The Toddler and Family: Promoting Optimum Growth and Development

Maternal Child Nursing Care, (Wong et al.) Chpt 37

 “The terrible twos”
 Ages 12 to 36 months
 Intense period of exploration
 Temper tantrums/obstinacy occur frequently

Biologic Development
 Weight gain slows to 4 to 6 lb/year
 Birth weight should be quadrupled by 2½
 Height increases about 3" per year
 Growth is steplike rather than linear

Sensory Changes
 Visual acuity of 20/40 acceptable
 Hearing, smell, taste, and touch increase in development
 Uses all senses to explore environment

Maturation of Systems
 Most physiologic systems relatively mature by the end of toddlerhood
 Upper respiratory infections, otitis media, and tonsillitis are common among toddlers
 Voluntary control of elimination
 Sphincter control—ages 18 to 24 months

Gross and Fine Motor Development

 Locomotion
 Improved coordination—between ages 2 and 3
 Fine motor development
 Improved manual dexterity age—12 to 15 months
 Throw ball—by 18 months

Psychosocial Development
 Erikson: developing autonomy
 Autonomy vs. shame and doubt
 Negativism
 Ritualization provides sense of comfort
 Id, ego, superego/conscience

Cognitive Development
 Piaget: sensorimotor and preconceptual phase
 Awareness of causal relationships between two events
 Learn spatial relationships

Invention of New Means Through Mental Combinations

 Imitation of behaviors
 Domestic mimicry
 Concept of time still embryonic

Preconceptual Phase
 Begins about age 2
 Transition between self-satisfying behavior and socialized relationships
Spiritual Development
 Spiritual routines can be comforting
 Religious teachings and moral development influence toddler behavior

Development of Body Image

 Refer to body parts by name
 Avoid negative labels about physical appearance
 Recognize sexual differences by age 2

Development of Sexuality
 Exploration of genitalia is common
 Gender roles understood by toddler
 Playing “house”

Social Development
 Differentiation of self from mother and from significant others
 Separation
 Individualization

Language
 Increasing level of comprehension
 Increasing ability to understand

Personal Social Behavior

 Toddlers develop skills of independence
 Skills for independence may result in tyrannical, strong-willed, volatile behaviors
 Skills include feeding, playing, dressing, and undressing self

Coping with Concerns Related to Normal Growth and Development

 Toilet training
 Sibling rivalry
 Temper tantrums
 Negativism
 Regressive behavior

Assessing Readiness for Toilet Training

 Voluntary sphincter control
 Able to stay dry for 2 hours
 Fine motor skills to remove clothing
 Willingness to please parents
 Curiosity about adults or sibling’s toilet habits
 Impatient with wet or soiled diapers

Promoting Optimum Health during Toddlerhood

 Nutrition
 Phenomenon of “physiologic anorexia”
 Sleep and activity
 Dental health
 Regular dental exams
 Removal of plaque
 Fluoride
 Low-cariogenic diet

Injury Prevention
 Motor vehicle injuries: car seat safety
 Drowning
 Burns
 Poisoning
 Aspiration and suffocation
 Bodily damage
Kids Are Different! They are not just little adults

Common Problems for Age

ADULTS
 Hypertension
 Diabetes
 Heart disease
 Alzheimer's
 Obesity
 Arthritis
 Lower back pain
 Cancer
 Respiratory
KIDs
 Accidents and Injuries
 Acute infectious diseases
 Resp --Asthma
 Obesity
 Diabetes
 Cancer
 Congenital

To recognize the abnormal you need to recognize the normal

Be Aware of:
 Developmental milestones
 Physical changes with age
 Normal vital signs for ages
 Parental relationship with the child
 Support persons

What do you know about kids?

 Develop from head to toe/ proximal to distal
 Organs are not as mature as an adult
 They are growing and developing
 Immune system is learning how to respond
 Move fast, talk fast and do things without considering the consequences
 Mentally fragile, need love, support and care

Nutrition
 Caloric need, (110 to 120 cal/kg/day
 fluid need (formula last quarter) by kg
 Routine
 Vitamin supplements, fluoride supplements
 Likes and dislikes
 Oral feeding, tube feeding, self feeder

SLEEP
 Sleep pattern and needs change with growth and age. (rapid growth requires more rest)
 Infants frequent extended rest
 School less but at least 8 to 10 hours
 Adolescent

Skin
 Protective role
Breaks down easily as infants and small
children–thin, easily damaged, sensitive .
 Lose body water and heat easily
 Quick assess for infection and pressure ulcers

Cardiac Risk factors in infants and children under 5 years

 At birth the ventricles are equal –by two months the left ventricle is larger due to the changes in vascular pressure.
 Cardiac muscle fibers are less developed and less organized resulting in limited functional capacity –immature
heart.
 Decreased stroke volume due to less ability to expand the ventricles ( less compliance)
 By age 5 years the heart muscle fiber are similar to the adult.

