PEDIATRIC NURSING

Alejandro S. Mendoza RN, MD

Initial Assessment
GENERAL PRINCIPLES
•Airway  suctioning and O2 if needed
•Definition of Terms •Body temperature
A. Growth:
Growth: increase in size of a
structure. Human growth is orderly •Positioning  head lower than the trunk
and predictable, but not even; it
follows a cyclical pattern. •Apgar scoring
B. Development:
Development: maturation of
physiologic and psychosocial
•Cord clamp  bleeding, AVA
systems to more complex state. •Voiding and meconium
C. Cephalocaudal:
Cephalocaudal: head-to-toe
progression of growth and •Footprints and fingerprints
development •Identification bands
GENERAL PRINCIPLES •Mother infant bonding
•Definition of Terms APGAR SCORING
D. Proximodistal:
Proximodistal: trunk-to-periphery
(fingers and toes) progression of
•Heart rate
growth and development •Respiratory effort
E. Phylogeny:
Phylogeny: development or evolution
of a species or group;
group; a pattern of •Muscle tone
development for a species •Reflex irritability
F. Ontogeny:
Ontogeny: development of an
individual within a species •Skin color
1 minute  initial adaptation to
Rates of Development extrauterine life
5 minutes  overall status
A. Fetal period and infancy:
infancy: the head and
neurologic tissue grow faster than other APGAR SCORING
tissues. INTERPRETATION
B. Infancy and adolescence:
periods
adolescence: fast growth
•7 to 10  Good condition
C. Toddler through school-age:
school-age: slow growth
periods
D. Toddler and preschool periods:
periods: the trunk •4 to 6  Fair condition
grows more rapidly than other tissue.
E. The limbs grow most during school-age
period. •0 to 3  In danger  resuscitation
F. The trunk grows faster than other tissue
during adolescence.
adolescence. Ongoing Physical Assessment

NEONATAL ASSESSMENT •Vital Signs

•Initial assessment •Vital statistics
•Ongoing assessment •Gestational age assessment
•Administer medications
•Physical assessment •Perform laboratory tests
•Sensory assessment
•Behavioral assessment
 •Direct coomb’s test
•Reticulocyte count
•Hct
•Administer Medications
–Vit K (Aquamephyton)
Ongoing Physical Assessment •.5 to 1 mg
•Vital signs: •IM
–RR •Prevent transient deficiency of
coagulation factors
•30 to 60 bpm –Erythromycin ointment
–Apical Pulse •.5%
•110  sleeping •1 to 2 cm
•120 – 160  awake •Neisseria gonorrhea, chlamydia
•180  crying
–Temperature PHYSICAL ASSESSMENT

•36  36.8 •Skin

–Blood Pressure •Head
•80/46 mmHg •Eyes
•Vital Statistics: •Ears
–Weight •Nose
•2,500 – 4,000 g •Mouth and throat
–Length •Neck
•18 – 21 inches •Chest
–Head Circumference •Genitalia
•13 – 14 inches •Extremities
–Chest Circumference
HEAD
•12 – 13 inches
Ongoing Physical Assessment •Eyes
–Normal
•Gestational Age •Color  gray
–Preterm •Absence of tears
–Term •Searching nystagmus
–Postterm
–Abnormal
•Laboratory Test
•Yellow sclera
–Mother  Rh neg or blood type O
•Blood type •Blue eyes
•Bilirubin level •Purulent discharge
 •Congenital cataracts •APD = TD
•Slight sternal retractions evident
•Ears during inspiration
–Normal –Abnormal
•Pinna  top is horizontal line with •Asymmetry of the chest
outer cantus of the eye, flexible,
cartilage present
•Depressed sternum
–Abnormal GENITALIA
•Low placement of ears •MALE
•Absent of startle reflex in –Normal
response to loud noise
•Urethral opening at tip of glans
penis
•Palpable tetes
–Abnormal
•Hypospadias
•Epispadias
MOUTH AND THROAT •FEMALE
•Epstein pearl –Normal
•Reflexes •Labia and clitoris usually
–Sucking edematous
–Gag •Urethral meatus behind clitoris
–Extrusion •Pseudomenstruation
•Candidiasis (thrush) –Abnormal
•Inability to pass NGT •Fused labia
•High pitch cry or absent •Meconium in the vaginal area
•Absence of vaginal opening
•Neck
–Normal EXTREMITIES

•Short, thick, usually surrounded •NORMAL

by skin folds –Ten fingers and toes
•Tonic neck reflex –Full range of motion
–Abnormal –Nail beds are pink, with transient
•Resistance to flexion cyanosis immediately after birth

•Fractured clavicle –Equal brachial pulses

•No tonic neck reflex –Sole usually flat
•Chest •ABNORMAL
–Normal –Polydactyly
 –Syndactyly  fused or webbed digits –Calories  100 to 200 kcal/kg
–Yellowing of nail beds –Fluid  150 to 180ml/kg
–Unequal gluteal folds –CHON  2.2g/Kg  1.6g/Kg
–Sole covered with creases –Fat  30 to 60% of daily calories
SENSORY ASSESSMENT HIGH RISK INFANTS
•Tactile Behaviors •According to size
–Sensation to touch, pain and pressure –LBW  < 2500g
•Olfactory behaviors –ELBW  < 1000g
•Vision Behaviors –MLBW  < 1500g
–Can see  7 to 12 inches –SGA
•Auditory Behaviors •Birth weight falls below 10 th

