PHARCARE 1 PRELIMS

I. General Principles of Health Care Sickness - has been one of mans greatest adversaries Medicine - Latin word medicus - it is a HEALING ART - Aims to help people become more active, live longer, live happier lives with less suffering and disability. - has become a part of the health care industry * AT THE TURN OF THE 20th CENTURY (1900): - men and women were frail at the age of 40. - life expectancy was 47.3 years. * BY THE AND OF THE 20th CENTURY: - Medical Advances - Life expectancy increased to 76 years. * TODAY: - People in their 80s and 90s are independent and physically active. - Medical Advances have been expensive

MILD ELECTRIC SHOCK - used to stimulate the muscles and the mind - used to cure mental illness called FARADIZATION. * Cleaning and treating wounds by CAUTERY (burning or searing tissue), POULTICES, and SUTURES. * Resetting dislocations and fractures by using SPLINTS to support or immobilize broken bones. * Discovery of NARCOTICS and stimulating properties of certain plant extracts. DIGOXIN a heart stimulant extracted from FOXGLOVE (Digitalis purpurea). OPIUM POPPY (Papaver somniferum) - source of may opiates including MORPHINE (heroine), THEBANE, CODEINE, PAPAVERINE and NOSCAPINE.

HEALTH CARE PROFESSIONALS * 11.6 Million work in healthcare in other countries * 778, 000 Physicians * 2.1 Million Nurses * 160,000 Dentists * Research, teaching or administration of medical facilities.

HISTORY OF HEALTH CARE - Diseases were warded off by incantations, dancing, magic, charms & talismans. TREPANNING - the perimeter of the hole in the Skull is rounded off in growth of new bony tissue, indicating that the patients survived the operation. - Remedy for insanity, epilepsy and headache. Dr. John Clarke - First physician to perform the operation in U.S. SPINNIG TREATMENT - was one of many treatments that attempted to rid the body of mental through physical means. THE SPREAD EAGLE - used to treat disorderly patients - cold water was poured from a height over the persons face until the patient is calm.

PHARMACIST * Has a unique body of knowledge and skills to contribute in our healthcare system. *Dispenses appropriate drug product and has the knowledge to assure safe and rational use of drugs. EARLY FUNCTIONS OF PHARMACISTS 1. Assisting in the selection of appropriate drug therapy. 2. Preparing, compounding and manufacturing drugs for individualized patients. 3. Dispensing and packaging the prescribed drug products including proper labeling. 4. Advising and educating patients on proper use of drugs. 5. Monitoring the outcome and responses of patients to the effect of drugs, both beneficial and adverse. 6. Serving the community resource person on drug and health information.

THE TEN STAR PHARMACISTS Pharmaceutical Care Giver Researcher Manager Communicator Leader Life-long learner Decision-maker Entrepreneur Teacher Agent of Positive Change CONCERNS AMONG HEALTH CARE PROVIDERS (1) Potential abuse, misuses and inappropriate use of drugs. (2) Increase in health care cost (3) Patient suffering THE PATIENT-ORIENTED PROFESSIONAL - Able to apply and provide drug knowledge to improve drug uses in the health care system. PRIMARY AIM - To attain success in the goals of therapy. - Pharmacist must approach the patient-counseling encounter as a HELPER and an ECUDATOR. THE TRADITIONAL PHARMACIST - Involved in the preparation and dispensing of medications. - At the direction of the physician. - Strongly allied with the medical profession. - View that the health professional should be in control of the patient. THE MODEL - Shift in the model of Pharmacy - From the focus on the medication to a focus on the patient. Need for a shift in the pharmacists approach. - From the health professional-centered MEDICAL MODEL to the patient-centered HELPING MODEL. MEDICAL MODEL Patient is PASSIVE TRUST is based on EXPERTISE and AUTHORITY of pharmacist. Pharmacist IDENTIFIES problem and determine solution. Patient is DEPENDENT on pharmacist PARENT-CHILD Relationship HELPING MODEL Patient is ACTIVELY involved TRUST is based on PERSONAL relationship developed over time. Pharmacist ASSIST patients in exposing problems and possible soln Patient DEVELOPS SELFCONFIDENCE to manage problems EQUAL relationship

