notes SG
TODDLER VITAL SIGNS
Normal toddler vital signs:
Heart Rate (HR): 80–140 beats/min
Respiratory Rate (RR): 25–30 breaths/min
Temperature: 96.8–100.4°F (36–38°C)
Oxygen Saturation (O2 sat): 95–100%
Blood Pressure (BP):
Males: about 85–91/37–46 mmHg
Females: about 86–89/40–49 mmHg
Important testing points:
Toddlers have faster HR and RR than adults
BP must be measured with the correct cuff size (width=~80% of arm circumference)
Too small cuff results in falsely high BP, too large cuff results in falsely low BP
Best BP site: right upper arm (use lower extremities if arm cannot be used)
Routine BP screening usually begins at age 3 unless high risk
Respiratory pattern tends to become more regular and rhythmic.
Temperature measurement methods:
Preferred methods:
Axillary (use disposable cover; not core temperature; if abnormal, use tympanic or temporal)
Temporal
Tympanic (use disposable cover; head turned away; pull pinna down and back)
Avoid oral thermometers if cooperation is not possible. Avoid rectal temps due to:
Mucosal injury
Infection
Perforation risk
Contraindicated in clients with hemorrhoids, diarrhea, coagulation disorders, immunocompromised status, or prior rectal surgery
If temp is abnormal, reassess rectally only if necessary.
Fever:
Fever is defined as 100.4°F (38°C) or higher
Management includes:
Rest
Fluids
Acetaminophen or ibuprofen if necessary (if rest/fluids alone are insufficient or if fever ≥ 102.0°F)
Do not use cold water for cooling (may cause shivering), instead use tepid water (30°C or 86°F) with sponge, and avoid submerging.
Signs of respiratory distress:
Tachypnea
Retractions
Nasal flaring
Stridor
Accessory muscle use
Cyanosis (late sign)
Retractions indicate respiratory distress displayed in various locations:
Intercostal: between ribs
Subcostal: below rib cage
Suprasternal: above sternum
Substernal: below sternum
Supraclavicular: above clavicle
Engage child with stethoscope at an age-appropriate level.
TODDLER DEVELOPMENTAL MILESTONES
General toddler growth:
Age: 1–3 years
Expected physical growth:
Gains about 4–6 pounds/year
Grows about 2–3 inches/year
Loses baby fat, achieving a leaner body
Coordination improves
At the end of this stage, the child's height is approximately half of their adult height
Legs may appear bowed until 15 months
Accumulates 20 deciduous teeth by age 2.5 years
Head circumference should be measured until 2 years of age
Requires 1,000 to 1,400 calories per day
Growth concerns:
Increase or decrease in percentiles of height, weight, or both from their expected trajectory
Plateau in height or weight from previous visits
Children born prematurely typically reach milestones later than those born full-term
Screening schedule:
Developmental screenings at 9, 18, and 30 months
Autism screenings at 18 and 24 months
Milestones by age:
15 months:
Takes independent steps
Stacks objects
Claps
Finger feeds
Uses spoon/cup
18 months:
Walks independently
Speaks at least 5 words
Scribbles
Uses spoon
Drinks from an open cup
Copies actions
24 months:
Runs
Uses stairs with support
Identifies 2+ body parts
Looks for caregiver’s facial cues
Uses one hand for holding while using the other hand
Appropriately uses gestures (blowing a kiss, nodding yes, waving, pointing)
30 months:
Jumps with both feet
Turns pages in a book
Vocabulary of about 50 words
Uses one or both hands to twist doorknobs, lids, or toys
Takes some clothes off independently
36 months:
Dresses partly by self
Strings objects
Speech is understandable
Plays with other children
Gross motor must-knows:
15 months: takes a few steps alone
18 months: climbs and walks independently
24 months: runs and kicks a ball
30 months: jumps
36 months: rides a tricycle
Fine motor must-knows:
Stacks objects
Scribbles
Uses spoon and cup
Twists lids
Removes clothes
Strings objects by age 3
Cognitive development by age 3:
Brain is approximately 80% developed
Follows 2-step commands
Identifies body parts
Begins to develop danger awareness
Uses imagination
Recalls from memory
Imitation
Discovers own preferences
Language development:
18 months: speaks more than 3 two-syllable words
2 years: forms 2-word phrases
3 years: communicates using 3-word sentences
Language growth can help reduce frustration and tantrums
Psychosocial stage (Erikson): Autonomy vs Shame and Doubt:
Key aspects of toddler behavior include egocentrism, which entails a focus on one's own needs and a lack of awareness of other individuals' needs, resulting in jealousy and frustration.
