NCM109 Lesson 4 Nursing Care of a Family with a Toddler
Mass Index
• Body Growth and Development
- Do not grow as quickly as the first year
- Grow at different rates (height and weight)
1. Heredity
2. Environment
• Years 1 to 3
- Babies triple their birth weight during the first year
- Toddlers gain only 5 – 6 lbs. of BW/yr.
- Gains 5 in. in height/yr.
- Most girls reach 53% of their adult height by age 2
- Most boys reach 50% of their adult height by age
2
THEREFORE… It is usually true that a tall two-year-
old will be a tall adult.
Christopher is 24 months old. He is currently 34 ½
in. tall. How tall will he be?
34.5 ÷ 50% = 69 in. (5’9)
If Paula is 32 in. tall at 2 yr. old, how tall will she be
when she becomes an adult?
32 ÷ 53% = 60 in. (5 ft
• Physical Growth
- As physical growth and development slow during
the ages of two to four, motor skills, cognitive
development and language take huge strides.
- In just a few short years, your child will go from
crawling and babbling as an infant to running,
jumping and excitedly telling stories as a
Kindergartener
• Weight, Height, Head Circumference, and Body
- Various measurement components are used to
measure normal and standard child physical
development
• Body Contour
- Toddlers tend to have a prominent abdomen –
because although they are walking well, their
abdominal muscles are not yet strong enough to
support abdominal contents.
- They have a forward curve of the spine at the sacral
area (lordosis).
- Bow leggedness
• Body Systems
- Vision > 20/50 (by 3 years)
- 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 bpm; 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
enlarged progressively so the threat of lower
respiratory infection becomes less.
- Stomach secretions become more acids; 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.
- IgG and IgM antibody production become mature at
2 years of age.
- The passive immunity obtain during intrauterine life
is no longer operative.
• Teeth
- Eight new teeth (the canines and first molars) erupt
during the 2nd year.
- All 20 deciduous teeth are generally present by 2.5
– 3 years of age.
NCM109 LEC Notes 1
 • Developmental Milestone 3 years Three-word sentences
- The development of a child mostly takes place in More than 75% of the child’s
the early years of his life. For excellent speech should be intelligible
developmental assessment and surveillance, nurses
must know the general principles of developmental
• Emotional Development
milestones in toddlers.
- Autonomy vs. Shame & Doubt (by Erikson)
- The three key domains that should be periodically
- Autonomy sense of independence
assessed include:
- They are negativistic.
1. language development,
- Because they realize they are separate individuals,
2. emotional development
they don’t have to do what others want them to do.
3. cognitive development
• Language Development Emotional Development
- Language is the single best indicator of intellectual 15 months Fears being alone, being
potential. abandoned, strangers,
- Language is the ability to communicate with objects, and places
symbols. Expresses independence by
- It is often mistaken as synonymous with speech; trying to feed and undress
the latter being defined as a vocal expression of self.
language. 18 months Negativism predominates
Fears water
- This is the domain with the greatest number of
Temper tantrums
delays.
Awareness of own gender
- “NO”, a manifestation of their developing autonomy. begins
- How to encourage Language Development: 24 months May resist bedtime & naps
1. Urge parents to name objects as they Fears the dark and animals
play with their child. Temper tantrums, negativism,
2. Answering child’s questions. Should and dawdling continue
be simple & brief because they have Bedtime rituals important
short attention span Explores genitalia
3. Reading aloud. Shows readiness for bowel
and bladder control.
Language Development 36 months Temper tantrums, negativism,
Birth Attunes to human voice and dawdling behavior
Develops differential subsides.
recognition of parents ‘voices Self-esteem increases due to
2-3 months Cooing (run of words) increased independence in
Musical sounds (ooh-ooh, eating, elimination & dressing.
ahh-ahh) Explores many emotions in
6 months Babbling (mixing vowels with pretend play.
mixed consonants) Separation anxiety subsides
Ba-ba-ba may develop fear of
9-12 months Jargoning (e.g. babbling with monsters.
mixed consonants, inflection,
and cadence)
Begins using mama, dada • Elimination
(non-specific) - Ready to toilet train between 18 – 24 mos.
12 months 1-3 words, mama and dada - Bladder control more difficult to control than bowel
(specific) control
18 months 20-50 words - Signs of readiness for toilet training:
Beginning to use two-word 1. Awareness of wet diaper
phrases 2. Able to follow directions
2 years Two-word telegraphic 3. Able to communicate elimination needs
sentences (e.g. mommy
4. Able to remain dry for longer period
come)
25-50% of child’s speech
5. Able to independently dress & undress
should be intelligible 6. Able to sit, squat, walk well.

