Chapter 18

Toddler

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Biology and Genetics
 12 to 18 months → 3 years of age
 Overview of developmental/physical changes
 2 to 4 inches height/year; 4 to 6 lb weight/year
 Continue to measure head circumference
 May measure length (recumbent) or height
(standing)

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 Physical Characteristics
by System
Kidneys ● Specific gravity similar to adults
● 500-600 mL urine at 2 years old
● Begin voluntary control

Gastrointestinal ● Functional maturity

● Needs more frequent meals/snacks
● Control of internal/external anal sphincters

Respiratory ● Lung capacity increases

● Respiratory rate decreases
● Smaller upper tract diameter (airway obstruction
potential)

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 Physical Characteristics
by System (Cont.)
EENT ● Similar to infant
● Continued risk for otitis media

Endocrine ● Become functional (exception: reproductive)

Circulatory ● Blood pressure increases

● Heart rate decreases
● More effective thermoregulation

Immunity ● Active immunity/immunizations by 18 months

● Exposure to new/different organisms—
begin to build immunity

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 Physical Characteristics
by System (Cont.)
Teeth ● All 20 primary teeth erupt by end
of toddlerhood
● At risk of choking because of immature
swallowing pattern

Musculoskeletal ● Increased size/strength of muscle fibers

● Myelination of corticospinal tract sufficient
for most movement
● Voluntary motor movements often with
involuntary movement on other side of body
● Does not show hand dominance

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Gordon’s Functional Health Patterns
 Health perception–health management pattern
 Nutritional-metabolic pattern
 Elimination pattern
 Activity-exercise pattern
 Sleep-rest pattern
 Cognitive-perceptual pattern
 Self-perception–self-concept pattern
 Roles-relationships pattern
 Sexuality-reproductive pattern
 Coping–stress tolerance pattern
 Values-beliefs pattern

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 Health Perception–
Health Management Pattern
 Little understanding of health
 Depend on caregivers for health
management
 Health behaviors (e.g., brushing teeth)
part of taught rituals
 Identify with behavior modeled by caregivers
 Nutrition
 Exercise

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 Nutritional-Metabolic Pattern

 Nutrition principles
 Ensure adequate iron intake
 Moderate amount of milk (low in Fe)
 Prevent dental caries: Bedtime bottle—water only
 Juice overconsumption
 Appetite decreased—assess intake over several
days
 Mealtime
• Opportunity to offer healthy, age-appropriate choices
• Avoid too much attention/punishment over food behavior

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 Elimination Pattern

 Toilet training
 Major parental concern
 Emotional/physical readiness—usually 18 months
of age or older
 Nurse provides anticipatory guidance to parents
on
• Developmental readiness of child
• Parental attitudes and process of toilet training

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 Activity-Exercise Pattern

 Always busy and exploring

 Most waking hours at play
 Exploring, imitating, creating rituals
 Risk for injury
 Parallel play: Side-by-side, but independent play
 Anticipatory guidance
 Appropriate toys, opportunities for learning and
social encounters, limit TV time

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 Sleep-Rest Pattern
 Need: 12 hours a day; one to two naps
 Schedules are helpful to avoid overfatigue
 Rituals help develop a sense of security
 Night terrors
 Normal, less frequent as child develops
 Not fully awake
 Instruct parent to speak soothingly, do not try to
wake child

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 Cognitive-Perceptual Pattern
 Sensorimotor → preoperational
 Egocentrism—world as relates to them
 Object permanence
 Play imperative—learn by repetition
 Hearing—critical for language/speech
 Hearing loss assessed at birth, can be tested
during toddler, preschool years
 Otitis media: Leading cause of hearing loss in
toddlers

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 Cognitive-Perceptual Pattern
(Cont.)
 Vision
 Amblyopia—diminished or loss of vision in one eye
• Brain favors normal eye
 Strabismus—deviation in line of vision
• Management focused on making child use eye with
reduced vision (lazy eye)
 “Red flags” of vision problems
 Taste and smell
 Begin learning conditioned association between
smell/taste; develop food aversions