They desire independence, control, and choices, explaining behaviors such as saying "no," temper tantrums, and defiance.
It is beneficial to offer limited choices and maintain consistency during temper tantrums.
Play:
Solitary play: a child plays independently without interaction with peers or adults.
Parallel play: playing beside another child, possibly without interaction.
Peer play (cooperative): engaging with other children in play, typically with peers of similar or varying ages, usually occurs around 2-3 years
Negativism:
Defined as a behavioral response characterized by negative reactions or opposition to requests from others.
Temper Tantrums:
Brief episodes of behavior disproportionate to the situation leading to:
Crying
Screaming
Hitting or slapping
Throwing toys/objects
Throwing themselves to the ground
Breath-holding
Head-banging
Often result from a child's desire for autonomy or an inability to express themselves verbally or through actions.
Management strategies include:
Walking away if the child is in a safe place
Removing the child from overstimulation
Talking calmly and getting to their eye level
Time-outs should last no more than one minute per year of the child's age.
Stress response:
Signs include:
Tantrums
Regression
Demand for attention
Irritability
Changes in appetite and sleep
Managing stress involves:
Maintaining routines
Allowing choices
Keeping the environment calm and safe
Reducing stimuli
Spending quality time with the child
REGRESSION
Definition: Regression refers to a return to earlier behavior that the child has previously outgrown.
Examples include:
Using baby talk
Wanting the bottle or pacifier again
Thumb sucking
Bedwetting/incontinence
Changes in sleep patterns
Seeking more parental comfort
Common causes of regression:
Illness
Hospitalization
Stress
Trauma
New sibling
Moving to a new home
Changes in daycare
Family conflict
Developmental changes, such as potty training
When is regression normal?: Often temporary during:
Stress
Illness
Changes
Developmental transitions
When to be concerned: Notify the provider if regression:
Persists for more than 2-3 weeks
Is severe
Parent teaching:
Parents should respond with:
Compassion
Patience
Reassurance
Parents should avoid responding with:
Anger
Punishment
Criticism
Shame
TOILET TRAINING
Big Idea: Toilet training is a significant developmental task but should never be rushed. Success requires child readiness.
Optimal age for readiness:
Most children are ready between 2-4 years old
Toilet training before 18 months to 2 years is not recommended
At around age 2, the nervous system matures enough for the child to:
Sense bladder fullness
Sense bowel fullness
Coordinate sphincters and relax appropriately on the toilet
Signs of readiness for toilet training:
Child should be able to:
Pull pants up/down
Feel urges to go
Communicate needs to caregivers
Show interest in using the toilet
Stay dry for several waking hours
Wake from naps dry
When NOT to commence toilet training:
Delay if the child:
Resists or gets upset
Displays frustration
Is not progressing
Avoid during significant changes like:
New baby
Moving
Illness
Hospitalization
Changes in daycare
Major routine changes
Potential problems during toilet training:
Regression
Toilet refusal
Stool withholding
Constipation
Urinary retention
Risks of toilet refusal:
Can lead to UTIs
Pyelonephritis
Chronic constipation
Parent teaching for toilet training:
Parents should be patient and consistent
Parents should avoid punishment and look for readiness
Stop the process if the child is not ready
Praise generously to encourage progress
Easy toilet training tips:
Let the child choose a potty chair
Use a child-sized potty
Ensure feet can touch the floor for stability
Keep the potty easy to reach
Maintain regular sitting times
Offer praise for all efforts
Never punish for accidents
Dress child in simple clothes free from complicated buttons/zippers
Use age-appropriate books/videos discussing toilet use
Teach all children to pee sitting first; boys can learn to stand later
If frustrated, stop and retry in 2-3 months
Potty chair facts:
Should be child-sized and secure
Must allow feet to be placed on the floor for comfort and control
SLEEP NEEDS
Normal sleep need: Toddlers typically need 11–14 hours of sleep over 24 hours (including naps + nighttime sleep).
