Growth and developement toddlers, preschool, and school age

what is a toddler

1-3 years of age. Fine and gross motor skills being developed: tolileting, feeding, grooming, dressing, autonomy, individuality, activities of daily living, motor skills, language development

Physical growth of toddler

• Average weight gain = 3 to 5 lb per year

• Length/height increases steadily in spurts (slower rate than infant)

  • Average increase 3 inches per year

  • About ½ adult height by age 2

• Head size more proportional to body by age 3

Physiologic Changes #1 for toddlers

• Anterior fontanel closes by 18 months

• Brain = 90% adult size by age 2

• Increased myelination = improved coordination, balance, and sphincter control/ toileting

• Head circumference measured till 3 years old

• Respiratory system

  • Alveoli continue to increase in number 

  • Trachea and airways remain small compared to adult

  • Tonsils and adenoids are relatively large: increase risk for infection= possible airway occlusion

• Cardiovascular system

  • Heart rate decreases

  • Blood pressure increases

  • Norm depends child age

Physiologic Changes #2 for toddlers

• Gastrointestinal system

  • Stomach increases in size

  • Small intestine grows in length

  • Less frequent stools—color varies with diet

  • Bowel control typically achieved by end of toddler period

• Genitourinary system

  • Bladder and kidney reach adult function by 16 to 24 months

  • Bladder capacity increases

  • Urethra remains relatively short which increases risk for UTIs

• Musculoskeletal system

  • Muscles maturing 

  • Swayback and pot belly until 3 years old

Developmental theories r/t toddlers

Erikson: autonomy vs shame:achieves autonomy and self control, seperates from caregiver.

Piaget: sensorimotor and preoperational; differentiaties self from objeccts; increased object permanence; beginning symbolic though-something rep something/associated meaning with something.

Freud

Sensory development

• Hearing intact since birth: increased ability of movement and manipulation

• Visual acuity continues to improve

• May prefer certain smells

• May prefer certain textures (soft vs. scratchy clothes)

• Explore environment with all five senses!

• Puts lots of things in mouth to learn abt them. Puts them at risk for harm

motor skill development for toddlers

• Development of _hand eye is necessary for the refinement of fine motor skills.

• Increased abilities of __mobility_and manipulation help the curious toddler explore and learn more about their environment

• As the toddler masters a new task, they gain confidence to conquer the next challenge.  

• The senses of light, hearing, and touch are useful in helping to coordinate gross and fine motor movement.

  • Gross Motor Skills

    • Repeating gross motor movements and skills strengthen large muscle groups

    • They often use physical actions to express their emotions

  • Fine Motor Skills

    • Adequate vision is necessary for the refinement of fine motor skills because eye-hand coordination is crucial for directing the fingers, hand, and wrist in small muscle tasks

motor skill development for toddlers depending on age

15 months: Gross motor: Takes few steps on own. Fine motor: feeds self finger food.

18 months: Gross motor: walks independently, climbs on/off furniture, seats self in chair, climbs stairs w/ assistance. FIne motor: scribble, tries to use a spoon, trows a ball, stacks 3 to 4 cubes.

24 months: Gross motor: Runs, kicks ball, walks upstairs with assistance. FIne motor: Eats with a spoon, stacks 7 cubes, points to named pictures and objects, starting to turn knobs

30 months: Gross motor: jumps with both feet. Fine motor: Turns knobs, turns book page one at a time, takes off some clothing items

36 months: Gross motor: puts on some clothes by self. FIne motor: Strings items together, uses fork, copies a circle.

Communication and Language Development for toddlers

• Language acquisition is automatic and spontaneous

• Language skills are enhanced with practice

  • Encouraging children’s speech and reading, singing, rhyming to them help build language skills.

• _Cognitive and imitation are important components in early language acquisition.

• When the toddler learns to use of the word “why” they use it to challenge adults and keep them talking.  It increases their understanding of the world.

Young children living in a bilingual family can learn more than one language at the same time. 

2 years old: 2 words in sentences

2-3 years old: 2-3 word sentences

3 year olds: 3 word sentences

language developemnt for toddlers

12 months: receptive language: understands no. Expressive lnguage: imitates or uses gestures such as waving goodbye

15months: receptive language: follows command accompanied by a gesture. Expressive language: Uses a finger to paint things, looks for a familar object when named, tries to say one or two words other than dada and mama

18 months: receptive language: follows a one word w/out a gestures. Expressive language: tries to day three or more than dada and mama

24 months: receptive langauge: points to named body parts, points to pictures in books. Expressive language: sentences of 2 words, uses gestures like blowing a kiss or nodding yes

30 months: receptive langage: follows a series of two independant commands, names items when pointed and asks “what this”. expressice language: vocabulary of abt 50 words, sentences of to with an action word

36 months: uses at least two back and forth exchanges when conversing, understands physical relationships-on, in, under- Expressive language: most outside the family understand speech, asks why, where and what, verbalizes action happening in picture, says first name when asked.

emotional and social development for toddlers

• Emotional development is focused on seperation and individualization

  • Seperate from caregivers • forming sense of control over self & environment

• Emotionally labile; may have temper tantrums

• Rituals and routines are important to provide stability and security for the toddler.  

• Toddlers rely on a security item to comfort themselves in stressful situations.  

• Aggressive behavior is normal in the toddler period, so parents should not blame them for the behavior, but should help them understand the results of this behavior.

• Up to parent to hold firm boundaries.

