Normal Pediatric Nursing

• Growth and Development

• The Consumers of Pediatric Care
– Neonate
– Infant
– Toddler
– Pre-schooler
– Schooler
– Adolescents
• Outline of Review
Normal Pediatric Nursing: Framework
• Nursing Process Approach
– Age-Group: Generalities
– Assessment: Normal Growth and Development, Head-to-toe assessment
– Diagnosis: Common Problems
– Implementation of nursing measures to address common problems
– Summary of the Age-group
– GENERAL PRINCIPLES

Definition of Terms
A. Growth: increase in size of a structure. Human growth is orderly and predictable, but
not even; it follows a cyclical pattern.

B. Development: maturation of physiologic and psychosocial systems to more complex

state.

C. Cephalocaudal: head-to-toe progression of growth and development

– Development proceeds from head down to the toes
– Infants achieve control of the head before the trunk
–
D. Proximodistal: trunk-to-periphery (fingers and toes) progression of growth and
development
– Development proceeds from the midline of the body to the extremities
• General principles
• Growth and development are continuous processes from conception until death.
• Growth and development proceed in an orderly sequence.
• Different children pass through the predictable stage at different rates.
• All body systems do not develop at the same rate
• Development is cephalocaudal
• General principles
• Development proceeds from proximal to distal body parts.
• Development proceeds from gross to refined skills.
• There is an optimum time for initiation of experiences or learning.
• Neonatal reflexes must be lost before development can proceed.
• A great deal of skill and behavior is learned by practice.
• Rates of Development
A. Fetal period and infancy: the head and neurologic tissue grow faster than other
tissues.
B. Infancy and adolescence: fast growth periods
C. Toddler through school-age: slow growth periods
D. Toddler and preschool periods: the trunk grows more rapidly than other tissue.
E. The limbs grow most during school-age period.
F. The trunk grows faster than other tissue during adolescence.
 Stages of growth and development
1. Pre-natal period
2. Neonate- birth to TWENTY-EIGHT days
3. Infancy- One month to 12 months
4. Toddler- 1 year to 3 years
5. Pre-school- 3 years to 6 years
6. School-aged- 6 years to 12 years
7. Adolescence- 12 years to 18 years
 The Personality Development
1. Psychosexual theory- Psychoanalytical theory
2. Psychosocial theory
3. Cognitive theory
4. Interpersonal theory
5. Moral development theory
• Psychosexual/Psychoanalytical
 Five Stages of psychosexual development
1. Oral
2. Anal
3. Phallic or Oedipal
4. Latency
5. Genital
• Psychosexual/Psychoanalytical
• Freud proposes that the underlying motivation to human development is an energy
form or life instinct called LIBIDO.
• Proposed concepts like: ID, EGO, SUPER EGO
• Child’s interests become focused on a particular body site.

ID
– developed during infancy
– "I know what I want and I want it now!”
– Pleasure principle
EGO
– developed during toddler period
– "I can wait for what I want!"
– Reality principle
– balances the id and superego
SUPEREGO
– developed during preschool period
– "I should not want that!”
– Conscience- Morality principle
• Psychosexual/Psychoanalytical
• Psychosexual/Psychoanalytical
• Psychosexual model (Freud)

1. Oral
a. 0-12 months
b. Pleasure and gratification through mouth
c. Behaviors: dependency, eating, crying
d. Distinguishes between self and mother
e. Develops body image, aggressive drives - biting
• Psychosexual model (Freud)
2. Anal
a. 1 year - 3 years
b. Pleasure through elimination or retention of feces
c. Behaviors: control of holding on or letting go
d. Develops concept of power, punishment, ambivalence, concern with cleanliness or being
dirty
• Psychosexual model (Freud)

