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INTRO: PROMOTING MATERNAL & CHILD HEALTH: FAMILY-CENTERED CARE

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INTRO: PROMOTING MATERNAL & CHILD HEALTH: FAMILY-CENTERED CARE

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GOAL: Promotion and maintenance of optimal family health to ensure cycles of optimal childbearing and childrearing"

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Something beautiful I have learned today is about these family cycles, wherein the influence of our parental affects a child's future self, may it be good or bad. But, the good thing about it is that we make the choice everyday in our lives whether we let ourselves adapt to a bad habit of them or not, whether it concerns our physicality, behavior, and attitude, or we end this cycle to make ourselves better from learning from their mistakes.

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What are we expected to do as maternal and childhealth nurses?

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What are we expected to do as maternal and childhealth nurses?

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1. Provide pre-conceptual health care

2. Care of women during three trimesters of pregnancy and the puerperium

3. Care of infants during the perinatal period (6 weeks before conception to 6 weeks after birth)

4. Care of children from birth through adolescence

5. Care in settings as varied as the birthing room, the pediatric intensive care unit, and the home

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1. Health Promotion

2. Health Maintenance

3. Health Restoration

4. Health Rehabilitation

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1. Declining live births

2. Increased births attended by health professionals

3. >50% born to unwed mothers

4. More babies born to adolescent mothers

5. Infant Mortality remains unchanged

6. Relatively Low Maternal mortality ratio

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"Family-centered care or Relationship-Centered Care is one of four approaches that provides an expanded view of how to work with children and families. Family-centered service is made up of a set of values, attitudes, and approaches to services for children with special needs and their families."

- wikipedia

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MODULE 1: LESSON 1: GROWTH AND DEVELOPMENT

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MODULE 1: LESSON 1: GROWTH AND DEVELOPMENT

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independent

interrelated

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Growth refers to PHYSICAL CHANGE.

Rapid (peak) - infancy, adolescence

Slows - childhood

Minimal physical growth - adult

General growth:

1. Respiratory, Digestive, Renal, Musculoskeletal, and Circulatory Tissue = proceed fairly smoothly during childhood.

2. Neurologic tissue =  grows so rapidly the first 2 years that the brain reaches mature proportions by 2 to 5 years.

3.  Lymphoid Tissue (Spleen, Thymus, Lymph Nodes and Tonsillar Tissue) = grows rapidly during infancy and childhood so children are protected against infection.

4. Reproductive Organs (genital tissue) show little growth until Puberty.

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Development refers to the increase in skill or ability to function.
Maturation is the process of aging; begins to adapt and show competence in new situations.
Behavior is the most comprehensive indicator of developmental status.

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1. Continuous processes from conception until death = at all times a child is growing new cells and learning new skills.

2. Proceed in an orderly sequence =  sequence of each stage is predictable

3. Different children pass through the predictable stages at different rates = Principle of Asynchronism means not all body parts grow at the same time/rate

4. All body systems do not develop at the same rate = certain body tissues mature more rapidly than others.

5. Development is cephalocaudal = Cephalo is a Greek word meaning “head”; caudal means “tail.”

6. Development proceeds from proximal to distal body parts = the child’s pattern of growth is in a head-to-toe direction, or cephalocaudal, and in an inward to an outward pattern called proximodistal.

7. Development proceeds from gross to refined skills = once children are able to control distal body parts such as fingers, they are able to perform fine motor skills.

8. There is an optimum time for initiation of experiences or learning = a child cannot learn to sit, for example, no matter how much the child’s parents have him or her practice until the nervous system has matured enough to allow back control.

9. Neonatal reflexes must be lost before development can proceed = an infant cannot grasp until the grasp reflex has faded & stand steadily until the walking reflex has faded.

10.  A great deal of skill and behavior is learned by practice = infants practice over and over taking the first step before they accomplish this securely.

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Factors Influencing Growth and Development

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Factors Influencing Growth and Development

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1. Genetic Inheritance = characteristics that babies inherit from the parents through the chromosomes.

2. Environmental Influences = baby comes in regular contact including the kind of care he/she receives affects the formation of the baby’s personality.

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1. Theory = a systematic statement of principles that provides a framework for explaining some phenomenon.

2. Developmental Theories = provide road maps for explaining human development

3. Developmental Tasks = skill or a growth responsibility arising at a particular time in an individual’s life

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1. Psychosexual Development – developing instincts or sensual pleasure (Freud)

2. Psychosocial Development – personality development (Erickson)

3. Moral Development – know right from wrong and apply in real-life situations (Kohlberg)

4. Cognitive Development – learn or understand from experience, to acquire and retain knowledge to respond to new situation and solve problems (Piaget)

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Paper Masters | Custom Research Papers for College Students

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Paper Masters provides custom research papers, college papers, discussion posts, powerpoints, book reviews, case studies, term papers, essays, master's thesis, proposals, capstone projects, for college students to use as a guide in writing projects on any academic topic.

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Sigmund Freud theorized that sexual feelings are present in some form from the newborn period through adulthood.

Personality is composed of three entities:
Id

the largest portion of the mind

the center of our primitive instincts and requires immediate gratification.

The neonate is the epitome of the id.

Ego

develops in infancy and is the conscious, rational part of the personality;

less inward seeking than the id

recognizes the larger picture

The ego acts as a censor to the id; if there’s a conflict between the id and the ego, neuroses may develop

Superego

represents the person’s conscience and ideals

it’s in a continuous battle with the Id

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Lawrence Kohlberg’s ideas of moral reasoning (the basis for ethical behavior) are based on the work of Piaget and the American philosopher John Dewey

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1. Rules are fixed & absolute

2. Judging actions according to individual needs

3. Conforming & being "nice"

4. Respecting authority

5. Considering individual rights

6. Ethical principles & abstract reasoning

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Weight
2x = 4-6 months
3x = 1 year

Weight Gain
1st 6 months = 2lbs/month
2nd 6 months = 1lb/month

Average
1 y/o male = 10 kg
1y/o female = 9.5 kg

Height

Increases during the 1st year by 50%

Grows from average birth length of 20 inches to about 30 inches (50.8cm to 76.2cm)