•Taste Behaviors percentile on intrauterine growth

curve
BEHAVIORAL ASSESSMENT –LGA  above 90 th
%
•Period of Reactivity •According to age
–30 minutes after birth
–Awake and active
–Premature
–VS are increased –Full term
–Mother infant bonding  breastfeeding
–Postmature
•Resting Period
–2 to 4 hours DEVELOPMENTAL THEORIES
–VS returning to baseline
–1 ½ sleep and difficult to be aroused
Psychosexual model (Freud)
•Second Period of Reactivity 1. Oral
–4 to 6 hours a. 0-18 months
b. Pleasure and gratification through mouth
c. Behaviors:
Behaviors: dependency, eating,
eating, crying,
crying,
biting
NUTRITION
d. Distinguishes between self and mother
e. Develops body image, aggressive drives
•GENERAL INFORMATION
Psychosexual model (Freud)
–Loses 5 to 10% and regain within 10 2. Anal
days a. 18 months - 3 years
–Gain of 28g /day  1 st
6 months b. Pleasure through elimination or retention
of feces
–Gain of 14g/day  2 nd
6 months c. Behaviors:
Behaviors: control of holding on or letting
go
–Weight gain d. Develops concept of power,
power, punishment,
•2x  6 months ambivalence, concern with cleanliness
or being dirty
•3x  1 year
Psychosexual model (Freud)
•4x  2 ½ year 3. Phallic/Oedipal
•DAILY NUTRIONAL REQUIREMENTS a. 3 - 6 years
b. Pleasure through genitals
c. Behaviors:
Behaviors: touching of genitals,
genitals, erotic
attachment to parent of opposite sex
d. Develops fear of punishment by parent of
same sex,
sex, guilt,
guilt, sexual identity
Psychosexual model (Freud)
4. Latency
a. 6 - 12 years
b. Energy used to gain new skills in social
relationships and knowledge
c. Behaviors:
Behaviors: sense of industry and mastery
d. Learns control over aggressive,
destructive impulses
e Acquires friends
Psychosexual model (Freud)
5. Genital
a. 12 - 20 years
b. Sexual pleasure through genitals
c. Behaviors:
Behaviors: becomes independent of
parents,
parents, responsible for self
d. Develops sexual identity, ability to love
and work
Psychosocial Model (Erikson)
1. Trust vs mistrust
a. 0 - 18 months
b. Significant relations: mother
c. Psychosocial virtues: hope,
hope, faith
d. Maladaptations & malignancies:
sensory distortion- withdrawal
Psychosocial Model (Erikson)
2. Autonomy vs shame and doubt
a. 18 months - 3 years
b. Significant relations: parents
c. Psychosocial virtues: will, determination
d. Maladaptations & malignancies:
impulsivity -- compulsion
Psychosocial Model (Erikson)
3. Initiative vs guilt
a. 3 - 5 years
b. Significant relations: family
c. Psychosocial virtues: purpose, courage
d. Maladaptations & malignancies:
ruthlessness -- inhibition
Psychosocial Model (Erikson)
4. Industry vs inferiority
a. 6 - 12 years
b. Significant relations: neighborhood and
school
c. Psychosocial virtues: competence
d. Maladaptations & malignancies:
narrow virtuosity -- inertia
Psychosocial Model (Erikson)
5. Identity vs role confusion
a. 12 - 20 years
b. Significant relations: peer groups,
groups, role
models
c. Psychosocial virtues: fidelity, loyalty
d. Maladaptations & malignancies:
fanaticism -- repudiation
Psychosocial Model (Erikson)
6. Intimacy vs isolation
a. 20 - 25 years
b. Significant relations: partners,
partners, friends
c. Psychosocial virtues: love
d. Maladaptations & malignancies:
promiscuity -- exclusivity
Psychosocial Model (Erikson)
7. Generativity vs stagnation
a. 25 - 45 years
b. Significant relations: household,
workmates
c. Psychosocial virtues: care
d. Maladaptations & malignancies:
overextension -- rejectivity
Psychosocial Model (Erikson)
8. Integrity vs despair
a. 45 years to end of life
b. Significant relations: mankind or “my
kind”
c. Psychosocial virtues: wisdom
d. Maladaptations & malignancies:
presumption -- despair
Interpersonal Model (Sullivan)
1. Infancy
a. 0 - 18 months
b. Others will satisfy needs
2. Childhood
a. 18 months - 6 years
b. Learn to delay need gratification
3. Juvenile
a. 6 - 9 years
b. Learn to relate to peers
Interpersonal Model (Sullivan)
4. Preadolescence
a. 9-12 years
b. Learn to relate to friends of same sex
5. Early adolescence
a. 12-14 years
b. Learn independence and how to relate to
opposite sex
6. Late adolescence
a. 14-21 years
b. Develop intimate relationship with person
of opposite sex
Cognitive Theory (Piaget)
A. 0 - 2 years: sensorimotor
-reflexes,
reflexes, repetition of acts
B. 2 - 4 years: preoperational
-no cause and effect reasoning;
egocentrism; use of symbols;
symbols; magical
thinking
C. 4 - 7 years: intuitive
-beginning of causation
–Child carries out actions to satisfy own
needs rather than society’s. The child
does something for another if that
person does something for him in return
CONVENTIONAL LEVEL level 2
•Stage 3
Age : 7-10
•Description:
–"Good boy/girl"
–Orientation to interpersonal relations
of mutuality
–A child follows rules because of a
need to be a good person in own eyes
and in the eyes of others
CONVENTIONAL LEVEL level 2

Cognitive Theory (Piaget) •Stage 4

D. 7 - 11 years: concrete operations
- uses memory to learn •Description:
- aware of reversibility
E. 11 - 15 years: formal operations
-reality, abstract thought
-can deal with the past, present and
future
KOHLBERG’S STAGES OF
MORAL DEVELOPMENT
Age : 10-12
–Law and Order
–Maintenance of social order, fixed
rules and authority
–Child follows rules of authority figures
as well as parents to keep the system
working
POSTCONVENTIONAL LEVEL level 3

