Growth & Development

Mary Lourdes Nacel G. Celeste, RN, MD Ellen H. Tinio, RN, MD

PEDIATRIC NURSING

Growth & development are occasionally used interchangeably but they are totally different .

Growth : generally used to denote an increase in physical size (quantitative change) wt--- kg ht ---cm

Development : used to denote an increased in skill or the ability to function (qualitative change) measured by 1. observing child¶s ability to perform tasks 2. recording parents¶ description 3. using standard tests

Two Parameters of Growth
Weight ± most sensitive measure of growth 
2x ----- 6 mos  3x-------1 yr  4x--------2-2 ½ yr

Height- increases by 1´/mo during 1st 6 mos 
ave. increase in Ht- 1st yr = 50 %

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Development
Increase in skills or capability to function How to measure development 
Observe child doing specific task  Role description of child¶s progress  DDST- Denver development screening test
o Language communication o Personal/ social interaction o Fine motor adaptive- hand movement o Gross motor skills- large body movement 

MMDST ± Metro Manila developmental screening test ( Phil version)
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Denver II TEST (Denver developmental screening test II) 125 easily administered developmental test items, with age norm, presented in a convenient one-page format

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Principles of Growth & Development
1. G & D is a continuous process continuous process from conception until death proceeds in an orderly sequence

2. Not all parts of the body grow at the same time or at the same rate All body systems do not develop at the same rate

Renal / digestive / circulatory / musculoskeletal = grow rapidly during childhood CNS, brain , Spinal cord = grow rapidly 1-2 yrs. Adult proportion by 5 yrs old
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3. Each child is unique. Different children pass through the predictable stages at different rates. There is an optimum time for initiation of experiences or learning.

4. Occurs in regular direction reflecting a definitive and predictable pattern

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G & D follows a trend or pattern:
I. Directional Trends ± occur in regular direction reflecting the development of neuromuscular function. This apply to physical, mental, social & emotional development and includes: a. Cephalocaudal b. Proximodistal - proceeds from proximal to distal body parts c. Symmetrical d. Mass to specific differentiation ± child learns from simple operation before complex function - from gross to refined skills

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G & D follows a trend or pattern: I. Directional Trends II. Sequential trend predictable sequence:

A. Locomotion- ( crawls > creeps > stands > walks > runs ) B. Socio-language skills solitary games > parallel III. Secular- worldwide trend of maturing earlier and growing larger as compared to succeeding generations

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Principles of Growth & Development

5. Behavior - most comprehensive indicator of developmental status 6. Play universal language of child

7. Skills & behavior are learned by practice 8. Neonatal reflexes must be lost before development can proceed. e.g : 
Plantar reflex should disappear before walking.  Moro reflex disappears before infant could roll.
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Stages
A. First Stage pre-natal begins from conception to birth

B. Second stage 1. neonatal 2. Infancy

from birth to 12 months first 28 days, first 4 weeks.

1 to 12 months

C. Third Stage 1. Toddler

Early Childhood ( 1-6 y/o) 1-3 y/o 4-6 y/o

2. Pre- school

D. Fourth Stage Middle Childhood 1. School age 6-12 y/o 2. Adolescence 13 18 y/o
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RATES OF DEVELOPMENT
Infancy & adolescence = fast growth periods Toddler & Preschool =alternating rapid & slow School age = slow growth period Fetal period- infancy = head and neurologic tissue grow faster than the other tissues Toddler & Preschool/ adolescence= trunks grow rapidly than other tissues. School age period = limbs grow most

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Types of development 
psychosexual development  psychosocial development  moral development  cognitive development

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1.Psychosexual development- specific type of development that refers to developing instinct or sensual pleasure (Freud) 2.Psychosocial development- refers to stages of personality development (Erikson) 3.Moral development- is the ability to know right from wrong and to apply this to real life situation (Kohlberg)

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4. Cognitive development- refers to the ability to learn or understand from experience, to acquire and retain knowledge, to respond to new situation, to solve problem (Piaget)  measured by intelligence tests, and by observing a child s ability to function effectively in his/her environment

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Theories of Growth & development
Freud, Sigmund Piaget, Jean Erikson, Erik Kohlberg, Lawrence
PSYCHOSEXUAL COGNITIVE PSYCHOSOCIAL

