Submitted by Joana Grace Alpay

PEDIA
BSN - 2 Section B
Nursing Care of Family with a Toddler
NURSING CARE OF FAMILY WITH A TODDLER
remember
1-3 years old = Toddler
Enormous changes take place both in the child and in
the family
Toddlers accomplish a wide array of developmental
tasks
Toddlers change from largely immobile, preverbal, and
dependent infants to walking, talking young children
with a growing sense of autonomy
Toddlers change so much
Toddlers learn so many skills that their abilities and
associated parental concerns can change from day to
day.
Parents in this period must (a) support their child’s
growing independence with patience and sensitivity
(b) learn methods for handling the child’s frustrations
that arise from the quest for autonomy
Nursing Process Overview
Assessment
Take a careful health history of the child.
Ask the parents about the toddler’s ability to carry
out activities of daily living.
Observe the toddler in a careful manner.
Diagnosis
Health-seeking behaviors related to normal toddler
development
Deficient knowledge related to the best method of
toilet training
Risk for injury related to impulsiveness of toddler
Interrupted family process related to need for close
supervision of a 2-year-old
Readiness for enhanced family coping related to
parents’ ability to adjust to new needs of the child
Readiness for enhanced parenting related to
increased awareness of poison prevention
Disturbed sleep pattern related to lack of bedtime
routine
Outcome Identification and
Planning
Establish realistic goals and outcomes to rapidly
meet the changing needs of the child.
Learn to cope with typical toddler behaviors.
Page 02
Implementation
Teach parents not only how to approach a current
problem but also how to learn adequate methods for
resolving similar situations that are sure to arise in
the future.
Demonstrate good communication skills with
toddlers.
Help parents learn healthy coping techniques.
Outcome Evaluation
Parents state child maintain a consistent bedtime
routine within the next 2 weeks.
Parents state they have childproofed their home by
putting a lock on the kitchen cupboard by the next
clinic visit.
GROWTH AND DEVELOPMENT
physical growth
remember
Toddlers are making great strides developmentally
Toddler’s physical growth begins to slow
weight, height and head circumference
Toddlers gain only about 5 to 6 lb (2.5 kg) and 5 in (12 cm) a
year
Toddler’s baby fat begins to disappear toward the end of the
second year and changes from a plump baby into a leaner,
more muscular one
Toddler’s appetite decreases accordingly, yet adequate
intake of all nutrients is still essential to meet energy needs
Head circumference increases only about 2 cm during the
second year compared to about 12 cm during the first year
Head circumference equals chest circumference at 6 months
to 1 year of age
By 2 years, chest circumference has grown greater than that
of the head
body contour
Toddlers tend to have a prominent abdomen because their
abdominal muscles are not yet strong enough to support
abdominal contents
They also have a forward curve of the spine at the sacral
area (lordosis). As they become more experienced at
walking, this will correct itself naturally.
Toddlers waddle or walk with a wide stance which increase
the lordotic curve, but it keeps them on their feet
 Nursing Care of Family with a Toddler
teeth
Eight new teeth (the canines and the first molars) erupt
autonomy
during the second year
All 20 deciduous teeth are generally present by 2.5 to 3 years
of age
body systems
Body systems continue to mature during Toddler
Respirations slow slightly but continue to be mainly
abdominal
The heart rate slows from 110 to 90 beats per minute; blood
pressure increases to about 99/64 mm Hg
The brain develops to about 90% of its adult size
In the respiratory system, the lumens of vessels enlarge
progressively so the threat of lower respiratory infection
becomes less
Stomach secretions become more acidic; therefore,
gastrointestinal infections also become less common
Stomach capacity increases to the point a child can eat
three meals a day
Control of the urinary and anal sphincters becomes possible
with complete myelination of the spinal cord so toilet training
is possible
IgG and IgM antibody production becomes mature at 2
years of age. The passive immunity obtained during
intrauterine life is no longer operative
developmental milestones
remember
Toddler period is a period of slow and steady, not
sudden, growth
Toddler development is influenced by the social
contact and opportunities children have to explore and
play behavior
experience new independence
It is strongly influenced by individual readiness for a
new skill
language development
“No” is the word used frequently by toddlers and that is a
manifestation of their developing autonomy
“No” may mean they are refusing a task, or they do not
understand it, or they may only be practicing a sound that
they have noticed has potent effects on those around them
Toddlers need exposure to conversation and need to read
often
Very active children may use fewer words than less active
children
nurse’s action
Encourage parents to practice naming objects as they
play with their child (ex. “ball,” “doll”)
Always answer a child’s questions in a simple and brief
manner
Rewording a question and reading a loud can reinforce
language development
Page 03
emotional development
Developmental task of the toddler is the development