• Give limited choices to help reduce temper tantrums

• Time out used to calm child. After address problems and what to do differently.

emotional and social developement for todddlers

Fears: loss of parents

• Seperation anxiety

  • As toddlers become more independent, they can tolerate only brief periods of separation from their parents

  • Parents should be honest about leaving and telling them when they will return in language the child can understand (i.e., after lunch)

• Fear of strangers:

• Stranger anxiety

  • Somewhat fearful of strangers unless they are accompanied by a family member

• Loud noises

• the dark

Signs of developmental delay for toddlers

After independent walking for several months: persistent tiptoe alking, failure to develop a mature walking pattern

By 18 months: Not walking, speaking or not understanding the function or common houshold items

By 2 years: Does not use 2 word sentences, doesnt imitate actions, doesnt follow basic intructions, cant push a toy with wheels

By 3 years: difficulty with stairs, cant copy circle, little interest in other kids, doesnt understand simple instructions, cant build tower of more than four blocks, diff manipulating small, extreme difficulty in seperation from parent to caregiver, doesnt engage in make believe, freq falling, cant communicate in short phrases, unclear speech, persistent drooling

Developmental milestonees for the three year old

 

Developmental Milestone	Goal
Gross motor	Balances on one foot Jumps on both feet Walks up steps using both feet Runs Rides a tricycle
Fine motor	Puts simple puzzles together Builds a tower of blocks Copies a circle or vertical line Turns knobs and opens lids
Psychosocial	Tolerates short separations from primary caregiver Dresses and undresses self Is possessive of own property Is nearly fully toilet trained

 

Cognitive	Searches and finds toys Locates body parts Knows relationship between things and persons Gives full name
Language	Uses words and gestures to indicate needs Uses two-word sentences Imitates sounds and words Sings simple songs Has increased vocabulary

Promoting heathly growth and development for toddlers

• Foundations of Self esteem

  • Love and respect regardless of the child’s gender, behavior, or capabilities: avoid calling child bad, if not bad

  • Familiarity with the daily routine

• Making expectations known through everyday routines helps to avoid confrontations

  • Knows what to expect and how to act

  • Preliminary discussion of what is going to happen and appropriate behavior with positive feedback helps prevent unwanted behavior

• Limit setting (and remaining consistent with those limits) helps toddler master their behavior.

• Toddler learn abt abt cooperation through the predictable flow of daily life

play for toddlers

• Play is the major socializing medium for toddlers

• Parents should limit television or screen time and encourage creative and physical play instead.  

• Parallel play– toddlers usually play alongside another child rather than cooperatively.

  • Don’t learn to share until in later toddlerhood

• It is important to provide a variety of safe toys to allow the toddler many different opportunities for exploring the environment.

• Adequate physical activity is necessary for the development and refinement of movement skills

  • At least 60 mins/day of structured physical activity

  • 1-several hours of unstructured physical activity per day

  • Indoor and outdoor play areas should encourage play activities that use large muscle groups

• Limit screen time until 18months; can talk to relatives on screen though.

• Ages 2-5: limit noneducational media/device use to 1hr/weekday, up to 3 hrs/weekend.

Promoting safety for toddlers

• Safety in the car: rear facing carseat- safer- causes less head, spine injuries, used up until 2, due to development of neck muscle and height and weight limit reached

• safety in water: increased risk for drwning, head circumference bigger=prone to falling, dont know how to swim until till abt 4

• Safety in the home: avoiding exposure to tobacco: decreases lung fx

• Preventing injury

• Preventing poisoning: lock up chemicals, leave in original packaging

Preventing injury for toddlers

Curiousity, mobility, and lack of impulse control all contribute to the incidence of unintentional injury. Have a limited understanding of boundaries and of danger: able to open drawers and doors, unlock deadbolts and climb. No guns in home, should be stored and locked away.

• Risk of fall injuries from climbing or riding toys

• able to reach and grab dangerous items from counters or stoves

Preventing poisoning for toddlers

• Poor taste discrimation allows for indigestion of chemical or other materials

• potentially poisonous substances should be stored out of the toddler’s reach, out of their sight, and in a childproof, locked in a cabinet: meds, alcohol, cleaning products, pesticides, wild mushrooms, plants, vape solution and edible cannabis, antifreeze, windshield washer solution, gasoline, kerosene, lamp oil

• 1 tsp of liquid nicotine is enough to kill a toddler, even skin contact can be dangerous.

Promoting nutrition for toddlers

• The child younger than 2 years should not have his or her fat intake restricted

  • A diet high in nutrient-rich foods and low in nutrient-poor high-calorie foods should be restricted.

  • Limit juice intake to 4-6 ounces per day and milk to 16-24 ounces per day – with meals

  • Forcing to eat when not hungry can cause obesity problems

  • bribing to eat is not healthy. Should drink from normal cup

• Ensure adequate intake of iron, vitamin D, calcium and zinc

• Toddlers often refuse new foods.  Reintroduce foods previously rejected.

• The parent decides which foods will be served or offered and the toddler decides how much will be eaten.  

promoting nutrtion and obesity prevention for toddlers

• Greatest risk factor is having a parent with a high body mass index (BMI).

  • Calculate and plot the BMI on standardized growth charts.  Trends over time may be predictive of the development of overweight or obeseity.

• Excessive juice intake (limit to 4 to 6 ounces per day) during meals.