Head Circumference

Increases rapidly: reflects brain growth

End of 1st year: brain reaches 2/3 of adult size

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Cardiovascular

HR slows down to 110-120 bpm by the end of the 1st year

Respiratory

RR slows to 20-30 breaths/min

Immune System

Functional by 2 months of age

Able to produce IgG & IgM by 1 year of age

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Dentition begins at 6 months

2 Lower incisors

Milk/Decidous Teeth (20)

complete by 2-3 years

shed off by 6-7 y/o

replaced by permanent teeth (32)

Formula: AGE IN MONTHS - 6
Ex. 10 months - 6 = 4 TEETH

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Gross Motor = ability to accomplish large body movements

Fine Motor = measured by observing or testing prehensile ability (ability to coordinate hand movements)

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Ventral suspension position

The newborn allows the head to hang down with little effort or control

1 month-old child: can lift the head momentarily

3 months: can maintain lifting the head

Landau Reflex

3 months: when held at ventral suspension, infant's head, legs, & spine extend

When head is depressed: hips, knees & elbows flex

Parachute Reflex

6-9 months: When infants are suddenly lowered toward a table from ventral suspension, the arms extend as if to protect themselves from falling

Prone Position

When lying at their stomach, newborns can turn their heads to move it out of the position where breathing is impaired.

Neck Righting Reflex

4 months: when infant turns the head to the side, shoulders, trunk & pelvis turn in that same direction.

Sitting Position

1 month: when placed on his/her back & pulled to a sitting position, the child has gross head lag in the first days of life.

6 months: can sit momentarily with support

Standing Position

Stepping Reflex: In a standing position, the infant's knees & hips flex rather than support more than momentary weight.

Fades at 3 months.

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1 month-old: still have a strong grasp reflex

2 month-old: as the grasp reflex begins to fade, they will hold an object for a few minutes before dropping it.

4 month-old: begins to have thumb opposition (ability to bring thumb and fingers together)

10 months: pincer grasp = enabling the child to pick up small objects.

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Language Development
1 = Cooing (dove-like) sounds

3 = Squeals with pleasure
4 = Talkative, cooing, babbling, gurgling & able to laugh out loud
5 = simple vowels sounds: goo-goo & gah-gah
7 = can imitate simple vowel sounds: oh-oh, ah-ah & oo-oo
9 = speaks a first word: da-da or ba-ba
12 = can say 2 words besides ma-ma &da-da; use those 2 words with meaning

Play (solitary)
1 = Interested in watching mobile over crib; spends time watching parents' face
3 = can handle small blocks or rattles
5 = handles plastic rings, keys & squeeze toys
6 = enjoy teething rubber rings & bathtub toys
7 = likes objects for transferring
8 = enjoys toys with different textures
9 = needs space for creeping
10 = plays games like Peek-a-boo
11 = cruises: walks with support
12 = enjoys put-in, take-out toys

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Infant Period = 1-12 months

Children double their weight at 4-6 months and triple it at 1 year.

Infants develop their first tooth at about 6 months

by 12 months, they have 6-8 teeth

The more infants are spoken to, the easier it is for them to acquire a language.

Providing infants with proper toys for play helps development

All infant toys need to be checked to be certain they are too large to be aspirated.

Important milestones of vision development during the first year are:
3 = follows moving objects past midline; focus securely without eyes crossing

According to Erikson, the development task of an infant is Trust VS Mistrust.

Safety is important.

Infants must be protected from falls and aspiration of small objects.

A skill of an infant cannot be accomplished in one day but may be accomplished the next.

Solid food is generally introduced into an infant's diet at 4-6 months of age.

Before they can eat solid food, they must lose their Extrusion Reflex.

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Common Concerns related to infant development include:

teething

thumb-sucking

use of pacifiers

sleep problems

constipation

colic

diaper dermatitis

baby-bottle syndrome

obesity

Nurses play a key role in teaching parents about these problems & measures to deal with them.

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Speaks in two-word sentences

20 deciduous teeth present at 2.5 years

Heart rate: 90-110 bpm

"Pouchy" abdomen from weak abdominal muscles

Chest circumference becomes bigger than head circumference at 2 years

Noticeable lordosis

"Baby fat" begins to disappear

Wide-based gait

Parental Difficulties in Evaluating Illness:
Evaluating seriousness of illness

- toddlers typically answer "No" to almost all questions

Differentiating tiredness from illness

- toddlers tend to whine or sleep when they are either tired or ill.

Evaluating nutritional intake
- toddlers are normally fussy eaters compared to infants.

Age-specific diseases to be aware of
- the toddler period is an important age to assess speech development; children should be further evaluated if they cannot use simple sentences composed of a noun and verb by 2 years of age.

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15 MONTHS

Fine Motor = Puts small pellets into small bottles Scribbles voluntarily with a pencil or crayon Holds a spoon well but may still turn it upside down on the way to mouth.
Gross Motor = Walks alone well; seat self in chair; Scribbles voluntarily can creep upstairs.
Language = 4–6 words
Play = Can stack 2 blocks; enjoys being read to; drops toys for adult to recover (exploring sense of permanence)

18 MONTHS

Fine Motor = No longer rotates a spoon to bring it to mouth
Gross Motor = Can run and jump in place. Can walk up and down stairs holding onto a railing. Typically places both feet on one step before advancing
Language = 7–20 words, uses jargoning; names 1 body
part
Play = Imitates household chores, dusting; begins parallel play (playing beside not with another child)

24 MONTHS

Fine Motor = Can open doors by turning doorknobs, unscrew lids
Gross Motor = Walks up stairs alone still using both feet on same step same time
Language = 50 words, 2-word sentences (noun - pronoun and Verb)
Play = Parallel play evident

30 MONTHS

Fine Motor = Makes simple lines or strokes for crosses with a pencil
Gross Motor = Can jump down from chairs
Language Verbal = language increasing steadily. Knows full name; can name one color and holds up fingers to show age
Play = Spends time playing house, imitating parents’ actions; play is “roughhousing” or active

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Rapid brain growth, increase in bone length and muscle growth