PQL - Patient Quality of Life - Welfare of humanity and the relief of human suffering is the primary concern. - Must learn to view medications use from the patients perspective. AN OATH I will use knowledge and skills to the best of my ability in serving the public and other health professionals. HEALTH - a GOAL TO STRIVE FOR - it is NOT ATTAINABLE CURE - Latin word cura CARE - Providing for the welfare of another - Attentive conscientiousness of devotion - Conveys a compassionate state of being and not merely attitude - Involves a profound respect for the otherness. CHARACTERISTICS OF A CARING BEHAVIOR: VITAL COMPONENTS OF A THERAPEUTIC RELATIONSHIP Mutual respect Honesty/Authenticity Open communication Cooperation Collaboration between patient and practitioner Empathy Sensitivity Promotion of patient independence Seeing the patient as a person Exercising patience and understanding Trust Competence Putting the patient first Offering reassurance Confidence Paying attention to the patients physical and emotional comfort Supporting the patient Offering advocacy Assuming responsibility for intervention Being willing to be held accountable for all decisions made and recommendation given

HEALTH CARE NEEDS OF A PATIENT MEDICAL Care MENTAL HEALTH Care DENTAL Care NURSING Care CHIRO-PRACTICE Care PEDIATRIC Care MATERNAL Care I Care Geriatric Care Pharmaceutical Care Surgical Care Nutritional Care Eye Care PRIMARY CARE - FRONT-LINE or FIRST CONTACT CARE - Person-centered - Comprehensive in scope - Not limited INTERACTIONS (Patient & other Health Care Providers) - COUNSEL - CONSULT - EDUCATION 4 Rs OF THE PHILOSOPHY OF PRACTICE - RULES - ROLES -RELATIONSHIP - RESPONSIBILITIES PHARMACEUTICAL CARE - A RESPONSIBLE PROVISION OF THERAPY for the purpose of ACHIEVING DEFINITE OUTCOMES that IMPROVE THE PATIENTS QUALITY OF LIFE. - Applying knowledge to promote the well being of others. - Requires responsiveness, sensitivity and commitment to others. -Generalist practice that emphasizes health, prevention and care. -A form of primary health. THE FOCUS 1. Patient-centeredness 2. Addressing both acute and chronic conditions 3. Emphasizing prevention 4. Implementing documentation systems that continuously record patients needs and care provided. 5. Being accessible to front-line or first contact. 6. Ensuring integration of care. 7. Being accountable

8. Placing emphasis on ambulatory patient. 9. Including education/health promotional intervention. 5 FACTORS TO BE CONSIDERED IN PHARMACEUTICAL PRACTICE 1. DENIAL 2. ANGER 3. DERPRESSION 4. BARGAINING 5. ACCEPTANCE VITAL POINTS Dont assume patients had information from the doctor Dont assume patients understand all information given Dont assume patients have resources to comply Dont assume patients dont care or are stupid Dont assume patients will comply if they understand Dont assume others will monitor of followup Dont assume patients will voluntarily seek help or information if there are problems
TRADITIONAL Primary Focus Continuity Strategy Orientation Rx order or OTC request Upon Demand Obey Drug Product CLINICAL Physicians or other health professionals Discontinuous Find Fault or Prevention Process
PHARMACEUTICAL CARE

PATIENT

CONTINOUS ANTICIPATE or IMPROVE OUTCOMES

WHAT A PHARMACIST CAN DO? - MINIMIZE WASTE and MAXIMIZE BENEFITS of medical treatments THE ROLE OF THE NEW PHARMACISTS Has evolved from being PRODUCT-ORIENTED to a PATIENT-ORIENTED professional. Extremely HEALTHY FOR BOTH PATIENT and PHARMACIST. Dispensers of therapy and drug effect interpretations as well as drugs. In the future, pharmacy services MUST be evaluated on PATIENT-OUTCOME rather that the number of prescriptions dispensed. It MUST be evolved TOWARDS INTERPRETATION and PATIEN CONSULTATION, related to the use of medication technologies.