3. Phallic/Oedipal
a. 3 - 6 years
b. Pleasure through genitals
c. Behaviors: touching of genitals, erotic attachment to parent of opposite sex
d. Develops fear of punishment by parent of same sex, guilt, sexual identity
*castration anxiety – boy
*penis envy – feeling of inferiority and jealousy (Girl)
• Oedipus complex – refers to the strong emotional attachment of a preschool boy
for his mother.
• Electra complex – is the attachment of a preschool girl for her father.
• Psychosexual model (Freud)
4. Latency
a. 6 - 12 years
b. Energy used to gain new skills in social relationships ( club or gang )and knowledge
c. 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: becomes independent of parents, responsible for self (fads, involving clothing,
hair & music)
d. Develops sexual identity, ability to love and work
• Erikson’s Psychosocial theory
• Trust versus mistrust
• Autonomy versus shame and doubt
• Initiative versus guilt
• Industry versus inferiority
• Identity versus role confusion
• Intimacy versus isolation
• Generativity versus stagnation
• Ego integrity versus despair
• Erikson’s Psychosocial theory
• Psychosocial Model (Erikson)
1. Trust vs mistrust
a. 0 - 18 months
b. Learn to trust others and self vs withdrawal, estrangement
Infant hungry  feed  comfortable
*learn to trust that when he or she has a need or in distress a person will come to meet
that need.
Inconsistent, inadequate > mistrust >fearful & suspicious
• Psychosocial Model (Erikson)
2. Autonomy vs shame and doubt
a. 18 months - 3 years
b. Learn self-control and the degree to which one has control over the environment vs
compliance or defiance (to oppose or resist)
- Ability to do as one pleases e.g. Opening a candy
- “No” – stage in which child must show that he is an individual in his own right.
- If children are never allowed to do things they want to do – doubt their abilities
• Psychosocial Model (Erikson)
3. Initiative vs guilt
a. 3 - 5 years
b. Learn to influence environment, evaluate own behavior vs fear of doing wrong, lack of
self-confidence, overrestricting action
*child learns how to do things (basic problem solving) and doing things is desirable.
Freedom to initiate motor play, exposed to play materials – initiative is reinforced
If children are made to feel that their play is silly, bad and stupid – Guilt feeling
• Psychosocial Model (Erikson)
4. Industry vs inferiority
a. 6 - 12 years
b. Creative; develop sense of competency vs sense of inadequacy
- Children industriously apply themselves to learning the skills that the society requires
of them.
- Period of inferiority – because the price of failing socially or scholastically is so high
• Psychosocial Model (Erikson)
5. Identity vs role confusion
a. 12 - 20 years
b. Develop sense of self; preparation, planning for adult roles vs doubts relating to sexual
identity, occupational career
“Who am I?” stage
• Psychosocial Model (Erikson)
6. Intimacy vs isolation
a. 18 - 25 years
b. Develop intimate relationship with another; commitment to career vs avoidance of
choices in relationships, work, or life-style
• Psychosocial Model (Erikson)
7. Generativity vs stagnation
a. 21 - 45 years
b. Productive; use of energies to guide next generation vs lack of interests, concern with
own needs
8. Integrity vs despair
a. 45 years to end of life
b. Relationships extended, belief that own life has been worthwhile vs lack of meaning of
one’s life, fear of death
• Piaget
• Sensori-motor (birth to 2 )
• Pre-operational (2-7)
– Preoperational preconceptual (2-4)
– Preoperational intuitive (4-7)
• Concrete operational (7-12)
• Formal operational (12 to adulthood)
• Cognitive Theory (Piaget)
A. 0 - 2 years: sensorimotor
-reflexes, repetition of acts
B. 2 - 4 years: preoperational/preconceptual
-no cause and effect reasoning; egocentrism; use of symbols; magical thinking
C. 4 - 7 years: intuitive/preoperational
-beginning of causation
• Cognitive Theory (Piaget)
D. 7 – 12 years: concrete operations
- uses memory to learn
- aware of reversibility
E. 12 - 15 years: formal operations
-reality, abstract thought
-can deal with the past, present and future
• Interpersonal theory
• This concept focuses on interaction between an individual and his environment
• Personality is shaped through “interaction” with significant others
• We internalize approval or disapproval from our parents
• Interpersonal theory

Personality has three SELF-SYSTEM

1. “Good Me” develops in response to behaviors receiving approval by parents/SO
2. “Bad Me” develops in response to behaviors receiving disapproval by parents/SO
3. “Not Me” develops in response to behaviors generating extreme anxiety in parents/SO
and this is denied as part of oneself
• Interpersonal Model (Sullivan)
1. Infancy
a. 0 - 18 months
b. Others (Caregivers) 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
• KOHLBERG’S STAGES OF
MORAL DEVELOPMENT
• Moral Theory
Pre-Conventional
Stage 1
Stage 2
Conventional
Stage 3
Stage 4
POST Conventional
Stage 5
Stage 6
 PRECONVENTIONAL LEVEL
 Stage 1 - Age Group: 2-3 years
• Description of morality:
– Punishment or obedience (heteronomous morality)
– A child does the right things because a parent tells him or her to avoid
punishment
– Child is UNABLE to understand other’s viewpoint
 Stage 2 - Age Group : 4-7 years
• Description of morality:
– Individualism- Hedonism
– 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- “an eye for an eye’

CONVENTIONAL LEVEL level 2

 Stage 3 - Age Group : 7-10 years
• Description of morality:
– Orientation to interpersonal relations of mutuality- CONFORMITY
– A child follows rules because of a need to be a good person in own eyes and
in the eyes of others
– “Good boy or Good girl”
• CONVENTIONAL LEVEL level 2
 Stage 4 - Age Group : 10-12 years
• Description of morality:
– Maintenance of social order, fixed rules and authority
– Child FOLLOWS RULES of authority figures as well as parents to keep the
system working
– LAW and ORDER
POSTCONVENTIONAL LEVEL level 3
 Stage 5 - Age Group : 12 and above
• Description:
– social contract, utilitarian law making perspective
– child FOLLOWS STANDARDS OF SOCIETY for the good of all people
• POSTCONVENTIONAL LEVEL level 3
 Stage 6 - Age :older than 12
• Descriptions:
– universal ethical principle orientation
– Respect and dignity of humanity
• Spiritual Development- Fowler
• Death Concepts (Kozier)
• Child’s Response to Death

1. Infants and toddlers - toddlers may insist on seeing a significant other long after that
person’s death.
2. Preschoolers - may see death as temporary; a type of sleep or separation.
3. School-age – See death as a period of immobility.
- Feel death is punishment.
4. Adolescents - Have an accurate understanding of death.
• Immediate Newborn Care
1. Establish and maintain a patent airway
– Never stimulate to cry unless secretions have been drained out.
– Head lower than the rest of the body (except in increased ICP)
– Suction secretions properly