Importance of sleep:
Supports immune function, brain growth, memory, learning, concentration, language, mood regulation, behavior regulation, and emotional resilience
Factors worsening sleep:
Excessive screen time
Blue light exposure
Overstimulation
Exciting bedtime activities
Noise from the environment
Irregular bedtime routines
Common sleep problems in toddlers:
Difficulty falling asleep
Night wakings
Excessive daytime sleepiness
Irritability
Snoring and breathing pauses
Nightmares and sleep terrors
Night terrors:
Characterized by:
Screaming
Fear
Sweating
Often not remembered upon waking
Good sleep habits:
Maintain a consistent bedtime
Establish a calming and predictable routine
Ensure a dimly lit room when getting into bed
Keep the sleeping environment dark and cool
Offer comforting yet safe sleep items (if appropriate)
Avoid electronics before bed
Reading is recommended before sleep
DENTAL CARE
Dental hygiene:
Brush teeth twice daily with fluoride-free toothpaste
Limit juice intake to less than 4 ounces/day
Refrain from using bottles and sippy cups
Replace toothbrush every 3-4 months or after illness
First examination with a dentist is recommended once the first tooth erupts or by age 12 months
Typically, thumb sucking or pacifier use stops between 2 and 4 years of age
SAFETY
Reasons toddlers are at high risk:
They are curious, impulsive, mobile, unaware of dangers, and typically explore via hand-to-mouth behavior.
Car seat safety guidelines:
Safest location: middle of the back seat
Utilize a 5-point harness
Ensure straps are snug and positioned at or below the child's shoulders with no slack
Chest clip should sit at axilla level
For children under 2 years, remain rear-facing
Avoid using bulky coats in the car seat, although a coat or blanket can be placed over the child once secured
Replace the car seat after any accident/crash
Many car seats expire after six years of use.
Fall prevention strategies:
Install baby gates at the top and bottom of stairs and near doors leading outside
Use doorknob covers
Keep doors and windows secured
Avoid using infant walkers
Opt for carpet over tile/wood to minimize injury risk
Drowning prevention:
Constant supervision is critical, along with:
Pool fencing
Self-latching gates
Alarms
Toilet seat locks
Limit access to bathrooms without supervision
Remove the bathtub drain plug when not in use
Use self-closing toilet seats
Remove toys from pool areas
Never leave a child unattended in the bath
Introduce swimming lessons when appropriate
Use life jackets as needed
Burn prevention strategies:
Keep hot water heater temperature at a maximum of 120°F
Ensure the child stays at least 3 feet away from hot surfaces (stoves, irons, fireplaces, hair tools)
Closely supervise kitchen and bathroom activities
Replace smoke alarm batteries every six months
Have a fire escape plan
Sunburn prevention:
Keep children out of direct sunlight from 10 a.m. to 4 p.m.
Use sunscreen with at least SPF 30
Apply sunscreen at least 30 minutes before going outside
Reapply sunscreen every two hours
Dress the child in SPF-rated clothing and sun hats
Poison prevention:
Keep medications and chemicals locked away
Avoid referring to medicine as "candy"
Maintain products in their original containers
Keep the poison control number readily available
If a child swallows poison:
Remove the item
Clear the mouth
Call poison control
Do not induce vomiting unless instructed by a professional
Other safety points:
Walkers may increase the risk of injury
Always use sunscreen with SPF 30+ and reapply as instructed.