TRANSFORMATION OF HEALTH CARE OLD PARADIGM NEW PARADIGM Emphasis on ACUTE Emphasis on the PATIENT CARE CONTINIUM OF CARE Emphasis on TREATING Emphasis on MAINTANING ILLNESS & PROMOTING WELLNESS Responsible for Accountable for HEALTH INDIVIDUAL PATIENTS DEFINE POPULATIONS All providers are DIFFERENTIATION based essentially SIMILAR on ability to value. Success achieved by Success is achieved by INCREASING MARKET INCREASING THE NUMBER SHARE OF IN-PATIENT OF COVERED LIVES AND KEEPING PEOPLE WELL. Goal is to FILL BEDS Goal is to PROVIDE CARE AT MOST APPROPRIATE LEVEL. Hospitals, physicians and Integrated Health System health plans are separate. II. OVERVIEW OF HEALTH CARE PATIENT - Any recipient of medical attention care or treatment. - Originally meant one who suffers. - health consumer, health care consumer or client. OUTPATIENT - An outpatient is a patient WHO IS NOT HOSPITALIZED FOR 24 HOURS OR MORE but who VISITS A HOSPITAL OR CLINIC OR ASSOCIATED FACILITY FOR DIAGNOSIS OR TREATMENT. INPATIENTS (Ampulatory Patients) - An inpatient is ADMITTED TO THE HOSPITAL AND STAYS OVERNIGHT OR FOR AN INTERMIDIATE TIME, usually several days or weeks or even years. * We MUST understand the patients as someone who possessed certain: Strengths Vulnerabilities Preferences Worries and Fears Hopes and Joys THE PATIENT IS THE CENTRAL REASON FOR YOUR WORKS AND THE ONLY REASON FOR A HEALTH PROFESSION.

* Our VALUES, BELIEFS, ATTITUDES, and CONCEPTS DEFINE US AS A PERSON. * The CRITICAL FRAME determines the patients beliefs about their health and health-related needs. THE PATIENTSS CONCEPT OF HEALTH - Begin by UNDERSTANDING THE WAYS THAT HEALTH PROFESSIONALS AND PATIENTS CONCEPTUALIZE HEALTH. - Health thinking, from the health professions perspective, has historically been based on a disease concept founded in the traditional biomedical model. DISEASE - Disease is any abnormal condition, affecting either the whole body or any of its parts, which impairs normal functioning. - Disease is described in terms of negative symptoms combined with the directly related physical pathology that causes those symptoms. - In this model, the concept of health is represented by THE ABSENCE OF DISEASE. CONCEPTUAL FACTORS How do you know what concept the patient has of health? Each of us has our own concept, but it is formed by many factors like, CULTURAL INFLUENCES, VALUES and BELIEFS. CULTURAL INFLUENCES - CULTURE is described as a property of society. - No such thing as a pure culture, because there is diversity, often recognizable as SUBCULTURES. - VARIATION may exist in education, socioeconomic status, and practiced religions. Access to care will continue to be segregated into 3 identifiable groups of patient: 1. EMPOWERED CONSUMERS who have resources, use technology, and WANT TO SHARE IN HEALTH DECISION MAKING. 2. WORRIED CONSUMERS who have health insurance but NO CHOICE IN PLAN. 3. PEOPLE WHO ARE EXCLUDED because they have no form of health insurance or method of payment other than OUT OF POCKET. * Pharmacists should view health and illness from the patients perspective