NCM109 LEC Notes 2

 • Socialization 2-7 yrs. Old Children deal more
- Become resistant to sitting in laps Preoperational Thought constructively with symbols.
- 15 mos. old They begin to use a process
✓ Enthusiastic interacting with other people termed “assimilation”.
provided those people are willing to follow They learned to change the
situation (or how they
them where they want to go.
perceived it) to fit their
- 18 mos. old
thoughts.
✓ Imitate the things they see Toddlers use toys in the
- 2 or more yrs. “wrong” way. – E.g. Given a
✓ Children become aware of gender toy hammer, instead of
differences. pounding with it, they might
✓ Identifies other children as girl/boy. shake it to see if it rattles.
• Play Behavior
- Parallel play
- Types of toys: Age Concept
a) Toys that require action 9 months Object permanence (people
and objects continue to exist
b) Trucks they can make go
even when an infant cannot
c) Rocking horses they can ride
see them).
d) Blocks they can stack This ability to maintain an
e) Toy telephone image of a person is the
f) Puzzle reason why separation
• Cognitive Development anxiety (6-18 months)
- This domain talks about thinking, memory, learning, develops when a loved one
and problem-solving. leaves the room.
9-15 months Cause and effect
12-18 months Toddler is called “little (understanding which actions
Stage 5 Tertiary Circular scientist” cause certain results).
Reaction Child experiments by trial & 1-3 years Magical thinking
error
Many children at 15 mos. Are
able to follow a rolling object • Promoting Toddler Safety
in different path. - Accidents are the major cause of death in infants
18-24 months Able to remember action & through young adults in the United States (CDC,
Stage 6 Invention of New imitate them later (deferred 2012).
Means through Mental imitation). - Aspiration or ingestion of small objects such as
Combination Transitional phase to the
watch or hearing aid batteries, pencil erasers, or
preoperational thought
parts of crayons is also a major danger for children
period.
Uses memory and imitation to of this age (Litovitz, Whitaker, & Clark, 2010)
act (deferred imitation). - Other unintentional injuries that occur frequently in
Object permanence become toddlers include motor vehicle accidents, burns,
complete. falls, drowning, and playground injuries. These
Able to think through actions occur because toddlers’ motor ability jumps ahead
or mentally project the of their judgement.
solution to a problem - By the end of the toddler. Children can't walk surely
Able to think through actions if they are left outside to play, they can very quickly
or mentally project the travel a block away. Because they cannot swim well
solution to a problem parents need to check whether backyard pools-
E.g. If given a box, a toddler
another area prone to unintended injury-are
will investigate how the top of
securely fenced (Bowman, Aitken, Robbins, et al.,
the box can be removed.
E.g. If given a 2nd box, with 2012).
different shape, the child can - One way for a parent to be reminded that the child
foresee how the top can be is it the backseat for safety and automobiles
removed. parents should keep their toddlers in rear facing
seats until age 2 years or until the child reaches the