PRECONVENTIONAL LEVEL
•Stage 5
Age :older
:older than 12
•Stage 1 •Description:
Age: 2-3
•Description: –social contract, utilitarian law making
perspective
–Punishment or obedience –child follows standards of society for
(heteronomous morality)
the good of all people
–A child does the right things because a
parent tells him or her to avoid POSTCONVENTIONAL LEVEL level 3
punishment
PRECONVENTIONAL LEVEL •Stage 6
Age :older
:older than 12
•Stage 2
Age : 4-7 •Descriptions:
•Description: –Principled Conscience
–Individualism, Instrumentalism, and –universal ethical principle
Exchange orientation
 –child follows internalized standards of •Response:flexion of toes
conduct
•Onset: birth
NEONATAL REFLEXES •Suppression: 12-18 mos
Reflex:
Reflex: Symmetric tonic neck NEONATAL REFLEXES
Stimulus:
Stimulus: neck flexion, neck extension
Response:arm
Response:arm flexion, leg extension, arm
•Reflex: Automatic neonatal walking
extension, leg flexion •Stimulus: contact of the sole in vertical
Onset:
Onset: birth-1month position tilting the body forward and from
Suppression:
Suppression: 4 mos side to side

NEONATAL REFLEXES
•Response: automatic alternating steps
•Reflex: positive supporting •Onset: birth
•Stimulus: tactile contact and weight •Suppression: 3-4 mos
bearing on sole
REFLEXES
•Response:leg extension for supporting
partial body weight •Blinking or corneal reflex
•Onset: 2 months •Pupillary reflex
•Suppression: 3-7 mos, replaced by •Doll’s eye  fixation develops
volitional standing •Sneeze reflex
NEONATAL REFLEXES •Sucking reflex
•Reflex: rooting •Gag reflex
•Stimulus: stroking the corner of the •Rooting reflex  3 to 4 months
mouth,upper or lower lip
REFLEXES
•Response:moving the tongue, mouth and
head towards the site of stimulus •Extrusion reflex  4 months
•Onset: birth •Cough reflex
•Suppression: 4 mos •Babinski reflex
•Moro reflex  3 to 4 months
NEONATAL REFLEXES
•Dance or step reflex  3 to 4 weeks
•Reflex: palmar grasp
•Stimulus: pressure or touch on the palm, NEONATAL SENSES
stretch of finger flexors •HEARING:
•Response:flexion of fingers –able to hear in the utero
•Onset: birth –within hrs after birth, hearing in NB
•Suppression: 4-6 mos becomes acute
•VISION:
NEONATAL REFLEXES
–focus on black and white objects
•Reflex: Plantar grasp –distance of 9-12 inches
•Stimulus: pressure on the sole just distal –pupillary reflex present at birth
to the metatarsal heads
 NEONATAL SENSES
•TASTE: Infant
A. Physical tasks
–developed before birth 1. Neonate (Birth to 1 month)
f. Sensory development
•TOUCH: 1) hearing and touch well developed at
–well developed at birth birth
2) sight not fully developed until 6 years
–react to painful stimuli a) differentiates light and dark at
birth
•SMELL: b) rapidly develops clarity of vision
–present as soon as the nose is cleared within 1 foot
of mucus c) fixates on moving objects
d) strabismus due to lack of
–ability to respond to odors can be used binocular vision
to document alertness

Infant Infant
A. Physical tasks A. Physical tasks
1. Neonate (Birth to 1 month) 2. 1 - 4 months
a. Weight:
Weight: 6 - 8 lb (2750 - 3629 g); gains a. Head growth:
growth: posterior fontanel
5 - 7 oz (142 - 198 g) weekly for first 6 closes
months b. Motor development
b. Length:
Length: 20 inches (50 cm); grows 1 1) reflexes begin to fade (e.g., Moro,
inch (2.5 cm) monthly for first 6 tonic neck)
months 2) gains head control;
control; balances
head in sitting position
3) rolls from back to side
Infant 4) begins voluntary hand-to-mouth
A. Physical tasks activity
1. Neonate (Birth to 1 month) Infant
c. Head growth A. Physical tasks
1) head circumference 33 - 35.5 cm (13 2. 1 - 4 months
- 14 inches) c. Sensory development
2) head circumference equal to or 1) begins to be able to coordinate stimuli
slightly larger than chest from various sense organs
3) increases by 1/2 inch (1.25 cm) 2) hearing: locates sounds by turning
monthly for first 6 months head and visually searching
3) vision: follows objects 180°
180°
Infant
A. Physical tasks
1. Neonate (Birth to 1 month) Infant
d. Vital signs A. Physical tasks
1) pulse: 110 - 160 and irregular; count 3. 5 - 6 months
for a full minute apically a. Weight:
Weight: birth weight doubles;
doubles; gains 3-
2) respirations: 32 - 60 and irregular; 5 oz (84-140 g) weekly for next 6
neonates are abdominal breathers,
breathers, months
obligate nose breathers b. Length:
Length: gains 1/2 inch (1.25 cm) for
3) blood pressure: 75/49 mm Hg next 6 months

Infant
A. Physical tasks Infant
1. Neonate (Birth to 1 month) A. Physical tasks
e. Motor development 3. 5 - 6 months
1) behavior is reflex controlled c. Eruption of teeth begins
2) flexed extremities 1) lower incisors first
 2) causes increased saliva and
drooling
3) enzyme released with teething
causes mild diarrhea,
diarrhea, facial skin
irritation
4) slight fever may be associated
with teething, but not a high fever
or seizures
2) may attempt to stand alone
Infant
B. Psychosocial tasks
1. Neonatal period
a. Cries to express displeasure
b. Smiles indiscriminately
c. Receives gratification through sucking
d. Makes throaty sounds

