Nursing care of a Family with a newborn milk is high in lactic acid, which reduces the amount
of putrefactive organism in stool.
The Gastrointestinal System
-bacteria may be cultured from the tract in most
babies within 5 hours after birth and all babies at 24
hours of life.
-Newborn stomach hold about 60 to 90mL, a
newborn has limited ability to digest everything
taken in, especially fat and starch because pancreatic
enzymes, lipase and amylase remain deficient for the
first few months.
-Immature liver function can lead to a tendency
toward lowered glucose and protein serum levels.
Stools
-First stool usually passed within 24 hours after birth.
-Consists of meconium – a sticky, tar-like, blackish
green, odorless materials formed from mucus,
vernix, lanugo, hormones and carbohydrates that
immaculate in the bowel during intrauterine life.
-If does not pass a meconium stool by 24 to 48 hours
after birth, the possibility of some problem such as
meconium ileus, imperforate anus or volvulus
should be suspected.
-Second or third say of life, newborn stool changes
and consistency.
-Transitional stool, bowel contains appear both
loose and green they may be resemble diarrhea to
the untrained eye.
-Fourth day of life, breastfeed babies’ pass three or
four light yellow stools per day that have soft
consistency and not foul smelling because breast
The Neuromuscular System
-A newborn who receives formula usually passes
two or three bright yellow stools a day of soft
consistency; these have noticeable odors compared
with the breastfeed babies’.
-A newborn placed under phototherapy lights as
therapy for jaundice will have bright green stools
because of increased bilirubin excretions.
-Newborn with bile duct obstructions have clay-
colored (gray) stools because bile pigments cannot
enter intestinal tract.
-Blood-flecked stools usually indicate an anal fissure.
The Urinary System
-Average newborn voids within 24 hours after birth.
-Newborns do not void within this time need to be
assessed for the possibility of urethral stenosis or
absent of kidneys or ureters.
-A single voiding in a newborn is about 15mL and
may be easily missed in an absorbent diaper.
-Specific ranges from 1.008 to 1.010.
-Daily urinary output about for the first 1 0r 3 days is
about 30-60 mL total.
-By week 1, total about 300mL.
-First voiding may be pink or dusky because of uric
acid crystals that were formed in the bladder in
utero; it is an innocent findings.
-Males should void with enough force to produce a
small projected arc.
-Females should produce a steady stream, not just
continuous dribbling.
-Term newborns demonstrate neuromuscular
functions by moving their extremities, attempting to
control head movements, exhibiting a strong cry,
and demonstrating newborn reflexes.
-Limpness or total absence of a muscular response
to a manipulation not normal and suggest narcosis,
shock, or cerebral injury.
-Newborn occasionally makes twitching or failing
movements of the extremities in the absence of a
stimulus because of the immaturity of the nervous
system; these are common and normal.
Blink Reflex
-Serves the same purpose as it does in an adult – to
protect the eye from any object coming near it by
rapid eyelid closure.
Rooting Reflex
-Newborn’s cheek is brushed or stroked near the
corner of the mouth; the infant will turn the head to
that direction.
-Serves to help a newborn to find food; when a
mother holds the child and allows her to brush the
newborns cheek.
-Disappears about the sixth week of life, not
coincidentally at the same time a newborns eyes
focus steadily so a food source can be seen.
Sucking Reflex
-Newborns lips are touched; the baby makes a
sucking motion. Like the rooting reflex, this reflex
help a newborn find food.
-Start to diminish at about 6 months of age. -
Disappears immediately if it is never stimulated such
as in a newborn tracheoesophageal fistula who
cannot take in oral foods.
-Can be maintained in such an infant by offering the
child a nonnutritive sucking object such as a pacifier.
Swallowing Reflex
-Same as in the adult.
-Food that reaches the posterior portion of the
tongue is automatically swallowed.
-Gag, sneeze, and cough reflexes also present in
newborns to maintain clear airway.
Extrusion Reflex
-In order to prevent the swallowing of inedible
substances, a newborn extrudes any substances that
are placed on the anterior portion of the tongue.
Palmar Grasp Reflex
-An object is placed in their palm by quick closing
their fingers on it.
-Mature newborns grasp so strongly they can be
raised form a supine position and suspended
momentarily from the examiners fingers.
-Disappears at about 6 weeks to 3 months of age; as
it fades, a baby begins to grasp meaningfully.
Step (Walk)-in-Place Reflex
-Who are held in a vertical position with their feet
touching and a hard surface will take a few quick,
alternating steps.
-Disappears by 3 months of age.
Placing Reflex
-Is elicited by touching the anterior lower leg against
a surface such as the edge of a table.
-The newborn makes a few quick lifting leg motions,
as if to step onto table.
Tonic Neck Reflex
-When the arm and the leg on the side toward which
the head is turned extend, and the opposite arm and
leg contract.
-This posture is most evident in the arms but should
not be totally absent in the legs.
-If you turn the head to the opposite side, he or she
may change the extension and contraction of legs
and arms accordingly.
-Also called a “boxer” or “fencing reflex”.
-Purpose of function of this reflex is still unknown.
-Disappears between the second and third months
of life.
Moro Reflex
-Moro (startle) reflex can be elicited with a loud
noise or by jarring the bassinet.
-Most accurate method of eliciting the reflex is to
hold a newborn in a supine position and then allow
the head to drop backward about 1 in.
-Stimulates the action of someone trying to ward off
an attacker and then covering up to protect the
body. I
-t is strong for the first 8 weeks of life and then fades
by the end of the fourth or fifth month.
Babinski Reflex
-Sole of a newborn’s foot is stroked in an inverted
“J” curve from the hell upward, newborn fans toes
(positive Babinski sign).
-Remains positive (toes fan) until at least 3 months
of age, when it is supplanted by the down turning
response.
Magnet Reflex
-Is a pressured applied to the soled of the feet of a
newborn lying in a supine position, he or she pushes
back against the pressure.
-This test of spinal cord integrity.
Crossed Extension Reflex
-A newborn is lying supine; if one leg is extended and
the sole of that foot is irritated by being rubbed with
a sharp object, such as thumbnail, the infant raises
the other leg and extends it as if trying to push away
the hand irritating the first leg.
Trunk Incurvation Reflex
-Lies in a prone position and is touched along the
paravertebral area on the back by a probing finger,
the newborn flexes the trunk and swings the pelvis
toward the touch.
Landau Reflex
-Is supported in a prone position by a hand, the
newborn should demonstrate some muscle tone.
-May bot be able to lift the head or arch the back of
his position but neither should the infant sag into an
inverted “U” position.
Deep Tendon Reflexes
-Both patellar and a biceps reflex are intact in a
newborn.
The Skin
-General inspection of a newborn’s skin includes
color, any birthmarks, and general appearance.
The Color
-Most term babies have a ruddier complexion for
their first month than they will have later in life
because of the increased concentration of red blood
cells in their blood vessels and a decrease in the
amount of subcutaneous fat, which makes blood
vessels more visible.
-In darker skinned newborns, cyanosis may appear
as dusky grey or whitish around the child’s mouth.
Cyanosis
-Generalized mottling of the skin is a common
findings in a newborns.
-The lips, hands, and feet are likely to appear blue
form immature peripheral circulation (termed
acrocyanosis).
-Acrocyanosis is a normal finding at birth through
the first 24 to 48 hours after birth.
-Central Cyanosis or cyanosis of the trunk, is always
a cause for concern. It indicated decreased
oxygenation that could occurring as the result of
temporary respiratory obstruction and also could
reflect a serious underlying respiratory or cardiac
disease.
Hyperbilirubinemia
-Is caused by the accumulation of excess bilirubin in
blood serum.
-In the average newborn, the skin and sclera of the
eyes begin to appear noticeably yellow on the
second or third day of life as a result of a breakdown
of fetal red blood cells (called physiologic jaundice).
This occurs because, as the high red blood cell count
built up in utero is being reduced, heme, and globin
are released.
-Heme is further broken down into iron and
protoprohyrin.
-Protoprophytin is then broken down into direct
biliburin, a compound which is fat-soluble and
therefore cannot be excreted by the kidneys.
-Carefully observe infants who are prone to
extensive bruising (large, breech or preterm babies)
for jaundice because bruising leads to hemorrhage
of blood into the subcutaneous tissue or skin; this
blood then has to be a broken down so can add to
the amount of indirect bilirubin accumulating.
Cephalohematoma
-is collection blood under the periosteum of the skull
bone caused by pressure at birth.
Acute bilirubin encephalopathy
-Or kernicterus it can interfere with the chemical
synthesis of brain cells, resulting in permanent brain
damage.
Pallor
-Is potentially serious because it usually occurs as
the result of anemia
Harlequin Sign
-Because of immature blood circulation,.
-Transient phenomenon and although startling, is of
no clinical significance.
-The odd coloring fades immediately if the infant’s
position is changed or the baby kicks or cries.
Birthmarks
-Have several common types of birthmarks that
occur in newborns.
Hemangiomas
-Are vascular tumors of the skin and occur in three
distinct types.
1. Nevus flammeus
-2 types
- Benign macular purple or dark-red
lesion (also called a port-wine stain)
 - Light pink patched: stork bites or
telangiesctasia
-present at birth
-Port wine: located in face, thighs
-stork bites: located in the nape of neck
2. Infantile hemangiomas or strawberry
hemangiomas
-elevated areas forms by immature
capillaries and endothelial cells
-appear at birth or within 2 weeks after birth
-size may enlarge up to 1 year of age
-can occur anywhere on the infant; most on
scalp, face, neck
3. Cavernous hemangioma
-caused by dilated vascular spaces
-raised and irregular shape: resemble a
strawberry hemangioma
-do not disappear with time
-some may have additional lesions on
internal organs
-located at face, behind ears, and the neck
Mongolian Spots
-are collection of pigment cells (melanocytes) that
appear as slate-gray patches across the sacrum or
buttocks and possibly on the arms and legs of
newborns.
-tend to occur most often in children of Asian,
Southern European, or African ethnicity and
disappear by school age without treatment
-This are not bruises.
Vernix Caseosa
-Is the white cream cheese- like substances that
serves as a skin lubricant in utero.
-Typically noticeable on a term newborn’s skin, at
least in the skin folds, at birth.
-Handle newborns with gloves to protect yourself
form exposure to vernix.
-Remove only the vernix that is contaminated by
meconium or blood.
-Never rub it away harshly because newborn sin is
tender and breaks in the skin caused by too vigorous
attempts of removal could open portals of entry for
bacteria.
Lanugo
-Is the fine, downy hair that covers a term newborn’s
shoulder, back, upper arms and possibly also the
forehead and ears.
Desquamation
-Within 24 hours after birth, the skin of most
newborns begins to dry. The dryness id particularly
evident on the palms of the hands and soles of the
feet and results in areas of peeling similar to those
caused sunburn.
Milia
-Sebaceous glands in a newborn are immature, so at
least one pinpoint white papule is usually found on a
cheek or across the bridge of the nose every
newborn.
-Disappear by 3 to 4 weeks of age as the sebaceous
glands mature and the plugged ones drain.
Erythema Toxicum
-Commonly presents on the skin of most term
newborns.
-Rash usually appears in the first to fourth day of life
but may appear as late as 2 weeks of age.
-Begins with small papules, increases in severity to
become erythematous by the second day and then
disappears by the third day.