Uses fingers to pick up small objects

Walks, runs, kicks, climb, rides tricycle, drinks from cup

Four times birth weight

Bladder control during the day, sometimes at night

Turns pages in book, and by age 3 draws stick people

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Stage 5 (between 12 and 18 months)
Tertiary Circular Reaction Stage

“a little scientist”

child experiments by trial and error methods

Stage 6 (between 18 and 24 months)

toddlers are able to try out various actions mentally rather than having to actually perform them—the beginning of problem solving or symbolic thought

Deferred Imitation = remember an action and imitate it later

Preoperational Thought

children deal much more constructively with symbols

Assimilation = change the situation (or how they perceive it) to fit their thoughts

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Freud = anal stage, toilet training is major focus

Erikson = autonomy versus shame and doubt

Havighurst = tasks of learning to control elimination process, learn sex differences, form concepts, learn language, and distinguish right from wrong

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Negativism

Ritualistic Behavior

Slowness in carrying out requests/ambivalence

Temper Tantrums

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Accidental ingestions (poisoning) are the type of accident that occurs most frequently

Potential Accidents:

Automotive accident

Burns

Falls

Poisoning drowning

Suffocation and choking

Electric shock

Animal bites

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Promoting Nutritional Health of a Toddler

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Promoting Nutritional Health of a Toddler

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Parents are unaware their toddler's appetite has decreased so food consumption will be less

teach parents to place a small amount of food on a plate and allow their child to eat it and ask for more rather than serve a large portion the child cannot finish

allowing self-feeding is a major way to strengthen independence

offering finger foods and allowing a choice between two types of food helps promote independence while exposing children to varied foods

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Promoting Toddler Development in Daily Activities

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Promoting Toddler Development in Daily Activities

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Learning how to promote autonomy yet maintain a safe, healthful environment should be a major goal for the family

Dressing
most children can put on their own socks, underpants, and undershirt

Sleep
Begin napping twice a day and sleeping 12 hours each night, and end it with one nap a day and only 8 hours' sleep at night.

Bathing
should depend on the parents' and the child's wishes and schedule

Care of Teeth
Encourage parents to offer fruit or protein foods rather than high carbohydrate items for snacks such as cookies

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learning self-reliance is the primary goal of the child during the toddler period

child still needs firm limits to feel secure

a child must be given some room to make independent decisions in areas that the parents feel they do not need to control

If parents punish children excessively at each move toward independence, children will not fight them indefinitely. Instead, they will begin to feel guilty for wanting to do things independently.

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Parental Concerns Associated with the Toddler Period 

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Parental Concerns Associated with the Toddler Period 

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Toilet Training

An individualized task for each child

should begin and be completed according to a child's ability to accomplish it, not according to a set of schedule

Three important developmental levels, one physiologic and the other two cognitive to reach:

They must have control of rectal and urethral sphincters, usually achieved at the time they walk well.

They must have cognitive understanding of what it means to hold urine and stools until they can release them at a certain place and time.

They must have a desire to delay immediate gratification for a more socially accepted action.

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Ritualistic Behavior

use only their spoon at mealtime, only their washcloth at bath time

not go outside unless mother or father locates their favorite cap

Negativism

do not want to do anything a parent wants them to do

reply to every request is a very definite "no"

Discipline

setting rules or road signs so children know what is expected of them

setting safety limits and protecting others or property

Two general rules to follow:
(a) parents need to be consistent
(b) rules are learned best if correct behavior is praised rather than wrong behavior punished.

Punishment = is a consequence that results from a breakdown in discipline, from the child's disregard of the rules that were learned.

Timeout = is a technique to help children learn that actions have consequences

Separation Anxiety

fear of being separated from parents begins at about 6 months of age and persists throughout the preschool period.

Temper Tantrums

kick, scream, stamp feet, shout "No, no, no" lie on the floor, flail arms and legs, and bang the head against the floor.

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Differentiating Temper Tantrums, Breath Holding, and Seizures

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Differentiating Temper Tantrums, Breath Holding, and Seizures

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Temper Tantrums:

Provocation = usually provoked-parent can state a reason for it (she asked toddler to come to dinner, toddler wanted to finish an activity

Appearance of Cyanosis: Child holds breath, becomes cyanotic, then slumps to floor

Breath Holding:

Provocation = Usually provoked; child very angry; child breathes out and forgets to breathe in

Appearance of Cyanosis = child breathes out, becomes cyanotic, then slumps to floor

Seizures:

Provocation = not provided

Appearance of Cyanosis = child slumps to floor first, then becomes cyanotic

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Assessment

taking a careful health history

ability to carry out activities of daily living (ADL)

Careful observation

child-parent relationship

Parents: BEST source of information

Nursing Diagnosis

focus on the parents’ eagerness to learn more about the parameters of normal growth and development or issues of safety or care

Health-seeking behaviors related to normal toddler development

Deficient knowledge related to best method of toilet training

Risk for injury related to impulsiveness of toddler

Interrupted family process related to need for close supervision of 2-year-old

Readiness for enhanced family coping related to parents’ ability to adjust to new needs of child

Readiness for enhanced parenting related to increased awareness for poison prevention

Disturbed sleep pattern related to lack of bedtime routine

Outcome Identification and Planning

focus largely on family education and anticipatory guidance

establish realistic goals and outcomes so they can meet the rapidly changing needs of their toddler and learn to cope with typical toddler behavior

Implementation

teach parents a good rule is to think of a toddler as a visitor from a foreign land who wants to participate in everything the family is doing but does not know the customs or the language

teach parents not only how to approach a current problem but also how to learn adequate methods for resolving similar situations that are sure to arise in the future

Health visits provide opportunities to help parents learn healthy coping techniques

demonstrating good communication skills with toddlers can serve as a model for healthy communication behavior with them

Outcome Evaluation

children change so much and learn so many new skills during this time that their abilities and associated parental concerns can change from day to day

Parents state child maintains a consistent bedtime routine within the next 2 weeks.

Parents state they have childproofed their home by putting a lock on kitchen cupboard by next clinic visit

Grandmother states she has modified usual activities to conserve strength to care for toddler granddaughter by 1 week’s time.

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The Critical stage of AUTONOMY vs. SHAME and DOUBT

child develops sense of independence and should be allowed to explore the environment with the encouragement of the primary caregiver

child should be taught to tolerate frustration through socialization and proper toilet training.