Infant Infant
A. Physical tasks B. Psychosocial tasks
3. 5 - 6 months 2. 1 - 4 months
d. Motor development a. Crying becomes differentiated at 1
1) supports weight on arms month
2) sits with support 1) decreases during awake periods
2) ceases when parent in view
Infant b. Vocalization distinct from crying at 1
A. Physical tasks month
3. 5 - 6 months 1) coos,
coos, babbles,
babbles, laughs;
laughs;
e. Sensory development vocalizes when smiling
1) hearing: can localize sounds above
and below ear Infant
2) vision: smiles at own mirror image B. Psychosocial tasks
and responds to facial expressions of 2. 1 - 4 months
others c. Socialization
3) taste: sucking needs have decreased 1) stares at parents’
parents’ faces when
and cup weaning can begin; chewing,
chewing, talking at 1 month
biting,
biting, and taste preferences begin to 2) smiles socially at 2 months
develop 3) shows excitement when happy at
Infant 4 months
A. Physical tasks 4) demands attention, enjoys social
4. 7 - 9 months interaction with people at 4
a. Teething continues months
1) 7 months: upper central incisors
2) 9 months: upper lateral incisors Infant
b. Motor development B. Psychosocial tasks
1) crawls;
crawls; may go backwards initially 3. 5 - 6 months
2) pulls self to standing position a. Vocalization: begins to imitate sounds
3) develops finger-thumb opposition b. Socialization: recognizes parents,
(pincer grasp) stranger anxiety begins to develop;
comfort habits begin
Infant
A. Physical tasks Infant
5. 10-12 months B. Psychosocial tasks
a. Weight:
Weight: birth weight tripled 4. 7 - 9 months
b. Length:
Length: 50% increase over birth a. Vocalization: verbalizes all vowels
length and most consonants
c. Head and chest circumference equal b. Socialization
d. Teething 1) shows increased stranger anxiety
1) lower lateral incisors erupt and anxiety over separation from
2) average of eight deciduous teeth parent
Infant 2) exhibits aggressiveness by biting
A. Physical tasks at times
5. 10-12 months 3) understands the word “no
“no””
e. Motor development
1) walks with help or cruises
 Infant
B. Psychosocial tasks
5. 10 - 12 months
a. Vocalization: imitates animal sounds,
can say only 4 - 5 words but
understands many more (ma, da)
b. Socialization
1) begins to explore surroundings
2) plays games such as pat-a-cake,
pat-a-cake,
peek-a-boo
3) shows emotions such as
jealousy, affection, anger, fear
(especially in new situations)
Infant
C. Cognitive tasks
1. Neonatal period:
period: reflexive behavior only
2. 1 - 4 months
a. Recognizes familiar faces
b. Is interested in surroundings
c. Discovers own body parts
Infant
C. Cognitive tasks
3. 5 - 6 months
a. Begins to imitate
b. Can find partially hidden objects
4. 7 - 9 months
a. Begins to understand object
permanence;
permanence; searches for dropped
objects
b. Reacts to adult anger; cries when
scolded
c. Imitates simple acts and noises
d. Responds to simple commands
Infant
C. Cognitive tasks
5. 10-12 months
a. Recognizes objects by name
b. Looks at and follow pictures in book
c. Shows more goal-directed actions
Infant
D. Nutrition
1. Birth to 6 months
a. Breast milk is a complete and
healthful diet; supplementation may
include 0.25 mg fluoride, 400 IU
vitamin D, and iron after 4 months.
months.
b. Commercial iron-fortified formula is
acceptable alternative;
supplementation may include 0.25 mg
fluoride if water supply is not
fluoridated.
c. Juices may be introduced at 5-6
months, diluted 1:1 and preferably
given by cup.
Infant
D. Nutrition
2. 6 - 12 months
a. Breast milk or formula continues to be
primary source of nutrition.
b. Introduction of solid foods starts with
cereal (usually rice cereal), which is
continued until 18 months.
Infant
D. Nutrition
2. 6 - 12 months
c. Introduction of other food is arbitrary;
most common sequence is fruits,
vegetables, meats.
1) introduce one new food a week.
week.
2) decrease amount of formula to
about 30 oz. as foods are added.
d. Iron supplementation can be stopped.
Infant
D. Nutrition
2. 6 - 12 months
e. Finger foods such as cheese, meat,
carrots can be started around 10
months.
months.
f. Chopped table food or junior food can
be introduced by 12 months
g. Weaning from breast or bottle to cup
should be gradual during second 6
months.
months.
Infant
E. Play (Solitary)
1. Birth to 4 months
a. Provide variety of brightly colored
objects, different sizes and textures.
b. Hang mobiles within 8-10 inches of
infant’s face.
Infant
E. Play (Solitary)
2. 5 - 7 months
a. Provide brightly colored toys to hold
and squeeze.
squeeze.
b. Allow infant to splash in bath.
c. Provide crib mirror.
3. 8 - 12 months
a. Provide toys with movable parts and
noisemakers;
noisemakers; stack toys, blocks; pots,
 pans, drums to bang on; walker and
push-pull toys.
toys.
b. Plays games: hide and seek,
seek, pat-a-
cake.
cake.
Infant
F. Fears
1. Separation from parents
a. Searches for parents with eyes.
b. Shows preference for parents.
c. Develops stranger anxiety around 6
months (peaks at 8 months).
2. Pain
Toddler (12 months to 3 years)
A. Physical tasks: this is a period of slow
growth
1. Weight:
Weight: gain of approximately 11 lb (5
kg) during this time; birth weight
quadrupled by 2 1/2 years
2. Height:
Height: grows 20.3 cm (8 inches);
3. Head circumference:
circumference: 19½ - 20 inches
(49 - 50 cm) by 2 years; anterior
fontanel closes by 18 months
Toddler (12 months to 3 years)
A. Physical tasks: this is a period of slow
growth
4. Pulse 110; respirations 26; blood
pressure 99/64
5. Primary dentition (20
(20 teeth)
teeth)
completed by 2 1/2 years
6. Develops sphincter control necessary
for bowel and bladder control
Toddler (12 months to 3 years)
B. Psychosocial tasks
1. Increases independence;
independence; better able to
tolerate separation from primary
caregiver.
2. Less likely to fear strangers.
strangers.
3. Able to help with dressing/undressing at
18 months; dresses self at 24 months.
months.
4. Has sustained attention span.
5. May have temper tantrums during this
period; should decrease by 2 1/2 years.
6. Vocabulary increases from about 10 - 20
words to over 900 words by 3 years.
Toddler (12 months to 3 years)
B. Psychosocial tasks
7. Has beginning awareness of ownership
(my, mine) at 18 months; shows proper
use of pronouns (I, me, you) by 3 years.
8. Moves from hoarding and possessiveness
at 18 months to sharing with peers by 3
years.
9. Toilet training usually completed by 3
years.
a. 18 months: bowel control
b. 2 - 3 years: daytime bladder control
c. 3 - 4 years: nighttime bladder control
Toddler (12 months to 3 years)
C. Cognitive tasks
1. Follows simple directions by 2 years.
2. Begins to use short sentences at 18
months to 2 years.
3. Can remember and repeat 3 numbers
by 3 years.
4. Knows own name by 12 months;
refers to self, gives first name by 24
months; gives full name by 3 years.
5. Able to identify geometric forms by 18
months.
Toddler (12 months to 3 years)
