Anticipatory Guidance

Preschool-School Age-Adolescent
Preschool
 Assessment and Approach
 Preparation Positions
 Allow to inspect equipment Prefer standing or sitting
 Offer brief demonstration Usually cooperative
 Leave underwear on supine or prone
 Make up story about procedure Prefer parent close by
 Use doll play Sequence
 Give choices where possible If cooperative: Head to toe
 Especially in hospital setting (still leave invasive until
 Use positive statements: I’ll bet you last)
can open your mouth really wide! If uncooperative: Proceed
 Praise cooperative behavior
as with toddler
Social Readiness
 Preschoolers are more agreeable than toddlers (less negativism)
 Moves towards group play
 Read books together
 Ask about his or her day
 Model good behavior (apologizing, respect)
 Praise good social behavior
 Help child express his or her feelings
 How does that make you feel? It’s okay to be ...
 Give chances to play and interact with other children
 Consider preschool (in home, center, church groups)
 Socialization

https://brightfutures.aap.org/Bright%20Futures%20Documents/B.ECh.PH.4yr.pdf
Speech
 Telegraphic speech: say the bare minimum number of
words  progresses into more words
 Talk a lot!
 Speech problems may present at this age
 Causes: Hearing loss, developmental delay, lack of stimulation
 Prevention and early intervention are key!
 Healthy Habits
 Healthy, family meals eaten together
 Bedtime routine
 Dental health-brush twice daily (with parent help)
 Limit screen time to 2 hours per day
 No TV in the bedroom
 Sign child up for activities, lessons, etc to promote physical
activity
 Sunscreen when outside

https://brightfutures.aap.org/Bright%20Futures%20Documents/B.ECh.PH.4yr.pdf
Nutrition
 Quality > Quantity
 Limit and dilute juice intake
 May develop strong preferences or food “fads”
 One day will like something and the next day will hate it
 Avoid making preschooler remain at table until they finish
their meal
 Develops unhealthy issues with food for the future
 Eating should never be a punishment or reward
 By age 5, more likely to try new foods
 Safety
• Much more aware of danger; can
be relied on to listen and obey
rules in a basic sense
• Magical and egocentric thinking
may put them at risk
• Still at risk for drowning,
poisoning, MV accidents
• Enforce safety items
 Car seats:
• Child must ride in approved car
seat until between 8-12 years
old AND 4 feet 9 inches tall
• Safest place is in the rear seat
https://brightfutures.aap.org/Bright%20Futures%20Documents/B.ECh.PH.4yr.pdf
Teach your child about how to be safe
with other adults. (start the
conversation early, but don’t harp too
much)
No one should ask for a secret to be kept
from parents.
No one should ask to see private parts.
No adult should ask for help with his
private parts.
Fears
• Fears: mutilation and intrusive procedures
• Egocentric and present-oriented
• Don’t understand times  make it more concrete (mom will be back
after dinner)
• Perceives illness as punishment
• Tolerate some separation
Fears
• May show signs of regression Guidance:
while in the hospital • Acknowledge their fear  don’t
• May deny pain to avoid say “this isn’t scary”
intervention • Night light, comfort item
• Able to describe location and • Desensitization  slowly make
intensity of pain (FACES it darker each night (if fear is
scale) dark)
• Physical signs of pain:
restlessness, irritability,
cries, kicks
• Common fears
• Dark, being left alone,
animals, ghosts & pain
Sleep
 Waking during the night is common during these ages
• May be related to social or environmental factors (fear, night terrors)

Daytime naps decrease and stop altogether during preschool years

Bedtime rituals are important when children are delaying going to bed
 Ignore attention seeking behavior
 Don’t take child into parents bed
 Don’t allow child to stay up late (no watching TV to fall asleep!)
 Nightlight in room, transitional object
 Consistency is key!
 Establish a routine (ie bath, story, bedtime)
Nightmares vs sleep terrors
 Nightmares are “frightening dreams followed by full arousal”
• Child wakes or cries after dream is over
• Occurs later in the night
• Easily reassured by parents
• Offer comfort, sense of protection
 Sleep terrors are only “partial arousal from deep sleep”
• Child will scream and not be fully awake during night terror
• Might shake and rock  can be disturbing for parents
• Usually occurs 1-4 hours after falling asleep (earlier in the night)
• Child is not aware of parent’s presence, not easily comforted
• Observe without interfering, don’t try to wake up
• Will grow out of it
Contact dermatitis
 Inflammatory reaction of the
skin in response to natural or
synthetic substances
 Caused by primary irritant
or sensitizing agent
 Plants (poison ivy)
 Animal irritants (wool,
feathers)
 Metal (nickel in jewelry and
clothing parts)
 Vegetable irritants (oils)
 Synthetic fabrics (dyes,
perfumes, soaps)
Contact dermatitis