-Sometimes called “flea-bite rash” because the
lesions are so minuscule.
Forceps Marks
-They may leave a circular or linear contusion
matching the rim of the forceps blade of the infants
cheek.
-Occurs with normal forceps use and does not
denote unskilled or overly vigorous application of
forceps.
Skin Turgor
-Newborn skin should feel resilient if the underlying
tissue is well hydrated.
-Poor turgor seen in newborns who suffered
malnutrition in utero, who have difficulty sucking at
birth or have metabolic disorders such as
adrenocortical insuffiency.
 -Poor turgor always needs to be reported as it
suggests poor hydration.
Question:
Beth Ruiz has milla on her nose. What teaching
point would constitute a quality and safety risk?
a. “these will disappear on their own, so you don’t
need to take any actions”
b. “Wash Beth the same way that the nurse first
taught you”
c. “Try to gentle scratch off these spots in a few days”
d. “Make sure that you keep Beth bundle warmly”
Answer: A
The Head
-Newborn head usually appears disproportionally
because it is about one fourth of the total body
length compared with an adult.
Fontanelles
-Are spaces or openings where the skull bones join.
-The anterior fortanelle is located at the junctions of
the two parietal bones and the two fused frontal
bones.
-It is diamond shape and measures 2 to 3cm in width
and 3 to 4 cm in length.
Sutures
-The separating lines of the skull, may override at
birth because of the extreme pressure exerted on
the head during passage through birth canal.
Molding
-Part of the infants head that engage the cervix
(usually the vertex) molds to fit the cervix contours
during labor.
Caput Succedaneum
-Is edema of the scalp that forms in the presenting
part of the head.
-Occurs in cephalic births and can either involve
wide areas of the head or be so confined that its size
of a large egg.
Cephalohematoma
-A collection of blood between the periosteum of a
skull bone and the bone itself is caused by rupture of
a periosteal capillary because of the pressure of
birth.
-It may be discolored (black and blue) because of the
presence of coagulated blood underneath the
periosteum.
Craniotabes
-Is a localized softening of the cranial bones probably
cause by pressure of the fetal skull against the
mothers pelvic bone in utero.
-It is more common in first-born infants than in
infants born later because of the lower positions of
the fetal head in the pelvis during the last 2 weeks of
pregnancy in primiparous women.
BATHING
-Recommends that most newborns receive a
complete sponge bath in 2 to 4 hours after birth
when their temperature and vital signs are stable.
-There is no need to use antibiotic cleansers and no
need to remove all the vernix.
-Babies of mothers with HIV transmission should
have through bath immediately to decrease the
possibility of HV transmission.
-All babies are sponge bathed once a day, although
the procedure may be limited to washing only the
baby’s face, diaper area, and skin folds.
-Supply bath water at 37 to 38 degree Celsius, a
temperature that feels pleasantly warm to the elbow
or wrist, plus a washcloth, towel, comb, and clean
diaper and shirt.
The Nursing Role in Health Promotion for
Childbearing Family
Principles of Growth and Development
-Growing up is a complex phenomenon because of
the many interrelated facets involved. Children do
not merely grow taller and heavier as they get older;
maturing also involves in their ability to perform
skills, to think, to related to people, and to trust or
have confidence in themselves.
Growth
-is used to denoted an increase in physical size or a
quantitative change
Development
-indicated increase in skill or the ability to function.
It is measured by observing the child’s ability to
perform specific tasks such as how well a child picks
up a small object, by recording the parents
descriptions of a child’s progress.
Maturation
-is a synonym for development.
Cognitive Development
-refers to the ability to learn or understand from
experience, to acquire and retain knowledge, to
respond to a new situation, and to solve problems.
-It is measured by intelligence tests and by observing
ability to function effectively in different
environment.
General Principles include:
 Growth and development are continued
process from conception until death
 Growth and development proceed in an
orderly sequence
 Children pass through the predictable stage
at all rated
 All body systems do not develop at the same
rate
 Development is cephalocaudal
 Development proceeds from proximal to
distal body parts
 Development proceeds from gross to refined
skills
 There is an optimum for initiation of
experiencing or learning
 Neonatal reflexes must be lost before
development can proceed
 A great deal of skill and behavior is learned
by practice
Factors Influencing Growth and Development
-Generic and environmental influences are primary
factors in determining if a child will be able to reach
his or her genetic potential.
Genetics
-From the moment of conception when a sperm and
ovum fuse, the basic genetic makeup of an individual
is cast.
-Such as eye color and height potential, inheritance
determines characteristics such as learning style.
-Can also inherit genetic abnormality, which could
result in disability or illness at birth or later in life
and so prevent optimal growth.
Gender
-Girls are born lighter and shorter than boys.
-Boys tend to keep this height and weight advantage
until prepuberty, at which time girls surge ahead as
they begin their puberty growth spurt 6 months to 1
year earlier than boys.
Health
-A child also inherits a genetically transmitted
disease may not grow as rapidly or develop as fully
as a healthy child depending on type of illness and
the therapy or care available for the disease.
Intelligence
-Children with high intelligence do not generally
grow faster physically than other children, but they
do tend to advance faster in skills.
-Children on high intelligence actually fall behind in
physical skills because they spend time with their
books or mental games rather than with games that
develop motor skills.
Temperament
-Is the usual pattern of an individual or an individual
characteristics manner of thinking, behaving, or
reacting to stimuli in the environment.
-Is not developed in stages but it is inborn
characteristics set at birth.
Reaction Patterns
-Chess and Thomas (1985) are a research who
identifies nine separate characteristics that define
temperament, or how children react to common
situations. Each child’s pattern is made up of a
combination of these individual elements.
Activity Level
-Level of activity among children differs widely right
from birth. Some babies seem to be constantly on
the go and rarely are quiet.
-They wiggle and squirm in their crib as early as 2
weeks of age.
Rhythmicity
-A child who has rhythmicity manifest a regular
rhythm in physiologic functions. Even as infants,
such children tend to wake up at the same time
every morning, is hungry and regular 4 – hour
period, nap at the same time every day.
Approach
-Refers to a child’s response on initial contact to a
new stimulus.
-They smile and talk to strangers and accept new
toys without apprehensions.
-Other children demonstrate withdrawal rather than
approach. They cry at the sight of strangers, new
toys, new foods; they fuss the first time they are
places at the bathtub.
Intensity of Reaction
-Meets new situations with their whole being. They
cry loudly, thrash their arms and begin temper
tantrums when their diapers are wet, hungry and
when parents leave them.
Distractibility
-Children who are easily distracted or who can easily
shift their attention to an new situation are easy to
care for.
-If children cannot be distracted this way, their
parents may describe them as stubborn, willful, or
unwilling to compromise because they persistently
return to an activity or refuse to adapt or change.
Attention Span and Persistence
-Is the ability to remain interested in a project or
activity for an average length of time.
-Some play by themselves with one toy for an hour,
others spend no more than 1 to 2 minutes with each
toy.
Threshold of Response
-Is the intensity level of stimulation necessary to
evoke a reaction.
-Children with a low threshold need to meet little
frustration before they react.
Mood Quality
-Is always happy and laughing is said to have a
positive mood quality.
Categories of Temperament
 The Easy Child- are rated as “easy to care
for” if they have a predictable rhythmicity,
approach, and adapt to new situations
readily, have mild-to-moderate intensity of
reaction, and have an overall positive mood
quality.
 The Intermediate Child- some characteristics
of both easy and difficult groups are present,
 The Difficult Child- are difficult if they gave
irregular in habits, have negative mood
quality, and withdraw rather than approach
new situations. Only 10% of children fall into
this category.
 The Slow-to-Warm-Up Child- fall into this
category if, overall, they are fairly inactive,
respond only mildly and adapt slowly to new
situations and have general negative mood.
Only 15% of children display this pattern.
Environment
-Children cannot grow taller than their genetically
programmed height potential allows, their height
can be considerably less than their genetic potential
if their environment hinders their growth.
Socioeconomic Level
-Because health care and good nutrition both cost
money, children born into families of low
socioeconomic means may suffer from a lack of both
of these.
-poor health supervision can leave the, without
immunization against measles or other childhood
illnesses and therefore vulnerable to permanent
neurologic damage.
-Poor nutrition can also leave them vulnerable to
disease because antibody formation depends on a
good protein intake.
The Parent –Child Relationship
-Parent expects a child to become as an adult varies
from culture to culture aand family to family but
plays a role in how much a child guided to try to
achieve in life.
-Cultural norms also play a role because some -Poor maternal nutrition may limit the growth and Epigenetic theories
cultures have different perspectives on education intelligence potential of a child by furnishing a less -stress that genes are true basis for growth and
and value different ways of contributing to society. that desired prenatal environment. development.

Ordinal Position in the Family Theories of Child Development Cognitive theorist

-The position in the family (first-born, middle child, -Theory is a systematic statement of principles that -such as Piaget stress learning skills are the key to
youngest child and only child) and the size of the provides a framework for explaining a phenomenon. achieving success in life.
family also have bearing on child’s growth and
development. Developmental Tasks FREUD’S PSYCHOANALYTICAL TEHORY
-An only child or eldest child in the family generally -Are a skill or growth responsibility arising at a -Sigmund Freud (1856-1939) an Australian
excels in language development because particular time in an individual’s life, the neurologist and the founder of psychoanalysis,
conversations are mainly with adults. achievement of which will provide foundations for offered the first real theory of personality
-Youngest child, may develop language more slowly, the accomplishment of the future tasks. development.
especially if older children “baby talk” with them. -Based on Freud’s observations of mentally
BASIC DIVISIONS OF CHILDHOOD
-Children learn by watching other children, however distributed adults, described adult behavior as being
Stage Age Period
so a youngest child who has a many examples to the result of instinctual drives of primarily sexual
Neonate First 28 days of life
watch may excel in other skills. nature (libido).
Infant 1 month-1 year
-He describe child development as being a series of
Toddler 1-3 years
Health psychosexual stages in which a child’s sexual
Preschooler 3-5 years
-Diseases that come from environmental sources can gratification becomes focused on a particular body
School-age child 6-12 years
have a strong an influence on growth and part each stage.
Adolescent 13-17 years
development as genetically inherited diseases.
Late Adolescent 18-21 years
-When parent treat children differently after they OAPHALAGE
have been critically ill the children are referred to as
Freud’s Stages of Childhood
“vulnerable children”. Sociocultural Theories Psychosexual Stage Age
-Are those that stress the importance of Infant Oral Stage
Nutrition environment on growth and development Toddler Anal Stage
-Nutrition has become major focus of health Preschoole Phallic Stage
promotion and disease prevention because the Learning Theory r
quality of child nutrition during the growing years -Suggest children are like blank pages that can be School-age Latent stage
child
has such major influence on heath, weight, and shaped by learning.
Adolescent Genital stage
stature.
ERIKSOM’S THEORY PF PSYCHOSOCIAL
DEVELOPMENT
-Erik Erikson (1902-1996) was trained psychoanalytic
theory but later developed his own of psychosocial
development, a theory that stresses the importance
of culture and society in development of the
personality.
The Infant
-Trust versus mistrust
-Other terms are “learning confidence” or “learning
to love”
-If care is inconsistent, inadequate, or rejecting,
infants learn mistrust; they become fearful and
suspicious of people and then of the world.
The Toddler
-Autonomy versus shame or doubt
-Autonomy (self-governance or independence) arises
from a toddler’s new motor and mental abilities.
