Nursing Care of a

Family with a
Toddler Child
 Objectives
1. Describe normal growth and development of a toddler as well as comm
on parental concerns.
2. Identify 2020 National Health Goals related to the toddler age group th
at nurses can help the nation achieve.
3. Assess a toddler for normal growth and development milestones.
4. Formulate nursing diagnoses related to toddler growth and developmen
t or parental concerns regarding growth and development.
5. Identify expected outcomes for nursing care of a toddler as well as help
parents manage seamless transitions across differing healthcare settings.
6. Implement nursing care to promote normal growth and development of
a toddler, such as discussing toddler developmental milestones with par
ents.
Toddler
• age span from 1 to 3 years

• enormous changes take place in a child and, consequently, in a family

• accomplish a wide array of developmental tasks
2020 National Health goals
A number of 2020 National Health Goals relate specifically to safety during
the toddler years. These include:
• Increase the use of child automotive restraints in children 3 years of age
and under from a baseline of 72% to 79%.
• Eliminate or improve elevated blood lead levels in children from a target
level of 0.9% of children to a target level of 0%.
• Increase the percentage of persons 2 years of age and older who have
had a dental visit in the past 12 months from a baseline of 44.5% to 49%.
• Maintain the rate of deaths caused by poisonings from a baseline at 13.1
out of 100,000 (U.S. Department of Health and Human Services, 2010; see
www.healthypeople.gov).
Growth and Development of a Toddler
Physical Growth

Weight Gains 5 to 6 lbs (2.5kg) / year

Height 5 in (12 cm) / year

Head Circumference increases only about 2 cm

A. Body Contour

• prominent abdomen
• forward curve of the spine at the sacral area (LORDOSIS)
• waddle or walk with a wide stance
 B. Body Systems
.Body systems continue to mature during this time:
.

• Respirations slow slightly but continue to be mainly abdominal. In the respiratory

system, the lumens of vessels enlarge progressively = lower respiratory
infection becomes less.
• HR : 90 b/m; BP : 99/64 mmHg.
• The brain : 90% of its adult size.
• Stomach secretes more acid; therefore, gastrointestinal infections become less
common.
• Stomach capacity increases = a child can eat three meals a day.
• Control of the urinary and anal sphincters becomes possible with complete
myelination of the spinal cord = toilet training
• IgG and IgM antibody production becomes mature at 2 years of age
= passive immunity
C. Teeth
2 years = Eight new teeth (the canines and the first molars)
2.5 to 3 years = All 20 deciduous teeth (Gonsalves, 2008).
Developmental Milestones
Age(Mos) Fine Motor Gross Motor Language Play

• Puts small pellets into

small bottles.
• Scribbles voluntarily with a • Walks alone • 4–6 words • Can stack 2 blocks;
pencil or crayon. • Can seat self in chair • Enjoys being read to
• Holds a spoon well but • Creeps upstairs • Drop toys for adult
15 may turn it upside down to recover
on the way to the mouth

• Run and Jump in place

• Can walk up and down • 7–20words, uses • Imitates household
• No longer rotates spoon the stairs with something jargoning chores, dusting, etc.
to bring to mouth to hold on to. Typically • names 1 body • BEGINS PARALLEL
18
places both feet on one part PLAY
step before advancing.
Age (Mos) Fine Motor Gross Motor Language Play
• Can open doors turning • Walks on stairs alone but • 50 words, • PARALLEL PLAY
the nob; still using both feet on 2-word EVIDENT
• Unscrews lids same step to advance sentences
24 • (noun-pronoun
and verb)
Ex: “Me go”

• Makes simple lines or • Can jump down from • Verbal language • Spends time playing
strokes for crosses with stairs increases house
pencil • Knows full name • Imitating parent's
• Can name one action
30
color • “Rough-housing” or
• Holds finger to active
show age
Language Development

• “No” = autonomy
• Encourage language development by naming objects as parents play with their child (“ball,”
“block,” “music box,” “doll”); Children should not be made to name an object before they can
have it.
• Always answer a child’s question