MORAL

FPEK
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Summary of Theories
THEORY Freud
psychosexual Infancy (0-1y) ORAL Sensorimotor Trust VS mistrust Toddler (1-3y) Anal Sensorimotor Preschool (3-6y) Phallic Oedipal Preoperational School age (6-12) Latency Concrete Industry vs. inferiority Adolescence (12-20y) Genital Formal operation Identity vs. role confusion
Postconventional/ Formal operation (deductive and abstract Thinking)

Piaget
cognitive

Erikson
psychosocial

Autonomy Initiative vs. guilt vs. Shame & doubt Pre-conventional
(intuitive phase)

Kohlberg moral

PrePreconvention conventio al nal
(Sensorimotor) (preconceptual phase)

Conventional/ Concrete Operational (inductive reasoning, beginning logical thinking)

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Sigmund Freud
Oral phase ( 0-18 months) 
Mouth is the site of gratification  Development of id  Activity of infant : biting, sucking , crying  Reason for sucking : enjoyment & release tension  N.I : provide oral stimulation even if NPO 
Pacifier Never discourage thumb sucking Breastfeeding

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Sigmund Freud
Anal ( 18 months-3 years old) 
Anus is the site of gratification  Activity of infant : elimination, retention or defecation of feces  Principle of holding on or letting go  1 ½ y ± 3 yrs : toilet training (toddlers)  N.I : help child achieve bowel and bladder control even if child is hospitalized  elimination is a way of discovery and exerting independence
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Sigmund Freud
Phallic phase ( 3y-6y)  Genitals : site of gratification  Masturbation & fantasy of life  Activity of infant : shows exhibitionism  Love of opposite sex (Parents oedipal complex/ electra complex)  increased knowledge of sex  Ego development  Reason for sucking : enjoyment & release tension  N.I : Accept child fondling his/her own genitalia as normal exploration
o Accept sexual interest and answer questions about birth or sexual difference o Answer child question directly o Resolved conflict : child identifies with the parents of same sex 

PRESCHOOL : right age to introduce sexuality
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Sigmund Freud ( Psychosexual)
Latent ( 7-12 y) 
Sexual drive depresses  Period of suppression  Child libido or energy is diverted to more concrete type of thinking; libido diverted to school  Superego and morality development  N.I : help the child achieve positive experience to promote self esteem
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Sigmund Freud
Genital ( 12-20y) 
His/her BODY is the site of gratification  Develops satisfying sexual and emotional relationships with members of the opposite sex  Achieves sexual maturity  Individual plans life goals & gain a strong sense of personal identity. 

NI: provide opportunities to relate w/ opposite sex; verbalization about new feelings
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OVERVIEW OF ERIKSON¶S DEVELOPMENTAL TASKS THROUGHOUT THE LIFESPAN Age Stage Erikson¶s Positive Outcome Negative Outcome Task I T T D

Exercises self-control nd influences the S D environment directly to y Preschool Initiative vs. egins to evaluate own ehavior; learns limits on Guilt influence in the environment to y School age Industry vs. Develops a sense of Inferiority confidence; uses creative energies to influence the environment to Adolescenc Identity vs. Develops a coherent y e Role sense of self; plans for a confusion future of work/education

T

A

Demonstrates defiance and negativism Demonstrates fearful, essimistic ehaviors; lacks self-confidence Demonstrates feelings of inadequacy, mediocrity, and selfdoubt Demonstrates inability to develop personal and vocational identity

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Erik Erikson ( Psychosocial)
Trust vs. Mistrust ( 0-18 months ) infant 
Foundation of all psychosocial tasks  To give or to receive T: appreciate environment as safe and people as dependable M: suspicious, fearful, shun emotional involvement  N.I. provide primary caregiver and visual stimulation
o Satisfy needs on time (breastfeeding) o Care must be consistent and adequate o Touch, eye to eye contact, soft music ± add to security

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Erik Erikson ( Psychosocial)
Autonomy vs. Shame & Doubt ( 18 mos-3 y) toddler A: build on new motor and mental abilities, take pride in accomplishments S: doubt and stop trying 
N.I : provide opportunities for decision making and give praises
o Give an opportunity of decision making like offer choices o Encourage to make decision rather than judge o Set limits
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Erik Erikson ( Psychosocial)
Initiative vs. Guilt ( 4-6 y ) preschool I: how to do things G: limited brainstorming and problem-solving skills 
N.I. provide opportunities for exploration, answer questions and do not inhibit fantasy
o Learn how to do basic things o Let explore new places & events o Recommended Activities : molding clay, finger painting will enhance imagination and creativity and facilitate fine motor dev¶t