-Children not only take pride in the new things they
can accomplish but also want to do everything
independently.
The Preschooler
-Initiative versus guilt
-Or learning how to do things such as drawing,
building an object from blocks, or playing dress up.
-Another word for initiative is creativity.
-Those do not develop initiative have limited
brainstorming and problem-solving skills later in life;
instead they wait for clues and guidance from others
before acting. They may also be unable to use sense of identity before they can reach out fully and
stimulated learning effectively. offer deep friendship or love to others. -Because
there is always a risk of being rejected or hurt when
The School-Age Child offering love or friendship, individuals cannot offer it
-Industry versus inferiority if they do not have confidence that they can cope
-Or self-confidence rather than inferiority with rejection or if they did not develop sense of
-During school age children learn how to do things trust as a infant or autonomy as a toddler.
well. -This is important for maternal and child health
-When they are encouraged in their efforts to do nursing because parents without a sense of intimacy
practical tasks or make practical things and are may have difficulty than others accepting a
praised or rewarded for the finished results, their pregnancy and beginning to love a new child.
sense of industry grows.
PIAGET’S THEORY OF COGNITIVE DEVELOPMENT
The Adolescent -Jean Piaget (1896-1980) a Swiss psychologist,
-Identity versus role confusion introduced the concepts of cognitive development,
-To achieve this, adolescent must bring together for or the way children learn and think.
everything they have learned about themselves as a -Piaget defines four stages of cognitive
son or daughter, an athlete, friends, a fast-food development, within the stages of growth, then finer
cook, a student, a garage band musician. units or schemas.
-If adolescent cannot do so, they are left with role
confusion or are left unsure of what kind of persons Stage of Development Age Span
they are or what kind of person they want to Neonatal Reflex 1 month
become. Primary circulation 1-4 months
reaction
-Some adolescent may seek a negative identity
Secondary circular 4-8 months
reaction
The Late Adolescent Coordination of 8-12 months
-Intimacy versus isolation secondary reactions
-Intimacy is the ability to relate will with other Tertiary circular reaction 12-18 months
people in preparation for developing future Invention of new means 18-24 months
relationships. through mental
combinations
-A sense of intimacy grows out of earlier
Preoperational thought 2-7 years
developmental tasks because people need a strong
Concrete operational 7-12 years
 thought
Formal operational 12 years
thought
The Infant
-Referred to the infant stage as first four stages of
the sensorimotor stage.
-Sensorimotor intelligence is a practical intelligence
because infant is not yet able to use words and
symbols for thinking and problem solving at this
early age.
-Babies relate to the world through their senses,
using only reflex behavior.
-During this stage, infants learn objects environment
their bottle, blocks, bed, or even parent are
permanent and continue to exist even though they
are out of sight or changed in some way.
-A great deal of the mouthing and handling of
objects by infants and the delight of watching a
caregiver appear is part of discovering permanence.
-Infants can identify their parents as different from
other adults as early as 4 months of age.
-The world begins makes sense and development
task for achieving trust falls into place when the
concept of permanence has been learned.
-Gaining permanence also contributes to separation
anxiety, which can begin 8-12 months of age.
The Toddler
-Is one if the transition as children completes the
fifth and sixth stages of the sensorimotor period and
begins to develop some cognitive skills of the
preoperative period, such as symbolic thought and
egocentric thinking.
-Children use trial and error to discover new
characteristics of objects and events.
The Preschooler
-Move on to a sub stage of preoperational thought
termed intuitive thinking.
-Intuitive thinking contributes to the preschooler
lack of conservation (the ability to discern truth,
even though physical properties change) or
reversibility (ability to retrace steps).
-Preschooler thinking is also strongly influenced by
role fantasy or how children would like something to
turn out.
-Children use assimilation (taking information and
changing it to fit for their existing ideas).
-Children believe their wishes are real as facts and
dreams are real as daytime happening during this
stage.
-This phenomenon is often called “magical
thinking”. Magical Thinking fades as, later on,
children learn accommodation (they change their
ideas to fit reality rather than the reverse).
The School-Age Child
-During which concrete operational thought begins
because school-age children can be seen using
practical solutions to everyday problems as well as
begin to recognize cause-and-effect relationships.
-Conservation of numbers is learned as early as age
of 7 years, conservation of quantity of age 7 or8
years, conservation of weight at age 9 years and
conservation of volume at age of 11 years.
-Reasoning during this school age tends to be
inductive or proceeds from specific to general.
The Adolescent
-Is the time when cognition achieves its final from or
when formal operational thought begins.
-Adolescent are capable of thinking in terms of
possibility- what could be (abstract thought) rather
than being limited to thinking about what is already
is (concrete thought).
-They can use deductive reasoning in addition to the
induction reasoning they used during school age or
can move from the general to the specific.
KOHLBERG’S THEORY OF MORAL DEVELOPMENT
-One more development that has relevance to
maternal and child health nursing is Kohlberg’s
(19277-1987) theory of moral development.
-A German Psychologist studied the reasoning of
boys and based on Piaget’s developmental stages,
develop a theoty on the way children gain
knowledge of right and wrong or moral reasoning.
Age (in years) Stage Description
Preconventional (Level I)
2-3 (1)Punishment/obedience
orientation. Child does right
because a parent tells him
or her to and to avid
punishment.
4-7 (2) Individualism. Carries
out actions to satisfy own
 needs rather than society.
Conventional (Level II)
7-10 (3) Orientation to
interpersonal relations to
mutuality. Child follows
rules because of a need to
be a good person in own
wyes of others
10-12 (4) Maintenance of social
order, fixed rules and
authority. Child finds
following rules satisfying.
Preconventional (Level III)
Older than 12 (5) Social contract,
utilitarian, law making
perspectives. Follows
standard for society for
good of all people.
Older than 12 (6) Universal ethical
principle orientation.
Follows internalized
standard of conduct
Nursing Care of a Family with an Infant
-Infancy is designated as the period of time from 1
month to 1 year of age.
-In these important months, an infant undergoes
such rapid development that parents sometimes
believe their baby looks different and demonstrate
new abilities every day.
Appearance of the Average Infant
-Follow across midline at 3 months
-Social smile at 2 months; first tooth erupts at 6
months
-Respiratory rate slows to 20-30 breaths/min by the
end of year
-Heart rate lows to 100-120 beats/min by end of first
year
-Pincer grasp at 10 months
-Abdomen protuberant
-Triples weight by 1 year
-Legs may appear short and bowed
-Grows in height by 50% (from 20-30 in.)
Physical Growth
-The physiologic changes that occur in the infant
year reflect both the increasing maturity and growth
of body organs.
Weight
-Most infants double their weight by 4 to 6 months
and triple it by 1 year.
-During the first 6 months, infants typically average
weight gain of 2lb per month.
-During the second 6 months, weight gain is
approximately 1lb. per month.
-The average 1 year old boy weighs 10 kg; the
average girl weight 9.5 kg
Height
-An infant increase in height during the first year by
50%, or grows from the average birth length of 20 in.
to about 30 in. (50.8 to 76.2cm)
Teeth
-The first baby tooth (typically a central incisor)
usually erupts at age of 6 months, followed by a new
one monthly.
-Fluoride supplementation should be administered
at 6 months of age.
-Some newborns (about 1 in 2,000) may be born
with teeth (natal teeth)
-or have erupt in the first 4 weeks of life (neonatal
teeth)
-Deciduous teeth are essential for allowing proper
growth of the dental arch.
Motor Development
-To assess motor development, both gross motor
development (ability to accomplish large body
movements)
-Fine motor development, measured by observing or
testing
-Prehensile ability (ability to coordinate hand
movements are evaluated.
Gross motor development
Four positions ventral suspension, prone, sitting, and
standing are used to asses motor development.
Ventral Suspension
-Refers to an infant’s appearance when held in
midair on a horizontal plane and supported by a
hand under abdomen.
-In this position, the newborn allows the head to
hang down with little effort at control.
-one month old infants lift their head momentarily
and then drop it again.
-Two month old infants hold their head in the same
place as the rest of their body, a major advance in
muscle control.
-By three months, infants life and maintain their
head well above the plane of the rest of the body in
ventral suspension.
-A Landau reflex is a new reflex that develops at 3
months. When held in ventral suspension, the
infants head, legs, and spine extend. This reflex
continues in most infants during the second 6
months of life.
-At 6 to 9 months, an infant also demonstrates a
parachute reaction from a ventral suspension
position.
Prone Position
-When lying on their stomach, newborns can turn
their head to move it out of a position where
breathing is impaired, but they cannot hold their
head raised for an extended time.
Sitting Position
-When placed on his or her back and then pulled to a
sitting position, a newborn has extreme head lag;
this lag present until 1 month.
By 2 months, infants can hold their head fairly
steady when sitting up, although their head does
tend to bob forward and will how head lag when
pulled to a sitting position.
-A 4 month old child reaches an important milestone
by no longer demonstrating head lag when pulled to
a sting position.
-By 5 month-old infant can be seen to straighten his
or her back when held or supported in a sitting
position.
-By 6 months, infants can sit momentarily without
support.
-By 7 month child can sit along but only when the
hands are held forward for balance.
-By 8 month child can sit securely without additional
support.
-At 9 months, infants sit so steadily that they can
lean forward and regain their balance
Standing Position
-A newborn stepping reflex can still be
demonstrated at 1 month of age.
-At 3 months, infants try to support part of their
weight on their feet.
-At 4 months, infants are able to support their
weight on their legs. They are successful doing this
because the stepping reflex has faded away.
-By 5 months, the tonic neck reflex should be
extinguished, and the Moro reflex should be fading.
-By 6 month, infants nearly support their full weight
when in standing position.
-A 7 month child bounces with enjoyment in a
standing position.
-Ten month old can pull themselves to a standing
position by holding onto the side of a playpen or a
low table, but they cannot let themselves down
again as yet.
-At around 11 month, an infant learns to “cruise” or
move about the crib or room by holding onto objects
such as crib, chairs, walls, and low tables.
-At 12 months the child can stand alone at least
momentarily.
Fine Motor Development
-One month old infants still have a strong grasp
reflex so they hold their hands in fists so tightly that
is difficult to extend their fingers.
-As the grasp reflex fades, a 2 month old infant will
hold an object for a few minutes before dropping it.
The hands are held open, not closed in fists.
-By 3 months, infants reach for attractive objects in
front of them. Their grasp is unpracticed so they
usually miss them. This is part of normal
development so they do not think their child is
nearsighted or farsighted or has poor coordination.
-4 month, infants bring their hands together and pull
their clothes. They will shake a rattle placed in their
hand.
-Thumb opposition (ability to bring the thumb and
fingers together) begins, but the motion is a
scooping or raking one, not a picking up one and is
not very accurate.
-5 month old children can accept object that are
handed to them by grasping with the whole hand.
They can reach and pick up objects without the
object being offered and often play with their toes as
objects.
-6 months, grasping has advanced to a point where a
child can hold objects in both hands. The Moro,
Palmar grasp, and tonic neck reflexes have
completely faded.
-7 month old infants can transfer toys from one hand
to the other. They hold a first object when a second
one is offered.
-8 months, random reaching and ineffective grasping
disappear as a result of advanced eye-hand
coordination.
At 10 months is the ability to bring the thumb and
first finger together in a pincer grasp.