 Goal of treatment is to prevent further exposure

 Look for pattern

 Topical steroids or systemic corticosteroids depending on

severity

 Nursing management:
• Look for evidence during assessment
• Counsel parents on how to avoid irritants
• Watch for evidence of infection
Bites and stings
 Bees, spiders, ants, etc
 Most are managed by simple symptomatic
measures
• Calamine lotion
• Ice compress
• Antihistamines
Watch for systemic response (generalized urticaria,
respiratory difficulty)
Avoid exposure
Recognize when medical attention is needed (bites
from poisonous insects, snakes)
School Age
Social Development

 Relationships with family

 Still important influence
 Parents are the primary influence in
shaping their child’s personality,
behaviors, and values
 Should be their parent, not friend
 Gradual introduction of autonomy
 Still need and want restrictions
 Not prepared to deal with all
problems in their environment
 Siblings are companions
 Conflict increases
 Social Development
 Socialrelationships: formation of
organized groups & clubs with
set-rules
 Identification with peers
 Important in gaining
independence from parents
 Early School Years:
 Few gender differences
 Later School Years:
 Boys associate with boys
and girls with girls
 “Best Friends”
 Clubs and Peer Groups
 Coping with Concerns Related to Normal Growth and
Development

 School experience
 Second only to the family as a
socializing agent
 Transmission of values of the
society
 Peer relationships become
increasingly important
 Latchkey children

19 Copyright © 2017, Elsevier Inc. All Rights Reserved.

 Development of Self-Concept & Sexuality

 Self concept
 Awareness of self- perceptions
 Also includes the development of
Body image, Self esteem, and
Sexuality
 Sexuality and Sex Education
 Increased socialization and media
exposure make this period an ideal
time
Nurse’s Role in Sex Education
 Treat sex as a normal part of growth and development
 Use correct terminology
 Questions and answers
 Let them ask; answer honestly
 Differentiation of sex and sexuality
 Values; problem-solving skills
 Open for communication with parents
 Stress importance of privacy and understanding their body
 Curiosity is normal at this age

21 Copyright © 2017, Elsevier Inc. All Rights Reserved.

 Play
 Groups, cliques, & clubs (“best friends”)
 Games have fixed, rigid rules
 Conformity and rituals
 Chants and Taunts
 Team sports with referee
 Accountable to team members
 Division of labor
 Competition
 Quiet Games:
• Collections
• Board, Computer, and Card
Games
• Reading
Exercise and Activity
 Sports
 Controversy regarding early participation in
competitive sports
 Concerns with physical and emotional maturity in
competitive environment
 Not emotionally mature enough to handle the pressure of
intense competition
 Emphasize that competition at this age should be fun and
enjoyable for everyone
 Acquisition of skills
 Generally like competition

23 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Nutrition

 Patterns influenced by family and peers

 Develop a taste for a variety of foods
 More likely to try new foods
 32% of food consumed outside the
home
 Encourage to eat good breakfast before
school
 Should be offered a balanced diet to
promote proper growth
 Avoid empty calories (soda, junk food)
 Caloric needs 6-12 years:
• boys: 16-17 kcal/cm
• girls: 13-14 kcal/cm
Obesity
 Defined as an increase in body weight
due to accumulation of excessive body
fat relative to a lean body mass
 Obesity is generally considered when
weight is more than the 95th percentile
for age, gender, and height
 Overweight is generally considered when
weight is more than the 90th percentile
 25% to 30% of children are obese

25 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Childhood Obesity

Impact Cause
 Increase in type 2  In 5%, the cause is underlying

diabetes disease (e.g., hypothyroidism,

 Risk of adult obesity other metabolic disease, central
nervous system disorders)
 Hypertension,
 Role of heredity
hyperlipidemia,  Patterns that parents exhibit, norms
cardiovascular for the family
disease  Inactivity
 Social isolation, low
 Patterns of eating behaviors
self-esteem,  Eating dinner late at night, not as a
depression family, microwave dinners
26 Copyright © 2017, Elsevier Inc. All Rights Reserved.
 Diagnosis

 Formula: weight (kg) / [height (m)]2

 BMI Percentile Calculator for Child a
nd Teen
 CDC obesity data and statistics
 Skinfold measurements
 Body fat measurements
 Diagnostic tests to rule out metabolic and
endocrine disorders

27
Nursing Considerations
 Assessment, planning, implementation
 Diet, exercise (limit screen time), behavioral and
group therapy
 Prevention, evaluation
 Family meals at home with parents whenever possible
 Medical therapies
 Pharmacologic therapies are generally not
recommended for weight loss in children
 Surgical therapies are hazardous in children

