exam 1 -part 2

preschool aged nutrition

The preschool child requires a well-balanced diet with fat content between 20-30% of calories consumed. 

Adequate physical activity and provision of a nutrient-dense diet (rather than foods high in fat and sugar) are the foundation for obesity prevention 

Preschoolers are erratic eaters and will eat very well one day and then may eat very little the next day. Food jags are not common in the preschooler but are common in the toddler. 

small portions on smaller sized plates and bowls with 

appropriately sized utensils 

Encourage child to serve self 

Allow child to decide when to stop eating (don’t force food) 

Snacks should be high quality (lean proteins, whole grain, fruits, veggies, dairy) 

Family mealtimes allow parents to model appropriate behaviors at meals and facilitate communication 

preschool ages nutrition - levels

500 to 800 mg calcium 

10 mg iron 

19 mg fiber 

Saturated fats less than 10% 

Diet high in nutrient-rich foods 

Limited amounts of poor-, high-calorie foods (fruit juices) 

Regular meals with healthy snacks in between 

preschool aged mental processes

Cognitive development moves form an egocentric approach to the world toward a more empathetic understanding of what happened outside of the self 

preschool aged mental processes - magical thinking

normal part of preschool development. In magical thinking, the preschooler believes that his or her thoughts are all-powerful. The fantasy experienced through magical thinking allows the preschooler to make room in his or her world for the actual or the real. Through make-believe and magical thinking, preschool-age children satisfy their curiosity about differences in the world around them.

preschooler - animism

The preschooler also attributes life-like qualities to inanimate objects (_animism_) gives further examples illustrating this developmental stage

preschooler - imaginary friends

The imaginary friend is not real and exists only in the child’s imagination. This friend serves as a creative way for the preschooler to sample different activities and behaviors and practice conversational skills. Despite this imagination, the preschooler is able to switch easily between fantasy and reality throughout the day. 

preschooler - night terrors

Due to the active imagination of a preschooler nightmares and night terrors may begin during this time

preschooler aged anticipatory guidance for parents

structure, appropriate limit setting, and consistency are the keys for effective discipline during this time, time out is an effective strategy  

Masturbation may occur as the preschooler discovers his or her body. If not excessive, it is considered a normal stage 

Help teach how to dress themselves 

Provide swimming lessons, BUT this does NOT reduce need for supervision

preschooler aged developmental stages - Erikson

Initiative vs. Guilt 

Preschoolers enjoy: Exploring, Imagining, Trying new activities 

They like to: Help, make choices, Be independent 

Positive encouragement develops initiative. 

Excessive criticism may cause guilt 

preschooler aged developmental stages - Piaget’s

Preoperational Stage 

Thinking is: Egocentric (sees world from own perspective) Magical/fantasy-based 

Limited understanding of cause and effect 

Uses symbols and imagination in play 

Improved language and memory skills 

preschooler aged developmental stages - Freud’s

Phallic Stage 

Increased awareness of body differences 

May become curious about genitals 

Identification with same-sex parent develops 

preschooler aged developmental stages - Kohlberg

Preconventional Level 

Behavior guided by: 

• Rewards 

• Punishment 

• Understands “good” and “bad” based on consequences 

preschool physical development

Motor Skill Development
Age  3 years	Gross Motor	Fine Motor
	Climbs well	Undresses self
	Pedals tricycle	Copies circle
	Climbs stairs with alternate feet	Builds a tower of nine blocks
	Bends over with falling	Screws/unscrews lids, nuts, bolts
5 years	Stands on one foot ≥10 sec	Dresses/undresses self
	Swings and climbs well	Prints some letters
	May skip	Feeds self well with utensils

preschool language development

Vocabulary rapidly increases 

Speaks in full sentences 

Asks many “why” questions 

Can tell simple stories 

The vocabulary of a preschooler increases to about 2100 words and the child speaks in full sentences with appropriate use of tense and prepositions. 

school ages motor skills

Fine motor: hand usage improves, eye-hand coordination and balance improve, can write, print words, sew, or build models. Takes pride in activities requiring dexterity and fine motor skills, such as playing musical instruments. 

With the development of gross motor skills and involvement in sports at school and in the community, safety education practices are required. Also, with participation in cooperative sports, injuries occur.

school aged anticipatory guidance

Nurses should inform child about expected changes in their body to promote self esteem and confidence  

Children learn the natural and logical consequences of discipline. 

