Growth and Develiopment Dr Daphne Miranda PEDIATRIC NURSING HEALTH ASSESSMENT considerations ns •General consideratio 1. Child - maintain eye contact, bend to child’s level - Use appropriate language - Allow child some warm up time - Respect child’s response, need for privacy - Incorporate play 2. Family Considerations - encourage parents participation - choose quiet environment for teaching and assessment - ask open ended questions - Focus on information needed or problem - Listen attentively, respect response, provide feedback - encourage questions Health History
•Biographical data •Chief complaint •Current or health status •Past health •Review of systems •Family history •Nutritional history •Psychosocial history – home and family structure, school and work, activity and discipline assessment, sexual and substance abuse assessment of adolescents Age related interview techniques Infant: speak softly, allow infant to identify you w/ a parent, use touch Toddler: allow toddler to stay close to parent, focus on favorite toy or unique characteristics of child Preschooler: use simple questions and words, allow child to manipulate equipment, use puppets and play School age: offer explanations, teach about health, provide demonstrations Adolescents: maintain confidentiality, facilitate trust, open and honest communication, nonjudgmental Physical Assessment - Complete less threatening and less intrusive procedure first to secure child’s trust Explain actions, what child should expect and let child manipulate equipment Developmental Approaches a. Infant: allow infant to sit on parent’s lap, encourage parents to hold infant, use distraction, enlist parent’s help b. Toddler : Toddler : allow toddler to sit on parent’s lap, enlist parent’s assistance, use play, praise cooperation c. Preschooler : Preschooler : use storytelling, doll, and puppet d. School age: maintain privacy, explain procedure and teach child about body e. Adolescent: provide privacy and confidentiality, provide options Head to toe assessment a. Measurements - height and weight, head circumference < 2 yo b. General Appearance – alertness, LOC, physical appearance, nutritional state, hygiene, behavior, interaction w/ parent and nurse, overall development c. Skin Skin – – color, texture, turgor turgor,, temperature, lesions, scars, edema, tatoos d. Hair – – distribution, characteristics, lice e. Nails Nails – – texture, shape, color, condition f. Lymph nodes – swelling. Mobility Mobility,, temperature, tenderness g. Head – size, shape, symmetry, fontanelles h. Eyes Eyes – – visual acuity i. Ears – hearing acuity j. Nose and sinuses – discharge, tenderness k. Mouth – tooth eruption, condition of hums, lips, teeth, palates, tonsils, tongue, buccal mucosa l. Neck – suppleness and range of motion m. Chest Chest – – shape, breasts, discharge, lesions n. Lungs – breath sounds o. Heart Heart – – sounds, murmurs, rubs
p. Abdomen – umbilicus, sape, bowel sounds, hernias, liver, spleen, kidneys, masses/tenderne masses/tenderness ss q. Genitalia female – stage of sexual devt, vulva, meatus, ext genitalia, discharge, lesions male – sexual devt stage, penis, scrotum, testes, urinary meatus, discharge, lesions r. Anus Anus – – fissures, bleeding s. Musculoskeletal Musculoskeletal – – muscle size, strength, posture, body alignment, symmetry, symmetry, ROM, gait, joint mvmt, swelling, redness, tenderness t. Neurologic Neurologic – – cerebral function, cranial nerve function, DTR’s, balance and coordination DEFINITION Growth - size, cm, kg Development - skill - complexity of function IMPORTANCE OF KNOWLEDGE OF GROWTH AND DEVELOPMENT 1. Health promotion and Illness prevention 2. Health restoration and maintenance STAGES OF GROWTH and DEVELOPMENT A. 1st Prenatal – conception – birth B. 2nd Neonate - birth - 28 days Infant - 1 month - 1 yo C. 3rd Toddler - 1 - 3 yo 1-6 yo (early childhood) Preschool - 3 - 6 yo D. 4th School age - 6 - 12 yo (middle childhood) Adolescence - 13 - 18 yo PRINCIPLES OF GROWTH and DEVELOPMENT 1. Continuous 2. Orderly and sequential 3. Highly individualiz individualized ed 4. Different rates 5.Cephalocaudal 6. Proximodistal 7. Simple to complex 8. Sensitive periods 9. Practice FACTORS THAT THAT AFFECT GROWTH and DEVELOPMENT I. Genetics a. Gender b. Health c. Intelligence d. Temperament Types of temperament Easy children – even tempered, regular and predictable; react to stimuli positively Difficult children – irritable, highly active and intense; react w/ negative withdrawal Slow to warm up – moody, inactive and moderately irregular; react w/ mild but passive resistance Nursing Management
•Understand variations •Provide parents information •Provide health education esp for families of children w/ illness
•Assess development FACTORS THAT INFLUENCE GROWTH AND DEVELOPMENT II. Environment a. Socioeconomic level b. Parent-Child Relationship c. Ordinal position in the family d. Health THEORIES OF GROWTH AND DEVELOPMENT Developmental task
- skill or growth responsibility arising at a particular time in an individual’s life - foundation of accomplishment of future tasks Erickson’s Theory of Psychosocial Development Trust vs Mistrust -infant T: safe environment; dependable people M: suspicious, fearful, shun emotional involvement NI: provide primary caregiver and visual stimulation Autonomy vs Shame and Doubt – toddler A: build on new motor and mental abilities, take pride in accomplishments S: doubt and stop trying NI: provide opportunities for decision making and give praises Initiative vs Guilt – preschool I: how to do things G: limited brainstorming and problem-solving skills NI: provide opportunities for exploration, answer questions and do not inhibit fantasy Industry vs Inferiority - school age Ind: how to do things well Inf: always worried about poor or incorrect performance NI: provide opportunities for completing short projects, give praise and rewards Identity vs Role Confusion – adolescent I: integrate image into a whole R: unsure of who they are or who they can become, may rebel NI: provide opportunities to discuss feelings and support and praise for decision-makin decision-making g
Stage 2 - 4-7 yo “mother says it’s wrong” individualism/egocentrism Conventional (Level II) Stage 3 – 7-10 yo “nice girl, nice boy” Stage 4 – 10-12 yo following rules is satisfying “Law and Order” Postconventional Postconvention al (level III) Stage 5 & 6 - >12 following standards for everyone’s good “Social Contract” “Principled conscience” Harry Sullivan Prototaxic mode – infancy – need for bodily contact and love; anxiety d/t unmet needs Parataxic mode – 2-5 yo - parents viewed as source of praise and acceptance Syntaxic mode – 5-8 yo - logical, rational and most mature type of cognitive functioning; need for peers and how to deal w/ them DEVELOPMENTAL AGE PERIODS Characteristics Growth and Development Milestones Reaction to Illness INFANCY – 0-1 yo
Freud’s Psychoanalytic Theory Oral – infant - oral stimulation for nutrition, enjoyment and release of tension NI: provide oral stimulation – pacifiers, breastfeeding, thumbsucking Anal - toddler - elimination is a way of discovery and exerting independence NI: achieve bowel and bladder control even if hospitalized Phallic – preschool - increased knowledge of 2 sexes NI: accept sexual interest and answer questions about birth or sexual difference Latent - school age - libido diverted to school NI: achieve positive experiences to promote self esteem Genital - Adolescent - establish sexual aims and finding new love objects NI: opportunities to relate w/ opposite sex; verbalizatio verbalization n about new feelings