Promoting Healthy Family Functioning
-A primary task of parents during the infant year is to
learn to interpret infant’s cues so they can better
decipher their needs.
-This becomes an easier task by 2 months of age,
when infants can indicate by their particular cry
whether they are feeling cold, hungry, wet or lonely.
-The first choice for feeding an infant during the first
12 months of life is BREAST MILK.
-Recommended that infants be exclusively breastfed
for 6 months.
-It is optimal if breastfeeding is then continued
through the entire first year. Some research
indicates that early weaning from breastfeeding can
lead to increased incidence of obesity.
-Switching to cow’s milk is not recommended
because the protein in it difficult for an infant to
digest possibly leading to such intestinal irritation
that slight but continuous gastrointestinal bleeding
occurs results in anemia.
Tips to help introduce solid foods to infants
-Infants are not ready to digest complex starches
until amylase is present in saliva at approximately 2
to 3 months.
-Biting movements begin at approximately 3
months.
-Chewing movements do not begin until 7 to 9
months.
-Therefore, foods that require chewing should not
be given until this age.
-Extrusion reflex needs to fade before infants
accept food readily.
-This is a lifesaving reflex in early infancy because it
prevents infants from swallowing or aspirating
foreign objects that touch the mouth.
-The reflex fades at 3 to 4 months at about the same
time gastrointestinal tract has matured to be ready t
digest solid food.
Teething
-Generally, gums are sore and tender before a new
tooth breaks the surface.
-As soon as tooth is through, the tenderness passes.
-Because of this pain, infants can be resistant to
chewing for a day or two and be slightly crank,
possibly because they are little hungry from not
eating as much as usual.
-Rubbing the gumline with a finger or a soft cloth
can help a new tooth erupt and so can be effective.
-Many over-the-counter medicines are sold for
teething pain. As a rule, these should be
discouraged, especially if they contain benzocaine, a
topical anesthetic.
-Teething rings can be placed in the refrigerator or
freezer to provide soothing coolness against tender
gums.
-Infants or children liquid acetaminophen (Tylenol)
may be given for teething discomfort after parents
check with their primary care provider for the
correct dose.
-High fever, seizures, vomiting or diarrhea, earache
are NEVER NORMAL SIGNS OF TEETHING may be
due to an underlying infection that requires further
evaluation.
Thumb-Sucking
-Surprisingly strong need in early infancy: Sonograms
demonstrates thumb sucking as early as in utero.
-Many infants begin to suck a thumb or finger at
about 3 months of age and continue the habit
through the first few years of life.
-The sucking reflex peaks at 6 to 8 months, whereas
thumb-sucking peaks at about 18 months.
-Reassure parents that this behavior is normal and
does not deform the jaw in infancy.
-Continued until school age can have dental arch
changes that can lead to asymmetric concerns such
as cross bite.
Use of Pacifiers
-Benefits of a pacifier include the following: They
appear to be comforting to an infant, they may aid in
pain relief, and there is a decreased risk of SIDS.
Risks associated with them are an increased
incidence of acute otitis media (ear infection),
possibly a negative impact on breastfeeding and
dental malocclusions, particularly if usage is greater
than 2 to 3 years.
- Reassure parents that this behavior is normal and
does not deform the jaw in infancy.
- Continued until school age can have dental arch
changes that can lead to asymmetric concerns such
as cross bite.
Head banging
-Rhythmically bang their head against the bars of a
crib for period of time before they fall asleep, an
action that can be distressing behavior for parents.
Sleep Concerns
-Infants should be placed on their backs up to sleep
until they are able to roll over on their own at
around 4 months of age.
-Co-sleeping is discouraged due to safety concerns.
-Breastfed babies tend to wake more often than
those who are formula fed because breast milk is
more easily digested, and so infants become hungry
sooner.
Constipation
-Breastfed infants are rarely constipated because
their stools tend to be naturally loose.
-Constipation may occur in formula-fed infants from
something as simple as if their diet is deficient in
fluid. This can be corrected simply by offering more
fluid.
-When infants defecate, their faces do turn red, and
they grimace and grunt.
-As long as their stools are not hard and contain no
evidence of fresh blood (as might occur with a rectal
fissure), this is no constipation but normal infant
behavior.
-Adding foods with bulk such as fruits or vegetables,
and increasing fluid intake generally relives the
problem.
-Hirschsprung disease (ananglionic megacolon, or
lack of nerve innervation to a portion of the colon)
may be manifested early in life as constipation.
-A careful history must then be taken to assess for
other symptoms of Hirschsprung disease; ribbon like
stools, bouts of diarrhea and a distended abdomen.
Loose Stools
-Stools of breastfeeding infants are generally softer
than those of formula-fed infants
-An infant who is formula fed can have loose stools if
the formula is not diluted properly.
-Occasionally, loose stools may begin with the
introduction of vegetables or fruits.
-Dehydration occurs rapidly in a small infant who is
not eating and is losing body fluid intake through
loose stools.
Colic
-Paroxysmal abdominal pain that generally occurs in
infants under 3 months of age and is marked by loud
intense crying
-Infants pull their legs up against their abdomen,
their faces become red and flushed, their fists
clench, and their abdomens become tense.
-If offered a bottle, an infant with colic will suck
vigorously for a few minutes as if starved and the
stop as another wave of intestinal pain.
-unknown cause
-may occur in susceptible infants from overfeeding
or form swallowing too much air while feeding.
-Formula-fed babies tend to have more symptoms
than breastfed babies, possibly because they
swallow more air while drinking or because formula
is harder to digest.
-Take a through history of an infant with signs of
colic because an intestinal obstruction or infection
can mimic an attack of colic and be misinterpreted
by the casual interviewer.
-Signs and Symptoms
 Rules of 3’s
-Occurs under 3 months of age
-Abdominal pain last up to 3 hours a
day and occurs at least 3 days every
week
-Bowel movement are normal
  Symptoms cramps, fever, cough, Allergy Entire diaper Changing the
-Difficulty to comfort cold or loss of activity (material in the area is brand or type
-Excessive crying Pyloric Stenosis Spitting up so forcefully diaper or to erythematous of diaper or
(an abnormally tight valve that milk is projected 3 laundry and irritated so washing
-Grimacing/Frowning
between the stomach or 4 ft. away products) the outline of solution
-Red Face
and duodenum) Management: Surgery the diaper on usually
-High pitched, piercing sound Gastroesophageal reflux Spitting up is a large the skin can be alleviates this
-Clenched Fists (a lax cardiac sphincter amount with each identified. problem
-Excessive Gas and esophagus allow for feeding. This requires
-Knees Drawn up to chest the regurgitation of medical atptention. Miliaria
-Management: gastric contents into the -Occurs most often in warm weather or when babies
-Small frequent feedings to prevent distention and esophagus)
are overdressed or sleep in overheated rooms.
discomfort -Cluster pinpoint, reddened papules with occasional
Diaper Dermatitis
-Offering a pacifier can be comforting vesicles and pustules surrounded by erythema
-Happens when parents do not change a child’s
-Reducing stimuli, taking infants for car rides, or usually appears on the neck first and may spread
playing a music box that stimulates the sound of a diaper frequently, feels is left in contact with skin,
upward to around the ears and onto the face or
and irritation may result in perianal area.
heartbeat are often reported as being helpful. down onto the trunk.
-There is some evidence using hydrolyzed protein, -Urine that is left in diapers too long breaks down
-Bathing an infant twice a day during hot weather
into ammonia- a chemical extremely irritating to
probiotics or prebiotics or a soy-based formula for particularly if a small amount of baking soda is
bottle-fed babies may be helpful. infant skin.
added to the bath water may improve the rash.
-Frequently diaper changing, applying an ointment,
-Eliminating sweating by reducing the amount of
Spitting Up and exposing the diaper area to air may relive the
clothing or lowering the room temperature should
problem
-Formula fed babies appear to do this more than bring almost immediate improvement and prevents
-Some infants may have to sleep without diapers at
breastfeed babies, possibly due to overfeeding further eruptions.
night to solve the problem
-Almost all milk that is spit up smells at least faintly
sour, but it should not contain blood or bile. Baby- Bottled Tooth Decay Syndrome
Fungal Diaper area is Antifungal
-Putting an infant to bed with a bottle can result in
Infection covered with medicine such
Normal early-infancy Spits up a mouthful of (monilial or lesions that are as Nystatin decay of all upper teeth and the lower posterior
spitting up milk (rolling down the candidiasis) bright red, w/ or teeth
chin) two or three times w/out oozing, -Decay occurs because, while an infant sleeps, liquid
a day (sometimes every that last longer form the propped bottle continuously soaks the
meal) than 3 days, and
Suggest illness Associated signs such as upper front teeth and lower back teeth (the lower
appear as red
diarrhea, abdominal front teeth are protected by the tongue)
pinpoint lesions.
-The problem is most serious when the bottle is
filled with sugar water, formula, milk or fruit juice
-The carbohydrate in these solutions ferments to
organic acids that demineralize the tooth enamel
until it decays.
-Advise parents never to put their baby to bed with a
bottle.
-If parents insist a bottle is necessary to allow a baby
to fall asleep, encourage them to fill it with water
and use a nipple with a small hole to prevent the
baby form receiving a large amount of fluid
-If the baby refuses to drink anything but milk the
parents might dilute the milk with water and more
each night until the bottle contains water only.
Obesity in Infants
-Obesity in infants is defines as a weight greater
than 90th to 95th percentile.
-Occurs when there is abnormal increase in the
number of fat cells because of excessive calorie
intake.
-If a child becomes obese because of over ingesting
milk, iron-deficiency anemia may also be present
because of low in iron content of both breast and
commercial milk
-Once infant obesity begins, it is difficult to revers, so
prevention is the key.
Nursing Care of a Family with an Toddler
-During this period, children accomplish a wide array
of developmental tasks and change from largely
immobile and preverbal infants who are dependent
on caregivers for the fulfillment of most needs to
walking, talking, young children with a growing
sense of autonomy (independence). To match this
growth parents must also change during this period.
Appearance of the average toddler
-Speaks in two-words sentences
-20 deciduous teeth present at 2.5 years
-Chest circumference becomes bigger than head
circumference at 2 years
-Heart rate 90 to 110 beats/min
-Noticeable lordosis
-“Pouchy” abdomen from weak abdominal muscles
-“Baby fat” begins to disappear
-Wide-based gait
Physical Growth
-Although toddlers are making great strides
developmentally, their physical growth begins to
slow.
Weight, Height, Head Circumference and Body
Mass Index
-If a child is not yet walking, continue to measure
height with the child lying down.
-A child gains only about 5 to 6lb (2.5 kg) and 5 in.
(12cm) a year during the toddler period, much less
than the rate of growth during the infant year.
-A child’s appetite decreases accordingly, yet
adequate intake of all nutrients is still essential to
meet energy needs.
-Ahead 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 should have grown
greater than of the head.
-Body mass index (BMI) screening is completed at 24
months to identify toddlers who are overweight or
underweight.
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 as well as they will be
able to do later.
-They also have a forward curve of the spine at the
sacral area (lordosis).
-Many toddlers waddle or walk with a wide stance.
This stance seems to increase the lordotic curve, but
it keeps them on their feet.
Body Systems: continue to mature during this time.
-Respirations slow slightly but continue to be mainly
abdominal
-Heart rate slows from 110 to 90 beats/min.
-Blood pressure increases to about 94/64 mmHg.