III. CONCEPTS OF HEALTH * How can we understand a persons culture in a way that helps to meet his or her health care goals and needs? Learn the values and attitudes considered important enough to pass down from one generation to the next. Understanding a patients cultural view of illness. CAMPINHA-BACOTE - Described this model of CULTURAL COMPETENCE IN HC DELIVERY as a framework for developing and implementing culturally responsive care. -The model assumes that culture competence is a process, not an event. - It recognizes that there is more variation within ethnic groups than across groups. - It assumes that the provision of culturally responsive care is directly related to the health professionals level of competence in the context of each patient. THE MODEL DEFINES THE CONCEPTS AS FOLLOWS: 1. CULTURAL AWARENESS is the SELFUNDERSTANDING of ones own cultural and professional background. 2. CULTURAL KNOWLEDGE is the PROCESS OF SEEKING AND OBTAINING AN EDUCATIONAL FOUNDATION about different cultural and ethnic groups. 3. CULTURAL SKILL is described as the ABILITY TO COLLECT RELEVANT CULTURAL DATA ABOUT THE PATIENTS PROBLEM as well as performing a culturally based physical assessment. 4. CULTURAL ENCOUNTER involves the HEALTH PROFESSIONAL ENGAGING IN CROSS-CULTURAL INTERACTIONS with individuals from diverse backgrounds. 5. CULTURAL DESIRE is the MOTIVATION OF THE HEALTH CARE PROVIDER TO ENGAGE IN THE PROCESS OF CULTURALLY RESPONSIVE CARE. HOW DOES ONE BECOME CULTURALLY COMPETENT? 1. Live with the group 2. Learning can be accomplished through reading convening focus groups Participating in community activities. CONCEPTS OF HEALTH HEALTH - Old English word for heal (hael) - WHOLE - Whole person and his or her integrity, soundness, or well-being. - Is the state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity (WHO) - Is the quality of life involving social, emotional, mental, and biological fitness on the part of the individual, which results in adaptations from the environment. 2 COMMON MEANINGS OF HEALTH FOR EVERYDAY USE: NEGATIVE DEFINITION POSITIVE DEFINITION Absence of Disease A state of well-being and Illness A state of complete physical, mental, and social well being not merely the absence of disease or infirmity.(WHO) 6 DIMENSIONS OF HEALTH PHYSICAL Health MENTAL Health EMOTIONAL Health ENVIRONMENTAL Health SOCIAL Health SPIRITUAL Health HOLISTIC HEALTH - is an approach that IDENTIFIES COMPONENTS OF HEALTH that function interdependently to influence an individuals health. WELLNESS - No generally accepted definition exists - Often is used interchangeably with health - Usually indicates a holistic approach that emphasizes personal responsibility toward health - It refers to an ONGOING EFFORT TO ACHIEVE OPTIMAL WELL-BEING. - Wellness is well-being. It involves engaging in attitude and behavior that enhance quality of life and maximize personal potential. - Well being is a subjective perceptive of BALANCE, HARMONY and VITALITY - Wellness is a choice

WELLNESS - Wellness is a way of life - Wellness is the integration of body, mind and spirit - Wellness is the loving acceptance of ones self. PRECUSOR OF ILLNESS * HEREDITARY Family history for diabetes mellitus, hypertension, cancer * BEHAVIORAL FACTORS Cigarette smoking, alcohol abuse, high animal fat intake * ENVIRONMENTAL FACTORS Overcrowding, poor sanitation, poor supply of potable water SYMPTOMS OF ILLNESS 1. SYMPTOM EXPERIENCE Examples: Transition stage The person believes something is wrong Experience some symptoms 3 aspects: o Physical fever, muscle aches, malaise, headache o Cognitive perception of having Flu o Emotional (worry on consequences of illness) 2. ASSUMPTION OF SICK ROLE Examples: Acceptance of the illness Seeks advice, support for decision to give up some activities 3. MEDICAL CARE Examples: Seeks advice of health professionals for the following reasons o Validation of real illness o Explanation of symptoms o Reassurance or prediction of outcome 4. DEPENDENT PATIENT ROLE Examples: The person becomes a client dependent on the health professional for help Accepts/rejects health professionals suggestions Becomes more passive and accepting May regress to an earlier behavioral stage 5. RECOVERY/REHABILITATION Example: Gives up the sick role and returns to former roles and functions