•4-6 mos -2x birthweight - 1ST 6 mos – 2 lb/mo; 2 nd - 6 mos – 1 lb/mo 1 yo - 3x birthweight HC=CC 6-12 mos 50% inc in height; - 1st 6 mos – trunk; 1 in - 2nd 6 mos – legs
•2/3 brain growth •HR 100-120 bpm •RR 20-30 12-18 mos - Ant fontanel fontanel 2 mos - Post fontanel - Immune system · 4 mos - Liquids to solids · 6 mos - Shivering - Tooth eruption · ECF 35%, ICF 40% ·
•Health visits – 2 weeks, 2 mos, 4 m os, 6 mos, 12 mos
Piaget’s Theory of Cognitive development Sensorimotor 1 mon-24 mo - relate through senses, separate from environment, practical intelligence Preoperational Thought 2-7 yo toddler: symbolic thought, simple abstractions, literal thinking, poor concept of time and distance, transductive reasoning pre-schooler: centering, egocentric, no reversibility, no cause and effect, assimilation, role fantasy Concrete Operational Thought 7-12 yo - systematic reasoning - memory to learn broad concepts and subgroups - seriation and classification - reversibility - inductive reasoning reasoning (specific to general) general) - conservation (7 yo – numbers; 7-8 yo quantity; 9 yo – weight; 11 yo – volume) Formal Operational Thought 12 yo - solve hypothetical problems, causality, time - talk time to sort attitudes and opinions
Kohlberg’s Kohlberg’ s Theory of Moral Development Preconventional (Level I) Stage 1 - 2-3 yo “mother or father says so” punishment obedience orientation
GROWTH AND DEVELOPMENTAL MILESTONES GROSS MOTOR 2 mos - 45 deg head ctrl 3 mos - 90 deg head ctrl 4 mos - lifts head & chest on prone - rolls over 5 mos - 6 mos - good head ctrl - sits w/ support 8 mos - sits w/o support 9 mos - pulls self to stand - creeps 10-11 mos – cruises 12 mos – stands alone; walks with someone’s hands FINE MOTOR 1 mo - eyes to midline 3 mos – eyes past midline 4 mos –bring hands together 5 mos – grasps/reach grasps/reaches es obj 6 mos – holds obj in 2 hands 7 mos - hand to hand transfer 9-10 mos - pincer grasp - points at obj 11 mos - bangs objects together 12 mos - throws toys - attempts 2 tower blocks LANGUAGE
1 mo - throaty gurgling sound 2 mos - differentiate a cry 3 mos - squeals 4 mos - coos and gurgles - moves head to sound 5 mos - simple vowel sounds 7-8 mos - “ma” when crying 9 mos - mama, dada; understands understands no-no 10 mos - understands gestures - responds to name 12 mos - obeys commands - one word other than mama, dada PERSONAL SOCIAL 2 mos - social smile 4 mos - plays with rattle; enjoys social interaction 7 mos - feeds self w/ crackers - recognizes familiar faces 8 mos - peek-a-boo - stranger anxiety 9 mos – waves bye bye 10 mos – nursery games 11 mos – holds arm arm or foot out in dressing 12 mos – attempts to use spoon; shows jealousy and affection PLAY – solitary play 1-3 mos
•Balloon mobiles •Mirror play •Stuffed animals •rattles •Being held 4-6 mos
•Squeeze toys •Busy boxes •Play gyms 7-9 mos
•Block play •Splashing bath toys •Cloth textured toys •Large balls 10-12 mos
•Picture books •Large blocks •Nesting cups PLAY
•Peek-a-boo •Rocking •Singing games •Squeaky toys •Pat-a-cake •Peek-a-boo •Feet & toes games •Fingers & hand games •Listening to stories •Making faces NUTRITION Lipase – dec until 1 yr Amylase – dec until 3 mos Immature liver – inefficient storage and formation of nutrients Extrusion reflex – until 4 mos Calories: 100-115 kcal/kg/day 0-3 mos - breastmilk 4-6 mos - semi-solid food Introduce one at a time Start with small quantities Cereals, strained vegetables, meat 7-9 mos - Finger food, fluids 10-12 mos – 3 meals w/ snacks