Things to expect:

Sphincter control begins at age 2

All deciduous teeth erupt by 2½ years

Pot-bellied appearance

Appropriate Play:

parallel play, sand, riding toys, water play, finger paints

Manage Temper Tantrums:

ignore behavior

monitor for safety

Nutrition:

Offer nutritious snacks

May experience food jags

Give 6 small meals esp. iron-rich food

Avoid giving hotdog, peanuts, and grapes

Toilet-training:

consider readiness, never punish

Hospitalization:

rooming-in, transitional object, offer choices

Consider water safety and injury prevention

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Preschool Stage

an important period of growth for parents

Setting limits

the physical growth slows considerably during this period, personality and cognitive growth continue at a rapid rate

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Increase the number of states with laws requiring helmets for bicycle riders under 15 years of age from a baseline of 10 states to 50 states

Reduce infectious diarrhea by at least 25% among children in licensed child care centers

Reduce acute middle ear infections among children age 4 and younger from a baseline of 344.7 health care visits per 1000 children to 294 visits per 1000 children.

Increase the rate of use of child auto restraints among children age 4 and younger from a baseline of 92% to 100%

Reduce the proportion of children 2 to 4 years of age who have dental caries in their primary or permanent teeth from a baseline of 18% to 11%

Reduce the rate of deaths caused by poisoning from a baseline of 6.8 per 100,000 to 1.5 per 100,000

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Vocabulary increases markedly

Tonsils appear enlarged

Pulse rate decreases to about 85 bpm

Handedness begins to be obvious

Genu Valgus (knock-knees) may be evident

Growth is only 2-3.5 inches a year

No new teeth develop

Body contour changes to be more childlike than babylike

Ectomorphic (slim)

Endomorphic (large)

Increased coordination makes bicycle, riding, running, kicking possible

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Head is close to adult size by six years old

Pulse rate decreases to about 85 beats per minute; blood pressure holds at about 100/60 mm Hg

Bladder is easily palpable above the symphysis pubis

voiding is frequent enough (9 or 10 times a day) that play must be interrupted

Motor abilities include jumping, skipping, throwing a ball, printing letters and numbers

Full set of 20 deciduous teeth

Weight gain is slight

Average child gains only about 4.5 lb (2 kg) a year

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3 YEARS OLD

Fine Motor = Undresses self; stacks tower of blocks, draws a cross
Gross Motor = Runs; alternates feet on stairs; rides tricycle; stands on one foot
Language = Vocabulary of 900 words
Play = Able to take turns; very imaginative

4 YEARS OLD

Fine Motor = Can do simple buttons
Gross Motor = Constantly in motion; jumps; skips
Language = Vocabulary of 1500 words
Play = Pretend imaginative play, creative play, make‐believe play, fantasy play

5 YEARS OLD

Fine Motor = Draws a 6-part man; can lace shoes
Gross Motor = Throws overhand
Language = Vocabulary of 2100 words
Play = Likes games with numbers or letters

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Psychosocial development
Developmental Task: Initiative Versus Guilt

If children are criticized or punished for attempts at initiative, they develop a sense of guilt for wanting to try new activities or have new experiences

need exposure to a wide variety of experiences and play materials so they can learn as much about the world as possible

ready to reach outside their homes for new experiences, such as a trip to the zoo or an amusement park

Socialization

Significant others now include grandparents, siblings, and preschool teachers (although parents remain central)

Regular interaction with same-age children is necessary to further develop social skills

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running and jumping in an open space

creative play with dress-up clothes, pretend kitchens, and dolls

art activities with paints, paper, crayons, blunt scissors, and markers

trips to the museum, park, fire station, zoo, library, and shopping mall

swimming and other individual sports and activities to encourage gross motor development

puzzles and toys to aid fine motor development and stimulate imagination

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Urge parents to provide play materials that encourage creative play, such as finger paints, soapy water to splash or blow into bubbles, mud to make into pies, sand to build castles, and modeling clay or homemade dough to mold into figures or make into pretend cookies

Imitation

need free rein to imitate the roles of the people around them

role playing should be fun and does not have to be accurate

imitate those activities best that they see their parents performing at home

Fantasy

begin to make this differentiation

become so engrossed in a fantasy role, however, they become afraid they have lost their own identity or have become “stuck” in their fantasies

both supporting the fantasy and yet reassuring a child she is still herself

let children know they are still recognizable

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Oedipus and Electra Complexes

Each child competes with the same-sex parent for the love and attention of the other parent

Parents may need help in handling feelings of jealousy and anger if a child is vocal in expressing feelings toward a parent

Gender Roles

need exposure to an adult of the opposite gender so they can become familiar with opposite gender roles

Encourage single parents to plan opportunities for their children to spend some time with adults other than themselves, such as a grandparent, a friend, or a relative of the opposite sex, for this exposure

Socialization

play with other children their age much more

sensitive and critical time for socialization

Four-year old, involving some testing and identification of their group role

Five-year-olds begin to develop “best” friendships, perhaps on the basis of who they walk to school with or who lives closest to them

Elementary Rule: an odd number of children will have difficulty playing well together pertains to children at this age: two or four will play, but three or five will quarrel

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Preschoolers:

Watch adults and imitate behavior

Imaginative= imaginary playmates

Creative and curious = WHY, HOW

Offensive language

Oedipal/electra complex

Sibling rivalry • “sex” – be honest’

Masturbation may be seen

Egocentrism increases

Play more related to real-life events (associative or cooperative)

Basic curiosity results in constant questions and improved reasoning ability

Language development more elaborate

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Cognitive Development:

3 years, cognitive development according to Piaget is still preoperational

enter a second phase called intuitional thought (intuitive thought phase)

Centering = lack the insight to view themselves as others see them or put themselves in another’s place; an important point to remember when explaining procedures to preschoolers

not yet aware of the property of conservation

Implications: not able to comprehend that a procedure done two separate ways is the same procedure

Moral and Spiritual Development:

determine right from wrong based

on their parents’ rules

have little understanding of the rationale for these rules or even whether the rules are consistent

depend on their parents to supply rules for them, thus, with difficulty seeing that the rules they know may also apply to a new situation

begin to have an elemental concept of God if they have been provided some form of religious training

Belief in an outside force aids in the development of conscience

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mortality of children during the preschool years is low

major cause of death being automobile accidents, followed by poisoning and falls

minor illnesses, such as colds, ear infections, and flu symptoms, is also high

Give reassurance that frequent minor illnesses are common in preschoolers.