NCM109 LEC Notes 3

 maximum height and weight for their particular seat
following that children need to ride in a car seat with
a five point restraint car seats should be placed in
the backseat so the child is not struck by the
passenger seat airbag (AAP, 2013)
- Accidents - Major cause of death in children of all
ages:
a) Accidental ingestion (poisoning) – Occurs
most frequently in toddlers
b) Aspiration or ingestion of small objects
c) MVA
d) Burns
e) Falls
f) Drowning
g) Playground injuries
h) Lead poisoning
• Promoting Toddler Development in Daily Activities
- Learning how to promote autonomy yet maintain a
safe, healthful environment — major goal for the
family.
• Dressing
1. By the end of the toddler period, most children
can put on their own socks and underpants.
Some may be able to pull on pants or shirts.
2. As soon as children are walking, they need
shoes that are firm enough to provide
protection from rough surfaces.
• Sleeping
1. Start period for toddler to nap twice a day and
sleeping 12 hours each night and end it with
one nap a day and only 8 hours of sleep at
night.
2. Some toddlers begin having night terrors or
awaken crying from bad dream and may
receive little sleep because they are reluctant
to fall back asleep.
3. When toddlers are tired, they naturally fall
asleep. Many toddlers are ready to be moved
out of a crib into a youth bed or regular bed
with side rails.
4. Toddler loves a bedtime routine: bath,
pajamas, a story, toothbrushing, being tucked
into bed, drink water, choosing a toy to sleep
with and turning the lights off.
• Bathing
- Toddler's bath should depend on the caregivers'
and childs' wishes and schedule.
1. Some caregivers prefer bathing a toddler
before evening meal because it has a
quieting effect.
2. Others prefer to give it at bedtime
because it has a relaxing effect and helps
the child to sleep.
• Dental Care
1. Toddlers often need between-meal snacks. To
help prevent dental caries, encourage healthy
snacks rather than high-carbohydrate items.
2. Calcium is especially important for the
development of strong teeth. Children should
continue to drink fluoridated water or receive
fluoride supplements.
3. Remind caregivers to avoid putting a child to
bed with a bottle. Urge caregivers to schedule
a first dental visit by 12 months of age.
4. Toddlers need a toothbrush they recognize as
their own and can begin to brush their teeth
with supervision.
• Parental Concerns Associated with the Toddler
Period
- Concerns in the toddler period usually arise because
of a conflict over autonomy.
• Toilet Training
- Toilet training is one of the biggest tasks of
toddlerhood. It should begin and be completed
according to a child's ability to accomplish it, not
according to a set schedule.
- Before children can begin toilet training, they
must have reached three important
developmental levels, one being physiologic
and the other two cognitive:
1. They must have control of rectal and
urethral sphincters.
2. They must have a cognitive
understanding of what it means to
hold urine and stools until they can be
released at a certain place and time.
3. They must have a desire to delay
immediate gratification for a more
socially accepted action.
- Common Guidelines for Toilet Training
1. Children are physically ready for toilet
training when they can walk securely.
2. Check that training pants pull down easily
and are free of complicated buttons or
snaps.
3. Purchase either a potty chair that sits on
the floor or potty seat that is placed on the
regular toilet.
4. Praise your child if they use the toilet
appropriately.
5. Be careful not to flush the toilet while your
child is sitting on it because 2-year-old
children are unable to realize they will not
be flushed away.
6. Do not allow a child to remain on a potty
chair for longer than 10 minutes.
NCM109 LEC Notes 4
 7. If your child does not seem ready on a • Temper Tantrums
day-today basis, return them to diapers for - Temper Tantrums occur as a natural consequence
a short period. of toddlers' development.
8. Some toddlers have difficulty remaining - A child's way of showing frustration or anger by
dry at night until they are 3 to 4 years old. whining and crying to screaming, kicking, hitting,
9. Do not wake your child during the night and breath holding.
and carry them to the bathroom to void. - When goals are not met, toddlers react with anger.
• Ritualistic Behavior - They occur because toddlers are independent
- Although toddlers spend a great deal of time every enough to know what they want, but they do not
day investigating new ways to do things, they also have vocabulary or wisdom to express their feelings
enjoy ritualistic patterns. in a more sociable and acceptable way.
- They want "their" spoon at mealtime or "their"
blanket at bedtime.
- The child who seems to need an excessive number
of objects to cling to or an excessive number of
routines may need more guidance.
• Negativism
- Toddlers typically go through a period of extreme
negativism with replies to every request as a very
definite "no".
- They can be baffled by the extreme change from
happy, cooperative infant to uncooperative toddler.
- This change indicates the toddler has learned that
they are a separate individual with separate needs.
- Extreme negativism will pass.
- A toddler's "no' can best be reduced by limiting the
number of questions asked of the child.
• Discipline
- Discipline means setting rules so children know
what is expected of them.
- Punishment is a consequence that results from a
breakdown in discipline or the child's disregard of
the rules that were set.
- Caregivers should begin to instill some sense of
discipline early in life to set limits.
- Consistency and praising correct behavior rather
than punishing wrong behavior are effective
principles to follow.
- A "time-out" is a technique to help children learn
that actions have consequences.
• Separation Anxiety
- The universal fear in this age group is known as
separation anxiety.
- Fear of being separated from parents begins about
6 months of age and persists throughout the
preschool period.
- Toddlers who have separation anxiety have difficulty
accepting being separated from their primary
caregiver.
- Most toddlers react best to separation if a regular
caregiver is present or if the childcare center has
consistent caregivers.

NCM109 LEC Notes 5

NCM109 LEC Notes 6