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Erik Erikson ( Psychosocial)
Industry vs. Inferiority ( 7-12 y) school age 
Child learns how to do things well  Give short assignment & projects

Ind: how to do things well Inf: always worried about poor or incorrect performance NI: provide opportunities for completing short projects, give praise and rewards
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Erik Erikson ( Psychosocial)
Identity vs. role confusion ( 12-20y ) adolescent 
Learn who he/she is or what kind of person he will become by adjusting to a new body image  Freedom from parent

I: integrate image into a whole R: unsure of who they are or who they can become, may rebel NI: provide opportunities to discuss feelings and support and praise for decision-making
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JEAN PIAGET

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Stages of Cognitive
Sensory Motor ( 0-2 y ) 
Children experience the world through movement and senses and learn object permanence.  Children are extremely egocentric, meaning they cannot perceive the world from others¶ viewpoints and explore using senses.

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Stages of Cognitive
Preoperational (2-7 y ) 
Magical thinking predominates.  Acquisition of motor skills  Children are still egocentric and cannot conserve or use logical thinking

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Stages of Cognitive
Concrete ( 7-12 y ) 
The child is able to classify, order, and sort fact.  Child moves from prelogical thought to solving concrete problems through logic .  Children begin to think logically but are very concrete in their thinking.  Children can now conserve and think logically but only with practical aids.  They are no longer egocentric .
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Stages of Cognitive
Formal operational ( 12-20 y ) 
Able to think abstractly and logically  Solving abstract and concrete problem  Development of abstract reasoning  Children develop abstract thought and can easily conserve and think logically in their mind.  Can solve hypothetical problems, causality, time

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LAWRENCE KOHLBERG

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Level 1 (Pre-Conventional) 
1. Obedience and punishment orientation (2-3Y) (How can I avoid punishment?) 2. Self-interest orientation (4-7Y) ( hat's in it for me?) 

Level 2 (Conventional) 
3. Interpersonal accord and conformity (7-10Y) (The good boy/good girl attitude) 4. Authority and social-order maintaining orientation ( 10-12Y) (Law and order morality) 

Level 3 (Post-Conventional) (>12Y) 
5. Social contract orientation 6. Universal ethical principles (Principled conscience)

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UNDERSTANDING THEM!

INFANT (0-12 MOS) TODDLERS (1-3 Y) PRESCHOOL (3-6 Y) SCHOOL AGE (6-12 Y) ADOLESCENCE (12-20 Y)

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Stages of Growth and Development
Infancy 
Neonate
o Birth to 1 month

Middle Childhood 
School age  6 to 12 years 

Infancy
o 1 month to 1 year

Late Childhood 
Adolescent  13 years to approximately 18 years

Early Childhood 
Toddler
o 1-3 years 

Preschool
o 3-6 years

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Developmental Assessment
Early detection of deviation in child¶s pattern of development Simple and time efficient mechanism to ensure adequate surveillance of developmental progress Domains assessed: 
cognitive  motor  language, social / behavioral  adaptive
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infant
Solo, mom interactive Facilitate motor & sensory dev¶t Fear of infancy : stranger anxiety begins at 6-7 months
o PEAKS : 8 months o Diminished : 9 months

Communicate :
o Respond to non-verbal o Slow approach o Use calm, soothing voice o Be responsive to cries o Allow security object ( blanket or pacifier)
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*Bruxism

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DAILY CARE
- bathing - diaper care - care of teeth - dressing - sleep ± 16-20hrs/day; - 6 mos- 1-2 naps, with 12h at night - 12 mos old; 1 nap with 12h at night - exercise

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Gross Motor Development
Newborn: barely able to lift head 6 months: easily lifts head, chest and upper abdomen and can bear weight on arms

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Head Control

Newborn
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Age 6 months

Sitting up
2 months old: needs assistance 6 months old: can sit alone in the tripod position 8 months old: can sit without support and engage in play

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Sitting Up

Age 2 months
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Age 8 months

Ambulation
9 month old: crawls 1 year: stands independently from a crawl position 13 month old: walks and toddles quickly 15 month old: can run