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Fear of the Dark

heightened by a child’s vivid imagination

Night waking from nightmares or night terrors reaches its peak

Night light = reassurance they are safe, that whatever was chasing them was a dream and is not in their room

source of the stress needs to be investigated

Fear of Mutilation

revealed by the intense reaction of a

preschooler to even a simple injury such as falling and scraping a knee or having a needle inserted for an immunization

need good explanations of the limits of health care procedures

fear of castration

Fear of Separation or Abandonment

intensifies because their keen imagination allows them to believe they have been deserted when they are safe

Relating time and space to something a child knows, such as meals, television shows, or a friend’s house, is most effective

A hospital admission or going to a new school often brings a child’s fear of separation

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Telling Tall Tales

Caution parents not to encourage the kind of storytelling, but instead help the child separate fact from fiction

Imaginary Friends = separate fact from fantasy about their imaginary friend

Difficulty Sharing

Assure parents that sharing is a difficult concept to grasp and that, as with most skills, preschoolers need practice to understand and learn it

Defining limits and exposing children to these three categories (mine, yours, ours) helps them determine which objects belong to which category

Regression

in relation to stress, revert to behavior they previously outgrew, such as thumbsucking, negativism, loss of bladder control, and inability to separate from their parents

new baby in the family

a new school experience

seeing frightening and graphic television news

stress in the home from financial or other problems, marital difficulties

separation caused by hospitalization

removing the stress is the best way to help a child discontinue this behavior

Thumb-sucking or other manifestations of stress are best ignored

Sibling Rivalry

A firstborn child is rarely allowed the privileges of a second child. The parents were untried, unsure of how far they should let a child venture or what level of responsibility a child could accept when the child was younger, or the firstborn serves as the “trial run” for all children who come after

feel secure and promote self-esteem, by supplying them with a private drawer or box for their things that parents or other children do not touch can be helpful

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Thumbsucking

Food likes and dislikes

Enuresis = Bed-wetting

Encopresis = fecal incontinence or soiling

Bruxism or grinding the teeth at night

- (usually during sleep), is a habit of many young children

- way of “letting go”, to release tension and allow themselves to fall asleep

- identifying and relieving the source of anxiety is essential for treatment

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Assessment

obtaining a health history and performing both a physical and developmental evaluation

history that details their usual performance level is therefore very important for accurate evaluation

child’s weight and height according to standard growth charts

assess a child for general appearance

Alert? Happy? Active? Healthy

Child can play actively without becoming exhausted

Assess the teeth for presence of cavities

Evaluate for a symmetrical gait

Frequent upper respiratory infections

Nursing Diagnosis

Health-seeking behaviors related to developmental expectations

Readiness for enhanced parenting related to parent’s pride in child

Delayed growth and development related to frequent illness

Risk for poisoning related to maturational age of child

Parental anxiety related to lack of understanding of childhood development

Risk for injury related to increased independence outside the home

Imbalanced nutrition related to child's many food dislikes

Outcome Identification and Planning

establishing a schedule for discussing normal preschool development with the parents

done at all health maintenance visits

accident prevention

plan opportunities for adventurous activities or messy play

Implementation

children imitate moods as well as actions – important nursing intervention

role-playing a mood or attitude you would like a child to learn – health assessment is an enjoyable activity

suggest preschoolers participate by listening to their heart or coloring the table paper – Accident prevention is also best taught by role modeling

a parent always crosses streets at the corner and does not start the car until seatbelts are in place

Outcome Evaluation

Child states importance of holding parent’s hand while crossing streets

Parent states realistic expectations of 3-year-old’s motor ability by next visit.

Mother reports she has prepared 4-year-old for new baby by next visit

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Child Care Center = provides child care while parents are at work or are otherwise occupied
Preschool = dedicated to stimulating children’s sense of creativity and initiative and introducing them to new experiences and social contacts they would not ordinarily receive at home

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LESSON 5: CARE OF A FAMILY WITH A SCHOOL-AGE CHILD

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LESSON 5: CARE OF A FAMILY WITH A SCHOOL-AGE CHILD

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School-age or middle childhood

refers to the stage of a child’s life from ages 6 to 12 years

The school-age years can be a spectacular journey filled with joys and successes as the child continues to grow and mature

time of slow physical growth, cognitive growth and development continue to proceed at rapid rates

always assess children as individuals to understand the particular developmental needs of each child based on what developmental status has been achieved, not on what stage you think the child should have reached

Children of school age may be more influenced by the attitudes of their friends

the first time children begin to make truly independent judgments

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annual average weight gain is approximately 3 to 5 lb (1.3 to 2.2 kg); the increase in height is 1 to 2 in (2.5 to 5 cm)

posture becomes more erect

slims down and becomes more agile and graceful

10 years of age

brain growth is complete, so fine motor coordination becomes refined

adult vision level is achieved

If the eruption of permanent teeth and growth of the jaw do not correlate with final head growth

malocclusion (a deviation from the normal) with teeth malalignment

immunoglobulins IgG and IgA reach adult levels and lymphatic tissue continues to grow up until about age 9

Appendicitis

Frontal sinuses develop at about 6 years =  sinus headache

pulse rate decreases to 70 to 80 beats per minute; blood pressure rises to about 112/60 mm Hg

Maturation of the respiratory system leads to increased oxygen–carbon dioxide exchange

increases exertion ability and stamina

Scoliosis may become apparent for the first time in late childhood

over age 8 should be screened

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Girls tend to develop slightly faster than boys; although boys are, on average, taller and heavier than girls until the adolescent growth spurt

The pubertal growth spurt begins in girls at about age 10 and in boys at about age 12

Feet are the first part of the body to experience a growth spurt

= Increased foot size is followed by a rapid increase in leg length and then trunk growth
=  leg growth increases more dramatically than trunk growth in boys although girls have a greater growth spurt in hip width, boys exceed girls in other areas of bone growth