28 Copyright © 2017, Elsevier Inc. All Rights Reserved.

 Sleep
 Highly individualized
 Rarely takes naps
 Average 5 year old:
 11 hours per night
 Average 12 year old
 9 hours per night
 More like adult
 Bedtime resistance peaks
from 8-11 years
Dental Health
 Developmentof
permanent adult teeth:
 Lose 4 teeth per year
 Begin with eruption of
6-year molars
 32 permanent teeth
 Dental hygiene and caries
attention are important due
to having permanent teeth
 Malocclusion
 Dental injuries
Injury Prevention
 Most common cause of severe injury and death in school-
age children is motor vehicle crashes: pedestrian/biking
and passenger
 Booster seats
 Bicycle injuries; benefits of bike helmets
 Appropriate safety equipment for all sports
 Skateboard, in-line skates, scooter

31 Copyright © 2017, Elsevier Inc. All Rights Reserved.

 Reaction to
Illness and Hospitalization
 Fears:
 Pain and bodily injury
 Having to undergo surgery
 Loss of control
 Separation from family, peers
and school
 Physical manifestations of stress:
 Stomachaches, headaches,
aggression, regression
 Death and dying
 Are also fascinated with all
aspects of death and dying
 Begin to understand the
permanence
 Response to Pain

 May see all behaviors of young

child, especially during painful
procedure, but less in anticipatory
period
 Typical stalling behavior – “Wait
a minute” or “I’m not ready”
 Muscular rigidity: clenched fists,
white knuckles, gritted teeth,
contracted limbs, closed eyes,
wrinkled forehead
 Nursing Interventions

 Communicate openly and honestly

 Yes, it’s going to hurt, but it will be over very
fast
 Explain rules and clarify misconceptions
 Encourage child’s participation in care
 Sense of autonomy
 Provide visiting for siblings and peers when
possible
 Use age appropriate therapeutic play
 Praise the child & focus on desired behavior

34
Adolescents
Self-Concept and Body Image
 Feelings of confusion in early adolescence (puberty)
 Acute awareness of appearance, comparison of
appearance with others
 Blemishes and defects are magnified out of proportion
 Matures to self-concept based on uniqueness and
individuality
 Allow for time to talk without parent during assessment

36 Copyright © 2017, Elsevier Inc. All Rights Reserved.

 Responses to Puberty

 Responses differ depending on the stage of

development
 Curiosity in early adolescence
 Concerns with “Am I normal?”
 Concerns for late-maturing teens
 Concept of “perfect body” achievement

37 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Social Development
 Goal is to define one’s identity independently from
parental authority (not ready for this yet)
 Much ambivalence
 Intense sociability; intense loneliness
 Acceptance by peers

"The young always have the same problem - how to

rebel and conform at the same time. They have now
solved this by defying their parents and copying one
another."

38 Copyright © 2017, Elsevier Inc. All Rights Reserved.

 Social Development
 Relationship with parents
 Changes during adolescence from a relationship of protection-dependency
to one of mutual affection and equality
 Difficult for adolescent AND parents
 Parents and the adolescent are learning to play new roles, learning
independence
 Tensions can arise as adolescent asserts their rights for grown up privileges

 Relationships with peers

 Peers assume a more significant role and can become very influential
 To belong is very important and adolescents behave in a way that will
ensure their establishment in a group and their acceptance
 Anticipatory Guidance
 Parents need support and guidance to help their adolescent through this
confusing time of changes in behaviors, emotions and physical
development.
 Encourage parents:
 Accept adolescent as unique individual
 Respect adolescent’s ideas, likes, dislikes
 Be involved with school functions, attend performances
 Listen and be open to their ideas and thoughts
 Provide opportunities for choosing options
 Provide clear, reasonable limits
 Respond to feelings as well as words
 Avoid comparison with siblings
 Provide unconditional love and acceptance
Nutrition and Diet
 The rapid increase in height, weight and muscle mass during
adolescence means there are increased nutritional needs.
 Pressure for time and commitments to activities negatively
affects teenagers’ eating habits.
 Omitting breakfast or eating breakfast of poor quality is
frequently a problem for adolescents.
 Excess intake of calories, sugar, fat, cholesterol and sodium is
coming during this stage.
 Inadequate intake of certain vitamins like folic acid, vitamin
B6 and vitamin A and minerals like iron, calcium, zinc are also
common
 Exercise important for physical fitness and body image
 Eating Disorders