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Ambulation

13 month old Nine to 12-months
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Fine Motor - Infant
Newborn has very little control. Objects will be involuntarily grasped and dropped without notice. 6 month old: palmar grasp ± uses entire hand to pick up an object 9 month old: pincer grasp ± can grasp small objects using thumb and forefinger

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Speech Milestones
1-2 months: coos 2-6 months: laughs and squeals 8-9 months: babbles mama/dada as sounds 10-12 months: mama/dada specific 18-20 months: 20 to 30 words ± 50% understood by strangers 22-24 months: two word sentences, >50 words, 75% understood by strangers 30-36 months: almost all speech understood by strangers
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Hearing
BAER hearing test done at birth Ability to hear correlates with ability to enunciate words properly Always ask about history of otitis media ± ear infection, placement of PET ± tubes in ear Early referral to MD to assess for possible fluid in ears (effusion) Repeat hearing screening test Speech therapist as needed
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Fine Motor Development

6-month-old 12-month-old

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** Best color for neonates: black & white

** Best color for infants: red **Use CAR SEATS for children according to ´Rule of 4·sµ when traveling = 4 years or younger = 40 lbs or less = 40 in. tall or shorter
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DEVELOPMENTAL MILESTONE Infancy ( 0-12 months )
Physical Growth Weight : 6 months = double the birth weight 1 year ( 12 months ) = triple the birth weight Length : 1 yr old = increase by 50% HC :: CC = 1 yr old HC=CC
2 mos = social smile ; 4 mos = head control complete , 5 mos = rolls over moro gone 6 mos = sits with support ; LOWER INCISOR erupts, uses palmar grasp 7 mos = transfers object hand to hand; 7-9 mos = object permanence 9 mos = sits without support ; bangs cubes , creeps / crawls ; 2 syllables; UPPER LATERAL INCISOR appears 12 mos = cruises, can walk with one hand being held 6-8 deciduous teeth

Gross & Fine motor

Socialization

1-3 mos = smiles and vocalizes cooing 3-6 mos= laughing aloud 7-9 mos = stranger anxiety 9 mos = say µ mama and dada¶ 10-12 mos = peek -a-boo 12 mos = show affection [ blow kisses on request]
PEDIATRIC NURSINGTheories

of Growth & development

Red Flags in infant development
1. Unable to sit alone by age 9 2. 3. 4. 5.

months Unable to transfer objects from hand to hand by age 1 year Abnormal pincer grip or grasp by age 15 months Unable to walk alone by 18 months Failure to speak recognizable words by 2 years
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ADDITIONAL INFO:
COMPUTATION OF WEIGHT : INFANT & CHILDREN 
< 6 MONTHS : Age (mos) X 600 + BW (g)  6-12 months : age (mos) X 500 + BW (g)  1-6 years old : Age (yrs) X 2 + 8  7-12 yrs old : Age (yrs) x 7 -5/2

# of deciduous teeth = age in month - 6

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TODDLER

1 3 yo

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DEVELOPMENTAL MILESTONE Toddler ( 1-3 y )
Physical Growth Weight : 2 ½ y = BW quadrupled Height : adult Ht 2x Ht at 2 y HC>CC 2 ½ yrs old = Primary dentition completed ( 20 teeth) 15 mos walks alone well 2 y = handle spoon well , runs & walk backward, copies vertical line; 50-200 words (2 word sentences) 2-3 yrs = day time bladder control, knows complete name 3 yrs = knows age & sex , achieves bowel bladder control 300-900 words 3-4 yr = night time bladder control 12-18 mos = imitates housework, name body part 19-24 mos = name picture

Gross & Fine motor

Socialization

PEDIATRIC NURSINGTheories

of Growth & development

Fine Motor - toddler
1 year old: transfer objects from hand to hand 2 year old: can hold a crayon and color vertical strokes 
Turns the page of a book  Builds a tower of six blocks

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Fine Motor

Older Toddler

3 year old: copies a circle and a cross ± builds using small blocks 4 year old: uses scissors, colors within the borders 5 year old: writes some letters and draws a person with body parts

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Toddler

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Toddler

Safety becomes a problem as the toddler becomes more mobile.