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Sexual Maturation

in girls usually occurs between 12 and 18 years; in boys, between 14 and 20 years gonadal hormone levels increase and cause the sexual organs to mature

onset of puberty varies widely, between 10 and 14 years of age

Puberty: What happens?
BOYS

12-13 years old

- height (you get taller)
- hair (hair grows on your face, arms, legs, chest, armpits, and between your legs)

11-12 years old

- Face (you may get pimples)
- androgens
- sebaceous gland
- privates (your penis and testicles get bigger)
- Sweat (your armpits sweat)

9-11 years old

Prepubertal weight gain occurs

Voice (your voice deepens)

GIRLS

11-12 years old

- Face (you may get pimples)
- Sweat (your armpits sweat)
- height (you get taller)

- hair (hair grows on your face, arms, legs, chest, armpits, and between your legs)

12-13 years old

- Menstruation (your period begins)

9-11 years old

- Breast (your breasts grow)

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Sexual and Physical Concerns

time for parents to discuss with children the physical changes that will occur and the sexual responsibility these changes dictate

time to reinforce previous teaching with children that their body is their own, to be used only in the way they choose

Concerns of Girls

Prepubertal girls are usually taller, by about 2 in (5 cm) or more than preadolescent boys

girl notices the change in her pelvic contour when she tries on a skirt or dress from the year before and realizes her hips are becoming broader

Crash diet

Girls are usually conscious of breast development and whether they are overdeveloped or underdeveloped

Breast self-examination and sexual responsibility

Supernumerary (additional) nipples may darken or increase in size at puberty

Early preparation for menstruation is important for future childbearing and for the girl’s concept of herself as a woman

good hygiene and reassurance they can bathe, shower, and swim during their periods

use either sanitary napkins or tampons

take precautions to avoid toxic shock syndrome

first menstruation, called menarche, usually starts around age 12 but can occur as early as age 9 and still be considered normal

The menstrual cycle may be irregular at first

consistent irregularities in her period should be assessed for malnourishment and obesity

Emotions

if irregularity continues beyond the first year, a careful history of the girl’s school, social, nutrition, level of exercise, and home adjustment should be taken

vaginal secretions will begin to be present

Explain that any secretions that cause vulvar irritation should be evaluated

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Concerns of Boys

aware of increasing genital size

testicular development precedes penis growth

be informed that hypertrophy of breast tissue (gynecomastia) can occur in prepuberty (most often in stocky or obese boys)

although they have pubic hair, they cannot yet grow a beard or do not have chest hair

seminal fluid is produced, boys begin to notice ejaculation during sleep, termed nocturnal emissions

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Physiological Development of School-Age Child (6 to 12 Years)

Brain reaches 90% to 95% of adult size, nervous system almost mature by age 12

Motor abilities progress to writing in script and in sentences by age 12

Sexual organs grow but are dormant until late in this period

All permanent teeth present except for 2nd and 3rd molars by age 12

The average child gains 28 teeth between 6 and 12 years of age: the central and lateral incisors; first, second, and third cuspids; and first and second molars

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Developmental Milestones of the School Age

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Developmental Milestones of the School Age

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Psychological development

Attending school marks an acceleration in the separation of the child from his parents

introduces the child to a new set of authority figures (teachers, school administrators) and strengthens the concept of peer relationships

Psychosocial development

Erikson’s stage of industry versus inferiority

child wants to work and produce, accomplishing and achieving tasks

focus on learning useful skills, self-identity emerges

if too much is expected of him, or if he feels unable to measure up to set standards, the negative attributes of inadequacy and inferiority may prevail

Language development and socialization

child has an efficient vocabulary and begins to correct previous mistakes in usage

begins to understand the double meanings of words and becomes proficient at giving others directions without using physical signals

Six-year-olds talk in full sentences, using language easily and with meaning

define objects by their use: a key is to unlock a door; a fork is to eat with

7-year-olds can tell the time in hours, but they may have trouble with concepts such as “half past” and “quarter to,” especially with the prevalence of digital clocks and watches

know the months of the year and can name the months in which holidays fall

can add and subtract and make simple change

age 9

discover “dirty” jokes

Like to tell them to friends or try to understand those told by adults

use swear words to express anger or just to show other children they are growing up

have a short period of intense fascination with “bathroom language”

12 years of age

a sense of humor is apparent

can carry on an adult conversation, although stories are limited because of their lack of experience

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First and Second Grades

peers are increasingly significant to the child

Same-sex cliques are established

competition becomes more common

bragging over accomplishments

child may be overly concerned with peer rules

more sensitive to criticism and ridicule

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Play

continues to be rough at age 6

when children discover reading as an enjoyable activity that opens doors to other worlds, they can begin to spend quiet time with books

Many children spend hours playing increasingly challenging video games, an activity that can either foster a healthy sense of competition or create isolation from others

7 years of age

decline in imaginative play

interest in collecting items such as baseball cards, dolls, rocks, or marbles

8 years of age

collections may become increasingly structured as children develop skills for sorting and cataloging

10 years of age

children become very interested in rules and fairness in competitive play situations

Children also begin discovering the Internet and how other children out there are waiting to talk to them in chat rooms

Music and artistic expression

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School and learning are viewed as an exciting experience

require concentration, attendance, and complex auditory and visual processing

major developmental tasks at this time are achievement in school and acceptance by peers

Cognitive Development of School-Age Child

In Piaget’s concrete operational stage, organizing facts and problem-solving

Uses inductive reasoning to solve new problems

Thinks logically and develops concepts of measurement

Generalizes about people, places, and things

Develops classification systems, understands reversal of events

Has an awareness of other’s feelings

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New Concepts Learned:

Decentering

- the ability to project oneself into other people’s situations and see the world from their viewpoint rather than focusing only on their own view

Accommodation

- the ability to adapt thought processes to fit what is perceived such as understanding that there can be more than one reason for other people’s actions

Conservation

- the ability to appreciate that a change in shape does not necessarily mean a change in size

Class Inclusion

- the ability to understand that objects can belong to more than one classification

These Cognitive Developments lead to some of the typical changes and characteristics of the school-age period