-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 lessens.
-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.
-Immune globulin (Ig) G and IgM antibody
production becomes mature at 2 years of age. The
passive immunity obtained during intrauterine life is
no longer operative.
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.
Language Development
-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 because this
implies underdevelopment.
-It is true that a delay in language can represent the
first symptoms of autism, but it also may only be a
temporary phenomenon until the child fully grasps
the essence of speech.
-A word that is sued frequently by toddlers and that
is a manifestation of their developing autonomy is
“no”. Toddlers may use the words to mean they are
refusing a task, that they do not understand, or they
may only be practicing a sound they have noticed
has potent effect on those around them.
- Children need to be exposed to words through
conservation and having books read to them.
-Urge parents to encourage language development
by naming objects _e.g. ball, block, music box, doll)
as they play with their child or when they give the
toddler something.
-Reading a loud is another effective way to
strengthen vocabulary.
Emotional Development
Autonomy
-is the development of a sense of autonomy versus
shame or doubt.
-Is to develop a sense of independence. A healthy
level of autonomy is achieved when parents are able
to balance independence with consistently sound
rules for safety.
Socialization
-they become resistant to sitting in laps and being
cuddles. This is not lack of a desire for socialization
but a function of being independent.
-At 15 months, children are still enthusiastic about
interacting with people, providing those people are
willing to follow them where they want to go.
-At 18 months, toddlers imitate the things they see
a parent doing, such as “study” or “sweep” so they
seek out parents to observe and imitate.
-By 2 or more years of age, children become aware
of gender differences and may point to other
children and identify them as “boy” or “girl”.
Play Behavior
-This side-by-side play (parallel play) is not unfriendly
but is a normal developmental sequence that occurs
during the toddler period.
-Caution parent that if two toddlers are going to play
together thy must provide similar toys because an
argument over one toy is likely to occur.
-Trucks they can make go, squeaky frogs they can
squeeze, rocking horses they can ride, pegs they can
pound, and a toy telephone they can talk into are all
favorites.
-They need only to watch a toddler tug a pull toy,
stop to see if it is following, walk again, and stop to
look to see if it is still following to understand the
feeling of accomplishment involved in manipulating
toys.
-At 15 months, children are still in a put-in, take out
stage, so they can continue to enjoy stacks of boxes
that fit inside each other. They enjoy throwing toys
out of a playpen or form a high chair tray as long as
someone will pick them up and return them again
and again.
At 18 month old child walks securely enough to
enjoy pull toys.
-By age 2 years, when toddlers begin to spend time
imitating adult action in their play such as wrapping
a doll and putting it to bed or “driving the care” they
begin to use fewer toys than before.
Cognitive Development
-Toddlers are described as “little scientist” because
of their interest in trying to discover new ways to
handle objects or new results that different actions
can achieve.
-At 15 months of age are able to follow a different
path (walk in back of the chair) to obtain the object
because they can project where it will stop rolling.
-Children at this stage are also able to remember an
action and imitate t later (deferred imitation); they
can do such things as pretend to drive a car or put a
baby to sleep because they have seen previously and
not just in the recent past.
-Children enter a second major period of cognitive
development termed preoperational thought and
begin to use a process termed assimilation.
Lead Screening
-CDC has set as a goal the elimination of elevated
blood lead levels in children.
-Between the ages of 6 months and 6 years who live
in communities with buildings build before 1950 and
immigrant children who might have been exposed to
sources of lead in another country should be tested
for the presence of lead in their body (lead
poisoning).
Dressing
-By the end of the toddler period, most children can
put their own socks and pants. Some may also be
able to pull on slacks, pullover shirts or simple
dresses.
Sleep
-They may begin the toddler period napping twice a
day and sleeping 12 hours each night it with one nap
a day and only 8 hours of sleep at night.
-If a child has difficulty falling asleep at night, it may
be time to omit or shorten an afternoon nap.
-Some toddlers begin having night terrors or awake
crying from a bad dream and so many receive little
sleep because they are reluctant to fall back asleep.
-As with any other activity of this period, a toddler
loves a bedtime routine: bath, pajamas, a story,
tooth brushing, being tucked into bed, having a drink
of water, choosing a toy to sleep with, and turning
out of the lights.
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 or the
child’s disregard of the rules that were learned.
-Two general rules to follow include:
1. Parents need to be consistent
2. Rules are learned best if correct behavior
is praised rather than wrong behavior
punished.
Separation Anxiety
-Fear of being separated from parents begins at
about 6 months of age and persists throughout the
preschool period.
-This universal fear in this age group is known as
separation anxiety.
-It helps if parents say goodbye firmly, repeat the
explanation they will be there when the child wakes
in the morning then leave.
-Prolonged crying only lead to more crying.
Temper Tantrums
-The child may kick; scream; stomp feet; shout, “No,
no, no”; flail arms and legs; bite; or bang his or her
head against the floor
-Occur as natural consequences of toddler’s
development. 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.
-A tantrum may also be a response to difficulty
making choices or decisions or to pressure form
activities such as toilet training.
Nursing Care of a Family with a Preschool Child
-Traditionally includes the years 3, 4, and 5.
-This is also an important period of growth for
parents because they may be unsure how much
independence and responsibility for self-care they
should allow their rapidly maturing child.
-Most children of this age want to do things for
themselves- choose their own clothing and dress
themselves, feed themselves independently, wash
their own hair and so forth.
Appearance of the average preschooler
-Vocabulary increases markedly
-Tonsils appear enlarged
-Pulse rate decreases to about 85 beats/min
-Genu valgus (knock-knees) may be evident
-Growth is only 2 to 3.5 in a year
-No new teeth develop
-Body contour changes to be more like childlike than
baby like
-Increased coordination makes bicycle, riding,
running, kicking possible
Physical Growth
-The wide-legged gait, prominent lordosis, and
protuberant abdomen of the toddler change to
slimmer, taller, and much more childlike
proportions.
-Ectomorphic body build (slim body build) or
Endomorphic body build (large body build) becomes
apparent.
Weight, Height, Body Mass Index and Head
Circumference
-Weight gain is slight during the preschool years; the
average child only about 4.5lb (2kg) a year.
-Height gain is minimal during this period: only 2 to
3.5 in (6 to 8 cm) a year on average.
-Head circumference is not routinely measured at
physical assessments on children over 2 years of age
because it changes little after this time.
Teeth
-Children generally have all 20 of their deciduous
teeth by 3 years of age; permanent teeth don’t
replace these until school age.
-Preserving teeth is important because they hold the
position for the permanent teeth as the child’s jaw
grows larger.
Language Development
-The extent of a 3 year old child vocabulary varies
depending on how much the child has been
encouraged to ask questions or participate in
conversations.
-A child needs simple answers to such questions to
encourage curiosity, vocabulary building and
questioning.
-Egocentrism or perceiving that one’s thought and
needs are better or more important than those of
others, is also strong during the preschool period.
-Preschooler define objects mainly in
relation to themselves.
-4 and 5 year old children enjoy participating
in mealtime conversation and can describe
an incident from their day in great detail.
Play
-Preschooler don’t need many toys because with an
imagination keener than it will be at any other time
in life, they enjoy games that use imitation such as
pretending they are a teacher, cowboy or cowgirl,
firefighter or store clerk.
-Many preschooler have imaginary friends at this
stage.
-4 and 5 year olds divide their time between
roughhousing and imitative play.
-5 year old becomes interested in group or reciting
songs they have learned in kindergarten or
preschool.
Emotional Development
Initiative
-Development task is to achieve a sense of initiative
versus guilt. –Children with a well-developed sense
of initiative like to explore because they have
discovered that learning new things is fun.
-If children are criticized or punished for attempts at
initiative, they can develop a sense of guilt for
wanting to try new activities or to have new
experiences.
-To gain a sense of initiative, preschooler need
exposure to a wide variety of experiences and play
materials so they can learn as much about how
things work as possible. They are ready to explore
outside their homes such as enjoying trip to the zoo
or amusement park.
-Urge parents to provide play materials that
encourage creative play such as finger paints, soapy
water to splash or blow into bubbles, san to build
castles, and modeling clay or homemade dough to
mold into figures or make into pretend cookies.
-What they make may not be recognizable; it is the
enjoyment of feeling the material and how can they
manipulate it that captures the experience.
Imitation
-Role modeling this way should be fun and does not
have to be accurate.
-If a parent is concerned that a child should
recognize these roles more accurately, it is usually
best to suggest that the parent not to stop the play
but rather explain further the work.
Fantasy
-Toddlers cannot differentiate between fantasy and
reality; they believe cartoon characters they see on
television are real.
-Preschooler begins to make this differentiation.
They may become so engrossed in a fantasy role that
they fear they are “stuck” in the fantasy and are no
longer themselves.
-Such intense involvement in play is part of “magical
thinking” which is active at this age.
Oedipus and Electra Complexes
-Oedipus Complex refers to the strong emotional
attachment of a preschooler boy demonstrates
toward his mother.
-Electra complex is the complex attachment of
preschooler girl to her father.
-Parents can be assured this phenomenon of
competition and romance in preschooler is a normal
part of maturing. Some parents may need in
handling feelings of jealousy and anger, however,
particularly if a child is vocal in expressing feelings
toward a parent.
Gender Roles
-Encourage single parents to plan opportunities for
their children to spend some time with adults other
than themselves, such as grandparent, a friends or a
relative of the opposite sex, for this experience.
Socialization
-Because 3 year olds are capable of sharing, they
play with other children their age much more
agreeably than do toddlers, which makes the
preschool period a sensitive and critical time for
socialization.
-4 year old continues to enjoy play groups, they may
become involved in arguments more than they did
at 3 years of age, especially as they become more
certain of their role in group.
-5 year old begin to develop “best” friendships,
perhaps on the basis of who they walk to school with
or who lives closest to them.
Dressing
-Many 3 and 4 year old can dress themselves except
for difficult buttons, although conflict may occur
over what the child will wear.
-Preschooler prefer bright colors or prints and so
many select items that are appealing in color rather
than matching.
Exercise
-Preschool is an active phase, so preschool play
tends to be vigorous
-Roughhousing helps to relieve tension and should
be allowed as long as it does not become destructive
-Love time-honored games or other more structured
games
-Promoting these types of active games and reducing
television watching cab be steps toward helping
children develop motor skills as well as prevent
childhood obesity.
Sleep
-Aware of their own needs; when they are tired, they
often curl up on a couch or soft chair and fall asleep.
-Children in this age group may refuse to go to sleep
because of fear of the dark an may wake ay night
terrified by a bad dream.
-This means that preschooler may need a night light
turned on, although they did not need one before.
Discipline
-A major parental responsibility when this happens is
to guide a child through these struggles without
discouraging the child’s right to have an opinion.
-A “timeout” is a useful technique for parents to
correct behavior throughout the preschool years.
-Timeout periods should be as many minutes
long as the child is old, so 3 to 5 minutes is
appropriate for preschoolers.
Common Fear of the Preschooler
-Preschooler imaginations are so active, this leads to
a number of fear such as fear of the dark, mutilation,
and separation or abandonment. These can rise in
incidence when combined with the stress of an
illness, hospitalization, or unsafe conditions in the
child’s community.
-Fears are so intense that they need therapy such as
desensitization in order for the fear to be
conquered.