SIBLING RIVALRY
Definition: Sibling rivalry refers to competition or conflict between siblings, which is common in toddlers.
Why toddlers struggle with sibling rivalry:
They tend to be egocentric, focused primarily on their own needs without fully grasping a sibling's needs, leading to jealousy.
Signs of sibling rivalry include:
Increased tantrums
Frustration
Attention-seeking behaviors
Interrupting
Clinginess
Jealousy
Regression in behaviors
Emotional responses with the arrival of a new baby:
Toddlers may feel displaced, lesser in importance, jealous, confused, or insecure.
Safety teaching:
Never leave a toddler alone with a newborn
Always supervise interactions
Watch play closely to prevent unintentional harm due to impulsivity or lack of understanding of infant fragility.
Strategies to reduce sibling rivalry:
Involve the toddler in preparations for the newborn
Make the toddler feel included
Provide frequent praise
Spend one-on-one time with the toddler
Avoid comparing siblings to one another
Minimize major life changes around the time of the baby’s birth
Be fair and consistent in treatment and expectations
Foster excitement in the toddler about being an older sibling.
Adjustments to the toddler’s life (like moving rooms, toilet training transitions, and weaning) should ideally happen a few months before or after the baby is born.
VACCINES
General vaccine facts:
Vaccines stimulate the immune system to create antibodies, build immune memory, reduce infections, complications, hospitalizations, deaths, and provide community protection.
A severe allergic reaction to a previous vaccination or its components is a major contraindication for revaccination.
MMR Vaccine:
Type: LIVE VACCINE
Protects against:
Measles
Mumps
Rubella
Schedule:
Dose 1: 12–15 months
Dose 2: 4–6 years (2 doses total)
Route: Subcutaneous injection (recommended in the tricep for children aged 12 months and older)
Contraindications:
Pregnancy
Immunosuppression
Neomycin allergy
History of severe reaction to the vaccine
Common side effects:
Fever
Mild rash
NCLEX point: Confirm that MMR is a live vaccine and live vaccines are contraindicated during pregnancy and for individuals who are immunosuppressed.
Research has not proven a causal relationship between the MMR vaccine and autism spectrum disorder (ASD).
Febrile seizures have been reported with both the MMR and MMR/varicella combination vaccines, with a slightly higher risk in the combination group.
DTaP Vaccine:
Protects against:
Diphtheria
Tetanus
Pertussis
Schedule for children under 7 years:
2 months
4 months
6 months
15–18 months (booster)
4–6 years (booster)
Route: Intramuscular (IM)
Use vastus lateralis in infants/toddlers
Use deltoid in children one year and older with sufficient muscle mass
Common side effects:
Soreness
Redness
Mild fever
Irritability
Contraindications:
Allergic reaction
Guillain-Barré syndrome
Severe pain or swelling following a previous dose
Tdap Vaccine:
Protects against:
Tetanus
Diphtheria
Pertussis
Schedule:
Given at 11-12 years, booster every 10 years thereafter
Pneumococcal Vaccine:
Protects against diseases caused by Streptococcus pneumoniae, which can lead to pneumonia, meningitis, and sepsis.
Schedule:
2 months
4 months
6 months
12–15 months (booster may be required)
For high-risk individuals (e.g., sickle cell disease or asplenia), PPSV is generally recommended following completion of the PCV series.
Route: IM
Use vastus lateralis in infants/toddlers
Use deltoid for older children
Common side effects:
Injection site soreness
Fever
Changes in sleep
Monitor for 15 minutes after administration for any adverse reactions:
Syncope
Allergic reactions
Live vaccine overview (for high-yield recall):
MMR (measles, mumps, rubella)
Varicella (chickenpox)
Rotavirus
LAIV (live attenuated influenza vaccine)
OPV (oral polio vaccine; not used in the U.S.)
PINWORMS
What they are: Pinworms are a helminth infection of the gastrointestinal system.