of a sense of autonomy versus shame or doubt.
To develop a sense of autonomy is to develop a sense
of independence.
Parents must encourage independence while still
maintaining consistently sound rules for safety.
Toddlers who are unable to try things because they will
hurt themselves may be left with a sense of doubt
Toddlers begin to make differentiation
Toddlers are being negativistic, obstinate, and difficult to
manage.
socialization
When walking well, toddlers become resistant to sitting
in laps and being cuddled.
At 15 months, toddlers are still enthusiastic about
interacting with people
By 18 months, toddlers imitate the things they see a
parent doing, such as “study” or “sweep”
By 2 or more years, children become aware of gender
differences
By 2 or more years, children may point to other children
and identify them as “boy” or “girl.”
Children play beside children next to them, not with
them.
Side-by-side play (called parallel play) is not unfriendly
but is a normal developmental sequence
Toddlers who have an aggressive personalities
probably have the most difficulty adapting to
playgroups
If two toddlers are going to play together, parents must
provide duplicate toys or an argument over one toy is
likely to occur
Toys children can control, giving them a sense of power
in manipulation, an expression of autonomy
At 15 months, children are still in a put-in, take-out stage
They enjoy throwing toys out of a playpen or from a highchair
tray
At 18 months, toodlers enjoy to pull toys
By age 2, they begin to use fewer toys than before and the act
of imitating has become their play.
By age
the end
2, The
of act
the of
period,
imitating
theyhas
begin
become
to liketheir
rough-housing
play. and
spend in this very active, stimulating type of play
 Nursing Care of Family with a Toddler
cognitive development
Toddler enters the fifth and sixth stages of Piaget’s
sensorimotor thought
Stage 5 (12-18 months)is a tertiary circular reaction stage,
toddlers in this stage are “little scientists”
Toddlers have also advanced beyond what they could do as
infants in dropping objects and watching where they roll. (For
example, they are able to follow a different path to obtain
the object.)
By stage 6 (18-24 months), toddlers can try out various
actions mentally rather than having to perform them—the
beginning of problem-solving or symbolic thought
Children are able to remember an action and imitate it later
(deferred imitation)
Object permanence becomes complete
“Object permanence” means understanding that items and
people still exist even when you can't see or hear them
At the end of the toddler period, children enter
preoperational thought (2nd major period) in which children
deal much more constructively with symbols
They begin to use a process termed assimilation, when they
are not able to change their thoughts to fit a situation, they
learn to change how they perceive it to fit their thoughts
HEALTH PROMOTION FOR A
TODDLER AND FAMILY
remember
Toddlers are prone to upper respiratory and ear
infections
nurse’s action
Encourage parents to promote the healthy development
of independence in their toddlers
Listen carefully to their concerns, and ask questions to
help separate the objective circumstances surrounding
a problem from the parents’ possible emotional biases
Provide guidelines on how to handle specific problems
PROMOTING TODDLER SAFETY
remember
Accidental ingestions (poisoning) (mostly from ingestion
of cleaning products) are the type of accident that
occurs most frequently in toddlers
Aspiration or ingestion of small objects is also a major
danger for children of this age
Motor vehicle accidents, burns, falls, drowning, and
playground injuries are other accidents
nurse’s action
Encourage the parents to childproof their home by
putting all poisonous products, drugs, and small objects
out of reach by the time their infant is crawling, and
certainly by the time their infant is walking
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Advise parents to supervise their toddlers at all times
Inform parents to check whether backyard pools are
securely fenced since toddlers cannot swim well
Inform parents to place their child in the back seat if the
car has a passenger seat airbag
Tell the parents the need for the toddler to wear a
helmet as they begin riding a tricycle
Advise the parents to move their child to a regular bed
with a side rail when they climb over the side rails of
their cribs and enjoy exploring the house early in the
morning before anyone else is awake
Encourage the parents to keep a safety gate on the
door of the room to keep a toddler contained and safe
Tell the parents to avoid letting their children to use real
cleaning compounds or sharp tools
LEAD SCREENING
The Centers for Disease Control and Prevention (CDC)
requires all children between the ages of 6 months and 6
years who live in communities with buildings built before 1950
to be tested periodically for the presence of too much lead in
their bodies
Lead poisoning is caused by eating, chewing, or sucking on
objects covered with lead-based paint
Lead is toxic to body tissue, and ingestion of it leads to
serious damage to the brain and nervous system, kidneys,
and red blood cells
Low level of lead may result in learning and behavioral
problems
High levels of lead may result in seizures, cognitive
challenges, coma, and even death
Symptoms of lead poisoning include irritability, headache,