• Limit sweets 

• Offer 3 small meals with 3 nutritious snacks per day 

  • 12-23 months:  fruit- ½ to 1 cup/day vegetables- 2/3 to 1 cup/day

  • 2-4 years:  fruit- 1 to 1.5 cups/day vegetables- 1 to 2 cups/day

Sleep and rest for toddlers

• Requirement

  • 18-month-old requires 13.5 hours/day

  • 24-month-old requires 13 hours/day

  • 3-year-old requires 12 hours/day

• A toddler should sleep through the night and take one daytime nap. 

• Transition to a youth or toddler bed when the child is capable of climbing over the rails

• Its best to have a standard bed with a nightly routine.  

  • Calm period with minimal outside distractions.

Teeth and gum health

The toddler should have a full set of primary (baby) teeth by age 30 months

• Prevent dental caries

  • Brush with plain water until age 2 years.  At 2 years begin using a pea-sized amount of fluoride toothpaste.

  • Avoid eating between meals and scheduled snacks

  • Use fluorinated water

  • Wean from the bottle and avoid using no-spill sippy cups after age 15 months. Can lead to dental cavities

• Dental exams should begin at age 1 year.  

addressing common developmental concerns for toddlers

• Toddler over the age of 2 years is capable of exercising voluntary control

• Watch for signs that toddler is ready for toilet teaching

• Parents should be calm, positive and non-threatening.  Use gentle praise and no reproaches

• Temper Tantrums

  • Ensure the child’s safety and, if possible, leave the child in his or her room or limit the number of onlookers.

  • “Time-out” may be used to resolve a conflict of wills.  

• Negativism- normal developmental occurence: avoid asking yes or no questions, offer the child simple choices, do not ask if they “want” to do something, if there is no choice

• Regression

  • Ignore the regressive behavior and praise age-appropriate behavior or attainment of new skills, may occur w/ new baby in house

• Signs of being ready to potty train: pull pants up and down,dry all night, announce having to go to bathroom, and when they have to defecate

Tips on discipline for toddlers

• Discipline should guide, correct, strengthen, and improve the child’s choices

• Nonnegotiable issues include items such as not hurting themselves or others, not destroying property, and not placing themselves in unsafe conditions.

• Respect the child as a person • Avoid pity

• Be patient, firm but kind •  Listen and be attentive

• Reward and praise often •  Encourage independence

• Encourage open expression of feelings •  Provide a healthy environment

• Ignore negative behavior when safety allows •  Model desired behaviors

• Use familiar routines when possible •  Offer choices 

• Try to understand the reason for the misbehavior •  Maintain control of emotions 

Pediatric nursing challenge in toddlers: Pain assessment

FLACC score. Toddler cant do self report pain assessment tool, cant give pain scale number

Common signs of child abuse

• Physical abuse

  • Bruises, welts (may be at different stages of healing)

  • Signs of multiple fractures at different stages of healing

  • Lacerations or tears

  • Cigarette or immersion burns on extremities or buttocks

  • Head injuries

  • Swollen, blackened eyes

• Sexual abuse

  • Difficulty walking or sitting

  • Bruises or bleeding from genitalia

  • Recurrent urinary tract infections

  • Symptoms of sexually transmitted illness

  • Inappropriate sexual behavior 

• Psychological/Abuse

  • Excessive anger, aggression

  • Poor peer relationships

  • Negativism, loss of pleasure

  • Low self-esteem, lack of trust

  • Developmental delays

  • Withdrawn behavior, regression

Preschoolers

Ages: 3-6. Should be able to bend over and not fall

Preschool child physical growth

• Weight—average increase of 5-7 lbs (2.3-3.2 kg) per year

• Stature—average increase of 2.5 to 3 in (6.75-7.5 cm) per year

• Loses baby fat, gains muscle

  • Appears more upright and slender

• Should continue to follow established growth curves
  

Preschool physiologic chnages

• Neurologic

  • Spinal cord myelinated by age 3

    • Allows for bowel and bladder tshort and o be achieved

• Respiratory

  • Alveoli increase in number

  • Airways increase in size

• Cardiovascular

  • Heart rate decreases

  • Blood pressure increases slightly

  • Innocent heart murmur may be heard

HEENT

• Eustachian tubes remain short and straight

• 20 decidious teeth should be present

• Genitourinary

  • Urethra remains short in children, making them susceptible to UTI

• Musculoskeletal

  • Bones increase in length and muscles strengthen and mature

  • Gross and fine motor skills increase

Developmental theories for preschoolers

• Erikson: _Initiative vs. guilt (3 to 6 years)

• Piaget: preoperational substages: preconceptual (2 to 4 years) and intuitive phases (4 to 7 years)

• Kohlberg: punishment–obedience orientation (2 to 7 years)

• Freud: phallic stage (3 to 7 years)

Motor skills for preschool

Communication and language development for preschoolers

• Preschoolers use nouns, verbs, and adjectives in their sentences

  • 4-year-olds – can form 3–4-word sentences and who, what, and where question

• 5-year-olds – can form sentences containing > 5 words with a  vocabulary between 2000-2400 words.

  • Vocabulary increases through repetition and practice

• Can express past, present, and future

• May have difficulty with word pronunciation with some hesitancy is speech

  • Gentle correction without criticism

• If a child uses an unacceptable word, a simple correction without a fuss is the best response.

Cognitive developement for preschoolers

• Magical thinking: Believes thoughts are all-powerful

• Animism: Attributes life-like qualities to inanimate objects

• Imaginary friend: Creative way to sample activities/behaviors and practice conversation skills

• Limited comprehension of word meaning: Left and right, causality, and time

• Transduction: extrapolating from one situation to another, even with unrelated events

• Centration: ability to focus or center attention on only one aspect of a situation at a time

• Explain time in relation to event. Ex. test after lunch.