Pathophysiology:
Ingestion of the organism in egg form
Remains in the gastrointestinal tract for 4-8 weeks before maturing to the adult form
Adult worms travel to the anus to lay eggs
Risk factors:
Contaminated hands
Contaminated bedding or clothing
Contaminated surfaces
Classic symptoms:
Anal itching (particularly worse at night)
Irritability
Disturbed sleep
Sometimes abdominal discomfort
Mnemonic: “nighttime itchy bottom = pinworms.”
Diagnosis:
Transparent tape test
Pinworm paddle test
Best performed early in the morning
Treatment:
Anthelmintic medications such as mebendazole
Repeat dosage in 2 weeks
Often it is suggested to treat all household members simultaneously
Nursing teaching:
Handwashing is critical
Trim fingernails regularly
Take morning showers
Wash bedding/clothes in hot water
Dry items on high heat
Advise against scratching to reduce secondary infections
CHICKENPOX (VARICELLA)
Cause: Varicella-zoster virus, which is highly contagious
Spread:
Respiratory transmission
Contact with vesicle fluid
Primary infection occurs in the upper respiratory tract
Within 2-6 days, the virus will enter the bloodstream leading to a rash appearing within 10-12 days
Key symptoms:
Itchy vesicles/blisters
Vesicles crusting over
Rash begins on the chest/trunk before spreading
May involve the scalp, mouth, eyelids, and genitals
Accompanied by fever, fatigue, sore throat, and headache
Course: Usually lasts about 5–7 days
Treatment: Mostly supportive, including:
Acetaminophen
Hydration
Calamine lotion
Oatmeal baths
Lukewarm baking soda baths
Antihistamines
Monitoring for potential skin infections
Important note: Avoid aspirin due to the associated risk of Reye’s syndrome in viral illnesses.
Isolation/home care:
Keep the child home until all lesions have crusted (~1 week)
Avoid contact with pregnant individuals, newborns, and immunocompromised persons
When hospitalized, employ airborne and contact precautions
Prevention: Varicella vaccine is recommended
Nursing interventions:
Ensure hydration, especially if oral lesions are present (encourage water, oral rehydration solutions, popsicles)
Dress in light cotton clothing
Avoid heavy blankets
Clear nails to avoid aggravations.
SCABIES
Cause: Scabies is caused by the mite Sarcoptes scabiei.
Pathophysiology:
Mites burrow under the skin (~10 mm) and lay eggs
Mites can survive under the skin for 1-2 months; eggs hatch within 2-3 weeks.
Risk factors:
Direct contact with an infected individual or their linens
Just 10 minutes of skin-to-skin contact is sufficient for transmission.
Classic symptoms:
Intense itching, especially at night
Burrows may be visible
Papules and rash often appear in webbing of fingers, wrists, genitals
Mnemonic: “night itching + burrows = scabies.”
Complications: Scratching can result in:
Impetigo
Cellulitis
Diagnosis:
Primarily clinical assessment
Skin scraping might be utilized for confirmation
Treatment:
Use permethrin cream
Apply from head to soles
Leave on for 8–14 hours before washing off
Concurrent treatment for close contacts is also necessary
Nursing teaching:
Treat all close contacts
Wash bedding/clothes in hot water
Dry items on high heat
Vacuum furniture
Emphasize the importance of nail trimming and avoiding scratching
Reinforce follow up as reinfestation may occur.
Cooling measures:
Cool baths or compresses may alleviate symptoms
LICE (PEDICULOSIS)
Cause: Lice are parasitic insects that feed on human blood.
Types include:
Head lice (Pediculus humanus capitis)
Body lice (Pediculus humanus corporis)
Pubic lice (Pthirus pubis)
Pathophysiology:
Hypersensitivity reactions develop
Symptoms appear within 2-6 weeks post-exposure
Spread:
Close contact
Sharing combs, hats, and bedding
Symptoms:
Itching
Red bumps
Sores from scratching
Visible nits attached to hair shafts
Nits:
Lice eggs that are oval, tightly attached to hair, and often confused with dandruff
They are harder to remove than dandruff.