Note: Because children learn language from imitating what they hear, they will
speak like those around them. If they are spoken to in baby talk, their
enunciation of words can be poor
Emotional Development

A. Autonomy
• Sense of Autonomy VS Shame or doubt (Erik Erickson, 1993)
Autonomy = Independence
Notioned to be negativistic, obstinate (stubborn), and difficult to manage.
B. Socialization
• Once toddlers are walking well, they become resistant to sitting in laps and being
cuddled
15 months - enthusiastic about interacting with people
18 months - imitate the things they see a parent doing, such as “study” or
“sweep,” so they seek out parents to observe and initiate
interactions.
2 or more years - become aware of gender differences and may point to other
children and identify them as “boy” or “girl.”
Play Behavior

• Parallel play – side-by-side play (normal developmental sequence)

• Age appropriate toys: ( toys they can control, giving them a sense of power in
manipulation, an expression of autonomy )

 Trucks,
 squeaky frogs,
 Waddling ducks,
 Rocking horses,
 Pegs,
 Blocks,
 Toy telephone
15 months - put-in, take-out stage; stacks of boxes or balls that fit inside each other
18-months - pull toys or toys should be strong enough.
2 years - imitating adult actions; Imitation is the play
By the end of the toddler period - rough-housing; spend at least part of every day in this very active,
stimulating type of play.
Cognitive Development
Fifth and sixth stages of Piaget’s sensorimotor thought ; “a little scientist”
Health Promotion For A Toddler And Family
Promoting Toddler Safety
Accidents (unintentional injuries) are the major cause of death in infants through late a
dolescents in the United States (CDC, 2012a).

Unintentional ingestions (poisoning) and auto accidents are the types of unintentional
injuries that occur most frequently in toddlers (Beirens, van Beeck, Brug, et al., 2010).

Aspiration or ingestion of small objects such as watch or hearing aid batteries, pencil er
asers, or parts of crayons is also a major danger for children of this age (Litovitz, Whitak
er, & Clark, 2010).
Urge parents to childproof their home by putting all poisonous products, drugs, and sm
all objects out of reach by the time their infant is crawling, and certainly by the time th
eir infant is walking, to avoid these problems (Lee & Marcdante, 2011).
• Other unintentional injuries that occur frequently in toddlers include motor vehicle accidents, bur
ns, falls, drowning, and playground injuries. These occur because toddlers’ motor ability jumps ah
ead of their judgment.

• Because they cannot swim well, parents need to check whether backyard pools— another area pr
one to unintended injury—are securely fenced (Bowman, Aitken, Robbins, et al., 2012).

. For safety in automobiles, parents should keep their toddlers in rear-facing seats until age 2 years,
or until the child reaches the maximum height and weight for their particular seat.
Car seats should be placed in the back seat so the child is not struck by the passenger seat airbag
(AAP, 2013). Remind parents that it is unsafe to leave a toddler alone in a car.
 Common Safety measures
Potential accident Prevention measures
• Maintain child in car seat; do not be distracted from safe driving by a child in a car.
• Do not allow child to play outside unsupervised.
• Supervise toddler who is too young to be left alone on a tricycle.
Motor vehicles • Teach safety with pedaling toys (look before crossing driveways; do not cross streets)
*But do not expect that toddler will obey these rules at all times
(in other words, stay close by).
• Never present medication as candy. Buy medications with childproof caps; put away
• immediately after use.
• Never take medication in front of child.
• Place all medication and poisons in locked cabinets or overhead shelves where child
cannot reach them.
• Never leave medication in parents’ purse or pocket, where child can reach it.
Poisoning
• Always store food or substances in their original containers.
• Know the names of house plants and find out if they are poisonous. (Call regional poison
control center for information.)
• Hang plants or set them on high surfaces beyond toddler’s grasp.
• Be certain that small batteries or magnets are out of reach.
• Post telephone number of nearest poison control center by the telephone.
• Inspect toys to be certain they are free of lead-based paint.
Lead Screening
LEAD POISONING
Lead is a cumulative toxicant that affects multiple body systems and is particularly harmful to
young children. Lead in the body is distributed to the brain, liver, kidney and bones. There is no
level of exposure to lead that is known to be without harmful effects.
(https://www.who.int/news-room/fact-sheets/detail/lead-poisoning-and-health)