Emotional and social development for preschoolers

• Friendships

  • Preschoolers learn how to make and keep a friend

• Social skills:

  • Cooperation

  • Sharing (of things and feelings)

  • Kindness

  • Generosity

  • Affection display

  • Conversation

  • Expression of feelings

  • Helping others

  • Making friends

• Temperament 

  • Influenced by parent’s expectation of child’s behavior

  • Determines child’s task orientation, social flexibility, and reactivity

• Fears

  • Exhibit variety of fears

  • Parents should acknowledge child’s fears

  • Reassurance and reality reinforcement are essential in helping them cope.

  • Common fears

    • Fear of dark

    • Fear of mutilation: a shot, scrape. Bandage helps soothe, to them.

    • Fear of abandoment: parents shouldnt sneak out, should tell child before leaving.
      

communicaton skills for preschoolers

4 years old: speaks in complete sentences with adult like grammear, follows a three part command, names common objects and familiar animals, vocab of 1500 words

5 years: can explain how to use something, talks abt past, future, and imaginary events, answers questions that use why and when, vocab of 2100

Growht and development promotion for preschoolers

• Building self-esteem

• maintaining routine and rituals

• Setting limits and remaining consistent with them

• Early recognition of signs of developmental delay

• Supporting development of self-care activities (e.g., dressing, toileting)

• Developing social skills within both the family and the larger society

Signs of developmental delay in preschoolers

4 years old: cant jump/ ride a tricycle, doesnt grasp crayon with thumb and finger, cant use the words “me” and “you” approp, doesnt engage in fantasy play.

5 years old: has little interest in playing with other children, cant build toer of six to eight blocks, cant use plurals or past tense, is easily distracted; cant concentrate on single activity for 5 mins

play in preschoolers

• Developing initiative

  • Sincere encouragement for efforts and accomplishments

  • Opportunity to decide now and with whom they want to play

  • Offer a variety of things and activities with both intended purpose and others that allow for imaginative play.

• Cooperative play (associative play)

  • Child must be able to understand limited rules

  • Have developed some social skills that permit them to begin to share and take turns.

  • Able to express their desires

  • Enjoy being with peers and interacting with them during play

Daily nutritional requirements

• 700 to 1,000 mg calcium 

• 7 to 10 mg iron

• 19 mg fiber

• Fat intake no less than 10% and no more than 35% daily calories

  • 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

building healthy eating habits for preschoolers

• Preschoolers are often erratic eaters!

• 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

RIsks of overweight and obesity for preschoolers

• Overweight is defined as BMI at or above the 85th percentile and below the 95th percentile for age and sex

• Obesity is defined as BMI greater than the 95th percentile for age and sex

• According to the CDC, overweight or obese preschoolers “are 5 times as likely as normal weight children to be overweight or obese as adults.”

• Consequences of childhood obesity include:

  • HTN, Hyperlipedemia, insulin resistance

• Discrepancies of obesity vary with cultures

Preventing preschooler obesity strategies for preschoolers

• Provide meals with the family and in a positive atmosphere.”

• Varied diet with plenty of plant- based foods; water should be primary beverage; avoid sugary foods and beverages.

• Physical activity – minimum of 60 mins./day of structured of at least 60 mins. to several hours per day of unstructured

• “limit media consumption_to 30 minutes per day and do not permit a television in the child’s bedroom.”

Sleep and rest for preschoolers

• Need 10-13 of sleep each day

  • Some children will take 1 nap

• Follow a bedtime routine

• Nightmares or night terrors are common in preschoolers

  • Nightmare-scary or bad dream followed by waking up, responsive to soothing, may have difficulty going back to sleep, may remember the dream

  • Night terrors-child sits up screaming, but is not fully awake; may have ↑ heart rate, ↑ respiratory rate, sweating; rapidly returns to sleep; child does not remember event

• May have diff falling asleep

• Need to have bedtime, and nightime routine

• avoid stim activites before bed

Teeth and gum health in preschoolers

• Daily dental hygiene

  • Provide a small, soft toothbrush

  • Provide toothpaste with fluoride

    • Teach the child to not swallow toothpaste

  • Ensure the child brushes daily in the morning and before bedtime

  • Show the child how to use a back-and-forth motion while the brush is against the gum line

• Foods

  • Limit high sugar foods

  • Offer fresh fruits and vegetables daily

• Health supervision

  • Dental visits every 6 months

discipline for preschoolers

• Successful discipline results from a loving and nuturing environment in which the child’s self-esteem is fostered with well chosen limits that are consistently enforced.

• The use of physical punishment (including spanking) has been associated with adult problems and is the least effect method of discipline.

• Parents should anticipate situations that may lead to undesired behavior

  • Use distraction to change the child’s focus

• Discuss misbehavior and explain why it is wrong or unacceptable.  

• Positive reinforcement for acceptable or desirable behavior

• Punishment for undesirable, intentional behavior

  • Time out – 1 minute for each year (5 mins for a 5-year-old) in a boring corner of the room without distraction.  

  • Removal of a privilege (playing with a favorite toy)

• Important to discuss why they are being disciplined

lying with preschooolers

• Lying is common

• Parents must role-model desirable behavior

  • Not lie

  • Remain calm and demonstrate an even temper

• Important to determine the reason for the lie prior to punishment

  • Did the child’s imagination get carried away

    • Should not punish the child but help them determine real vs. imaginary

  • To avoid punishment

    • If the child admits the truth, there should be a reduced punishment

    • The child must learn that lying is worse than the misbehavior itself.