Parents should teach children rules established by the family, values, and social rules of conduct. 

Discipline should be consistent, applied fairly, and focus on the development of the child. 

Positive acknowledgement of positive behaviors is more likely to encourage those positive behaviors and promote development. 

12 hours of sleep is required 

adolescent anticipatory guidance

Sports and physical fitness 

Learning and participation in school activities 

Safety issues 

Proper nutrition and healthy eating habits 

Healthy sleep hygiene and adequate rest 

Personal care 

Healthy sexual life 

Appropriate discipline 

Mental health resources 

Discuss alcohol, tobacco, drugs, peer pressure 

Discuss driving 

Choose words carefully so that message and intent are clear 

Clearly express expectations and set limits 

adolescents - Erikson

psychosocial: stages: identity vs. role confusion or diffusion → characteristics: focus is on body changes; importance of peer culture becomes primary. 

child life specialist roles

To minimize stress experienced by the children and families, pediatric nurses, child life specialists CLS’s), and other health care professionals recommend the use of atraumatic care.

CLS’s are specially trained individuals that are a part of the multidisciplinary team and works with health care providers and parent to create an atmosphere that promotes child’s wellbeing.

The goals of the CLS is to decrease the child’s anxiety and fear while improving and encouraging the child’s understanding and cooperation.

communication techniques

Basics of communicating with children 

Introduce yourself to child and explain your role 

Position yourself at the child’s level. Never just tower over them (this is intimidating)  

Smile and make eye contact if culturally appropriate 

Direct questions and explanations to the child 

Observe for nonverbal cues 

Allow the child to remain with the parents 

oral care of children

teach children & adolescents appropriate tooth brushing & flossing techniques 

Encourage use of fluoride-containing toothpastes 

Encourage routine dental visits 

Optimal oral health is not limited to the prevention & tx of dental caries 

It includes anticipatory guidance about nonnutritive sucking habits, injury prevention, oral cancer prevention, & tongue & lip piercing 

risk assessment screening types

risk assessment is performed by the physician or provider which includes subjective and objective data to see the likely hood of the child 

universal screening → an entire population is screened.  

selective screening is done when a risk assessment identifies risk factors. 

lead poisoning is a problem that affects children mostly younger than 6 years of age the most due to their play habits. They crawl on the ground and put things in their mouth.  

screening tests are procedures or laboratory analysis used to identify children with a certain condition (have high false positive, need follow up) 

characteristics of immunity

active → acquired when a person’s own immune system generates the immune response. It last for many years or a lifetime

passive → when immunoglobulins of one person are transferred to another (breast feeding, placenta) only last weeks or months

obtaining immunization history

When obtaining an immunization history from the parent, ask, “when and where did your child receive his (or her) last immunization?” The answer will provide more information than simply asking, “Are your child’s immunizations up to date?” The nurse can compare this information with that on the immunization record, discover in what settings the child is getting health care, and use the information as a starting point in a discussion of any reactions to previous immunizations. 

blood lead

Lead poisoning is a problem that affects children mostly younger than 6 years of age the most due to their play habits. They crawl on the ground and put things in their mouths.  

Elevated blood lead levels (5 μg/dL or higher) remain a preventable environmental health threat 

• Symptoms: headaches, stomach pain, inattentiveness, irritability, hyperactivity, decreased bone & muscle growth, poor muscle coordination, problems with language and speech, cognitive impairments, hearing problems, & seizures

pediatric assessment - health history

The health history in children includes more than just the chief complaint, history of present illness, and past medical history, it is important to include the perinatal history and developmental milestones

Safety measures are included in the functional history section of the health history.

The parents’ employment status and occupation are important as they may affect the parents’ ability to spend time with the child, as well as determine financial status.

The functional history should include nutrition, physical activity, screen habits, sleep behavior, elimination patters, relationships, adaptive devices and sexual practices

Perform a 3 generation family health history. Asking about the age and health status of the mother, father, siblings, and other family members helps to identify trends and specific health issues that can indicate the need for additional health screening

pediatric assessments - reviewed of systems

inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing.