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Toddlers
Communication :
o Approach cautiously o Accept verbal communication literally o Learn the toddler words for common item and use them in conversations. o Use short & concrete terms o Repeat explanation and description o Use play for demonstration o Use visual aids o Explain and allow to handle equipment to use o Encourage to use comfort object
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Toddlers
Fear : Separation Anxiety
o don¶t prolong good bye o tell when you will be back

Characteristic trait
o Negativistic ³NO´ ± way to search for independence o Rigid , ritualistic and stereotype o Temper tantrums- head banging , screaming , stamping feet, hold breath 
Ignore behavior

o Love rough tumbling play o Loves toilet training
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Temper Tantrums-in order to control self & others. Mx: IGNORE THE BEHAVIOR or direct them to activities they can master.(When things are rearranged or are strange; or when persons or places are unfamiliar) Accidents because they are naturally active, mobile & curious ±(set limits & exert external control) . LOVE & CONSISTENCY are the 2 most important concepts in child rearing.
EGOCENTRIC ± uses ³ MINE ³ for everything

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Issues in parenting - toddlers
Stranger anxiety ± should dissipate by age 2 ½ to 3 years Temper tantrums: occur weekly in 50 to 80% of children ± peak incidence 18 months ± most disappear by age 3 Sibling rivalry: aggressive behavior towards new infant: peak between 1 to 2 years but may be prolonged indefinitely Thumb sucking Toilet Training

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Toddlers
Characteristic traits
o Loves toilet training o Failure of toilet training ± unreadiness 
Clues for readiness Can stand, squat alone Can communicate toilet needs Can maintain dry for 2H

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NUTRITION
Decrease in appetite because of the slow growth rate Picky eaters, dawdling with meals 1, 300 kcal/day Allow self feeding Allow choice between 2 types of food Offer finger food, appetite of 3 year olds is more capricious than that of 1 year olds Risk of aspiration

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DAILY CARE
- dressing ± can put on socks, underpants, undershirt - sleeps ± 12-14H/night w/ 1 nap - dependency on security object (transitional toy) - may ask to sleep with bottle - may rebel against going to sleep - bathing - care of teeth - since all 20 deciduous teeth are out by 2 ½ yrs, start teaching brushing of teeth; first dental check up shld be bet. 12-18 mos.
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Toddlers

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REACTION TO ILLNESS and NURSING INTERVENTIONS

Regressive behaviors - reassurance Nutrition ± allow finger food Dressing changes ± allow to pull off tape Medication ± allow choices of ³chaser´ after oral medication

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Hygiene ± allow choice of bath time toy, allow to put toothpaste Pain ± allow to express pain Stimulation Elimination ± continue potty training Rest ± allow choice of toy at bedtime

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NOTES: 1. Accidents are the chief cause of death in toddlers. Most accidental deaths in children under age 3 years are related to MOTOR VEHICLE ACCIDENTS. 2. When caring for a toddler in the hospital, the nurse should prevent SEPARATION ANXIETY by encouraging rooming-in. To help the toddler deal with frustration & loss of autonomy, the nurse should provide the toddler with a POUNDING BOARD or PUNCHING BAG.
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3. SECURITY OBJECT ² something a toddler becomes strongly attached to like doll, stuffed animal, pillow or blanket; if separated from the security object, the toddler usually reacts with extreme frustration & anxiety. 4. The DENVER DEVELOPMENT SCREENING TEST is used to screen the development of toddlers. ( ex. Most toddlers can remove their own clothes between 12 & 18 mos. And put their own clothes between 19-24 mos. 5. Turn pot handles in when on stove top. 6. Poisoning: most common in 2 year olds

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Consider every non food substance a hazard and place out of child¶s sight/ reach. Keep all medications, cleaning materials etc. in clearly marked containers in locked cabinets. provide barrier on open windows to prevent falls.