Fear of the Dark
-The tendency of the fear of the dark is an example
of a fear heightened by a child’s vivid imagination: a
stuffed toy by daylight becomes a threatening
monster at night. Children awaken screaming
because of nightmares.
-Giving sleep medication to counteract the sleep
does not solve the basic problem.
Fear of Mutilation
-Is also significant during the preschool age, as
revealed by the intense reaction of a preschooler to
even a simple injury such as falling and scarping a
knee or having a needle inserted for an
immunization.
-They dislike procedures such as needle sticks, rectal
temperature assessments, orthoscopic
examinations, or having nasogastric tube passes into
their stomach.
-A child cries afterward not only form the pain but
also from the intrusiveness of the injury or
procedure.
Fear of Separation or Abandonment
-Another major concern for preschooler
-Their sense of time is still so distorted that they
cannot be comforted by assurances such as
“Mommy will pick you up from preschool at noon”.
-Caution parents to be sensitive to such fears when
they talk about missing children or if they have their
preschooler’s photo of fingerprints taken for
identification
Behavior variations
-A combination of a keen imagination and immature
reasoning results in a number of other common
behavior variations in preschoolers.
Telling Tall Tales
-Stretching stories to make them seem interesting is
a phenomenon frequently encountered in
preschoolers.
-Caution parents not to encourage this kind of
storytelling but instead help the child separate fact
from fiction by saying “That’s a good story, but now,
tell me what really happened”. This conveys the idea
that child has not told the truth, yet does not squash
imagination or initiative
-Parents must be alert to not dismiss important
information inadvertently such as children reposting
an adult molesting them.
Imaginary Friends
-Although imaginary friends are normal, creative
part of the preschool years and can be invented by
children who are surrounded by real playmates as
well as by those who have few friends, parents may
find them disconcerting.
Difficulty sharing
-Sharing is a concept that first cones to be
understood around at the age of 3 years.
-Around 3 years of age, children begin to understood
some things are theirs, some belongs to others and
some van belong to both.
Regression
-Generally in relation to stress, revert to behavior
they previously outgrew, such as thumb-sucking,
negativism, loss of bladder control and inability to
separate form their parents.
-Help parents understand that regression in these
circumstances is normal, and a child thumb-sucking
is a little different form the parents reaction to
stress, so it’s easier for them to accept and
understand.
Sibling Rivalry
-Jealousy of a brother or sister may first become
evident during the preschool period because this is
the first time children have enough vocabulary to
express how they feel and partly because
preschoolers are more aware of family roles and
how responsibilities at home are divided.
-To help preschoolers feel secure and to promote
self-esteem during this time, reminding them that
there are things they can do that a younger sibling is
not allowed to do and supplying them with a private
drawer or box for their things that parents or other
children do not touch can be helpful.
-A private box serves as a defense against younger
children who so not yet appreciate property rights.
Preparing for a new sibling
-Help parents to not underestimate the significance
of a bed to a preschool child because it is securely,
consistency and “home”.
-The latter may be a direct route to sibling rivalry or
jealousy
Sex Education
-Children become acutely aware of the difference
between boys and girls
-Preschooler questions about genital organs are
simple and fact finding
-Explanation should be simple
-It is important that parents do not convey that
these body parts are never to be talked about so
they leave an open line of communication for sexual
questions
Broken Fluency
-Repetition and prolongation of sounds, syllables
and words
-“Secondary stuttering” because the child began to
speak without this problem and then, during the
preschool years, developing it
-Children are unaware that they are not being fluent
unless it is called to their attention
-You may need to remind parents that this is a part
of normal development and if accepted as such will
pass
Bathroom Language
-Preschoolers imitate the vocabularies of their
parents or older children in the family so well during
this time that they incorporate swear words into
their vocabularies if they hear these used.
-Parents may have to remind that children do not
necessarily understand what the word they are suing
means
Nursing Care of a Family with a School-Age
-Term “school age” refers to children between the
ages of 6 and 12 years.
Physical Growth
-Average annual weight gain for a school age is
approximately 3 to 5lb (1.3 to 2.2kg): the increase in
height is 1 to 2 in (2.5 to 5 cm).
-Children who did not lose a lordosis and knock-
kneed appearance during the preschool period lose
this now.
Sexual Maturation
-At a set point in brain maturity, the hypothalamus
transmits an enzyme to the anterior pituitary gland
to begin production of gonadotropic hormones,
which then activate changes in the testes and
ovaries to cause puberty. Hormone changes that
occur with puberty.
- Sexual maturation in girls usually occurs between
the years of 12 and 18; in boys, between 14 and 20
years.
- Puberty is occurring increasingly earlier, however,
and in a class of 11-year-old sixth graders, it is not
unusual to discover more than half of the girls are
already menstruating.
Sexual and Physical Concerns
- The school-age period is a time for parents to
discuss with children the physical changes that will
occur and the sexual responsibility these changes
dictate.
- This is also a time to reinforce previous teaching
with children that their body is their own, to be used
only in the way they choose.
- In both sexes, puberty brings changes in the
sebaceous glands. Under the influence of androgen,
glands become more active, setting the stage for
acne.
-Vasomotor instability commonly leads to blushing;
perspiration also increases.
Concerns of Girls
- Prepubertal girls are usually taller by about 2 in. (5
cm) or more than preadolescent boys because their
typical growth spurt begins earlier.
- Sometimes, a girl notices the change in her pelvic
contour when she tries on a skirt or dress from the
year before and realizes her hips are becoming
broader.
- You can assure her that broad bone structure of
the hips is part of an adult female profile.
- Girls are usually conscious of breast development.
- Breast development is not always symmetrical, so
it is not unusual for a girl to have breasts of slightly
different sizes.
- Supernumerary (additional) nipples may darken or
increase in size at puberty. Be sure girls understand
that a supernumerary nipple is affected by the
hormones in her body in the same way as other
breast tissue, so she isn’t concerned by the
accessory nipple enlarging with puberty or in a
future pregnancy.
- Irregular periods can cause concern because girls
need to know when their periods will occur so they
can get used to this new phenomenon and learn to
trust their bodies
Concerns of Boys
- If they do not know testicular development
precedes penis growth, they can worry that their
growth will be inadequate.
- Hypertrophy of breast tissue (gynecomastia) can
occur in prepubescent boys, most often in those
who are obese.
- As increased seminal fluid begins to be produced,
boys begin to notice ejaculation during sleep,
termed nocturnal emissions.
- Preadolescent boys may believe the old myth that
loss of seminal fluid is debilitating; also, boys may
have heard the term “premature ejaculation” and
worry this is a forewarning of a problem in years to
come. Both are fallacies.
Teeth
- Deciduous teeth are lost and permanent teeth
erupt during the school-age period.
- Because of this, the average child gains 28 teeth
between 6 and 12 years of age: the central and
lateral incisors; first, second, and third cuspids; and
first and second molars.
Gross Motor Development
- A 7-year-old child appears quiet compared with the
more active 6-year-old. Gender differences usually
begin to manifest themselves in play: where girls
may gravitate to more traditional female roles and
activities and boys may gravitate to more traditional
male roles and activities.
- The movements of 8-year-olds are more graceful
than those of younger children, although, as their
arms and legs grow, they may appear awkward in
their play and eating habits. They ride a bicycle well
and enjoy sports such as gymnastics, soccer, and
hockey.
- Nine-year-olds are on the go constantly, as if they
always have a deadline to meet.
They have enough eye–hand coordination to enjoy
baseball, basketball, and volleyball.
-By 10 years of age, children are more interested in
perfecting their athletic skills than they were
previously.
- At 11 years of age, many children feel awkward
because of their growth spurt and drop out of sports
activities rather than look ungainly attempting them.
They may channel their energy into constant motion
instead: drumming fingers and tapping pencils or
feet. This fall in sports participation may bother
parents who see sports as the key to popularity, self-
esteem, fitness, and teamwork.
- Twelve-year-olds plunge into activities with
intensity and concentration. They often participating
in sports events for charities such as walkathons.
They may be refreshingly cooperative around the
house, able to handle a great deal of responsibility
and complete given tasks.
Fine Motor Development
- Six-year-olds can easily tie their shoelaces. They
can cut and paste well and draw a person with good
detail. They can print, although they may routinely
reverse letters.
- Seven-year-olds concentrate on fine motor skills
even more than they did the year before. This has
been called the “eraser year” because children are
never quite content with what they have done.
- By 8 years of age, children’s eyes are developed
enough so they can read regular- size type. This can
make reading a greater pleasure and school more
enjoyable. Eight-year-olds are able to write script in
addition to print. They enjoy showing off this new
skill in cards, letters, or projects.
- By age 9 years, their writing begins to look mature
and less awkward. Reading and writing are fun.
These are activities that can help a child pass the
hours during an illness.
Play
- Play continues to be active at age 6 years; however,
when children discover reading as an enjoyable
activity that opens doors to other worlds, they can
begin to spend quiet time with books.
- Many children spend hours playing increasingly
challenging video games, an activity that can either
foster a healthy sense of competition or create
isolation from others.
- By 7 years of age, children require more props for
play than when they were younger.
- Around 7 years of age, children also develop an
interest in collecting items such as baseball cards,
dolls, rocks, or marbles. The type of item is not as
important as the quantity.
- As a child reaches 8 years of age; time is spent
sorting and cataloging. Eight-year-olds also like table
games but hate to lose, so they tend to avoid
competitive games. They may change the rules in
the middle of a game to keep from losing.
- Nine-year-olds play hard. They wake in the
morning, squeeze in some activity before school,
and plan something the moment they arrive home
again.
- Many 10-year-olds spend most of their time playing
screen games. Boys and girls play separately at age
10 years, although interest in the opposite sex is
apparent. Boys show off as girls pass their group;
girls talk loudly or giggle at the sight of a familiar
boy. Girls become more interested in the way they
look and dress. Slumber parties and campouts
become increasingly popular.
- Children age 11 and 12 years enjoy dancing and
playing table games; they are accommodating
enough again to be able to play with younger
siblings who need the rules modified to their
advantage.
Language Development
- Six-year-olds talk in full sentences, using language
easily and with meaning. They no longer sound as
though talking is an experiment but appear to have
incorporated language permanently. They still define
objects by their use (e.g., a key is to unlock a door, a
fork is to eat with).
- Most 7-year-olds can tell the time in hours, but
they may have trouble with concepts such as “half
past” and “quarter to,” especially with the
prevalence of digital clocks.
- Because children discover “dirty” jokes at about
age 9 years, they like to tell them to friends or try to
understand those told by adults. They use swear
words to express anger or just to show other
children that they are growing up.
- By 12 years of age, children can carry on an adult
conversation, although stories are limited because of
a lack of experience.
Emotional Development
- Children enter the school-age period with the
ability to trust others and with a sense of respect for
their own worth.
- They should have practiced or mimicked adult
roles, learned to share, discovered that learning is an
adventure, and grasped the idea that doing things is
more important and more rewarding than watching
things being done (a sense of initiative).
Cognitive Development
- The age from 5 to 11 years is a transitional stage
where children undergo a shift from the
preoperational thought they used as preschoolers to
concrete operational thought or the ability to reason
through any problem they can actually visualize
figures, science specimens, sports materials, or
books and spend much time attending to and
enhancing such collections.
Children can use concrete operational thought
because they learn several new concepts during
school age, such as:
-Decentering, the ability to project one’s self into
other people’s situations and see the world from
their viewpoint rather than focusing only on their
own view.
