlers.

Suggestions for Managing Tantrums:

For further reading: Nursing Diagnoses and Related Interventions, Nursing Care Plan, pp.
856-858 (Pillitteri)

References:
Kozier, Erb, 2016. Fundamentals of Nursing, 10th ed., Promoting Health from Conception through
Adolescence, Ch. 21 pp. 336 – 337
Pillitteri, A. 2010. Maternal and Child Health Nursing 6th ed. Nursing Care of a Family with Toddler, Ch.
30 pp. 840 - 860
G&D Module 3: Toddler, Prepared by:
Ms. Donnabelle Lumbatan – Abdullah, RN, MAN
Ms. Amnah C. Sharief, RN