Constitutional symptoms (i.e. fever, weight loss, vital signs)

pediatric assessment - physical assessment

The sequence of the physical examination in children should be based on the child’s developmental age, level of cooperation, and severity of illness, obtain heart rate and respiratory while an infant or young child is quiet, perform intrusive procedures such as examination of ears, mouth, and throat last in the infant or young child

The nurse should inspect the infant’s throat during a yawn or cry.

Do exam for school age or adolescent head to toe reserving genitalia and anus for last

The assessment of pain in children is considered to be the “fifth vital sign.” use age appropriate measurement tools to assess pain in children

The FLACC pain scale should be used to measure pain in children who are too young to verbally or conceptually quantify their pain, or when there is a language barrier.

pediatric assessment - temp.

Temperature can be tympanic, temporal, oral, axillary, and rectal and for children should be taken in the least invasive method that is accepted by the child, parent, physician, or nurse practitioner. Tympanic can be used in children over 3 but is highly dependent on the user’s technique. Temporal (forehead) can be used for any child over 90 days old except for a child who is ill with a fever

Rectal temperature measurement should be avoided in the neonate and the immunosuppressed child.

Oral for cooperative children over 5 keeping in mind oral intake, oxygen, and nebulized meds may affect it, axillary can be used for children who are uncooperative, neurologically impaired, immunosuppressed, or have injuries or surgery to the oral cavity

Rectal is usually unnecessary but keep in mind to insert no more than 1 inch (2.5cm)

pediatric assessment - vital signs

Heart rate:

• infant 80-150

• toddler 70-120

• preschooler 65-110

• school-age 60-100

• adolescent 55-95 

Respiratory rate:

• infant 22-55

• toddler 20-30

• preschooler 20-25

• school-age 14-22

• adolescent 12-18 

BP: children 3 and up 

pediatric assessment - fontanelle

In the infant, always palpate the anterior fontanel to determine size, shape, and whether flat or distended.

Fontanels should be soft and flat, report a bulging fontanel immediately, depressed fontanel can be a sign of dehydration, bulging can be increased intracranial pressure. large fontanels can indicate down syndrome or congenital hypothyroidism, a fontanel that gets larger over time can indicate the development of hydrocephalus especially if they also have an acceleration in head circumference growth.  Palpate the skull for asymmetry, overriding or open sutures or deformities. Palpate the jaw joints and palpate lymph nodes looking for size, mobility and consistency

common hospital admissions

Diseases of the respiratory system, such as asthma and pneumonia accounts for the majority of hospitalizations in children under 5.  

Older children: respiratory diseases, mental health problems, injuries, & gastrointestinal disorders 

Adolescents: Problems related to pregnancy, childbearing, mental health, & injury 

reactions to hospitalizations

Hospitalization creates a series of traumatic and stressful events in a climate of uncertainty 

Children can experience separation anxiety which is distress related to removal from family and familiar surroundings.  

Children have different ways to cope:

• magical thinking is a type of thinking in preschool-age children that allows for fantasies and creativity to be part of their cognitive abilities 

• regression is a defense mechanism used by children to deal with conflict by returning to a previous stage that may be more comfortable for them. 

invasive procedures such as a venipuncture should never be performed in the crib, bed, or playroom.

strategies to reduce fear in common hospital situations 

EX. Darkness, such as going to MRI or radiology or at night – keep light in the exam room, use a night light in child’s room, allow child to hole care giver’s hand or toy if possible. 

Teaching guidelines  

• read stories to prep kids 

• talk about going to hospital and what it will be like 

• be honest and encourage feedback 

• visit and tour hospital  

• bring special items from home 

• include sibling in prep 

use of restraints

The nurse should use a clove hitch type of knot to secure restraints with ties to allow quick, easy access and release of the restraint. 

Emphasize the restraints are to maintain the child’s safety and that it is not a punishment

rules of a school nurse

Nurses develop health plans for children in the school setting called Individual health plans. They plan support for the child with complex health needs, such as asthmatics, serious allergies, diabetes, physical disabilities, ADD/ADHD, seizure disorders.   

caring for a special needs child

The Maternal Child Health Bureau defines children with special health care needs as “those who have or are at risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services…” 

Many parents experience grief as a result of losing the perfect child of which they dreamed.  