Decentering enables a school-age child to feel compassion for others, which was not possible in younger years

Understanding Conservation is possible, a school-age child is not fooled by perceptions as often as before; because of this, sibling arguments over food (your piece of pie is bigger than mine, his glass of cola is bigger than mine)

The ability to classify objects leads to the collecting activities of the school-age period

Class inclusion is also necessary for learning mathematics and reading, systems that categorize numbers and words

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begins to accept rules but may not necessarily understand them.

used for selective attention, occurs between ages 5 and 7

ability to reason and memorize improves, and the child tends to use mnemonic strategies to remember new information

child is ready for basic reading, writing, and arithmetic

much better understanding of cause and effect

Adult reassurance of the child’s competence and basic self-worth is essential

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Emotional Development

ability to trust others and with a sense of respect for their own worth

can accomplish small tasks independently because they have gained a sense of autonomy

have practiced or mimicked adult roles and had the opportunity to explore at preschool or other social environments

should have learned to share, to have discovered that learning is fun and an adventure

Moral and spiritual development
Kohlberg’s Conventional Level

child behaves according to socially acceptable norms because an authority figure tells him to do so

This obedience is compelled by the threat of punishment (external factors)

Ages 11 to 12

as the child begins to approach adolescence, school and parental authority is questioned and, occasionally, even challenged or opposed

importance of the peer group intensifies, and rough, bold, or even brazen behavior becomes increasingly common

peer group becomes the source of behavior standards and models

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Parental guidance, love, and support are absolutely essential for the development of values during this time

child at this age needs the opportunity to make decisions within defined boundaries

those boundaries are set by responsible adults in the child’s life

Spiritual lessons should be taught in concrete terms during this stage

Repeated religious rituals, such as praying and attending church services, may comfort them

begin to learn about the rituals and meaning behind their religious practices, so the distinction between right and wrong becomes more important

Parent role modeling is also important

school-age children are rule-oriented; when they pray, they may expect their God to follow rules also (if you are good and pray for something, you should receive it)

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Keys to health
Being Healthy, remember PEDS

Proper nutrition

Exercise

Dental hygiene

Sleep

Proper Nutrition

encouraged to eat a variety of healthy foods, such as lean meats, fruits, vegetables, and grains, to ensure proper nutritional intake

Encouraging healthy eating habits now (during school age and ideally, before) will lay a stable foundation for adolescence, when caloric needs increase

Childhood obesity is increasing, and measures should be taken to avoid high-fat, high-sugar, low-protein foods

Encouraging proper nutrition

stock the pantry and refrigerator with healthy choices for afterschool snacks (raw vegetables, low-fat yogurts, fresh fruits)

avoid taking children to fast-food establishments where high-fat foods are abundant

teach children how to read nutrition labels while shopping at the grocery store

involve children in planning and preparing meals for the family

offer candy and other sweets as an infrequent privilege rather than a reward for good behavior

change their own eating habits to model good dietary habits for their children

Exercise and activity

Encouraged

to help the child begin healthy habits for a lifetime

prevent childhood obesity

sport teams or sporting events

same-sex events, making them less intimidating

Dental hygiene

Teeth should be brushed at least twice a day and, if possible, after meals

Drinking water should contain fluoride or fluoride supplements should be given

Flossing should be taught, and parents should monitor for method and compliance until the child is 8 years old

Regular dental cleanings should be scheduled every 6 months

Sleep and rest

Requirements for sleep and rest are unique and relate to the child’s activity level and physical health

generally don’t require an afternoon nap, and compliance at bedtime becomes easier

Children should develop healthy sleep habits by not having a television in their bedrooms

Sleepwalking and sleep talking may begin during this stage, and parents should take measures to ensure the child’s physical safety during these episodes.

Nightmares are usually related to a real event in the child’s life and can usually be eradicated by resolving any underlying fears the child might have

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Coping with concerns

School Phobias

called school refusal or school avoidance

may be a sign of a separation anxiety

occur after a particular trauma, such as the death of a pet, illness within the family, or a move to a new school

fear of the school itself and what the child experiences there

Possible reasons for school phobias include:

= being the target of a bully
= anxiety about academic achievement
= having problems adapting to the school structure

Stealing

simply wants items for himself

Stealing at the end of middle childhood is commonly a sign that something is lacking in that child’s life

Possible causes include a lack of:

= financial means
= attention from a parent or caregiver
= sense of property rights

Parents should recognize the child’s property rights and offer some privacy in this regard, when possible

A child who knows that his own property is respected is more likely to understand the importance of respecting the property of others

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Assessment

history and physical examination to assess growth and development

school activities and progress

Interview children 10 years or older at least in part without their parents present

Nursing Diagnosis

Health-seeking behaviors related to normal schoolage growth and development

Readiness for enhanced parenting related to improved family living conditions

Anxiety related to slow growth pattern of child

Risk for injury related to deficient parental knowledge about safety precautions for a school-age child

Imbalanced nutrition, more than body requirements, related to frequent consumption of snack foods

Delayed growth and development related to speech, motor, psychosocial, or cognitive concerns

Outcome Identification and Planning

children tend to enjoy small or short term projects rather than long, involved ones

Behavior problems need to be well defined before outcomes are identified and interventions planned

Implementation

more comfortable if they know the “hows” and “whys” of actions

May not cooperate with a procedure until they are given a satisfactory explanation of why it must be done

watch you to see your attitude as well as your actions in a given situation

Outcome Evaluation

parents to look back on problems identified at the last visit and discuss if and how they were resolved

Parent states he allows child to make own decisions about how to spend allowance

Child lists books she and her parents have read together in past 2 weeks

Child states he understands his growth is normal, even though he is the shortest boy in his eighth-grade class

Child does not sustain injury from sports activities during the summer recess

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LESSON 6: CARE OF FAMILY WITH ADOLESCENT

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LESSON 6: CARE OF FAMILY WITH ADOLESCENT

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• the period between 13 and 18 or 20 years

• time that serves as a transition between childhood and young adulthood

• defined not so much by chronologic age but by physiologic, psychological, and sociologic changes

• divided into:

• early period (13 to 14 years)

• middle period (15 to 16 years)