• Important for parents to determine ehy child is lying, to avoid punishment?

sex education and masturbation for preschoolers

• ex Education

  • Before attempting to answer questions

    • Identify what the child is actually asking

    • Determine what the child already thinks about the subject

  • Answer simply, directly, and honestly the information that is being requested only.

• Masturbation

  • Exploration of own genitalia is normal in preschoolers.

  • Don’t overreact to the behavior.  It may increase the frequency 

  • Explain that there are certain rules about this activity and that nudity and masturbation are not acceptable in public

    • Teach preschoolers that no other person can touch their private parts unless it is the parent, doctor, or nurse checking to see when something is wrong.

Preventing injury with prescholers

Preschoolers display poor judgment related to safety issues making close supervision of them important to avoid accidental injury during this period.

• Gun (Ryckman)

  • Keep the gun unloaded

  • Keep the gun _locked

  • Store the ammunition locked and in a seperate place from the gun

  • Never let children know where the keys are located

  • Before the child goes to a friend's house,ask the friend's parent whether the family has firearms in the house and how they are stored. 

• Car 

  • Forward facing car seat until age 4 years whose height meets the size requirement

  • Booster seat until a height of 145 cm 4’9and age of 8-12 years

  • The back seat is the safest place for a child to ride.

    • If a child < 12 years must ride in the front seat due to limited availability in the backseat, deactivate the passenger airbag.

• Bicycle

  • Approved bicycle helmet at any time the child is riding

  • Correctly sized bicycle:  

    • Balls of the feet should reach both pedals while the child is sitting on the seat and has both ands on the handlebars

    • Children younger than 5 years should have pedal brakes

    • Only ride on the sidewalk 

• Water

  • Never leave them unattended near pools or other bodies of water.

  • 5-foot gate with latching gate around swimming pool

  • No diving, unless depth is verified safe by an adult

  • Life–saving devices readily available around pools

  • Not allowed to swim in a canal or fast-moving water source

  • Wear personal flotation device when riding in boats or fishing off  riverbanks.

Preschooler pain assessment

wong-baker FACES pain resting scale

Schoolage child

Ages 6-11

Physical growth for schoolage children

• Grow an average of 2.5 in per year

• Increase weight by average of 7 lb per year

• Early on, boys and girls are similar in height and weight

• Later, girls may develop faster than boys in height and weight; boys will “catch-up” later

• Secondary sexual characteristics begin to appear

• Expectations of behavior should be consistent with age, not appearances

Organ system maturation for school aged children

• Neurologic system: 

  • Brain and skull grow very slowly; cognitive processes mature

• Respiratory system:

  • Respiratory rates decrease; respirations are diaphragmatic in nature

• Cardiovascular system:

  •  Blood pressure increases and pulse rate decreases

• Immune system: 

  • Matures to adult level around 10 years old; fewer infections experienced

• Gastrointestinal system: 

  • Deciduous teeth replaced by permanent teeth; fewer gastrointestinal upsets; stomach capacity increases; caloric needs are lower, but appetite may increase

• Musculoskeletal system: 

  • Greater coordination and strength; muscle still immature and can easily be injured

• Genitourinary system: 

  • Bladder capacity increases (age in years + 2 oz)

  • Prepubescence occurs

    • Begins in the 2 years before the beginning of puberty with about a 2-year difference in onset between boys and girls

    • Characterized by the development of secondary sexual characteristics

      • A period of rapid growth for girls

      • A period of continued growth for boys

  • Sexual development in both boys and girls can lead to embarrassment concern over physical appearance, and low self-esteem.

• menstrual period ranges from: 9-16

• Educate abt body changes to promote comfort

• Discuss emotional, social, resposibility, and risk of sexual activity

Gross motor and fine motor skills for schoolaged children

Gross Motor:

•  Coordination, balance, and rhythm improve

•  May become awkward as bodies growing faster than able to compensate

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

Benefits of physical activity for schoolaged children

• Cardiovascular fitness

• Weight control

• Emotional tension release

• Development of leadership and social skills

Sensory development for schoolaged children

Hearing: 

• Hearing screening to identify hearing loss

•  Avoid exposure to excessive noise to prevent hearing loss.

Vision:  

• Children should have an eye exam prior to the start of school and then annually

Signs of vision problems

• Eye rubbing, squinting

• Avoiding reading 

• Frequent HA

• Holding reading materials close

• Problems with depth perception or hand–eye coordination

• Sports- related eye injuries and eye protection are important in this age group.

• Amblyopia/lazy eye: one eye is more near sided than other

language and communication skills for schoolaged children

• Vocabulary expands to 8,000 to 14,000 words

• Culturally specific words are used

• Reading efficiency improves language skills

• More complex grammatical forms are used

• Development of metalinguistic awareness occurs

• Metaphors are beginning to be understood

Emotional and social developmental for schollage children

• Temperament: common groups

  • Easy and adaptable

  • Slow to warm

  • Difficult and easily frustrated

• Self-esteem development

  • Face the process of self-evaluation from a framework of either self confidence or self-doubt  based on mastery of earlier developmental tasks of initiative and autonomy.