Diagnosis:
Primarily clinical through visualization of lice or nits, with potential use of a Wood lamp
Treatment:
First-line treatment: topical permethrin
Administer first treatment followed by a repeat treatment
Typically one week later
Environmental cleaning is necessary to prevent reinfestation.
Directions for permethrin application:
Shake well
Shampoo hair first (avoid conditioner)
Apply to towel-dried hair, protecting the eyes
Leave on for 10 minutes before rinsing with warm water
Remove nits with a fine-toothed comb
Caution:
Lindane and ivermectin are linked to neurotoxicity; caution is advised for use in children.
Nursing interventions:
Use fine-toothed combs for nit removal
Launder infested clothing and bedding in hot water, and dry on high heat
Trim fingernails to reduce the spread of infection.
MEASLES (RUBEOLA)
Cause: Measles is a highly contagious viral disease that is vaccine-preventable.
It induces immunosuppression and “immune amnesia.”
Pathophysiology:
First affects regional lymph nodes
Subsequently spreads throughout the body, affecting lymphoreticular cells of organs (spleen, liver, bone marrow)
Inflammation occurs as the virus infects various tissues
The virus continues to replicate, impairing the host's immune system
Spread:
Respiratory droplets
Saliva/contact
Virus can remain airborne for up to two hours
Incubation: Approximately 10-14 days
Early symptoms: Classic prodrome includes:
Fever
Cough
Coryza/rhinorrhea
Conjunctivitis
Then presents with Koplik spots in the mouth and a rash that starts at the hairline and spreads downwards
Mnemonic: “3 C’s + Koplik spots + descending rash.”
Diagnosis: Clinical diagnosis is often sufficient, but serology or PCR testing may be beneficial.
Treatment: Supportive care only, including:
Hydration
Nutritional support
Vitamin A supplementation on days 2 and 3
Infection control measures and airborne precautions for hospitalized patients
Nursing care:
Manage fever
Encourage fluid intake
Use humidification for cough/congestion
Promote rest
Monitor closely for breathing difficulties and dehydration
Provide family education and support as needed
Prevention:
MMR vaccine is vital
Practice isolation for cases and contact tracing during outbreaks
SUPER HIGH-YIELD MEMORIZATION BOX
Psychosocial stage for toddlers: Autonomy vs Shame and Doubt
Normal sleep needs: 11-14 hours/day
Toilet training: Age 2-4 years, with readiness being more critical than age
Red flags to watch out for:
Tantrums exceeding 5 per day
Tantrums lasting longer than 15 minutes
Extreme aggression
Regression lasting over 2-3 weeks
Severe changes in sleep/appetite
Persistent refusal to toilet train with complications
Live vaccines:
MMR
Varicella
Rotavirus
LAIV
MMR vaccine details:
Administered at 12-15 months and again at 4-6 years
Given subcutaneously
MMR is a live vaccine
DTaP vaccine details: Administered at 2, 4, 6, 15-18 months, and again at 4-6 years; delivered intramuscularly (IM).
Pneumococcal vaccine details: Given at 2, 4, 6, and 12-15 months, IM route.
Pinworms: Characterized by anal itching at night, diagnosed with the tape test during the morning, treated with mebendazole.
Chickenpox: Noteworthy for its itchy vesicles, avoid aspirin due to Reye’s syndrome risk; transmission includes airborne/contact routes.
Scabies: Presents with intense nocturnal itching and visible burrows, treated with permethrin applied from head to toe for 8-14 hours.
Lice: Involves the detection of nits attached to hair shafts, treated with permethrin with a repeat in 1 week.
Measles symptoms: Includes cough, conjunctivitis, coryza, Koplik spots, and rash that descends from the hairline.
Child says ‘no’ to everything: Reflects the autonomy and negativism phase.
Toilet training management: Should pause during significant family stress and retry later.
New baby leads to regression in toddler’s behavior: Often indicates sibling rivalry.
Feet dangling on the potty chair: Can decrease training success due to lack of stability.