• late period (17 to 20 years)

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Assessment

• obtain a health history separately from parents to promote independence and responsibility for self-care

• be aware they may be very self conscious with physical exam

Nursing Diagnosis

• health-seeking behaviors related to normal growth and development

• low self-esteem related to facial acne

• anxiety related to concerns about normal growth and development

• risk for injury related to peer pressure to

use alcohol and drugs

• readiness for enhanced parenting related to increased knowledge of teenage years

Outcome identification and planning

• respect the fact they have a strong desire to exert independence or do things their own way

• including them in planning is essential so the plan will be agreeable and accepted

• establishing a contract

• are very present-oriented

• teaching by peers

Implementation

• evaluate how an intervention appears from an adolescent’s standpoint before beginning teaching

Outcome Evaluation

• client states she is able to feel good about herself even

though she is the shortest girl in her class

• client states he has not consumed alcohol in 2 weeks

• parents state they feel more confident about their ability to parent an adolescent.

• client states she feels high self-esteem despite persistent facial acne

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Growth and development of an adolescent

• grow both rapidly and mature dramatically

• recognizing that adolescents may have differing responsibilities and life experiences based on cultural expectations can be useful when making an assessment

• include factors such as occupational hazards or the effects of job, family, and financial stress on an adolescent

• readiness for early childbearing may also be important

PHYSICAL GROWTH

Apocrine sweat glands

heart and lungs increase in size more slowly than the rest of the body

PR:70 beats per minute RR: 20 breaths per minute BP: 120/70 mm Hg

Major milestone: Onset of puberty at 9 to 12 years of age and the cessation of body growth at 16-20 years of age

Ages 11 and 14 years

Girls: begins to menstruate

Boys: begins to produce spermatozoa

puberty is the time at which an individual first becomes capable of sexual reproduction

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Primary & Secondary Sex Characteristics 

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Primary & Secondary Sex Characteristics 

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Play or Recreation
Urge parents to encourage youngsters to play sports for their own health and well-being and the companionship involved

Work with others, accept responsibility and spend money wisely
15-old children may spend a great deal of time in their room

EMOTIONAL DEVELOPMENT
Developmental Task: Identity Versus Role Confusion

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HEALTH PROMOTION FOR AN ADOLESCENT AND FAMILY

Promoting adolescent safety

accidents, most commonly those involving motor vehicles, are the leading cause of death

• motorcycles, motorbikes, and motor scooters

• every safety precaution available when in a motor vehicle

• drivers and riders should wear safety helmets to prevent head injury

• long pants to prevent leg burns from exhaust pipes

• full body covering to prevent abrasions in case of an accident.
• advise adolescents who choose these forms of transportation to be as familiar with safety rules as automobile drivers

• they need to wait to drive motorcycles or scooters until they are emotionally mature enough to use sound driving judgment

• drowning is another chief accident

• teaching all children to swim is not the only preventive measure, because some drownings occur when good swimmers go beyond their capabilities on dares or in hopes of impressing friends

• teaching water safety, such as not swimming alone or when tired

• homicide and suicide, related to the easy accessibility of guns to teenagers

• gang violence and the desire to protect themselves

• accidental gunshot injuries

• athletic injuries because of the vigorous level of competition

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RECOMMENDED DIETARY REFERENCE INTAKES

Increased number of calories

• necessary carbohydrates, vitamins, protein, and minerals are essential

• large amounts of iron are necessary

• females require a high iron intake

• increased calcium plus physical exercise is necessary for rapid skeletal growth as well as to “stockpile” calcium to prevent osteoporosis later in life

• zinc is necessary for sexual maturation and final body growth

• good sources of iron are meat and green vegetables; calcium is abundant in milk and milk products; meat and milk are also high in zinc

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HYPERTENSION

POOR POSTURE

BODY PIERCING AND TATTOOS

FATIGUE

ACNE

OBESITY

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CONCERNS REGARDING SEXUALITY AND SEXUAL ACTIVITY

STALKING

HAZING

CONCERNS REGARDING SUBSTANCE ABUSE

REFERS TO THE USE OF CHEMICALS TO IMPROVE A MENTAL STATE OR INDUCE EUPHORIA

CONCERNS REGARDING DEPRESSION AND ATTEMPTED SUICIDE

SUICIDE

CONCERNS REGARDING RUNAWAYS

RUNAWAY

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LESSON 7: FAMILY WITH AN MIDDLE-AGED & OLDER ADULT

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LESSON 7: FAMILY WITH AN MIDDLE-AGED & OLDER ADULT

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Adulthood is often divided into three phases:

young adulthood = young adults are defined as people 20 to 40 years old

middle adulthood = middle-aged adults as 40 to 65 years old

late adulthood

Adult Age Span includes three very different generations:

Baby Boomers (born in years 1945–1964)

Generation X (birth years 1965–1978)

Generation Y or the Millennials (birth years 1979–2000)

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Physical Development

Human body is at its most efficient functioning at about age 25 years

musculoskeletal system is well developed and coordinated

period when athletic endeavors reach their peak. All other systems of the body (e.g., cardiovascular, visual, auditory, and reproductive) are also functioning at peak efficiency

physical changes are minimal during this stage, weight and muscle mass may change as a result of diet and exercise.

extensive physical and psychosocial changes occur in pregnant and lactating women

Psychosocial Development

psychosocial development of the young adult is great

basic developmental task is establishing intimacy or very close friendship

Occupational choice and education are largely inseparable

sense of intimacy versus isolation

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Cognitive Development

Young adults are able to use formal operations, characterized by the ability to think abstractly and employ logic

For example, young adults are able to generate hypotheses about what will happen, given a set of circumstances and do not have to engage in trial-and-error behavior

Moral Development

Young adults who have mastered the previous stages of Kohlberg’s theory of moral development enter the postconventional level

At this time, the person is able to separate self from the expectations and rules of others and to define morality in terms of personal principles

When individuals perceive a conflict with society’s rules or laws, they judge according to their own principles

Spiritual Development

According to Fowler (1981), the individual enters the individuating reflective period sometime after 18 years of age

the individual focuses on reality

The religious teaching that the young adult had as a child may now be accepted or redefined