Water – 125-150 ml/k/day from 0-6 mos - 135 ml/kg/day from 6-12 mos DAILY CARE - bathing - diaper care - care of teeth - dressing - sleep – 10-12 hrs/day; hrs/day; 1 or more naps by 12 mos old - exercise Concerns - Constipation - Teething – cleanliness - thumb sucking – until school age - pacifiers – wean after 3 mos - head banging – begin 2 nd half of infancy to preschool, naptime, under 15 min - sleep problems – breastfed infants wake up sooner; - spitting up - diaper dermatitis - miliaria/prickly heat – papular papular,, erythematous on neck, ear, face, trunk - baby bottle syndrome - Loose stools – breastfed - Colic – paroxysmal abdominal pain, < 3 mos, inc in formula fed - Obesity – 32 oz formula daily, add fiber and water to diet - Stranger anxiety REACTION TO ILLNESS Discomfort and pain Lack of stimulation Separation anxiety Disruption of routine NURSING CARE Soothing stimulation Toys from home Human contact Provide/Anticipate Provide/Anticipat e needs TODDLER – 1 –3 yo TODDLER – holding on, letting go
•Slowed growth •Wt gain 5-6 lbs (2.5 kg) •BW quadruples 2.5 yo •5 in (12 cm) •Baby fat disappears •brain 90 % adult size •CC > HC; inc by 2 cm •HR 90 bpm •BP 99/64 TODDLER
•Protruberant abdomen •bowlegged •Stomach capacity increases •Control of urinary and anal sphincters •IgG and IgM •20 deciduous teeth GROWTH AND DEVELOPMENTAL MILESTONES Gross
•15 mos – walks alone well •18 mos – run and jump in place - walk up & down stairs holding on to railing - seat self in chair
•24 mos – walks up & down stairs one step at a time •2 ½ yo – tiptoes, jumps balls, rides rides tricycles tricycles •3 yo - throws balls, - stands on 1 foot momentarily Fine motor blocks, scribbles •15 mos - 2 tower blocks, •18 mos – 3-4 tower blocks
•24 mos – vertical stroke •30 months – 8 tower blocks LANGUAGE
•15 mos - vocalizes wants - jargon - 3 words other than dada, mama
•18 mos - uses phrases •2 yo - short sentences; 2-3 words; 300 words - pronouns - points to one body part
•2 ½ - full name •3 yo - speaks fluently using longer sentences - tells stories - plurals PERSONAL/SOCIAL
•15 mos - pats pictures - imitates housework
•18 mos - turns page 2-3 at a time - uses spoon
•2 yo - removes garments - toilet trained by day (2-3 yrs old)
•3 yo - dry by night (3-4 yrs old) - washes and dries hands NUTRITION
•Decrease in appetite/ Physiologic anorexia •picky eaters, food jags •Milk – 1L/day •1, 300 kcal/day •Single food instead of mixtures •Allow self feeding •Allow choice between 2 types of food •Offer finger food •Risk of aspiration PLAY - parallel play - imitation
•Babbling and talking •Ball games •Clay •Listening to music •Listening to stories •Large blocks Making music and noise
•Push and Pull toys •Puppet play •Scribbling •Stack-and-dump toys DAILY CARE - dressing – can put on socks, underpants, undershirt - sleep – 8-12 hours sleep w/ 1 nap - bathing - care of teeth CONCERNS
•Toilet Training bowel control – 18 mos daytime bladder ctrl – 2-3 yo nighttime bladder ctrl – 3-4 yo CONDITIONS: 1. control of sphincters 2. cognitive understandin understanding g 3. delay immediate gratification 4. mature nervous system * Should not be initiated during times of stress Negativism Temper Tantrums – “extinction”
Accidents Rituals Egocentrism Fears: loss of parents, loud noises, going to sleep, large animals Sibling rivalry Discipline -consistent, planned, private, initiated after behavior Separation anxiety – 18 mos Transitional Transitio nal objects REACTION TO ILLNESS and NURSING INTERVENTIONS fear of separation - Assure of parents return phases: protest, despair, detachment Defense mech: Regressive behaviors - reassurance Nutrition – allow finger food Dressing changes – allow to pull off tape Medication – allow choices of “chaser” after oral medication Hygiene – allow choice of bathtime toy, allow to put toothpaste Pain – allow to express pain Stimulation Elimination – continue potty training Rest – allow choice of toy at bedtime PRE SCHOOL 3-5 yo PRE SCHOOL Future body build apparent Increased skeletal growth Handedness 5 yo - may have permanent teeth Tonsils inc in size IgG and IgA increases PRE SCHOOL HR 85 bpm BP 100/60 3 - 5 kg/yr 2 - 3.5 in/yr Frequent voiding