Elevated lead levels are caused by eating, chewing, or sucking on objects (e.g., windowsills, paint
chips, furniture) that are covered with lead-based paint.
Additional sources of lead poisoning can include:
• Toys manufactured in countries where restrictions on lead are not enforced or cribs that were p
ainted with lead-based paint
• Soil around the exterior of the house and contaminated food grown there
• Dust or fumes created by home renovation
• Pottery made with lead glazes or jewelry made from lead or lead alloys
• Colored print in newspapers or older lead-based water pipes • Lead dust brought home on the
clothing of parents who work with lead products such as batteries.
Promoting Nutritional Health of a Toddler
Take note during toddler stage:
a. Appetite is decreased
b. Promotion of independence is important
c. They usually do not like food that is “mixed up”
d. They often prefer brightly colored foods to bland colors.

TODDLERS NUTRITION
• Sedentary children ages 1 to 3 years = 1000 kcal daily;
• Active children ages 1 to 3 years = 1400 kcal daily
(U.S. Department of Agriculture [USDA], 2005)
• Needs Protein and carbohydrate, diets high in sugar should be avoided to help prevent toddler obesity
• Fats should generally not be restricted for children under 2 years old; however, children over 2 years old should
have a total fat intake between 30% and 35% of calories
• Trans fats 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, after which 2% milk can be introduced (Whitney & Rolfes, 2013).
Promoting Toddler Development in Daily Activities

A. Dressing - most children can put on their own socks and underpants, simple dress
B. Sleep – Need for sleep declines; 8 – 12 hours with naps in between; they naturally fall asleep when
they are tired.
- Other toddlers resist naptime as part of their developing negativism.
- They love 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.
- Many toddlers are ready to be moved out of a crib into a youth bed or regular bed with protective
side rails or a chair strategically placed beside it by the end of the toddler period.
C. Bathing - 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.
NOTE: DON’T LEAVE THE CHILD UNATTENDED WHEN BATHING
D. Care of Teeth - toddlers need to have a toothbrush they recognize as their own; At the end of the toddler
period, they can begin to do the brushing themselves under supervision
- first visit to a dentist skilled in pediatric dental care at about 12 months of age for
assessment of dentition
Promoting Healthy Family Functioning

Learning self-reliance is the primary goal of a child during the toddler

period

• Help parents to understand their responses towards the attempts of a toddler at

being independent which are crucial to the healthy development of their child.
• If parents punish children excessively at each move toward independence, children
will not fight them indefinitely. Instead, they will begin to feel guilty for wanting to
do things independently.
• Caution some parents not to begin to function at the same level as their toddler.
• At bedtime, naptime, or anytime they are tired, toddlers may become much more
like their old selves, wanting to sit on a parent’s lap and be rocked or
picked up and carried, this is natural.
Parental Concerns Associated With the Toddler Period
A. Toilet Training - one of the biggest tasks a toddler tries to achieve; toilet training is an
individualized task for each child.

Before children can begin toilet training, they must have reached three important developmental l
evels, one physiologic and the other two cognitive:
• They must have control of rectal and urethral sphincters, usually achieved at the time they walk well.
• They must have a cognitive understanding of what it means to hold urine and stools until they can release them
at a certain place and time.
• They must have a desire to delay immediate gratification for a more socially accepted action.

NOTE: Some toddlers smear or play with feces, often at about the same time that toilet training is started. Teach
parents to accept this behavior for what it is: enjoyment of the body and of the self, and the discovery of a new
substance. After a child is fully toilet trained, this activity rarely persists.
 How To Toilet Train A Toddler
1. Children are physically ready for toilet training when 7. Do not allow a child to remain on a potty chair for
they walk securely. much longer than 10 minutes (less than that if he is
resistant).
2. Use pull down pants to avoid accidents.
8. If your child is not ready or does not successfully use
3. Purchase either a potty chair that sits on the floor or the potty on a day-to-day basis, have him return to
an infant seat that is placed on the regular toilet diapers for a short period.