Upper respiratory system

 Nose—cartilage is soft, passage way is short and small, easily occluded.
 short Eustachian tube- shorter, straighter
 mucous membranes - soft and new- sensitive, increased mucus production- small amount can plug airway easily
 Mouth – sensitive gums; teething; decreased bacteria
 Smaller airways
 Larynx is more sensitive
 Throat - narrow, shorter passageway, easily obstructed; larger tonsillary glands
 Smallest part of the airway is the cricoid ring

Respiratory system
 The respiratory rate is higher in children
 This takes more energy and water
 Complianc- measure of how easily chest wall expands and recoils with breathing-peripheral airways are relatively
stiff
 Breath sounds “refer” easily through a child’s thin chest wall.
 Airway resistance – anything that opposes or retards flow of air
 Apnea more common in children

Respiratory Differences
 Chest – decreased chest expansion; fatigue easier- weaker muscles tire easily.
 Primarily diaphragmatic breathings
 Airways – flexible; spasm and collapse easily.
 Alveoli – fewer in number; develop as the child grows until school age.
 Decreased surfactant in lungs of premature infant.
 Increased metabolic rate increases O2 need
 Right bronchus more vertical.

Renal System
 Kidney function –born with all the nephrons at birth but they mature and increase in size as we grow years.
 Fluid needs vary with weight, exercise and body functions.
 Input and output is extremely important in children.

Bone structure-Affected by:

 nutrition, environment factors
 weight bearing capacity
 growth and age
 illness, treatment and medication
Nursing Interventions- must consider all the above when caring for the growing child

Changes in Body temperature

 Fever- increases metabolic rate by 10% for every 1 degree C leading to increased fluid needs, calorie and O2.
(Shivering increases this 3 to 4 times more) greater than 37.8 C (100 F)
Measurement of temperature
 Oral
 Ear
 Axillary
 Skin
 Rectal – never in a child who is receiving chemotherapy or clotting problems

When,Why and How to Treat Fever

 When – the degree of elevation, age of the child, possible causes
 Why – relief of discomfort, prevention of secondary responses
 How -- environmental approaches; medication

When caring for the Child: Birth through Adolescents

Consider:
 Age
 Body size, structure, surface area
 physical growth pattern and needs
 organ maturation and function
 immunity
 developmental ability
 psychosocial needs
 Family needs

Communication
 Techniques
Listen and look, use more Do”s than Don’t
Make request simple, communicate at eye level, get the child’s attention
Don’t talk about them or at them but to them, Respect them
 Be aware of stressors for age
 Be attentive to their developmental age
 Be honest
 Use play

Goals of parents, teachers and health care providers?

 To help every child reach their optimal potential:
 growth and development
 health issues
 psychosocial development
Pediatric health maintenance and screening
PURPOSE
 Primary --- preventing illness or injury before it begins
 Secondary – identification of illness at an early stage (screening)
 Tertiary--- directed toward minimizing disability and promoting rehabilitation

Primary – Prevention starts with day 1 and should continue throughout a lifetime
Examples of primary preventive measures from day 1: Newborn’s
 Screen mom’s before delivery
 Testing for metabolic, hematological and endocrine disorders; PKU
 Administer vitamin K, eye medication
 Immunizations
 Assess status, close observation during the first few days- nurses are the first on the scene!
 Vital signs – R(30-40) HR (100-140) T
 Respiratory effort, cardiac sounds, pulses, color,
 Reflexes- tongue extrusion, suck, swallow, rooting, palmar grasp, moro
 Urination, bowel movement
 Body measurements,
 Body movement- head support? Stiff, floppy, jerky?

Primary Prevention :
 Well child checks- 2 weeks to 18 years
plot growth, (pattern)
head circumference, weight
physicals
vision and hearing screens
development screens
temperament- “goodness for fit”
Immunizations
Anticipatory Guidance
 Education- Gordon’s functional health
nutrition
realistic expectation
sleep-rest
mobility
safety
love and security
SAFETY
 Name bands, bed rails, identify visitors,
 Mobility - transportation
 Restraints- IVs
 Education
 Baths or showers
 Toys
 Plants and gifts
 Set limits

Secondary
 Screening for an illness or injury: Clinic setting, school, ER, at hospital for work-ups. Recognize the problem
early and treat.

Tertiary Health Prevention

 Directed toward minimizing disability an promoting health.
 ROM, activity, distraction, nutrition, medication, Rehab, home health, family counseling,

So what makes Kids different?

 They are growing and developing!!!!
Many factors affect their growth and development and as nurse involved in their care we must
consider ever aspect of our care are a potential influence on their reaching their fullest potential.

Medication Administration
 Always check the proper dosage for the child’s for weight. (heparin, insulin and theophylline must always be
doubled checked by another RN before administration)
 Measuring device- use the one that will give you the most accurate dosage and is not bigger than what you may
need.
 Technique – check positioning; get help when needed, give the child a choice when possible; don’t give options
when there is none.
 Carefully choose the route, oral, SQ,IM,IV
 IV – be sure med is compatible with the solution and other medications running; is made for IV administration.
 IM
 site– consider muscle mass,(infants vastus lateralis, toddler ventrogluteal )
 amount to be given,
 needle length and gage

Treat the whole family

 Adjustment phase
 Culture and experience
 Parental response to illness

LOOK BEFORE YOU TOUCH - SEARCH

 Social stimulation
 Energy
 Appearance
 Reaction to parent (consol ability)
 Cry
 Hydration

Immunizations: review series approach and why necessary

Note: when a patient is behind in the series, never start over, just pick up where left off,
CDC has a schedule for “catch up”

 http://www.health.state.mn.us/divs/idepc/immunize/hcp/schedules.html

 Center for Disease Control