GROWTH AND DEVELOPMENTAL MILESTONES Gross 3 1/2 yo - stands on 1 foot 5 sec - upstairs on 1 foot/step; down 2 feet /step 4 – 4 ½ - climbs stairs - hops on 1 foot, skip - catch ball 5 yo – heel to toe walk - skips Alternate foot and runs - throw and catch a ball, jump rope, balance on alternate feet FINE MOTOR 3 yo – copies circle, imitates cross 4 –4 1/2 - draws man w/ 3 parts - copies square, trace diamond - lace shoes 5 yo - copies triangle and diamond - writes alphabet, first name LANGUAGE 3 ½ yo - knows sex - counts to 3 or more - 900 words 4 yo - exaggerates and boasts - 1, 500 words - why questions 5 yo- talks constantly - 2, 100 words PERSONAL/SOCIAL 3 ½ yo - dresses w/ supervision - separates more easily from mother 4 yo – buttons up 4 ½ - dresses w/o supervision 5 yo – uses a knife, spoon fork; focus on social aspects of eating NUTRITION Slow/Steady growth Decreased appetite Reject vegetables, mixed dishes, liver Offer small servings Discourage “grazing” – eating small amounts of non
nutritious food Healthy snack food PLAY – associative play
•Dress up clothes •Housekeeping toys •Dolls and other toys for pretending •Bikes and climbing toys •Paper and crayons •simple crafts •Large blocks DAILY CARE accidents – bicycle safety safety,, seat belts dressing – choose own clothes sleep – 11-1 11-13 3 h per day; resist taking naps exercise – very active bathing – can wash and dry hands; need supervision care of teeth – independent brushing; 1 st dental visit CONCERNS - imitation - Oedipus and electra complex - gender roles – need exposure to parents of opposite sex - Socialization – capable of sharing - Discipline – “time out” - Common fears – dark, mutilation/castration, separation, separation, animals, ghosts - Telling tales - Imaginary friends - sharing – define limits and teach property rights - Regression –reaction to stress - Sibling rivalry - sex education - pre-school center - broken fluency - swearing - High energy level - Curiosity REACTIONS/CONCERNS IN ILLNESS AND NURSING INTERVENTIONS - nutrition – food in animal/alphab animal/alphabet et shapes - dressing change – allow allow to measure, cut tape, tape, see see incision site - medication – allow to choose “chaser” - hygiene – allow allow choice choice of of toys, toys, wash hands and face - pain – allow allow pain expression, handle syringe, analgesic - stimulation School Age 7 – 11 yo SCHOOL AGE
•3-5 lb/yr •1-2 in /yr •10 yo – brain growth complete •Adult vision •Abundant tonsillar and adenoid tissue •“innocent” heart murmurs •HR 70 bpm •BP 112/60 •28 permanent teeth •Pubertal onset SECONDARY SEX CHARACTERISTICS Female breast devt
•St 1 (prepubertal) •St 2 – breast buds •St 3 – further enlargement of breasts and areola; no separation of contours
•St 4 – breast mound •St 5 – adult configuration Male genitalia devt
•St 1 – prepubertal
•St 2 – enlargement of testes and scrotum; rugae, reddening of scrotum lengthening of penis •St 3 – further enlargement, lengthening •St 4 – increase length and width of penis, devt of glans, darkening of scrotum
•St 5 – adult configuration GROWTH AND DEVELOPMENTAL MILESTONES 6 yo – skip, jump, tumble, hop, ride bicycle, walk a straight line; first molars 7 yo – central incisors; sexual differences differences seen in play; quiet play 8 yo – improved coordination; playing w/ gang important; eyes fully developed GROWTH AND DEVELOPMENTAL MILESTONES 8 yo – script writing 9 yo – all activities done w/ gang - hero worship; adult articulation; 10 yo – more improved coordination - well mannered w/ adults 11 yo – active but awkward - mixed sex activities 12 yo – coordination improves - joins organization organizations s PERSONAL/SOCIAL/PLAY Competitive play and recreational activities Hobbies and personal interests