  • If school-age children regard themselves as worthwhile, they have a positive self-concept and high self-esteem

Emotional and social developmental for schoolage children fears

 

Age	Fear
6-7 years	Strange loud noises, ghosts and witches, being alone at night, bodily injury, school
7-8 years	Dark places, catastrophes, not being liked, physical harm
8-9 years	Failure in school, being caught in a lie, divorce or separation of parents, being a crime victim.
9-11 years	Becoming ill, heights, pain, evil people

• Parents should not cater to fears

• Relaxation tech should be used to help manage fears

emotional and social developement for schoolage children

• Peer relationships

  • Continuous peer relationships provide the most important social interaction

  • Learn to respect differing points of view

  • Peer groups establish norm and standards that signify acceptance or rejection

• Teacher and school influences

  • Transmit values of society and establishes peer relationships.

  • Important in shaping the socialization, self-concept, and intellectual development of children.

• Family influences

  • Beginning of peer group influences, with testing of parental and family values.

  • Beginning to strive for independence, but parental authority and controls continue to jmpact choices and values.  

Developmental theories for schoolage children

Erickson: industry vs inferiority: interested in: how things are made, success on personal/ social tasks, outside activities, peers, learning

Piaget: concrete operational: learns by manipulating objects, no abstract thinking, understands time

Kohlberg: conventional: acts are wrong because you get punished; behavior is right or wrong.

Feud: Latency: focus on activities that develop social/ cognitive skills

• More interested in own group of friends of same gender. More peer relationships vs romantic relationships

Safety issues for schoolaged children

• Car safety

  • As presented in preschooler lecture

  • Rules of conduct for car rides must be established.

  • Children younger than 13 years of age should not ride in the front seat of a vehicle with an airbag.

• Pedestrian safety

  • Children younger than 10 years should not be unsupervised pedestrians

  • Teach safe street and pedestrian practices

• Bicycle and sport safety

  • Bike helmets (required by law in some states, but not in MI)

  • Helmets, knee and elbow pads for skating or skateboarding

• Fire safety

  • Educate about the hazards of fire

  • Supervise children while cooking and microwaving food.  

• Water safety

  • School-age children should learn how to swim and learn water safety.

Safety precautins to teach children schoolage children

• Wear protective equipment.

• Observe traffic signals.

• Practice water safety:  learn to swim, and never swim alone.

• Use the buddy system when walking to and from school.

• Never talk to nor accept rides from strangers.

• Always follow your instincts and avoid peer pressure.

Child maltreatment for schoolage children

• Child maltreatment includes physical abuse, sexual abuse, emotional abuse and neglect

  • Physical abuse refers to injuries that are intentionally inflicted on a child and result in morbidity or mortality.

  • Sexual abuse refers to involvement of the child in any activity meant to provide sexual gratification to an adult.

  • Emotional abuse may be verbal denigration of the child or occur as a result of the child witnessing domestic violence.

  • Neglect is defined as failure to provide a child with appropriate food, clothing, shelter, medical care, and schooling.  

• A history of childhood abuse is associated with the development of anxiety and depressive disorders, suicidal ideation and attempts, and alcohol and drug use.  

Child abuse for schoolage children

• Assessment

  • Screening questions for children

    • Are you afraid of anyone at home?

    • Who could you tell if someone hurt you or touched you in a way that made you uncomfortable?

    • Has anyone hurt your or touched you in that way?

  • Questions for parents

    • Are you afraid of anyone at home?

    • Do you ever feel like you may hit or hurt your child when frustrated.  

Child abuse-physical exam for schoolage children

• Perform a  gentle but through physical examination, using a soft touch and calm voice. 

• Observe the parent-child interaction, noting fear or an excessive desire to please.  

• Inspect the skin for bruises, burns, cuts, abrasions, contusions, scars, and any other unusual or suspicious marks.

• Observe for inflammation of the oropharynx (may occur with forced oral sex).

• Inspect the anus and penis or vaginal area for bleeding or discharge (which may indicate sexual abuse)

child abuse- nursing care in schoolaged children

• Nursing Management

  • Refer suspected cases of neglect or abuse to Child Protective Services

  • When abusive activity is identified in the hospital, notify the social services ad risk management departments.  Notify the charge nurse and may need to get assistance from the hospital security.

  • Provide consistent care to the abused child by assigning a core group of nurses to help foster a therapeutic relationship and trust in adults.

  • Role model appropriate caretaking activities to the parent or caregiver.

    • Call attention to normal growth and development parents helping to manage realistic expectations.

  • If a child is removed from the home and placed in foster care, provide the education necessary to assume the child’s care.

Nutrition assessment for schoolage children

• Check height and weight compared to previous measurements; assess BMI for age

• Nutrition history including a 24-hour recall of what was consumed

• Inquire about family meals and the social aspects of eating including who prepares the meals

• Solicit from both parent and child

• Identify any knowledge gaps relating to nutrition

nutrtional needs in schoolage children

• Needs vary based on age, gender and activity level

• Needed calories decrease while appetite increases

  • Increased body fat occurs earlier in girls than boys

  • Diet preference established in preschool years persist

Children also need:

• Fiber: 25 g for 4‐ to 8‐year‐olds; 26 to 31 g for 9‐ to 13‐year‐olds

• Moderate to vigorous exercise for 60 minutes per day

• Daily fruits and vegetables

• Whole grain breads and cereals

• Non-fat (skim) or low-fat milk

NUTRITIONAL NEEDS OF THE AVERAGE SIZED SCHOOL-AGE CHILD (AGE GROUPS)

Obesity management for schoolage children

• Children and adolescents aged 6 years or older with a BMI >=95 should receive comprehensive, intensive behavioral interventions.  Often multidisciplinary teams

  • Psychology sessions (targeting both parents and child), group sessions, information on healthy eating, safe exercising, and reading food labels.