C. Cognitive tasks
6. Achieves object permanence;
permanence; is
aware that objects exist even if not in
view.
7. Uses “magical”
“magical” thinking;
thinking; believes own
feelings affect events (e.g., anger
causes rain).
8. Uses ritualistic behavior;
behavior; repeats skills
to master them and to decrease
anxiety.
9. May develop dependency on
“transitional object” such as blanket or
stuffed animal.
Toddler (12 months to 3 years)
D. Nutrition
1. Caloric requirement is approximately
100 calories/kg/day.
2. Increased need for calcium, iron, and
phosphorus.
3. Needs 16 - 24 oz milk/day.
4. Appetite decreases.
5. Able to feed self.
6. Negativism may interfere with eating.
7. Initial dental examination at 3 years.
Toddler (12 months to 3 years)
E. Play
1. Predominantly- “parallel
“parallel play”
play” period.
2. Provide toys appropriate for increased
locomotive skills: push toys,
toys, rocking
horse,
horse, riding toys or tricycles;
tricycles; swings and
slide.
3. Give toys to provide outlet for aggressive
feelings:
feelings: work bench, toy hammer and
nails, drums, pots, pans.
4. Provide toys to help develop fine motor
skills,
skills, problem-solving abilities: puzzles,
puzzles,
blocks;
blocks; finger paints, crayons.
crayons.
Toddler (12 months to 3 years)
G. Fears: separation anxiety
1. Learning to tolerate and master brief
periods of separation is important
developmental task.
2. Increasing understanding of object
permanence helps toddler overcome this
fear.
Toddler (12 months to 3 years)
G. Fears: separation anxiety
3. Potential patterns of response to
separation
a. Protest:
Protest: screams and cries when
mother leaves; attempts to call her
back.
b. Despair:
Despair: whimpers, clutches
transitional object, curls up in bed,
decreased activity, rocking.
c. Denial:
Denial: resumes normal activity but
does not form psychosocial
relationships; when mother returns,
child ignores her
Preschooler (3 to 5 years)
A. Physical tasks
1. Slower growth rate continues
a. Weight: increases 4 - 6 lb (1.8 - 2.7
kg) a year
b. Height: increases 2 1/2 inches (5-6.25
cm) a year
c. Birth length doubled by 4 years
2. Vital signs decrease slightly
a. Pulse: 90-100
b. Respirations: 24-25/minute
c. Blood pressure: systolic 85-
100 mm Hg
diastolic 60-90 mm Hg
Preschooler (3 to 5 years)
A. Physical tasks
3. Permanent teeth may appear late in
preschool period; first permanent teeth
are molars,
molars, behind last temporary teeth.
4. Gross motor development
a. Walks up stairs using alternate feet by
3 years.
b. Walks down stairs using alternate feet
by 4 years.
c. Rides tricycle by 3 years.
d. Stands on 1 foot by 3 years.
Preschooler (3 to 5 years)
A. Physical tasks
4. Gross motor development
e. Hops on 1 foot by 4 years.
f. Skips and hops on alternate feet by 5
years.
g. Balances on 1 foot with eyes closed
by 5 years.
h. Throws and catches ball by 5 years.
i. Jumps off 1 step by 3 years.
j. Jumps rope by 5 years.
Preschooler (3 to 5 years)
A. Physical tasks
5. Fine motor development
a. Hand dominance is established by 5
years.
b. Builds a tower of blocks by 3 years.
c. Ties shoes by 5 years.
d. Ability to draw changes over this time
1) copies circles,
circles, may add facial
features by 3 years.
2) copies a square,
square, traces a
diamond by 4 years.
Preschooler (3 to 5 years)
B. Psychosocial tasks
1. Becomes independent
a. Feeds self completely.
b. Dresses self.
c. Takes increased responsibility for
actions.
2. Aggressiveness and impatience peak at 4
years then abate.
3. Gender-specific behavior is evident by 5
years.
years.
4. Egocentricity changes to awareness of
others; rules become important;
important;
understands sharing.
Preschooler (3 to 5 years)
C. Cognitive development
1. Focuses on one idea at a time;
time; cannot
look at entire perspective.
2. Awareness of racial and sexual
differences begins.
a. Prejudice may develop based on
values of parents.
b. Manifests sexual curiosity.
curiosity.
c. Sexual education begins.
d. Beginning body awareness.
awareness.
Preschooler (3 to 5 years)
C. Cognitive development
3. Has beginning concept of causality.
4. Understanding of time develops during
this period.
a. Learns sequence of daily events.
events.
b. Is able to understand meaning of
some
time-oriented words (day of week,
month, etc.) by 5 years.
5. Has 2000-word vocabulary by 5 years.
6. Can name 4 or more colors by 5 years.
7. Is very inquisitive (why?, why? why?).
why?).
Preschooler (3 to 5 years)
D. Nutrition
1. Caloric requirement is approximately 90
calories/kg/day.
2. May demonstrate strong taste
preferences.
preferences.
3. More likely to taste new foods if child can
assist in the preparation.
Preschooler (3 to 5 years)
F. Play
1.Predominantly associative play
2. Enjoys imitative and dramatic play.
play.
a. Imitates same-sex role functions in
play.
b. Enjoys dressing up, dollhouses,
trucks, cars, telephones, doctor and
nurse kits.
3. Provide toys to help develop gross motor
skills: tricycles,
tricycles, wagons,
wagons, outdoor gym;
gym;
sandbox, wading pool.
Preschooler (3 to 5 years)
F. Play
4. Provide toys to encourage fine motor
skills,
skills, self-expression, and cognitive
development: construction sets, blocks,
carpentry tools; flash cards, illustrated
books, puzzles;
puzzles; paints,
paints, crayons,
crayons, clay,
clay,
simple sewing sets.
5. Television,
Television, when supervised, can provide
a quiet activity; some programs have
educational content.
Preschooler (3 to 5 years)
G. Fears
1. Greatest number of imagined and real
fears of childhood during this period.
2. Fears concerning body integrity are
common.
a. Magical and animistic thinking allows
children to develop many illogical
fears (fear of inanimate objects,
objects, the
dark,
dark, ghosts).
ghosts).
School-age (6 to 12 years)
A. Physical tasks
1. Slow growth continues.
a. Height: 2 inches (5 cm) per year
b. Weight: doubles over this period
c. At age 9,
9, both sexes same size;
size; age
12,
12, girls bigger than boys
2. Dentition
a. Loses first primary teeth at about 6
years.
b. By 12 years, has all permanent teeth
except final molars.
School-age (6 to 12 years)
A. Physical tasks
3. Bone growth faster than muscle and
ligament development; very limber but
susceptible to bone fractures during this
time.
4. Vision is completely mature;
mature; hand-eye
coordination develops completely.
5. Gross motor skills: predominantly
involving large muscles; children are very
energetic,
energetic, develop greater strength,
strength,
coordination, and stamina.
6. Develops smoothness and speed in fine
motor control.
School-age (6 to 12 years)
B. Psychosocial tasks
1. School occupies half of waking hours;
hours; has
cognitive and social impact.
a. Readiness includes emotional
(attention span), physical (hearing
and vision), and intellectual
components.
b. Teacher may be parent substitute,
substitute,
causing parents to lose some
authority.