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PRE SCHOOL 3-5 yo

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DEVELOPMENTAL MILESTONE PRESCHOOL ( 3-6 y )
Physical Growth

First permanent teeth are molar Visual acuity 3y = 20/30 ; 4 y = 20/20

Gross & Fine motor

3 y = handedness established , rides tricycle 4 y = copies square 5 y = copies diamond , throw & catches ball

Socialization

3 y = 900 words 4 y = enjoy entertaining others Imaginary friends

PEDIATRIC NURSINGTheories

of Growth & development

Pre-School

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Fine motor and cognitive abilities
Buttoning clothing Holding a crayon / pencil Building with small blocks Using scissors Playing a board game Have child draw picture of himself 
Pre-school tasks

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NUTRITION
Slow/Steady growth Decreased appetite Offer small servings Healthy snack food

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DAILY CARE
accidents ± bicycle safety, seat belts dressing ± choose own clothes sleep ± resist taking naps exercise ± very active bathing ± can wash and dry hands; need supervision care of teeth ± independent brushing

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Red flags: preschool
Inability to perform self-care tasks, hand washing simple dressing, daytime toileting Lack of socialization Unable to play with other children Able to follow directions during exam Performance evaluation of pre-school teacher for kindergarten readiness

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Pool Safety

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Preschooler characteristic traits
Curious, creative, imaginative & imitative Favorite word : ³WHY´ , ³HOW´ Complexes: word identification to parent of same sex and attachment of parent of opposite sex. 
Oedipal complex : boy to mom  Electra complex : girl to dad  Cause marital discord

Death : SLEEP ONLY

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PRE-SCHOOL
They love to watch adults & imitate their behavior - Oedipus and electra complex - gender roles ± need exposure to parents of opposite sex - Socialization ± capable of sharing - Discipline ± ³time out´ - Common fears ± dark, mutilation, separation - Telling ³lies´ & brag & boast in order to impress others - Imaginary friends & playmates are common
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Preschooler Behavioral Problem
Telling Tall tales- over imagination Imaginary friend- to release tension and anxiety Sibling rivalry ± jealousy to new baby Regression- going back to early stage
o Thumb sucking o Baby talk o Bed wetting o Fetal position

Masturbation sign of boredom
o Divert attention- offer toy.
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PRESCHOOL
Communication 
Offer choices  Speak in simple sentences  Be concise and limit length of explanation  Allow asking question  Described procedure about to be performed  Use play to explain procedure & activities  Allow handling equipment

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REACTIONS/CONCERNS IN ILLNESS AND NURSING INTERVENTIONS
-

fear of the dark ± allow dim light and parent to sit beside child

- Fear of body mutilation - Prepare for and explain procedure; reassure - Fear of injury, pain and the unknown Encourage expressive play/medical play - Fear of separation/abandonment ± relate time and space to familiar situations
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-

nutrition ± food in animal/alphabet shapes dressing change ± allow to measure, cut tape, see incision site medication ± allow to choose ³chaser´ hygiene ± allow choice of toys, wash hands and face pain ± allow pain expression, handle syringe, analgesic stimulation

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School Age 6 12 yo

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DEVELOPMENTAL MILESTONE SCHOOL AGED ( 6-12 y )
Physical Growth

Ht = 2 inch/yr Vision completely matured Lymphoid tissue hypertrophy Ability to perform complex movement 7 y = complete Myelinization 9-12 y = uses tool and equipment , follows direction enthusiastic at work & play.

Gross & Fine motor

Socialization

9-12 yrs old = loves secret, organize secret clubs Play activity is mostly same sex groups

PEDIATRIC NURSINGTheories

of Growth & development

School-Age

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School Years: fine motor
Writing skills improve Fine motor is refined Fine motor with more focus 
Building: models ± legos  Sewing  Musical instrument  Painting  Typing skills  Technology: computers

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School performance
Ask about favorite subject How they are doing in school Do they like school By parent report: any learning difficulties, attention problems, homework ‡ Parental expectations
‡ ‡ ‡ ‡

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Red flags: school age
School failure Lack of friends Social isolation Aggressive behavior: fights, fire setting, animal abuse

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School Age: gross motor
8 to 10 years: team sports Age ten: match sport to the physical and emotional development

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School Age

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School Age: cognitive
Greater ability to concentrate and participate in self-initiating quiet activities that challenge cognitive skills, such as reading, playing computer and board games.

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SCHOOL
Communication 
Establish limits  Provide reassurance to help in alleviating fears and anxieties  Engage in conversations that encourage thinking.  Use medical play technique  Use photographs, books, doll and videos to explain procedures  Explain in clear terms  Allow time for composure & privacy.
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Traits
Authority figure : teacher 
Fear :
o School phobia o Displacement from school o Loss of privacy o Fear of death ( 7-9 y ) permanent

Industrious Modest Can¶t bear to lose ± will cheat Love collection- stamp
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DAILY CARE
dressing ± influenced by peers sleep ± 8-12 hrs; no naps exercise ± games, bike riding, walking hygiene ± 8 yo ± capable of bathing alone 5. care of teeth ± 2x yearly visit to the dentist; brush daily 6. safety ± bicycle, school bus safety, prevention of falls and sports injuries
1. 2. 3. 4.