DISEASE - An alteration in body functions resulting in REDUCTION OF CAPACITIES OR A SHORTENING OF THE NORMAL LIFE SPAN. COMMON CAUSES OF DISEASE BIOLOGICAL AGENTS microorganisms INHERITED GENETIC DISEASES- Achondroplasia DEVELOPMENTAL DEFECTS - imperforate anus - Cleft palate PHYSICAL AGENTS - hot and cold substances, - radiation - ultraviolet rays CHEMICAL AGENTS lead, emissions from smokebelching cars TISSUE RESPONSE TO IRRITATION fever - Inflammation METABOLIC PROCESS inadequate iodine causing goiter, inadequate insulin in diabetes mellitus EMOTIONAL/PHYSICAL REACTION TO STRESS anxiety, fear RISK FACTOR OF A DISEASE Genetic and Physiological Factors Age Environmental Lifestyle CLASSIFICATION OF DISEASE A. According to Etiologic Factors 1. HEREDITARY due to defect in the genes of one or other parent which transmitted to the offspring Examples: diabetes mellitus, hypertension 2. CONGENITAL due to a defect in the development, hereditary factors, or prenatal infection; present at birth Examples: cleft lip, cleft palate 3. METABOLIC due to disturbance or abnormality in the intricate processes of metabolism Examples: diabetes mellitus, hyperthyroidism 4. DEFICIENCY results from inadequate intake or absorption of essential dietary factors Examples: osteomalacia, which is vitamin D deficiency in adults 5. TRAUMATIC due to injury Examples: fractures

6. ALLERGIC due to abnormal response of the body to chemical or protein substances or to physical stimuli Examples: asthma, skin allergy 7. NEOPLASTIC due to abnormal or uncontrolled growth of cancer cells 8. IDIOPATHIC cause in unknown; self-originated; of spontaneous origin Example: cancer 9. DEGENERATIVE results from the degenerative changes that occur tissue and organs Examples: osteoporosis, osteoarthritis 10. IATROGENIC results from the treatment of a disease Examples: hypothyroidism after thyroid surgery; alopecia (hair Loss) after chemotherapy B. According to Duration or Onset 1. ACUTE ILLNESS usually has a short duration and is severe Examples: appendicitis 2. CHRONIC ILLNESS usually longer than 6 months and can also affect functioning in any dimension Examples: hypertension Remission period during which the disease is controlled and symptoms are not obvious Exacerbation The disease becomes more active again at a future time, with recurrence of pronounced symptoms C. Others. Diseases may also describe as: 1. ORGANIC any health condition in which there is an observable and measurable disease process. e.g. inflammation or tissue damage 2. FUNCTIONAL no anatomical changes are observed to account for the symptoms present, may result from abnormal responses to stimuli. Examples: irritable bowel syndrome 3. OCCUPATIONAL results from factors associated with the occupation engaged in by the patient Examples: cancer among chemical factory workers 4. FAMILIAL occurs in several individuals of the same family Examples: hypertensive, cancer 5. VENEREAL usually acquired through sexual relation Examples: AIDS, gonorrhea