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 Self-Perception–
Self-Concept Pattern
 Erikson: Autonomy vs. doubt/shame
 Relinquish dependence on others
 Need to explore world
 Physically
 Relationships—“NO” and temper tantrums
 Guidance to parents
 Safe environment
 Promoting autonomy
 Preventing and dealing with temper tantrums

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 Roles-Relationship Pattern
 Roles understood as they relate to child
 Sibling rivalry: Ongoing negotiation of roles
and relationships
 Imitate others
 Prefer others’ possessions
 Child abuse
 Nurses:
• Need to be aware of potential; s/s abuse
• Report when child abuse suspected

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 Sexuality-Reproductive Pattern

 Genital exploratory behavior and

masturbation
 Normal developmental process
 Opportunity to learn about body
 Recommend using correct anatomical terms

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Coping–Stress Tolerance Pattern
 Temperament
 Individual style of emotional/behavioral response
across situations
 Foundation for coping
 Influenced by environmental characteristics
 Influences psychosocial adjustments
 Nurse can assist parents in recognizing
temperament and developing management
strategies

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 Values-Belief Pattern

 Healthy behaviors reflect positive

values/beliefs
 Toddler’s environment
 Teach right/wrong
 Contribute to security, belonging, autonomy
 Values/beliefs
 Interactions with parents
 Religious rituals/beliefs
 Development facilitated by consistent behavioral
expectations, reinforcing acceptable behavior
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 Environmental Processes:
Physical Agents
 High risk for accidental injury
 Structural hazards
 “Babyproof” the environment
 Inspect for hazards in unfamiliar environments
 Appropriate supervision
 Toys
 Inspect toys
 Risk of small removable parts, batteries, toxic paint,
sharp edges

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 Environmental Processes:
Physical Agents (Cont.)
 Sports
 Improper storage of guns, heavy equipment
 Need for bike helmets
 Drowning: Highest risk ages 1 to 3
 Can drown in water if covers nose/mouth
 Danger: Pools, tubs, toilets, pails of water
 Burns
 Hot liquids, electrical cords, fireplaces
 Lower water heater to 120° to 125° F

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 Motor Vehicle–Related Injury

 One of leading causes of death 1 to 4 years

 Child safety seats
 Correct seat for weight of child
 Proper installation of safety seat
 Rear seat position preferred
 Pedestrian accident potential at home
 Killed/injured in driveway by backing vehicle

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 Biological Agents and Poisoning
 Biological agents
 Potential of bioterrorism: Talk about fears,
appropriate precautions/response
 Poisoning—greatest risk ages 1 to 2
 Use mouths as way to explore environment
 Medications, household products, plants, cigarettes,
alcohol, cosmetics
 Suspected poisoning—contact Poison Control Center
 Chronic poisoning—lead
• Teach primary prevention; secondary prevention (screening)

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 Determinants of Health:
Social Factors and Environment

 Day care—HHS four-step approach

 Interview potential provider and observe setting
 Check references
 Make decision based on specific criteria
 Get and stay involved
 Culture and ethnicity
 Toddlers shaped by family values/beliefs
 Knowledge, respect, negotiation across cultures
needed for high-quality health outcomes

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 Levels of Policy Making
and Health
 Legislation
 Safety and injury prevention
 Abuse and neglect protection
 Assistance for handicapped children 0 to 3 years
 Economics
 Toddler mortality/morbidity rates increase in poverty
 Medicaid, uninsured, SCHIP program

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 Health Services/Delivery System
 Health care delivery system
 Adequacy of system significantly affects health
of toddler
 Routine assessment needed
• Growth/development
• Immunizations
• Discussion of developmental concerns
• Anticipatory guidance

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 Nursing Application
 Nurses involved with the family
 Provide education that is focused on the physical
and developmental changes that occur in the
toddler stage
 Teach some health-promotion activities to toddlers
 Engage in screening activities
 Inform parents about routine health examinations
and the childhood immunization schedule
 Educate parents about resources available in the
community that may provide free or low-cost
injections

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