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CONCERNS
-

problems w/ articulation ± disappears 9 yo School anxiety and phobia Sex education Stealing ± 7 yo ± importance of money Violence/terrorism ± education;reassurance Bullying Recreational drug and alcohol use Likes to stay up late; slumber parties Nightmares common Awakens early in the morning

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REACTION TO ILLNESS AND NURSING INTERVENTIONS

1. Death and disability - Still need comfort 2. Unknown events & procedures - Allow

to help w/ care & treatment 3. Loss of ctrl & independence - Give choice 4. Loss of contact w/ peers - Allow visits 5. Disruption of school - Talk about interests

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1. nutrition ± allow choices 2. dressing ± ask opinions on bulk of

dressing and where to apply tape 3. medicine ± teach name and action, allow to choose form if possible 4. pain ± allow expression of pain, explain source and cause 5. stimulation

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ADOLESCENT (13-20 y)
Androgen inc sebaceous gland activity resulting in acne Apocrine glands inc activity 13 yo 2nd molars PUBERTY capable of sexual reproduction Secondary sexual characteristics 32 permanent teeth should be present by age 18-21 yrs

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13 to 18 Year Old

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Adolescent
As teenagers gain independence, they begin to challenge values Critical of adult authority Relies on peer relationship Mood swings especially in early adolescents

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Adolescent behavioral problems
Anorexia Attention deficit Anger issues Suicide

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Adolescents

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Adolescent Teaching
Relationships Sexuality ± STD¶s / AIDS Substance use and abuse Gang activity Driving Access to weapons

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Adolescents

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Adolescent
Fear 
Obesity  Acne  Homosexuality  Death  Replacement form friends

SIGNIFICANT PERSON : Opposite sex Traits
o o o o o Idealistic Rebellious Reformers Conscious with body image Adventure some

Problem :
o Vehicular accident, smoking, alcoholism, drugs o Premarital sex
PEDIATRIC NURSING

GROWTH AND DEVELOPMENTAL MILESTONES 13 yo sports

15 yo - enjoys privacy - stays in room 16 yo - part time job - charitable causes

PEDIATRIC NURSING

Pubertal development: a. Female: pubertal changes start between ages 8 and 13 years and changes take place for 3 to 4 years. Breast development commonly precedes pubic hair development. Most girls reached adult height midway through puberty. b. Male: pubertal changes start between age 9 ½ and 13 ½ years and changes take place for about 3 years. Testicular enlargement is usually the first sign of male pubertal development. Most boys reached adult height during the latter half of puberty.

PEDIATRIC NURSING

Pubertal development sign of sexual maturity
BOYS 
Testicular enlargement (9 ½ y)  Pubic/axillary hair  Growth spurt  Voices changes

GIRLS 
Breast bud (thelarche)  Pubic hair  Growth spurt  Menarche

PEDIATRIC NURSINGTheories

of Growth & development

REACTION TO ILLNESS
AND NURSING INTERVENTION

Main issue ± body image ± educate and Allow participation in tx decisions; compassionate understanding Fears loss of control and independence - Respect privacy and confidentiality Fears injury and pain - Provide opportunities for self expression Separation from peers and lack of emotional support - Approach w/ caring and understanding, age compatible roommate, Phone at bedside

PEDIATRIC NURSING

Hospitalized patient : What will I do ????