  • Incorporate behavior change techniques such as problem solving, monitoring diet and physical activity behaviors, and goal setting.  

• Selecting healthy foods; regular meal planning ahead of time

• Engaging in an active lifestyle; incorporating exercise into the daily schedule.

• Family lifestyle changes are crucial and should not only focus on changing the child’s habits.

Promoting sleep and rest in schoolage children

• 10-12 hours of sleep required

• Should have predictable bedtime expectations and wake-up times

• Children may need help in winding down to promote sleep

• Night terrors and sleepwalking may occur but should resolve by age 8 to 10 years

Developemntal concerns for schoolage concerns

• Television and video games (setting limits on both the content and amount of time)

  • Too much time in front of a screen can lead to aggressive behavior, less physical activity, and obesity.  

  • Healthy People 2030 recommend to limit screen time in children 2-17 years to <2 hours per day

• Bullying

  • Defined s repeated negative actions by one or more persons against chosen victims.

  • There are usually three groups involved:  the bully, the victim, and the bystanders.

  • Signs that a child is being bullied include sleeping problems, irritability, poor concentration,, problems with schoolwork, missing belongings or money, and frequent unexplained psychosomatic complaints- physical presentation of psychological stressors; stomach, head hurting- 

  • Cyberbullying refers to usie of the Internet, phone or other technology to repeatedly harass or taunt persons.

School violence for school age children

• School violence can be defined as any harm, whether physical or psychological, that is directed toward schoolchildren and their property

• Two common factors known to contribute to school violence

  • Breakdown in communication in the home and school

  • Easy availability of weapons.

• Signs that indicate a behavior may lead to violence

  • Difficulty getting along with peers

  • Outbursts of temper, violence directed toward pets

  • Decreased productivity in the home or at school

  • Sleeping or eating problems

  • Social isolation

  • Preoccupation with violent movies or video games

Promoting appropriate discipline in schoolage children

• 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 acknowledgment of positive behavior are more likely to encourage those positive behaviors and promote development

• Natural consequence: not discipline; Ex: leave bike in drive way, gets ran over by car.

• Logical consequence: discipline.

Cultural influences on growth and development for schoolage children

• Habits

• Beliefs

• Language

• Religious customs

• Values (Family vs. Peers)

Why is body water important

Medium in which body fluids are dissolved 2. Essential for cellular function 3. Where metabolic reactions take place

Distrubution of body fluids

Total Body Water (TBW) ◼ Intracellular fluid (ICF) – fluid contained within the cells ◼ Extracellular fluid (ECF) – fluid outside the cells ◼ __________ – contained within the blood vessels ◼ __________ – surrounding the cell ◼transcellular __________ – contained within specialized body cavities: cerebral spinal fluid, sinovial fluid, plural fluid

Infants and young children have a greater need for water and are more _vulnerable to alterations in _fluid_____ and electrolyte balance. • Infants have a greater fluid intake and output relative to size. • Water and electrolyte disturbances occur more frequently and more rapidly. _infant and young children_adjust less promptly to those alterations.

Loss can occur thru: heat, Respiratory

Total body fluid

• Body water percentage for weight varies with age

• Newborns highest percentage water: 75% total body water

• ECF is 50% for a newborn and about 30% for toddlers

• Decreases with increasing age – towards adolescence and in adults

• 45% total body water

Maintenance fluid requirements

FORMULA: Up to 10 kg 100 mL/kg/24 hr

11- 20 kg 1000 mL + 50 mL/kg for each kg above 10 kg

> 20 kg 1500 mL + 20 mL/kg for each kg above 20 kg

Normal range for urine specific gravity?

Normal range 1.016-1.022

In the absence of kidney disease. What does: low specific gravity indicate? Fluid volume excess

high specific gravity indicate?

Urine output

Reduced bladder capacity in infancy (30 ml in newborn).

• Expected urine output in the infant and child is 0.5-2ml

• General consideration is at least _1ml/kg/hr

• One year old voids about 400 – 500 ml per day

• Infant and toddlers void _9-10 time/day. By age 3 the average number of voids is the same as an adult

• Adolescent average urine output is about 800 – 1,400 ml per day with an adult average number of voids 3-8 times/day.

Physiological Differences Place Infants at Risk for Overhydration, Dehydration, and Electrolyte Imbalances

• Increased body surface area: allows larger quantities to be loss htru their skin, longer GI tract another source of fluid loss, especially if they have diarrhea

• Increased metabolic rate

• Kidneys are functionally immature at birth: have harder time concentrating urine

• Higher fluid requirement: ingest and excrete a greater amount of fluid per kilogram of body weight: maintenance requirement include both water and electrolytes

COnditions that decrease fluid needs

CHF, SIADH, Kidney disease, Postoperatively  Mechanical ventilation  Increased intracranial pressure

Fluid overload s/s

_increased___________urine output ◼ Edema (_infants may have puffy eyelids_________ may have _weight gain__________) ◼ Elevated venous pressure ◼ Hepatomegaly ◼ Slow, bounding pulse ◼ __weight gain_____________ ◼ Lethargy ◼ Increased spinal fluid pressure ◼ CNS manifestations (seizures, coma) ◼ __full__ fontanel (<18 mos.) ◼

Laboratory findings: decreased specific gravity decreased hematocrit decreased serum electrolytes

Edema

Edema results from anything that

1. Alters the retention of sodium, such as renal disease or hormonal influences

2. Affects the formation or destruction of plasma proteins, such as starvation or liver disease.

3. Alters membrane permeability, such as nephrotic syndrome or trauma Edema may be localized to a small or large area, or it can be generalized.