6. EPIDEMIC attacks a large number of individuals in a community at the same time Examples: SARS 7. ENDEMIC present more or less continuously or recurs in a community Examples: malaria in Palawan, goiter in Mountain Province 8. PANDEMIC an epidemic disease which is extremely widespread involving an entire country or continent 9. SPORADIC a disease in which only occasional cases occur Example: Dengue during rainy season, leptospirosis during floods HEALTH PROMOTION MODEL INDIVIDUAL PERCEPTIONS MODIFYING FACTORS PARTICIPATION IN HEALTH INDIVIDUAL PERCEPTION * Perceived susceptibility to an illness Example: Family history to diabetes mellitus increases risk to develop the disease * Perceived seriousness of an illness Example: diabetes mellitus is a lifelong disease * Perceived threat of an illness Example: Diabetes mellitus causes damage to the brain, heart, eyes, kidneys, blood vessels MODIFYING FACTORS * Demographic variables Examples: Age, Sex, Race * Structural variables Example: knowledge about the disease * Sociopsychologic variables Examples: social pressure or influence from peers * Cues action Examples: internal: fatigue, uncomfortable symptoms; external: mass media, advice from Others. LEAVELL AND CLARKS AGENT HOST-ENVIRONMENT MODEL 1. AGENT any factor or stressor that CAN LEAD to illness or disease 2. HOST persons who may or may not be AFFECTED by a disease 3. ENVIRONMENT any factor external to the host that may or may not PREDISPOSE the person to a certain disease

HEALTH SYLE - The sum of personal health decisions that affect the individual and the community - Both very personal and very interpersonal It is described as being influenced by 1. The information you have about your health 2. Your values 3. Your social support 4. Your health-related skills 5. Your health-related resources 6. The momentum developed by your healthrelated decisions INDICATORS OF HEALTH STATUS * PERSONAL HEALTH STATUS 1. Satisfaction with life 2. Zest for life 3. Functional level of physical fitness 4. Minimum of illness * COMMUNITY HEALTH STATUS 1. MORBIDITY refers to the rate of ILLNESS in a group. MORTALITY refers to the rate of DEATH in a group. 2. LIFE EXPECTANCY refers to the number of years a person is expected to live FACTORS THAT AFFECT HEALTH BEHAVIOR AND STATUS Race Sex Income PREDISPOSING, REINFORCING, AND ENABLING FACTORS * PREDISPOSING FACTORS 1. Life experience 2. Knowledge 3. Cultural and ethnic heritage 4. Beliefs and values * ENABLING FACTORS 1. Abilities 2. Mental and Emotional capabilities 3. Resources 4. Facilities * REINFORCING FACTORS 1. Support 2. Encouragement and discouragement from people in your life

ACTIVITIES TO PROMOTE HEALTH AND PREVENT ILLNESS 1. Have a regular physical examination (yearly) 2. Women o Regular PAP test o Monthly BSE (breast self-examination) 3. Men o Regular testicular self examination 1. Annual dental examination 2. Regular eye examination 3. Exercise regularly (3x/wk for 30 mins.) 4. Do not smoke, avoid second hand smoke 5. Avoid alcohol, recreational drugs 6. Reduce fat and increase fiber in diet 7. Sleep regularly 8. Maintain ideal body weight

IV. STAGES OF HUMAN DEVELOPMENT INFANCY (1 month to 1 year) Developing a sense of trust and belonging from a relationship with mother and father Differentiating self from environment Learning o Eat solid food o Walk o Explore o Communicate TODDLER (1 to 3 years) Developing o Will power o Independence Learning o Exploring environment o Run o Communicate verbally o Control urination PRESCHOOL (3 to 6 years) Working on o Autonomy o Dressing self o Washing Developing sense of o Time o Space o Distance o Imagination

SCHOOL-AGE (6 to puberty) Developing o Sense of work o Planning and carrying out projects o Learning the skills for survival in the childs culture o Developing modesty o Playing cooperatively Learning o Read o Calculate Developing neuromuscular coordination Learning to control emotions ADOLESCENT (12 to 20 years) Developing o Physical maturity o Autonomy from home and family o Self-identity Coping with body images YOUNG ADULTHOOD (18 to 40 years) Establishment of enduring close physical and emotional relationships Child bearing Child rearing Establishing financial security Community responsibility Social interaction with peers MIDDLE ADULT (40 TO 65 years) Separation from children Establishment in a job Adapt to aged parents Adapt to physiological changes of aging Adjustment to altered relationship with spouse OLDER ADULT (40 TO 65 years) Acceptance of own life as valuable and appropriate Adaptation to reduced physical health and strength Possible death of spouse Adjustment to retirement income Development of relationship with new family members Adaptation to change in living location and style *Development proceeds in orderly and predictable pattern *Thorough knowledge of normal behavior is required to detect abnormalities in development