fatigue, and abdominal pain
A small amount of blood taken by a finger prick is analyzed.
A positive result (over 10 g/dL) must be confirmed by further
testing
PROMOTING NUTRITIONAL
HEALTH OF A TODDLER
remember
A toddler’s appetite is smaller than an infant’s
Toddler’s appetite has decreased so food consumption
will be less
Allowing self-feeding is a major way to strengthen
independence in a toddler
Offering finger foods and allowing a choice between
two types of food helps promote independence
Toddlers usually do not like food that is “mixed up”
They often prefer that different foods do not touch one
another on their plate
They eat all of one item before going on to another
They often prefer brightly colored foods to bland colors
nurse’s action
Teach the parents to place a small amount of food on a
plate rather than serve a large portion the child cannot
finish
Educate the parents while the child is still an infant that
this decline in food intake will occur to prevent anxiety
 Nursing Care of Family with a Toddler
toddler nutrition
Sedentary children ages 1 to 3 years should consume 1000
kcal daily
Active children in this age group may need up to 1400 kcal
daily
Protein and carbohydrate needs are often those most easily
met during the toddler period
Diets high in sugar should be avoided
Fats can be consumed by children under 2 years old
Children over 2 years old should have a total fat intake
between 30% and 35% of calories, come from fish, nuts, and
vegetable oils
Trans–fatty acids should be kept to a minimum.
Adequate calcium and phosphorus intake is important for
bone mineralization
Milk should be whole milk until age 2 years
PROMOTING ADEQUATE INTAKE WITH A
VEGETARIAN DIET
A vegetarian diet can be easily designed for a toddler who
prefers finger foods because many vegetables, fruits, and
grains such as pieces of oranges, peaches, raisins,
chickpeas, tomatoes, and crackers are easily eaten this way
Using fortified soy milk prevents fluid, protein, B12, and
calcium deficiencies
Tofu or Quom should be part of every meal to supply protein
PROMOTING TODDLER DEVELOPMENT
IN DAILY ACTIVITIES
remember
Toddler’s new independence and developing abilities in
self-care present special challenges for parents
Learning how to promote autonomy yet maintain a
safe, healthful environment should be a major goal for
the family
dressing
Parents may be reluctant to encourage toddlers to dress
themselves as it is often easier and quicker to put their
clothes on for them because a toddler who is dressed by
parents will be wearing clothes in the correct way
When toddlers dress themselves, they invariably put shoes on
the wrong feet and shirts and pants on backward
Sneakers are ideal toddler shoes because the soles are hard
enough for rough surfaces and arch support is limited
nurse’s action
Encourage parents to give up perfection for the benefit
of the child’s developing sense of autonomy
Instruct the parents to begin with a positive statement
such as “You did a good job,” before making the switch
when they feel the need to change the child's clothes
Help the parent understand that the child may be
resisting because she wants to dress herself
Page 05
Instruct the parents on the need for shoe soles that are
firm enough to provide protection from rough surfaces
as soon as children are up on their feet and walking
Tell the parents to avoid extremely firm or ankle-high
shoes since a toddler’s arches are still developing
sleep
remember
The amount of sleep children need gradually decreases
as they grow older
Parent’s insistence that a child get more sleep may
lead to sleeping problems or refusal to sleep at all
If a child cannot fall asleep at night, shorten an
afternoon nap
If a child is so short-tempered at dinnertime that eating
is impossible, maybe the child needs two naps a day
Toddlers naturally fall asleep when they are tired
They may begin to resist naps, as they do not want to
miss anything
Other toddlers resist naptime as part of their
developing negativism
Toddler loves a bedtime routine: bath, pajamas, a
story, brushing teeth, being tucked into bed, having a
drink of water, choosing a toy to sleep with, and
turning out the lights
Toddlers, especially when they are tired, like to see
parents as firm, consistent people who can be counted
on to be reliable over and over
nurse’s action
Caution the parents to say “We’ll do this after naptime,”
otherwise, the child may be reluctant to nap the next
day for fear of missing another activity
Inform the parents to tell the older siblings not to point
out all the exciting things a toddler misses while
napping
Encourage the parents to include naptime as part of the
lunchtime routine, not as a separate activity.
Caution the parents not to let a child’s sleep be
controlled by the bedtime routine because it can delay
it
Remind parents to stress that sleeping in a regular bed
does not give children the right to get in and out of bed
as they choose
Instruct the parents to give their children a feeling of
independence but still keeps them safe
bathing
remember
Toddlers usually enjoy bath time, and parents should
make an effort to make it fun by providing a toy, such
as a rubber duck, boat, or plastic fish
Bath time is usually so enjoyable for toddlers that
parents can use it as a recreational activity or
something to do on a rainy day when they can find
nothing else to interest their child
Nursing Care of Family with a Toddler Page 06