 Anorexia Nervosa
 Attempt to establish “control” & restore
order
 Bulimia Nervosa
 Sense of loss of “control” & hopelessness
 May include varying degrees of
 Laxative abuse, exercise excess, diet pills,
etc.
 These disorders take a tremendous
physical and emotional toll
 Sleep
 During growth spurts, need for sleep is increased
 Need about 9 hours per night
 1 in 4 teens are sleep deprived (getting less than 6 hours)
 They have a tendency of staying up late, making it
difficult to get up in the morning for school and
activities, etc.
Acne Vulgaris

 Peaks at ages 16-18

 Factors influencing the development of
acne:
 excessive sebum production
 Comedogenesis
 bacteria “P. acnes”
 Presents as papules, pustules, nodules, cysts or non-
inflamed comedones
 Often causes emotional distress and social withdrawal
 May lead to permanent scarring
Acne

 Contributing factors
 Hormonal
 Obstructive
 Stress, hygiene and certain foods are unlikely
 Treatment and Control
 GENTLE cleansing
 Retinoids: Tretinoin (Retin-A)
 Benzoyl peroxide
 Topical or oral antibiotics
 Especially for cystic acne
 Oral contraceptives
 If hormonal
 Accutane
 LOOK UP FOR THE QUIZ!
Promoting Optimum Health During
Adolescence
 Stress reduction
 Sexuality education and guidance
 Media influences
 Knowledge from peers, TV, social media, movies, magazines
 Need factual information, presentation based on developmental
maturity and ability to ask questions
 Need the adults in their lives to provide factual information, answer
their questions
 Role modeling

48 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Adolescent Sexuality/
Sexual Health
 Dating  Contraception
 Sexual orientation  Sexually transmitted
 Sexual experimentation diseases
(wide range)  Teen pregnancy
 Reasons for sexual  Sexual orientation
experimentation  Sexual Abuse and
 Curiosity
Exploitation
 Pleasure  Date Rape
 Conquest  Molestation and
 Peer pressure to conform acquaintance rape

49 Copyright © 2017, Elsevier Inc. All Rights Reserved.

Anticipatory Guidance
 Be aware that Adolescents:
 Are struggling for independence
 May exhibit unpredictable behavior
 Are extremely sensitive to feelings and
behaviors that affect them
 May receive a different message from what
was sent
 Consider friends extremely important
 Have a strong need to belong
 Anticipatory Guidance

 Drinking and driving

 Risk taking behaviors
 Truancy and Crime
 Violence and aggression
 Media and internet
 Sex trafficking
Depression and Suicide
 A common problem in teens
 May be hidden under a “behavior problem”
 May be regarded as “normal” teen moodiness
 May be a high-achieving, “successful” teen
 Remember  
  the vulnerability of this age group and their

 
unsophisticated coping…
                                                                   
 Depression & Suicide
Warning Signs
 Any suicide ideation, attempt, plan or gestures 
immediately go to ER
 Self-destructive, reckless behavior; lack of self-worth
 Morbid thoughts; preoccupation with mortality
 Withdrawal, apathy, “flat” affect
 Irritability or mood lability
 Excessive sleeping, psychosomatic complaints
 Truancy, deteriorating school performance(missing
school)
 Improved mood after a depression: can sometimes
indicate that they have made a plan for SI
 Giving away valued possessions
 Social / Environmental risk factors
Cutting -- Self-Injury (SI) or
Self-Mutilation (SM)

 Means to cope with emotion

 Inner arms, inner thighs,

feet, axillae, under breasts
Substance Abuse
 Drug abuse, misuse, and addiction
 Voluntary behaviors
 Culturally defined
 Use of drugs for other than an acceptable medical purpose
 Drug tolerance and physical dependence
 Involuntary physical responses

Substance Abuse Nursing Considerations

 Acute care: Narcan, inpatient rehab
 Long-term management
 Family needs and family support
 Prevention: early education about dangers
59
Substance Abuse
 Tobacco
 Alcohol
 Other Drugs:
 Ecstasy, GHB, Rohypnol
 Cough syrup
 Inhalants
 Marijuana
 Methamphetamines
 Heroin
 Cocaine
 Ketamine, PCP, LSD
Tobacco
Why do kids smoke?
 Imitation of adult behavior
 Peer pressure
 Perceived popularity of
smokers
 Less likely to smoke if
parents and family do not
smoke
 Less likely to smoke with
high-performance sports
activities
 Smokeless tobacco
increasingly popular
61
Effects
 Undisputed damage related to
tobacco use
 Decreased lung function
 Addiction and dependence on
nicotine
 Earlier age of smoking makes it
more difficult to quit later in life
 Smokeless: Carcinogenic,
periodontal disease, tooth
erosion, soft tissue damage
Antismoking Campaigns
 Peer-led programs are most effective
 Emphasize social consequences rather than long-term
health problems: yellow teeth, smelling bad
 Use of multimedia images
 School and community settings
 Begin in elementary school and continue through high
school

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