•Arts and crafts •Biking •Board games •Clubs •Collecting items •Chess •Comic Books – ability to read one of most significant skills NUTRITION Good appetite May go on food jags Food w/ high nutritional value - more calories and nutrients - hungry after school – give snacks and make mealtimes enjoyable DAILY CARE dressing – influenced by peers sleep – 8-12 hrs; no naps exercise – games, bike riding, walking hygiene – 8 yo – capable of bathing alone care of teeth – 2x yearly visit to the dentist; brush daily * 6 yo – eruption of permanent teeth safety – bicycle, school bus safety, prevention of falls and sports injuries CONCERNS problems w/ articulation – disappears 9 yo Sex education Stealing – 7 yo – importance of money Violence/terrorism Violence/terro rism – education;reas education;reassurance surance School anxiety and phobia, bullying, intimidating teachers, something bad happening to parents Recreatio nal drug and alcohol use Obesity nocturnal enuresis and encopresis (stool leakage; boys > girls) REACTION TO ILLNESS AND NURSING INTERVENTIONS
•Cause of illness – external forces; aware of significance of different illnesses
•Defense mech: reaction formation -
Death and disability disability,, immobilization - Still need comfort Unknown events & procedures - Allow to help w/ care & treatment Loss of ctrl & independence - Give choices Loss of contact w/ peers - Allow visits Disrupti on of of school - Talk about interests concerns over modesty
-nutrition – allow choices -
dressing – ask opinions on bulk of dressing and where to apply tape medicine – teach name and action, allow to choose form if possible
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body injury injury,, pain pain – allow expression expression of pain, pain, explain source and cause stimulation ADOLESCENT 13-18 yo ADOLESCENT
•Girls taller than boys 2-8 in, 15-55 lbs •Growth stops 16-17 yo •Boys grow 4-12 in and gain 15-65 lbs •Growth stops 18-20 yo •Heart and lung size increase more slowly •HR 70 bpm •RR 20 breaths/min •BP 120/70 ADOLESCENT
•Androgen inc sebaceous gland activity resulting in acne •Apocrine glands inc activity •13 yo – 2 molars •PUBERTY – capable of sexual reproduction characteristics s •Secondary sexual characteristic nd
GROWTH AND DEVELOPMENTAL MILESTONES 13 yo – sports 15 yo - enjoys privacy - stays in room 16 yo - part time job - charitable causes NUTRITION faddish diet give responsibili responsibility ty for food planning increased calories, Ca, protein DAILY CARE dressing and hygiene care of teeth sleep – need more sleep exercise – daily CONCERNS Socialization – falling in love Obesity; Diseases – HPN Acne Body piercing Fatigue - emotional fatigue Menstrual irregularities Sexuality and sexual activity Poor posture Stalking – educate girls Substance abuse Suicide runaways discipline – firm, limit setting REACTION TO ILLNESS AND NURSING INTERVENTION Defense mech: Denial and displacement Main issue – body image – educate educate and Allow participation in tx decisions; compassionate understanding understanding Fears loss of control and independence - Respect privacy and confidentiality Fears injury and pain - P rovide opportunities opportunities for self expression Separation from peers and lack of emotional support Approach w/ caring and understanding, age compatible roommate, Phone at bedside Nutrition – food preferences Dressing – final appearance of dressing, and time for changing Medicine – choice for injection site, teach name and action Rest – time and length of rest periods Hygiene – respect modesty modesty,, extent of self care Pain – allow pain expression, ask for analgesics stimulation