School-age (6 to 12 years)
B. Psychosocial tasks
2. Morality develops
a. Before age 9 moral realism
predominates: strict superego,
superego, rule
dominance; things are black or white,
right or wrong.
wrong.
b. After age 9 autonomous morality
develops: recognizes differing points
of view, sees “gray” areas.
School-age (6 to 12 years)
B. Psychosocial tasks
3. Peer relationships
a. Child makes first real friends during
this period.
b. Is able to understand concepts of
cooperation and compromise (assist
in acquiring attitudes and values);
learns fair play vs competition.
competition.
c. Help child develop self-concept.
d. Provide feeling of belonging.
School-age (6 to 12 years)
B. Psychosocial tasks
4. Enjoys family activities.
5. Has some ability to evaluate own
strengths and weaknesses.
6. Has increased self-direction.
self-direction.
7. Is aware of own body; compares self to
others;
others; modesty develops.
School-age (6 to 12 years)
C. Cognitive development
1. Period of industry
a. Is interested in exploration and
adventure.
adventure.
b. Likes to accomplish or produce.
produce.
c. Develops confidence.
School-age (6 to 12 years)
C. Cognitive development
2. Concept of time and space develops.
a. Understands causality.
b. Masters concept of conservation:
permanence of mass and volume;
concept of reversibility.
reversibility.
c. Develops classification skills:
understands relational terms; may
collect things.
d. Masters arithmetic and reading.
School-age (6 to 12 years)
D. Nutrition
1. Caloric needs diminish in relation to body
size: 85 kcal/kg.
2. “Junk”
“Junk” food may become a problem;
excess sugar, starches, fat.
3. Obesity is a risk in this age group.
4. Nutrition education should be integrated
into school program.
School-age (6 to 12 years)
E. Play
1. Rules and ritual dominate play;
individuality not tolerated by peers;
knowing rules provides sense of
belonging; “cooperative
“cooperative play.”
play.”
2. Team play: games or sports
a. Help learn value of individual skills and
team accomplishments.
b. Help learn nature of competition.
competition.
3. Quiet games and activities: board games,
collections, books, television, painting
4. Athletic activities: swimming, hiking,
bicycling, skating
School-age (6 to 12 years)
G. Fears:
more realistic fears than younger
children; include death,
death, disease or bodily
injury,
injury, punishment;
punishment; school phobia may
develop, resulting in psychosomatic
illness.
Adolescent (12 to 19 years)
A. Physical tasks
a. Girls:
Girls: height increases approximately 3
inches/year; slows at menarche; stops
around age 16.
b. Boys:
Boys: growth spurt starts around age 13;
height increases 4 inches/year; slows in
late teens.
c. Boys double weight between 12 and 18,
related to increased muscle mass.
Adolescent (12 to 19 years)
A. Physical tasks
d. Body shape changes
1) boys become leaner with broader
chest.
2) girls have fat deposited in thighs,
hips, and breasts; pelvis broadens.
e. Apocrine glands cause increased body
odor.
odor.
f. Increased production of sebum and
plugging of sebaceous ducts causes
acne.
acne.
Adolescent (12 to 19 years)
A. Physical tasks
4. Sexual development: girls
c. Development of secondary sex
characteristics and sexual functioning
under hormonal control
d. Breast development is first sign of
puberty.
1) bud stage: areola around nipple
is protuberant.
2) breast development is complete
around the time of first menses.
Adolescent (12 to 19 years)
A. Physical tasks
5. Sexual development: boys
a. Development of secondary sex
characteristics,
characteristics, sex organs and
function under hormonal control.
b. Enlargement of testes is first sign of
sexual maturation; occurs at
approximately age 13, about 1 year
before growth spurt.
c. Scrotum and penis increase in size
until age 18.
d. Reaches reproductive maturity about
age 17, with viable sperm.
Adolescent (12 to 19 years)
A. Physical tasks
5. Sexual development: boys
e. Nocturnal emission:
emission: a physiologic
reflex to ejaculate buildup of semen;
natural and normal; occurs during
sleep (child should not be made to
feel guilty; needs to understand that
this is not enuresis).
f. Masturbation increases (also a normal
way to release semen).
g. Pubic hair continues to grow and
spread until mid 20s.
h. Facial hair;
hair; appears first on upper lip.
Adolescent (12 to 19 years)
A. Physical tasks