Vulnerable child syndrome refers to a clinical state in which parental reactions to a serious illness or event in the child’s past continue to have long-term psychologically harmful effect on the child and parents for many years. 

When familied become exhausted become with home care of their child with special needs, respite care resources may be able to provide relief.  

Horseback riding for the child who is handicapped is also called hippotherapy 

palliative and hospice care

When a child is receiving palliative care, the focus is on symptom relief rather than curative care. 

Nurse management of the dying child. 

Focus on the family as a unit of care 

communication with families during death of a child

Be attuned to the entire family's needs and emotions in order to foster a holistic connection with the child & family 

Listen to the child & family; be still & silent for a time to accomplish this. Foster respect for the whole child by attending to him or her as such. 

Acknowledge that parents have diverse needs for information & participation in decision making. Allow & encourage family customs or rituals in relation to death and dying.  

Each child & family is individual; discuss their particular fears & anxieties in order to determine the child's & family's needs for education & support 

Organ donation 

A child that dies unexpectedly is a candidate for organ donation. 

Organ donation should be a separate conversation than discussing the impending death. 

All expenses are paid by the receiving family. The child will still be able to have an open casket if desired. The family’s culture and values will be honored.  

infant

Birth to 12 months

play → solitary

gross motor → cephalocaudal

fine motor → proximodistal

milestone → movement; roll, sit, stand

cognitive → trust vs. mistrust

language → 1-2 words

common concept → object permanence

discipline → none

HR → 80-150

RR → 22-55

toddler

1–3 years

play → parallel

gross motor → walking

fine motor → using a spoon

milestone → potty training

cognitive → object permanence

language → 10-50 words, telegraphic speech

common concept → separation/stranger anxiety continues

discipline → timeout

HR → 70-120

RR → 20-30

preschooler

3–5 years

play → co-operative

gross motor → climbing/skipping

fine motor → write letters

milestone → care for themselves

cognitive → kind/generous

language → 200 - 2000 words

common concept → magical thinking

discipline → time out

HR → 60-110

RR → 20-25

school aged

6 - 12 years

play → co-operative

gross motor → riding a bike well

fine motor → writing sentences

milestone → reading/telling time

cognitive → concrete operational

language → reading efficiently, complex words

common concept → loosing teeth, doubles weight

discipline → time out. grounding, taking away privileges

HR → 60-100

RR → 14-26

teen

13 - 18 years

play → team/grown

gross motor → adult-like, riding motor bikes, running races

fine motor → writing paragraphs, papers

milestone → driving

cognitive →formal operational

language → adult language slang

common concept → “it won’t happen to me”

discipline → take away privileges

HR → 55 - 95

RR → 12 - 20

psychosocial development - preschool aged (3-5)

Erikson’s Initiative vs. Guilt

They:

• love exploring and learning

• feel proud when successful

• develop confidence when encouraged

• may feel guilty if criticized or unable to succeed

Goal:
Help preschoolers build confidence and independence through encouragement and praise.

cognitive development - preschoolers

Preschoolers are in Piaget’s:

Preoperational Stage

They:

• think imaginatively

• are egocentric

• enjoy pretend play

• use magical thinking

• may have imaginary friends

• do not think logically yet

• may not understand death is permanent

moral and spiritual development - preschoolers

the develop

• conscience (inner voice, feeling bad after doing something wrong)

• understanding of right vs. wrong

• morals

• spirituality/faith

during ages about 3–6 years.

Kohlberg’s theory:

preconventional morals → preschooler decides good or abd based on punishment, rewards, adult approval. children obey adults because they have authority

infant - trust vs. mistrust

“Can I trust the world?”

toddler - autonomy vs. shame/doubt

“Can I do things myself?”

pre-school - initiative vs. guilt

“Is it okay to try new things?”

school age - industry vs. inferiority

“Can I succeed?”

adolescent - Identity vs. Role Confusion

“Who am I?”

trying to figure out

• beliefs

• values

• career goals

• relationships

• future identity

DTap vaccine

1st dose at 2 months

2nd dose at 4 months

3rd dose at 6 months

4th dose at 15 - 18 months

5th dose at 4 - 6 years

recommended ages for catch up immunization → 9 months, 12 months, 19 - 23 months, 2 - 3 years

dose → 0.5 mL

route → IM

injections sites and needle sizes