4. Place child on the potty chair or toilet at regular 9. When boys have mastered defecation, it is time to
interval. include urination.

5. Praise your child if he does urinate or defecate. 10. Some toddlers have difficulty remaining dry at night
Remind him to wash his hands. until they are 3 to 4 years old. Do not pressure your
child to accomplish nighttime dryness, but assume
6. Be careful not to flush the toilet while the child is that he is doing the best he can do
sitting on it.
11. Do not wake your child during the night and carry
him to the bathroom to void.
B. Ritualistic Behavior
• Although toddlers spend a great deal of time every day investigating new ways to do things and
doing things they have never done before, they also enjoy ritualistic patterns.

C. Negativism - As part of establishing their identities as separate individuals, toddlers typically go

through a period of extreme negativism.
They do not want to do anything a parent wants them to do. Their reply to every request is a very
definite “no.”
This change indicates toddlers have learned that they are separate individuals with separate needs.
Parents may need some help to realize that this is not only a normal phenomenon of toddlerhood
but also a positive stage in development.
• Parents understand that this behavior is not specific to the age but to the first feeling of
independence.
• A toddler’s “no” can best be reduced by limiting the number of questions asked of the child. A
father does not really mean, for example, “Are you ready for dinner?” He means, “Come to the table
. It’s dinnertime.” A mother asks, “Will you come take a bath now?” She means, “It’s time for your b
ath.” Making a statement instead of asking a question in this way can avoid a great many negative
responses
D. Discipline - means setting rules or road signs so children know what is expected of them.
Punishment is a consequence that results from a breakdown in discipline, from the child’s disrega
rd of the rules that were learned.

Parents should begin to instill some sense of discipline early in life because part of it involves sett
ing safety limits and protecting others or property (e.g., a child must stay away from the fireplace
or heater, she must not go into the street, she must not hit other children).

• Two general rules to follow are

(a) parents need to be consistent
(b) rules are learned best if correct behavior is praised rather than wrong behavior
punished.

“Timeout” is a technique to help children learn that actions have consequences.

E. Separation Anxiety - 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.

Toddlers who have separation anxiety have difficulty accepting being separated from their primary
caregiver to spend the day at a day care center or if they or their primary caregiver is hospitalized.

• Most toddlers react best to separation if a regular babysitter is employed or the day care center
is one with consistent caregivers.
• It helps if toddlers have fair warning they will have a babysitter. For example, they could be told,
“Mommy is fixing dinner early because Mommy and Daddy are going to visit some friends
tonight.”

• Parents should say goodbye firmly. Prolonged goodbyes only lead to more crying. Sneaking out
prevents crying and may ease the parents’ guilt, but it can strengthen fear of abandonment so
should be discouraged.
F. Temper Tantrums
• Temper tantrums occur as a natural consequence of toddlers’ development (Taylor, 2007); they
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 be a response to difficulty making choices or decisions or to pressure from

activities such as toilet training.
• Tantrums may also occur if parents are saying “no” too frequently with regard to such things
as touching the coffee table, using a spoon, or running and jumping, thus making children
feel constantly thwarted.
• A tantrum may also be a response to difficulty making choices or decisions or to pressure fro
m activities such as toilet training.
 Temper Tantrums
Best approach is for parents to simply tell a child that they disapprove of the tantrum
and then ignore it. They might say, “I’ll be in the bedroom. When you’re done kicking,
you come into the bedroom, too.”
Children who are left alone in a kitchen this way will usually not continue a tantrum
but will stop after 1 or 2 minutes and rejoin their parents. Parents should then accept
the child warmly and proceed as if the tantrum had not occurred. This same approach
works well for nurses caring for hospitalized toddlers.