nurse’s action PARENTAL CONCERNS ASSOCIATED

Remind the parents not to leave their child alone
unsupervised even though they can sit well in the
bathtub
Inform the parents that toddlers might slip and get their
head under water or reach and turn on the hot-water
faucet and scald themselves
care of teeth
remember
Toddlers often need between-meal snacks.
Calcium is especially important to the development of
strong teeth and is good for snacks
Toddlers need to have a toothbrush they recognize as
their own
Toward the end of the toddler period, they can begin
to do the brushing themselves under supervision
WITH THE TODDLER PERIOD
remember
This usually arises because of a conflict over autonomy
toilet training
remember
Toilet training is one of the biggest tasks a toddler tries
to achieve
Toilet training is an individualized task for each child
It should begin and be completed according to a child’s
ability to accomplish it, not according to a set schedule
In the US, toilet training is usually introduced during the
toddler period
In other countries, toilet training may be started as soon

nurse’s action as a child can sit, at about 6 months

Encourage parents to offer fruit or protein foods rather
than high-carbohydrate items for snacks such as
cookies
Remind parents it is better for a child to brush
thoroughly once a day, probably at bedtime, than to do
it poorly many times a day
Inform the parents that they can use dental floss to
clean the child’s teeth and remove plaque
Encourage parents to schedule a first visit to a dentist
skilled in pediatric dental care at about 12 months of
age for assessment of dentition
Educate parents to maintain a positive attitude about
dentist visits avoid the use of frightening words like
“drill” or “shot,” and answer their child’s questions
honestly without going into too much detail
PROMOTING HEALTHY
Praise is used in the United States as a common means
of encouraging toddlers to learn new tasks
Other cultures believe praise will bring a child harm by
attracting evil spirits; strategies of shame or strict
discipline are used instead
Children are ready for toilet training when they begin to
be uncomfortable in wet diapers by pulling or tugging at
soiled diapers; they may bring a parent a clean diaper
after they have soiled so they can be changed
Some toddlers smear or play with feces, about the same
time that toilet training is started because they have
become aware of body excretions
After a child is fully toilet trained, playing with feces
rarely persists
Before children can begin toilet training, they must have
reached three important developmental levels, one
physiologic and the other two cognitive:

FAMILY FUNCTIONING
remember Must have control of rectal Must have a cognitive
Self-reliance is the primary goal of a child during the and urethral sphincters, understanding of what it
usually achieved at the time means to hold urine and
toddler period
they walk well stools
Children must be given some room to make
independent decisions in areas that the parents feel
they do not need to control
At bedtime, naptime, or anytime they are tired, toddlers
may become much more like their old selves, wanting Must have a desire to delay
to sit on a parent’s lap and be picked up and carried immediate gratification for a
more socially accepted
nurse’s action action