MAJOR DEVELOPMEMTAL TASK * BEHAVIOR An expression of complex interaction FOUR FIELDS: o MOTOR behavior o ADAPTIVE behavior o LANGUAGE development o PERSONAL SOCIAL behavior MOTOR BEHAVIOR * GROSS MOTOR Involves posturing of the head, trunk and extremities Necessitates movement of all or much of the body * FINE MOTOR Illustrated by well-coordinated movements of small muscles o Fingers ADAPTIVE BEHAVIOR Most significant Most closely related to intelligence Involves: o Ability to utilize and manipulate objects o Motor and sensory coordination in the solution of practical problems o Resourcefulness in using past experience in adjusting to new situations LANGUAGE DEVELOPMENT Ability to understand another person and to be able to make oneself understood o Reflex sounds and feeble gestures (3rd week) Crying Cooing o Babbling (3rd to 8th month) Ma-ma, da-da o Gestures (starts at the 4th month) o Word usage PERSONAL SOCIAL BEHAVIOR Affected by environment and culture Includes: o Habits affecting feeding, bowel and bladder control o Ability to get along with other people

DEVELOPMENTAL MILESTONES NEWBORN Tonic neck reflex position when supine Fisted hands Complete head lag Dolls eye movement Startles (Moro reflex) 1 MONTH Legs more extended Raises head slightly from prone position Watches person, follows moving object Smiles, diminishes activity when talked to 2 MONTHS Symmetrical position Head control up to 45 from prone position Hands no longer fisted Change in activity when spoken to Vocalizes (small throaty sounds) 3 MONTHS Moves head towards sound Holds rattle temporarily Alert 4 MONTHS Can follow moving objects with eyes Both hands activate towards toy Takes toy in hand to mouth 5 MONTHS Good head control Laughs loudly Reaches for objects 6 MONTHS Sits with support Rolls over 7 MONTHS Plays with rattle Bounces Recognizes familiar faces 8 MONTHS Transfers objects from hand to hand Sits without support Imitates hand movement Sits well Holds bottle when feeding Creeps

10 MONTHS Pulls to feet Uses thumb and index finger to hold small objects Understands gestures 11 MONTHS Stands with support Does nursery games (peek-a-boo) Repetitive consonant sounds (mama) Two words with meaning Responds to sound of name 12 MONTHS Stands alone Cruises or walks holding to furniture Attempts to use a spoon Obeys commands or requests Cooperates in dressing 15 MONTHS Walks alone, crawls up stairs Feeds self with spoon Builds tower of 2 cubes Jargon, four to five words Hugs parents 18 MONTHS Seats self in childs chair Creeps up stairs Builds tower of 3 cubes Imitates a vertical stroke Plays ball Has 10 words 24 MONTHS Runs well Can go up and down the stairs Uses a fork Combines 2 or 3 words in a sentence Toilet-trained during the day 2 YEARS Runs well Can go up and down the stairs Uses a fork Combines 2 or 3 words in a sentence Toilet-trained during the day 2 YEARS Jumps Builds tower of 6 cubes Imitates a circle Dry by night

3 YEARS Stands on one leg Builds tower of 10 cubes Knows sex and full name Dresses self except for buttons and tying shoes 3 YEARS Rides tricycle Dresses self except for buttons and tying shoes Counts to 3 or more 4 YEARS Walks up and downstairs alternating feet Imitates a cross Recognizes 2 or more colors Cleans oneself, combs hair and brushes teeth 6 YEARS Can write fairly well Draws a complete person with clothes Adds and subtracts Distinguishes between left and right Dresses self completely