-Accommodation, the ability to adapt thought
processes to fit what is perceived such as
understanding that there can be more than one
reason for other people’s actions. A preschooler
might expect to see the same nurse in the morning
who was there the evening before, whereas a
school-age child will understand that different
nurses work different shifts.
-Conservation, the ability to appreciate that a
change in shape does not necessarily mean a change
in size. If you pour 30 ml of cough medicine from a
thin glass to a wide one, the preschooler will say that
one glass holds more than the other; a school-age
child will know that both glasses hold an equal
amount.
-Class inclusion, the ability to understand that
objects can belong to more than one classification. A
preschooler is able to categorize items in only one
way, for example, stones and shells are found at the
beach; a school-age child can categorize them in
many ways such as by different materials or by a
difference in sizes and shapes, not just that they are
found at the beach.
Dental Carriers
- Caries (cavities) are progressive, destructive lesions
or decalcification of the tooth enamel and dentin.
- Neglected caries result in poor chewing and
therefore poor digestion, abscesses and pain, and
sometimes osteomyelitis (bone infection) if the jaw
bone is involved.
Malocclusion
- Malocclusion (a deviation of tooth position from
the normal) may be congenital due to conditions
such as cleft palate, a small lower jaw, or familial
traits tending toward malocclusion.
Bullying
- A frequent reason school-age children cite for
feeling so unhappy that they turn guns on
classmates or commit suicide is because they were
ridiculed or bullied to the point they could no longer
take such abuse
Nursing Care with an Adolescent
- Adolescence is generally defined as the period
between ages 13 and up to 20 years, a time that
serves as a transition between childhood and
becoming a late adolescent.
- Adolescents invariably feel a sense of pressure
throughout this period because they are mature in
some respects but still young in others.
Physical Growth
-Onset puberty at 8 to 12 years of age
-Cessation of body growth around 16 to 20 years
-Boys typically grow about 4 to 12in. (10 to 30 cm) in
height and gain about 15 to 65lb (7 to 30 kg) during
their teenage years.
-Girls grow 2 to 8 in. (5 to 20 cm) in height and gain
15 to 55lb (7 to 25kg).
-Stops with closure of the epiphyseal lines of the
long bones, which occurs at about 16 to 17 years of
age in females and about 18 to 20 years of age in
males.
Body Systems
-Heart and lungs increase in size more slowly-
adolescent may have insufficient energy and become
fatigued trying to finish the various activities that
interest them
-Pulse rate and respiratory rate decrease slightly to
(70 beats/min and 20 breaths/min, respectively)
-Blood pressure increases slightly (to 120/70 mmHg)
by late adolescence
-With adulthood, blood pressure becomes slightly
higher in males than in females because more force
is necessary to distribute blood to the larger male
body organs
-Androgen stimulates sebaceous glands to extreme
activity- resulting in acne, common adolescent skin
problems.
-Apocrine sweat glands (i.c. glands present in the
axillary and genital area)-produces a strong odor in
response to emotional stimulation
-Adolescent shower or bathe more frequently in
order to be free of body odor because of this
change
Teeth
-Adolescents gain their second molars at about 13
years of age.
-Third molars (wisdom teeth) between 18 and 21
years of age.
-Third molars may erupt at early as 14 to 15 years of
age.
Puberty
-Time at which an individual first becomes capable of
sexual reproduction
-usually occur between ages 11 and 14 years old
-Girl has entered puberty when she begins to
menstruate
- a boy enters puberty when he begins to produce
spermatozoa
Developmental Milestones
Play or Recreation
-Recreation such as listening to music, texting or
chatting, or following a sports team’s wins and
losses.
-Team (or school) loyalty becomes intense and
following a coach’s instructions becomes mandatory
-Overuse injuries from athletics occur in early
adolescence
-Most adolescents spend a great deal of time just
talking with peers as social interaction, either face-
to-face or through electronic media
-Conflict can arise if parents disapprove of the
number of hours spent in this activity, afraid their
children are wasting important hours, or at least
exchanging a great deal of trivial conversation
-Beginning at age 16 years, most adolescents want
part-time jobs to earn money.
-Such jobs can teach young people how to work with
others, accept responsibility, and how to save and
spend money wisely.
-These activities fulfill an adolescent’s need for
satisfying interaction with others as well as
indicators of maturity and willingness to accept adult
roles
Emotional Development
- Early Adolescent Developmental Task: Identity
versus Role Confusion
-Late Adolescent Developmental Task: Intimacy
versus Isolation
-Socialization
Early Adolescent Developmental Task:
Identity versus Role Confusion
-The task of forming a sense of identity is for
adolescents to decide whom they are and what kind
of person they will be.
The four main areas in which they must make gains
to achieve a sense of identity include:
1. Accepting their changed body image
2. Establishing a value system or what kind of
person they want to be
3. Making a career decision
4. Becoming emancipated from parents
- If young people do not achieve a sense of identity,
they can have little idea what kind of person they are
or may develop a sense of role confusion
Body Image
-Some adolescents, for example, are disappointed
with their final height
-Adolescents are usually their own worst critics,
never pleased with any aspect of their bodies
-Those with low self-esteem may need parental or
health care provider support to understand that a
person’s worth is based on more than physical
appearance.
Self-Esteem
- Adolescence is a period of particular crisis for girls
who are trying to find a place in a male-dominated
society.
-Less pressure on boys, who may have already
learned to be competitive, independent, and
separated from feelings
- Long-term psychological problems, notably eating
disorders, which occur in both boys and girls, may be
one unfortunate result of repressing inborn feelings
in order to conform.
-Parents can help both girls and boys deal with these
conflicts by encouraging them to maintain their
honesty and integrity.
Value System
-Adolescents develop their values throughout their
childhood as they interact with their family.
-As they increase the amount of time they spend
with their peer group, they may question these
values and participate in experiences that may put
them at risk for physical and/or psychological harm. 
- Identifying risk-taking behaviors and offering
guidance and support is important in promoting the
health of the adolescent.
Social Coupling
-individuals tend to dress and behave similarly to
other members of their peer group
-Bullying behavior may be directed at individuals
who don’t conform to or associate with a peer
group.
-Bullying behaviors should be identified, and the
appropriate interventions should be initiated.
-Individuals begin to explore their sexual
preferences and may question their gender identity.
-Encourage an open dialogue with adolescents to
assist them to process their feelings and establish
their own identity.
-Counseling may be helpful to assist with family
communication if the family is not accepting
Career Decision
-making a career decision becomes more and more
difficult
-adolescents are encouraged to wait until they have
been in college for 2 years before choosing a major
Emancipation from parents
-major issue during the middle and late adolescent
years
-two reasons: Some parents may not yet be ready
for their child to be totally independent, and some
adolescents may not yet be sure they want to be on
their own
-encourage parents to give adolescent more
freedom
Late Adolescent: Developmental Task: Intimacy
Versus Isolation
-Those who do not develop a sense of intimacy are
left feeling isolated; in a crisis situation, they have no
one to whom they feel they can turn to for help or
support.  (although they continue to grow taller until about 18
-A sense of intimacy is closely related to the sense of
trust learned in the first year of life because, without
the feeling that one can trust others, building a
sense of intimacy is difficult.
- Parents should feel an obligation to inform their
children of their
feelings about early sexual relationships.
-At the same time, they have to be realistic that
some adolescents will not follow their advice as
shown by the rising rates of teenage pregnancy and
sexually transmitted diseases, including HIV
- If parents suspect their adolescent is sexually
active, counsel them to be certain their child is
knowledgeable about safer sex practices
- In our busy modern society in which adolescents
engage in such a variety of activities, they may need
help learning how to project themselves into
another person’s situation and to ask themselves
how the world looks from that position.  plan their future.
-This concept, empathy, is the ability to understand
the feelings of another, or, in other words, a
developed sense of intimacy in its finest form.
Socialization
- Early teenagers may feel more self-doubt than self-
confidence
-Both male and female early adolescents tend to be
loud and boisterous
-experience “crushes,” or infatuations with
schoolmates
-age 14 years, teenagers have become quieter and
more introspective
- Most 15-year-olds fall “in love” five or six times a
year. However, many of these relationships are
based on attraction because of physical appearance
-By age 16 years, boys are becoming sexually mature
years of age).
-Both sexes are better able to trust their bodies than
they were the year before.
-By age 17 years, they tend to have adult values and
responses to events.
-They have left behind the childish behaviors they
used in early adolescence—shoving and punching—
to get the attention of others
Cognitive Development
-The final stage of cognitive development, the stage
of formal operational thought, begins at age 12 or 13
years and grows in depth over the adolescent years.
-Problem solving in any situation depends on the
ability to think abstractly and logically. With the
ability to use scientific reasoning, adolescents can
 
-Thinking abstractly is what allows adolescents to
project themselves into the minds of others and
imagine how others view them or their actions
(display compassion).
Moral and Spiritual Development
-Almost all adolescents question the existence of
God and any religious practices.
-This questioning is a natural part of forming a sense
of identity and establishing a value system at a time
in life when they draw away from their families.
Health Promotion for an Adolescent and Family
Promoting Adolescent Safety
-Unintentional injuries, most commonly those
involving motor vehicles, are the leading cause of
death among adolescents
-Athletic injuries, especially overuse injuries from
poor conditioning, tend to increase in number during
adolescence because of the vigorous level of
competition that occurs in organized sports.
Promoting Nutritional Health for an Adolescent
- Adolescents experience such rapid growth that
they may always feel hungry
-If their eating habits are unsupervised, because of
peer pressure and when in a hurry to get to other
activities, they tend to eat faddish or quick snack
foods rather than more nutritionally sound ones.
- Some adolescents turn away from the basic food
groups to eat sweets, soft drinks, or empty-calorie
snacks and so are left poorly nourished. \
-This type of eating pattern, combined with a lack of
exercise, also leads to obesity  -Good sources of iron are meat and green
-Adolescents who are slightly obese because of
prepubertal changes may begin low-calorie or
starvation diets during adolescence to lose weight.  -be careful to not use so much fluoride through the
-Some diet so excessively they develop eating
disorders such as bulimia or anorexia nervosa
-Weight-loss diet is appropriate during adolescence
Recommended Dietary Reference Intakes
-Increased number of calories to support the rapid
body growth that occurs.  meals to increase the amount of protein supplied
-Foods must come from a variety of sources to
supply necessary amounts of carbohydrates,
vitamins, protein, and minerals
-Deficient in both male and female adolescent diets
are iron, calcium, and zinc.
Iron
-To meet expanding blood volume requirements
-Females require a high iron intake not only because
of this increasing blood volume but also because
iron begins to be lost with menstruation
-Girls with a heavy menstrual flow (i.e.,
menorrhagia) and especially those who participate in
strenuous athletics may need to take an additional
iron supplement to prevent iron deficiency anemia
Increased calcium and vitamin D plus physical
exercise
-Necessary for rapid skeletal growth as well as to
“stockpile” calcium to prevent osteoporosis later in
life
Zinc
-Necessary for sexual maturation and final body
growth
Recommended Reference Dietary Intakes
vegetables, calcium is abundant in milk and milk
products, and meat and milk are also high in zinc.