5. Sexual development: boys
i. Voice changes due to growth of
laryngeal, cartilage.
j. Gynecomastia:
Gynecomastia: slight hypertrophy of
breasts due to estrogen production;
will pass within months but causes
embarrassment.
Adolescent (12 to 19 years)
B. Psychosocial tasks
1. Early adolescence:
adolescence: ages 12-14 years
a. Starts with puberty.
b. Physical body changes result in an
altered self-concept.
c. Tends to compare own body to others.
d. Early and late developers have
anxiety regarding fear of rejection.
e. Fantasy life, daydreams,
daydreams, crushes are
all normal, help in role play of varying
social situations.
f. Is prone to mood swings.
swings.
g. Needs limits and consistent discipline.
Adolescent (12 to 19 years)
B. Psychosocial tasks
2. Middle adolescence:
adolescence: ages 15-16 years
a. Is separate from parents (except
financially).
b. Can identify own values.
c. Can define self (self-concept,
strengths and weaknesses).
d. Partakes in peer group; conforms to
values/fads.
e. Has increased heterosexual interest;
interest;
communicates with opposite sex; may
form “love” relationship.
Adolescent (12 to 19 years)
B. Psychosocial tasks
3. Late adolescence:
adolescence: ages, 17-19 years
a. Achieves greater independence.
independence.
b. Chooses a vocation.
vocation.
c. Participates in society.
d. Finds an identity.
e. Finds a mate.
mate.
f. Develops own morality.
g. Completes physical and emotional
maturity.
Adolescent (12 to 19 years)
C. Cognitive development
1. Develops abstract thinking abilities.
2. Is often unrealistic.
3. Is capable of scientific reasoning and
formal logic.
logic.
4. Enjoys intellectual abilities.
5. Is able to view problems
comprehensively.
 •Ig A
Adolescent (12 to 19 years)
D. Nutrition •Lactoferrin
1. Nutritional requirements peak during •Lysozyme
years of maximum growth: age 10-12 in
girls, 2 years later in boys •Leukocytes
2. Appetite increases.
increases. •Macrophages
3. Inadequate diet can retard growth and
delay sexual maturation. DISADVANTAGE
4. Food intake needs to be balanced with
energy expenditure. Prevents other from feeding the infant
5. Increased needs include calcium for Limits paternal role in feeding
skeletal growth; iron for increased muscle
mass and blood cell development; zinc Compels the mother to monitor her diet
for development of skeletal and muscle carefully
tissue and sexual maturation. Maybe difficult to a working mother
Adolescent (12 to 19 years)
F. Activities: Digest quickly  more feeding
group activities predominate (sports are
important); activities involving opposite ADEQUATE ???
sex by middle adolescence. •Wets 6 to 8 diapers a day
G. Fears
•Gaining weight
1. Threats to body image:
image: acne, obesity
2. Injury or death BOTTLE FEEDING
3. The unknown ADVANTAGE
Permits the father to feed
Child’s Response to Death
1. toddlers - may insist on seeing a Mother  medications
significant other long after that person’s
death. Fewer feedings
2. Preschoolers - See death as temporary;
temporary; Feeding  public  embarrassment
a type of sleep or separation.
DISADVANTAGE
3. School-age – See death as a period of
immobility. Cost
- Feel death is
punishment.
punishment. Greater preparation and effort
4. Adolescents - Have an accurate
understanding of death.
Hands  clean
Requires refrigeration and storage
BREAST FEEDING
ADVANTAGE No transfer of maternal antibodies
Readily available Doesn’t benefit mother physiologically
Economical
IMMUNIZATION
Promotes facial muscles, jaw and
teeth •BCG
Mother infant bonding –Infants
Reduced incidence of allergies •.05 ml
Reduced incidence of maternal •Intradermal
breast cancer •Right deltoid
Transfer of maternal antibodies –School Entrants
 •.1ml •F – ear of stranger peaks at 8 months
•Intradermal •A – llow to use a pacifier if NPO
•Left deltoid
•N – ote the weight changes
•DPT
–6, 10 and 14 weeks •T – rust V.S. mistrust
–.5ml •S – olitary play
–Intramuscular TODDLER (1 to 3yr)
–Upper outer portion of the thigh
•T – alk to the child at simple terms
IMMUNIZATION
•O – ffer choices to the child to provide
•Hepatitis some control
–6, 10, and 14 weeks •D – on’t leave alone near the bathtub or
–.5ml swimming pool
–Intramuscular •D – oubt and shame V.S. Autonomy
–Upper outer portion of the thigh •L – earns about death @ age 3
•OPV
•E – limination pattern
–6, 10 and 14 weeks
–2 drops •R – rituals and routines
–Mouth TODDLER