Types of edema

• Peripheral edema or localized or generalized palpable swelling of the interstitial space. :infants may have puffy eyelids as a sign of edema. Can be a sign of fluid volume overload related to excessive IV fluid infusion

• Ascites, or the accumulation of fluid in the abdominal cavity (usually associated with renal or liver abnormalities)

• Pulmonary edema, which occurs when interstitial volume increases

• Cerebral edema, which is a particularly threatening form of edema caused by trauma, infection or other etiologic factors, including vascular overload of hypotonic solution

• Overall fluid gain, which is especially seen in patients with kidney disease.

Nuring care for fluid overload

Management and Nursing Care ◼fluid restrictions _____________ adherence ◼ Administer _diuretics____________ ◼ Monitor vital signs ◼ Monitor neurologic signs, as necessary ◼ Monitor daily weights_________________ ◼ Review electrolyte labs ◼ Implement _seizure precautions______________

• fever_\

• tachypnea _

• v/d

• burns_

• High output kidney failure

• Diabetes insipidus

• DKA_

• Radiant warmer (preterm infant)

• Phototherapy (infants)

• Postoperative bowel surgery

• Gastric suctioning

Dehydration comparison chart

Dehydration lab findings

• Blood: ↑ hematocrit, Variable serum electrolytes, ↓ serum bicarbonate, ↑ BUN, ↑ serum osmolality ◼

• Urine ↑ specific gravity

Dehydration- nursing care

• Provide replacement of fluid losses: Oral replacement solution or IV fluid bolus

• Provide maintenance fluid and electrolytes

• Measure fluid intake and output

• Monitor urine specific gravity

• Monitor body weight

• Monitor serum electrolytes

Pediatric maintenance IV fluids

• The AAP recommends the use of isotonic solutions with adequate potassium chloride and dextrose for maintenance IV fluids in children: Dextrose: 5%, Sodium:

• 0.9 % NaCl (Normal Saline): Isotonic solution – Current recommendation, As maintenance IV solution may increase risk of hypernatremia & metabolic acidosis

• *Concentration of NaCl is determined by clinical status ◼

• Potassium: 20 mEq KCl/L = 10mEq/500mL: Do not hang an IV solution with K+ until urine output has been established

Electrolytes- Potassium

• Major electrolyte in intracellular fluid

• Function: neuromuscular_ & _cardiac__________

• Nursing Considerations: Normal range _3.5-5.0_mEq/L: False increases can occur from specimen collection & dehydration

• Patient physical assessment: Hypokalemia: most commonly caused by K+ loss though the use of some diuretics, diarrhea, or excessive sweating, or deficient dietary intake.

• S & S: irregular heart rhythmm and cardiacdysrhythmias, general discomfort or irritability, muscle weakness, paralysis

• Hyperkalemia: most commonly caused by renal failure or overaggressive treatment of deficiency.

• S & S: heart rhythm and ECG changes tingling in the extremities, weakness, numbness, paralysis

• Cardiac monitoring should be considered

Electrolytes- sodium

Major extracellular fluid electrolyte

• Function: neuromusclar________________ & __fluid management_____________ ◼

• Nursing Considerations: ◼

• Normal range is _135-145___________mEq/L ◼ Physical assessment ◼

• Hyponatremia can be caused by SIADH, subarachnoid hemorrhage, brain tumor, meningitis, or encephalitis ◼

• S & S : general _fatigue_________, __weakness________, nausea, headache, confusion, seizure, coma, death ◼

• Hypernatremia results from excessive Na+ intake or retention with excessive loss of water from diarrhea, diuretics, vomiting, sweating, heavy respirations or severe burns.

• S & S: signs of _dehydration_________, twitching, _irritability____________, delirium, fatigue, weakness, nausea, headache, confusion, seizure, coma, death

• Consider implementing _seizure precautions________________________

Why is pH so important in the body’s function?

Every metabolic reaction that takes place in the body is controlled by enzymes. ◼ They are very specific and operate within very specific environmental conditions involving temperature and narrow ranges of pH. What is pH? ◼ A gauge of ________________________________ What is normal pH of arterial blood? ◼ ________________for adults and children ◼ ________________for infants and children

Acid base balance

Metabolic activities produce acidic products. ◼ Ketone bodies ◼ Phosphoric acid ◼ Carbonic acid ◼ Lactic acid

All are regular metabolic outcomes

acid base regulation

• Respiratory System: Removing CO2 (with deep, rapid breathing) ◼ Retaining CO2 (with shallow, slower breathing) ◼ Renal System ◼ Reabsorb CO2 (correction of acidosis) ◼ Excretion of CO2 (Correction of alkalosis)

ABG- normal

pH ◼ adults and children is 7.35 - 7.45 ◼ infants and children < 2 yrs. is 7.32 – 7.49 PCO2 (partial pressure of carbon dioxide) ◼ adults and children 35-45 mm Hg ◼ infants and children < 2 yrs. is 26-41 mm Hg HCO3 (bicarbonate) ◼ adults 21-26 mEq/L ◼ Newborns and infants is 16-24 mEq/l PaO2 (partial pressure of oxygen) ◼ Adults 80-100 mm Hg ◼ Newborns 60-70 mmhg