PEDIATRIC NURSING

DEVELOPMENTAL STAGES Hospitalized Pediatric patients
Infant & toddlers ( 0-3 y ) 
Separation anxiety
o Protest ± crying, screaming, kicking, verbal attack o Despair- withdrawn, depressed o Detachment-only after lengthy separation 

Fear of injury and pain
o Affected by previous experience, separation from parents 

Loss of control- toddler has its own rituals 
regression
PEDIATRIC NURSINGTheories

of Growth & development

DEVELOPMENTAL STAGES Hospitalized Pediatrics
Infant & toddlers ( 0-3 y ) 
INTERVENTION:
o Provide swaddling & soft talking to the infant o Provide forthe art of snugly wrapping your baby in a blanket for Swaddling is oral stimulation like pacifier warmth and security. o Provides routine It can keep him from being disturbed by his & rituals own startle reflex o Provide choices to toddlers o Allow toddler to express feeling of protest o Encourage to talk o Allow as much mobility as possible o Anticipate temper tantrum o Maintain pain reduction
PEDIATRIC NURSINGTheories

of Growth & development

DEVELOPMENTAL STAGES Hospitalized Pediatrics
PRESCHOOLER (3-6 Y) 
A. Separation anxiety ± less serious
o Protest o Despair o Detachment 

B. Fear of injury & pain
o Invasive procedure & mutilation o Imagine worst thing can happen o Believe they did something wrong 

C. loss of control
PEDIATRIC NURSINGTheories

of Growth & development

DEVELOPMENTAL STAGES Hospitalized Pediatrics
PRESCHOOLER (3-6 Y) 
INTERVENTION:
o Provide a safe & secure environment o Communication o Allow to express anger o Accept aggressive behavior o Leave favorite toy o Allow mobility, provide play and diversional o Place in the room with same age o Explain procedure simply on their level o Allow wearing underpants
PEDIATRIC NURSINGTheories

of Growth & development

DEVELOPMENTAL STAGES Hospitalized Pediatrics
SCHOOL AGED (6-12 Y) 
A. Separation anxiety
o Accustomed to period of separation from the parents o More concerned of missing school & friends 

B. Fear of injury & pain
o Bodily injury & pain o Death o Uncomfortable in any sexual examination 

C. loss of control
PEDIATRIC NURSINGTheories

of Growth & development

DEVELOPMENTAL STAGES Hospitalized Pediatrics
SCHOOL AGED (6-12 Y) 
INTERVENTION:
o o o o o o o o o o Encourage rooming-in Become involved with his own care Accept regression but encourage independence Provide choices Allow expression of feeling verbally & non-verbally Acknowledge fear and concerns Explain all procedures Allow to wear underpants Contact friends Provide educational need

PEDIATRIC NURSINGTheories

of Growth & development

DEVELOPMENTAL STAGES Hospitalized Pediatrics
ADOLESCENCE (13-20 Y) 
A. Separation anxiety
- Source : separation from friends 

B. Fear of injury & pain
o Being different from others o May give impression they are not afraid though they are terrified o Become guarded when any areas R/T to sexual development are examined 

C. loss of control
o Seek help and reject
PEDIATRIC NURSINGTheories

of Growth & development

DEVELOPMENTAL STAGES Hospitalized Pediatrics
ADOLESCENCE (13-20 Y) 
INTERVENTION
o Encourage question o Explore feelings o May wear own clothes o Allow privacy o Use body diagram to prepare for procedure o maintain contact with peers o Identify formation of future plans o Help develop positive coping mechanism
PEDIATRIC NURSINGTheories

of Growth & development

STAGE Age Infancy Birth-1 yr Toddler 1-3 years Preschool 3-6 years School Age 6-12 years Adolescence 13-20 years Solitary self is the interest of activities; alone but enjoys presence of others Parallel plays alongside, but not with another; has not learned sharing yet Associative plays in random without group goal; follows a leader Cooperative Competitive

PEDIATRIC NURSING

PLAY
Infancy (0-1y) Solitary Soft stuffed animals Crib mobiles, rattle, musical toys, push toys Toddler (2-3y) Parallel Push/pull toys Block, sand, finger paint, bubbles, large ball, crayon, telephone, wooden puzzles Preschool (3-6y) School age (6-12) Adolescence (13-20y) Competitive Cooperative Competitive Imaginary playmates Dress up clothes, paints , paper crayon . Loves running & jumping

Rules & Games & rituals Athletics Team sport Drawing, Competition & collecting strict rules is items , dolls important , pet , guessing Sports, games , videos, board movies, games , TV, parties, radio , dancing , videos , hobbies, computer music , games computer games, makeup
of Growth & development

PEDIATRIC NURSINGTheories

IT is not enough to have a good mind; the main thing is to use it well
-Rene Descartes-

PEDIATRIC NURSING

-end-

PEDIATRIC NURSING

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