IMMUNIZATION •P – ush-pull toys (mobile), parallel play

(forget sharing)
•Measles
–9 months •R – rituals and routines (eyes and
consistency), regression
–.5ml
•A – utnomy VS shame and doubt,
–Subcutaneous accidents (death)
–Left outer part of the upper arm •I – nvolve parents
•Vitamin A Contraindication:
•S – eparation anxiety
–Fever
–Compromise Immune system •E – limination and explore
–Seizure disorder must be controlled COMMON ACCIDENTS
–Never give gluteal P – revent further absorption
O – ff, shower or wash off
I - dentify
INFANCY (0 to 1 yr) S - upport
•I – ron supplement (4 to 6 months), O – ngoing safety education
N – otify local poison control center
immunization
•N – o choking hazard PRESCHOOL (3 to 6 yr)
•P – lay is associative/cooperative
•R – gression is common
•E – xplain procedures
•S – ame age group for room assignment
•C - urious
•H – ighly imaginative
•O – bserve for initiative VS guilt
•O – ff limits to the kitchen (risk for
poisoning and burn)
•L – oss of body part is a common fear
PRESCHOOL
•M - utilation
•A – associate play, abandonment
•G - uilt
•I – nitiative, imaginary playmate,
imagination
•C – urious  “Y”
SCHOOL AGE ( 6 to 12 yr)
•S – ame sex stage
•C – ompetitive play
•H – eroworship
•O – bserve for industry VS inferiority
•O – ff limits to vehicles
•L – oss of control is a common fear
•E – xplain procedurse
•R – egression is common
SCHOOL AGE
•D – eath (bogeyman), honesty  funerals
and burials
•I – ndustry VS inferiority (collections)
•M – odesty (privacy)
•P – eers (own sex)
•L – oss of control  hospitalization,
encourage
decision making
•E - xplaination of procedures
ADOLESCENT (12 to 18 yr)
•P – eer group  activities, peer pressure
•A – ltered body image  don’t want to be
seen different
•I – dentity – image  college or career
•R – ole diffusion
•S – eparation from peers
SAMPLE QUESTIONS
•Two month old Kristin is brought to the
health clinic for his first immunization against
DPT. What route should the nurse use to
administer the vaccine?
•Oral
•Intramuscular
•Intradermal
•Subcutaneous
•The nurse should teach Kristin’s mother
about the normal reaction an infant can
experience approximately 12 to 24 hours
after DPT. One of these reactions could be:
•Lethargy
•Mild fever
•Diarrhea
•Nasal congestion
Mrs. Ortega brings her 4-month-old child
Paula, to the clinic. She says, “The soft
spot near the front of the Paula’s head is
still big. When will it close?” The nurse’s
response should be guided by knowledge
that most often the anterior fontanel
 closes when the infant’s age is between
about?
•2 to 4 months
•4 to 8 months
•8 to 12 months
•12 to 18 months
•Mrs. Ortigas brings her 4-month-old infant,
Timmy, to the clinic. He appears well. Mrs.
Ortigas asks the nurse when she should
wean Timmy from breast-feeding and have
him use a cup. The nurse should explain
that Timmy will show readiness to be
weaned when he is:
•Taking solid foods well
•Sleeping through the night
•Shortening his nursing time
•Eating on a regular schedule
•In counseling a teenage mother on the
first-solid food to introduce to her 5-month-
old child, least allergenic foods are given.
Which of the following should be
recommended in the usual order in
introducing solid foods?
• •8 months
•Eggs
•Pureed chicken
•Bananas
•Rice cereal
•A nurse is observing all of the following
babies in the clinic. Which baby may be
experiencing a developmental delay?
•A 1-month-old who does not coo
•A 3-month-old who does not crawl
•An 8-month-old who does not walk
•A 10-month-old who does not sit
•A first-time mother is concerned that her
6-month-old infant is not gaining enough
weight. The best response for the nurse to
make is which of the following?
•“Birth weight doubles by 6 months of age.’
•“Birth weight doubles by 3 months of age.”
•“The baby will eat what he needs.”
•“You need to make sure the baby finishes
each bottle.”
•The nurse discusses Lucy’s motor skill
development with her mother. The nurse
explains to Lucy’s mother that at about 7
months of age, Lucy will most likely to be
able to
–Walk with support
–Feed herself with a spoon
–Stand holding onto furniture
–Sit alone using her hand with support
•A mother of an infant asks the nurse when
she can expect her baby to sit up. The nurse
informs the mother that an infant can
generally sit up without support at:
•4 months
•6 months
•10 months
•A mother of a 10-month-old baby asks a
clinic nurse about appropriate and safe toys
for the baby. The nurse tells the mother that
the most appropriate toys for a 10-month-old
is which of the following?
•cradle gym
•Teddy bears
•Low rocking horses
•Blocks
•Which is the best way to deal with a
toddler who is having a temper tantrum?
–Reason with the child
–Threaten the child
 –Spank the child •Identity
–Ignore the child’s outburst •Mastery
•Initiative
•The nurse observes a group of 2-year-old
children at play in the beach. The nurse
would expect to see:
•The mother of a 10-year-old student is
•Four children playing soft ball concerned about her daughter’s compulsion
•Three children playing tag for collecting things. The nurse explains that
this behavior is related to the cognitive
•Two children playing sandbox building ability to perform:
castles side by side •Concrete operations
•One child digging a hole •Formal operations
•When assessing a 2-year-old child •Coordination of secondary schemas
brought by his mother to the clinic for a •Tertiary circular reactions
routine check-up. The nurse would expect
the child is able to do which of the following?
•Ride a tricycle
•Tie his shoelaces
•Kick a ball forward
•Use blunt scissors
•Mrs. Sara tells the nurse that her 4-year-
old son, Charles does not seem to know the
difference between right and wrong. She
explains that he knows he should not push
other children, but the only reason for not
pushing them is that he avoids trouble. Mrs.
Sara is describing typical behavior of a child
who has reached with level of moral
development as described by Kohlberg?
•Autonomous
•Conventional
•Preconventional
•Principles
•A mother brings her 5-year-old son to the
pediatrician’s office for a complete health
appraisal before he enters kindergarten next
moth. The nurse should focus part of the
assessment on the child’s achievement of
psychosocial tasks. At this age, he should
be trying to accomplish a sense of
•Autonomy