Promoting Nutritional Health with a Varied Diet
Vegetarian diet
-vegetables generally contain fewer calories
-adolescents need to consume large amounts of
them to achieve an adequate caloric intake
-Textured vegetable protein or tofu can be added to
and help meet adolescent growth needs
Glycogen Loading
-Athletes need more carbohydrate or energy
-Glycogen loading is a procedure used to ensure
there is adequate glycogen to sustain energy
through an athletic event.
-Several days before a sports event, athletes lower
their carbohydrate intake and exercise heavily to
deplete muscle glycogen stores.
- They then switch to a diet high in carbohydrate.
-With the renewed carbohydrate intake, muscle
glycogen is stored at two to three times the usual
level, which supplies them with up to twice the
glucose needed for sustained energy 
Promoting Development of an Adolescent in daily
Activities
Dress and Hygiene
- Capable of total self-care and, because of their
body awareness, may even be overly conscientious
about personal hygiene and appearance
Care of Teeth
- Very conscientious about tooth brushing because
of a fear of developing bad breath.
-Continue to use a fluoride paste rather than a brand
advertised as providing white teeth.
-continue to drink fluoridated water to ensure firm
enamel growth
use of mouth rinses or toothpaste that they develop
fluorosis (i.e., a blue discoloration of teeth
Sleep
-adolescents may sleep restlessly as their mind
reworks the day’s tensions.
-Even long periods of sleep, therefore, may not leave
them feeling refreshed
-frequent lack of sleep can lead to chronic fatigue or
depression
-medication is not usually recommended for
adolescents; instead, they are urged to reduce
activity to get more sleep
Exercise
- Adolescents need exercise every day both to
maintain muscle tone and to provide an outlet for
tension
-Adolescents who are involved in structured athletic
activities do receive daily exercise.
Sun Exposure
-avoid excessive sun exposure so they don’t develop
skin cancer (i.e., melanoma) from ultraviolet rays.
-Encourage teenagers to use sunscreen, avoid
tanning beds, and report to their primary healthcare
provider any skin mole that changes in shape or
color
Common Health Problems of an Adolescent
Hypertension
-Adolescents who are obese, who are African
American, who eat a diet high in salt, or who have a
family history of hypertension are those most
susceptible to developing this disease.
-medications plus education can help to greatly
reduce the incidence of cardiovascular disease as
they reach adulthood
-blood pressure is above the 95th percentile
 127/81 mmHg for 16-year-old girls  risk for contracting a blood borne disease as sharing
 131/81 for 16-year-old boys for two
consecutive readings in different
settings
Poor Posture
-This is due to imbalance of growth that arises from
the skeletal system growing a little more rapidly than
the muscles attached to it.
-Girls, especially, may slouch so as not to appear
taller than boys or to diminish the appearance of
their breast size if they are developing more rapidly
than their friends.
-another reason may be related to carrying
backpacks that are too heavy
- Urge children of both sexes to use good posture
during these rapid-growth years.
-Assess posture at all adolescent health appraisals to
detect the difference between simple poor posture
and the beginning of spinal dysplasia or scoliosis
(i.e., lateral curvature of the spine)
Body Piercing and Tattoos
-Strong mark of adolescence
-a way for adolescents to make a statement of who
they are and that they are different from their
parents.  Assessment
-Be certain they know the symptoms of infection at a
piercing or tattoo site (e.g., redness, warmness,
drainage, swelling, mild pain) and to report these to
their healthcare provider if they occur because
serious staphylococcal or streptococcal infections
can occur at piercing sites.
-It is important to caution adolescents that sharing
needles for piercing or tattooing carries the same
needles for intravenous drug use.
Fatigue
- may be a beginning symptom of disease
-Assess an adolescent’s diet, sleep patterns, and
activity schedules
-Blood tests may be indicated to rule out anemia and
common infections in adolescents
Menstrual Irregularities
-Menstrual irregularities can be a major health
concern of adolescent girls as they learn to adjust to
their individual body cycles
Acne
- a self-limiting inflammatory disease that involves
the sebaceous glands, which empty into hair shafts
(the pilosebaceous unit). 
It is the most common skin disorder of adolescence,
occurring in as many as 80% to 95% of adolescents
-occurs slightly more frequently in boys
- The most common locations of acne lesions are the
face, neck, back, upper arms, and chest
-Flare-ups are associated with emotional stress,
menstrual periods, or the use of greasy hair creams
or makeup that can further plug gland ducts.
-ask adolescents if they are troubled with acne and
to what extent it interferes with their self-image
because this can be a major cause of stress in
adolescents. 
-Inspect for facial, chest, and back lesions on physical
examination.
Therapeutic Management
The goal of therapy for acne is threefold:
(a) decrease sebum formation
(b) prevent comedones
(c) control bacterial proliferation.
Obesity
-Most overweight adolescents have obese parents,
suggesting that both inheritance and environment
play a part in the development of adolescent
obesity.
-Obesity can interfere with developing a sense of
identity
-Because of stress related to weight, the attempted
suicide rate for obese female adolescents is higher
than for non-obese adolescents
-Health teaching with these adolescents may need to
begin with a discussion of “normal” weight and
standard food portions
Concerns Regarding Sexuality and Sexual Activity
-Adolescents who engage in sexual risk behaviors
can have unintended health outcomes, including
unplanned pregnancies and sexually transmitted
infections (STIs) such as HIV
-When discussing sexuality with adolescents, the
nurse should avoid assumptions about the gender of
the adolescent’s partner.
-Ask open-ended questions when providing
education on health promoting behaviors. This will
also help the adolescent feel more open to asking
questions.
-Counseling can assist adolescents improve their
perspective and also learn how to say no.
-For adolescents who agree to have intercourse but
who do not really want to, the primary reasons given
are peer pressure, curiosity, and affection for their
partner
-Information on date rape and rape prevention
should be provided as adolescents are in a high-risk
age group for date rape
-One form of date rape occurs when flunitrazepam
(Rohypnol) (i.e., the “date-rape drug”), a colorless,
odorless, and flavorless benzodiazepine drug, is
dropped into a drink, causing drowsiness, impaired
motor skills, and amnesia for a time
-a urine specimen analysis will reveal the drug’s
metabolites or that the drug was ingested
Stalking
-refers to repetitive, intrusive, and unwanted actions
such as constant and threatening pursuit directed at
an individual to gain the individual’s attention or to
evoke fear.
-Electronic media can be used for cyber stalking,
Internet harassment, and Internet bullying to
embarrass, harass, or threaten adolescents
-To avoid stalking, adolescents should be aware of
and avoid situations where they will be vulnerable to
being alone with a stalker and, with assistance,
report stalking to law enforcement.
Concerns regarding hazing and bullying
-Bullying can easily continue into adolescence and
actually becomes more serious because this can be
the time the bullied child has the ability to retaliate
through self-destructive behavior or school violence
-Hazing, a form of organized bullying, refers to
demeaning or humiliating rituals that prospective
members have to undergo to join sororities,
fraternities, adolescent gangs, or sports teams 
-To help prevent this from happening to their child,
urge parents to be aware of what clubs or
organizations their adolescent joins and what the
requirements for membership are.
-Help adolescents make sound decisions about what
type of hazing their organization advocates by asking
them about the subject at health assessment
Concern regarding substance use disorder
- refers to the use of chemicals to improve a mental
state or induce euphoria.
-This is so common among adolescents that as many
as 50% of high school seniors report having
experimented with some form of drug
- Use of drugs occurs in adolescence from a desire to
expand consciousness, peer pressure, or a desire to
feel more confident and mature; it also can be a
form of adolescent rebellion related to childhood
adversity or violence.
-Stages of drug use range from experimentation
where teenagers try drugs to enhance social
acceptance to regular use, where they actively seek
the effect of drugs to relieve everyday stress 
Prescription and over the counter drugs
-Methylphenidate (Ritalin) is a drug frequently
prescribed for attention deficit hyperactivity disorder
-methylphenidate (Ritalin) is a stimulant, when oral
tablets are crushed and injected intravenously, they
produce a feeling of giddiness and extreme well-
being.
-they do not completely dissolve, the resultant small
particles remaining in the bloodstream can result in
complications such as pulmonary embolus or
emphysema
- a number of inhalants, such as oil-based cooking
spray, gas, butane, or lighter fluid,  may be abused
by adolescents.
Inhalants can lead to cardiac failure from
suffocation. 
-Mephedrone, commonly called “bath salts,” is a
stimulant that creates an enjoyable “high” and is
available for purchase online and so is easily
obtained by adolescents.
-The effect of using it is seen more regularly in
emergency departments as the cause of reckless
driving or unconsciousness
Alcohol
- can cause diseases such as cirrhosis
-is linked to destructive behaviors such as addiction,
depression, and vulnerability to date rape.
Tobacco
- cigarette smoking leads to increased cardiovascular
and respiratory illnesses by middle age
- Helping adolescents find other methods to
demonstrate their maturity, such as allowing them
opportunities for increased decision making and
emphasizing that being able to not smoke is a sign of
true maturity
Marijuana
- Breakdown products of marijuana are not readily
eliminated from the body and remain in the fatty
cells of the brain.
-This residue can create synaptic gaps that interfere
with electrical brain waves and memory storage,
especially for short-term memory.
-Physical and psychological effects of all forms of
marijuana are:
 euphoria and a sense of well-being
 temporary impairment of coordination
 rapid mood swings
 Decreased attention span
 loss of memory for recent events (up to 1
hour’s time).
-Withdrawal symptoms include irritability,
drowsiness, and cravings for high-carbohydrate
snacks.
Cocaine
- Psychological effects produced are:
 Euphoria
 Excitement
 Restlessness
 increased sociability, and
 possible hallucinations.
- Chronic inhalation of cocaine can cause ulceration
in the mucous membrane of the nose, and injection
of the substance exposes an adolescent to the risk
of HIV and AIDS or hepatitis B.  -Injury proneness, carelessness, and death wishes
During pregnancy, it can cause separation of the
placenta with potential fetal and maternal death  such as ”this is the last time you will see me”
Concern Regarding Depression and Self-Injury
- Self-injury includes a range of self-destructive
actions from cutting to suicide, the planned intent to
end one’s life.
0Cutting is found more frequently in girls than boys
and can begin as early as grade school
-Successful suicide occurs more frequently in males
than in females
-more females apparently attempt suicide than
males (a ratio of about 8:1)
- Adolescent suicides tend to be attempted most
often in the spring or the fall, reflecting school stress
at these times of year, and between 3 PM and
midnight, reflecting depression that increases with
the dark.
-Suicide is so common in adolescents it ranks in the
top four causes of death in the 10- to 24-year-old
age group
-If school failure, loss of a girlfriend or boyfriend, loss
of a competition with loss of self-esteem, or
rejection by a peer group is superimposed on
existing depression, the pressure may be great
enough to cause some adolescents to attempt
suicide. 
Suicide Warning Signs
- Giving away prized possessions
-Organ donations questions, such as “how do you
leave your body to a medical school?”
-Sudden, unexplained elevation of mood, which may
indicate the individual has reached a decision about
the suicide and feels relief
-Decrease in verbal communication or a statement
-Withdrawal from peer activities or previously
enjoyed events
-Previous attempt(80% of all completed suicides
have been preceded by a failed attempt)
-Preference for art, music, and literature with
themes of death
-Recent increase in interpersonal conflict with
significant others
-Running away from home
-Recent experience of a friend or famous person
committing suicide
-Inquiring about the hereafter
-Asking for information about suicide prevention and
intervention
-Any sustained deviation from the normal pattern of
behavior