Help the parents understand their responses to these

attempts at independence is crucial to the healthy
development of their children
Caution the parents not to begin to function at the
same level as their toddler
Teach parents that a child refusing to accept help is not
refusing to accept love
Nursing Care of Family with a Toddler
nurse’s action
Teach parents not to underestimate the difficulty of the
task they are expecting their child to achieve
Instruct the parents to provide their toddlers with play
substances of similar texture to the feces and change
diapers immediately after defecation to prevent them
from playing with actual feces
Teach parents to accept this behavior for what it is:
enjoyment of the body and of the self, and the discovery
of a new substance
ritualistic behavior
remember
Toddlers enjoy ritualistic patterns
They will use only “their” spoon at mealtime, and only
“their” washcloth at bath time
They will not go outside unless their mother or father
locates their favorite cap
negativism
remember
Toddlers typically go through a period of extreme
negativism
They do not want to do anything a parent wants them
to do
Their reply to every request is a very definite “no.”
The more parents try to make children obey them, the
more children are likely to resist
A toddler’s “no” can best be eliminated by limiting the
number of questions asked of the child
Making a statement instead of asking a question can
avoid a great many negative responses
nurse’s action
Help the parent to realize that the extreme change from
happy and cooperative infants to irritating,
uncooperative toddlers is not only a normal
phenomenon of toddlerhood but also a positive stage in
development
Help the parent understand that the change indicates
that toddlers have learned they are separate individuals
with separate needs
discipine
remember
“Discipline” means setting rules
“Punishment” means a consequence that results from
a breakdown in discipline
Parents should begin to instill some sense of discipline
early in life because part of it involves setting safety
limits and protecting others or property
“Timeout” is a technique to help children learn that
actions have consequences
Page 07
Parents should give one warning. If the child repeats the
behavior, parents select an area that is nonstimulating,
such as a corner of a room or a hallway
Two general rules to follow:
01 Parents need to be consistent
Rules are learned best if correct behavior is
01
praised rather than wrong behavior punished
nurse’s action
Remind parents that “discipline” and “punishment” are
not interchangeable terms
Explain to the parents how to effectively use the
timeout technique.
Example: “If you hit your brother, you’ll have a
timeout.”
separation anxiety
remember
Fear of being separated from parents begins at about
6 months of age and persists throughout the preschool
period
Separation anxiety = the universal fear of toddler
Toddlers have difficulty accepting being separated
from their primary caregiver to spend the day at a
daycare center
Prolonged goodbyes only lead to more crying
Sneaking out prevents crying and may ease the
parents’ guilt, but it can strengthen the fear of
abandonment
nurse’s action
Instruct the parents to say goodbye firmly, repeat the
explanation and then leave
TEMPER TANTRUMS
remember
Every toddler has a temper tantrum at one time or
another
The child may kick, scream, stamp feet, shout “No, no,
no,” lie on the floor, flail arms and legs, and bang the
head against the floor
They may even hold their breath until they become
cyanotic
A halt after inspiration is harmless breath-holding; the
child has a distended chest and air-filled cheeks
A halt after expiration is the true breath holding; it is a
neurologic problem in which children appear to
“forget” to breathe in at the peak of anger
Nursing Care of Family with a Toddler Page 08

They become so short of breath that they slump to the

floor. “Slump” means falling heavily
Temper tantrums occur as a natural consequence of
toddlers’ development
It occurs because toddlers are independent enough to
know what they want but they do not have the
vocabulary or the wisdom to express their feelings
Tantrums may be a response to an unrealistic request
by a parent
Tantrums may occur if parents are saying “no” too
frequently
Tantrums may be a response to difficulty making
choices or decisions or to pressure from activities such
as toilet training
Tantrums are taxing for the parents; they are also
energy-consuming for children. “Taxing” means requiring
too much effort both physically and mentally
nurse’s action
nutrition and the physically challenged or
chronically ill toddler
remember
Toddlers need experience feeding themselves
nurse’s action
Help the parents accept the accidents that occur with
self-feeding, particularly if the child has difficulty with
coordination
Encourage the parents to provide finger foods if
possible
Instruct the parents that when toddlers are unable to
receive finger foods at all, provide other experiences in
independence such as letting them choose what toy to
take to bed

Instruct the parents to tell a child simply that they

disapprove of the tantrum and then ignore it
Encourage the parents to accept the child warmly and
proceed as if the tantrum had not occurred
additional info
CONCERNS OF THE FAMILY WITH Erikson’s developmental task for the toddler
period is to form a sense of autonomy or
A PHYSICALLY CHALLENGED OR independence versus shame or doubt
CHRONICALLY ILL TODDLER Toddlers make great strides forward in
development, but their physical growth slows.
remember A critical milestone of toddler development is
being able to form two-word sentences (a noun
Children with disabilities may find it difficult to achieve
and a verb) by 2 years of age
a sense of autonomy because they may never be
Toddlers are capable of preoperational thought
totally independent
or are able to deal much more constructively
Toddler with a long-term illness or who is physically
with symbols than they could while infants
challenged can be expected to exhibit normal toddler
behaviors, such as temper tantrums, and to have
normal outlooks, such as negativism
Toilet training is difficult for a child who is hospitalized;
hospitalization can result in regressive behaviors
“Regressive” means returning to the previous state
If a chronically ill child has difficulty with ambulation,
soiling accidents may occur beyond the usual age
because of the inability to reach a bathroom easily
Vulnerable children or Medically fragile = Children who
survive a long-term illness

nurse’s action
Allow toddlers to do as much for themselves as
possible
Instruct the parents to investigate the child’s activity
carefully and explain the difference between tantrums
and seizures
Inform the parents that the toddler’s insistence on
having their own way is more often an indication of
age and development rather than of illness
Remind parents that a toddler who is chronically ill will
still demand independence and has the right to
explore