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Musculoskeletal – muscle size, strength, posture, body


Growth and Develiopment alignment, symmetry, ROM, gait, joint mvmt, swelling,
Dr Daphne Miranda redness, tenderness
PEDIATRIC NURSING HEALTH ASSESSMENT t. Neurologic – cerebral function, cranial nerve function,
DTR’s, balance and coordination
General considerations
1. Child DEFINITION
- maintain eye contact, bend to child’s level Growth
- Use appropriate language - size, cm, kg
- Allow child some warm up time Development
- Respect child’s response, need for privacy - skill
- Incorporate play - complexity of function
2. Family Considerations
- encourage parents participation IMPORTANCE OF KNOWLEDGE OF GROWTH AND
- choose quiet environment for teaching and assessment DEVELOPMENT
- ask open ended questions 1. Health promotion and Illness prevention
- Focus on information needed or problem 2. Health restoration and maintenance
- Listen attentively, respect response, provide feedback
- encourage questions STAGES OF GROWTH and DEVELOPMENT
Health History A. 1st
Biographical data Prenatal – conception – birth
Chief complaint B. 2nd
Current or health status Neonate - birth - 28 days
Past health Infant - 1 month - 1 yo
Review of systems C. 3rd
Family history Toddler - 1 - 3 yo 1-6 yo (early childhood)
Nutritional history Preschool - 3 - 6 yo
Psychosocial history – home and family structure, school and D. 4th
work, activity and discipline assessment, sexual and School age - 6 - 12 yo (middle childhood)
substance abuse assessment of adolescents Adolescence - 13 - 18 yo
Age related interview techniques
Infant: speak softly, allow infant to identify you w/ a parent, PRINCIPLES OF GROWTH and DEVELOPMENT
use touch 1. Continuous
Toddler: allow toddler to stay close to parent, focus on 2. Orderly and sequential
favorite toy or unique characteristics of child 3. Highly individualized
Preschooler: use simple questions and words, 4. Different rates
allow child to manipulate equipment, use puppets 5.Cephalocaudal
and play 6. Proximodistal
School age: offer explanations, teach about health, provide 7. Simple to complex
demonstrations Adolescents: maintain confidentiality, 8. Sensitive periods
facilitate trust, open and honest communication, 9. Practice
nonjudgmental
Physical Assessment FACTORS THAT AFFECT GROWTH and DEVELOPMENT
- Complete less threatening and less intrusive procedure first
to secure child’s trust Explain actions, what child should I. Genetics
expect and let child manipulate equipment a. Gender
Developmental Approaches b. Health
a. Infant: allow infant to sit on parent’s lap, encourage c. Intelligence
parents to hold infant, use distraction, enlist parent’s help d. Temperament
b. Toddler: allow toddler to sit on parent’s lap, enlist parent’s
assistance, use play, praise cooperation Types of temperament
c. Preschooler: use storytelling, doll, and puppet Easy children – even tempered, regular and predictable;
d. School age: maintain privacy, explain procedure and react to stimuli positively
teach child about body Difficult children – irritable, highly active and intense; react w/
e. Adolescent: provide privacy and confidentiality, provide negative withdrawal
options Slow to warm up – moody, inactive and moderately irregular;
Head to toe assessment react w/ mild but passive resistance
a. Measurements
- height and weight, head circumference < 2 yo Nursing Management
b. General Appearance – alertness, LOC, physical Understand variations
appearance, nutritional state, hygiene, behavior, Provide parents information
interaction w/ parent and nurse, overall development Provide health education esp for families of children w/
c. Skin – color, texture, turgor, temperature, lesions, scars, illness
edema, tatoos Assess development
d. Hair – distribution, characteristics, lice
e. Nails – texture, shape, color, condition FACTORS THAT INFLUENCE GROWTH AND
f. Lymph nodes – swelling. Mobility, temperature, DEVELOPMENT
tenderness II. Environment
g. Head – size, shape, symmetry, fontanelles a. Socioeconomic level
h. Eyes – visual acuity b. Parent-Child Relationship
i. Ears – hearing acuity c. Ordinal position in the family
j. Nose and sinuses – discharge, tenderness d. Health
k. Mouth – tooth eruption, condition of hums, lips, teeth,
palates, tonsils, tongue, buccal mucosa THEORIES OF GROWTH AND DEVELOPMENT
l. Neck – suppleness and range of motion Developmental task
m. Chest – shape, breasts, discharge, lesions
n. Lungs – breath sounds - skill or growth responsibility arising at a particular time
o. Heart – sounds, murmurs, rubs in an individual’s life
p. Abdomen – umbilicus, sape, bowel sounds, hernias, liver, - foundation of accomplishment of future tasks
spleen, kidneys, masses/tenderness
q. Genitalia Erickson’s Theory of Psychosocial Development
female – stage of sexual devt, vulva, meatus, ext Trust vs Mistrust -infant
genitalia, discharge, lesions T: safe environment; dependable people
male – sexual devt stage, penis, scrotum, testes, urinary M: suspicious, fearful, shun emotional involvement
meatus, discharge, lesions NI: provide primary caregiver and visual stimulation
r. Anus – fissures, bleeding
Autonomy vs Shame and Doubt – toddler Postconventional (level III)
A: build on new motor and mental abilities, take pride in Stage 5 & 6 - >12
accomplishments following standards for everyone’s good
S: doubt and stop trying
NI: provide opportunities for decision making and give “Social Contract”
praises “Principled conscience”
Initiative vs Guilt – preschool
I: how to do things Harry Sullivan
G: limited brainstorming and problem-solving skills Prototaxic mode – infancy – need for bodily contact and
NI: provide opportunities for exploration, answer questions love; anxiety d/t unmet needs
and do not inhibit fantasy Parataxic mode – 2-5 yo - parents viewed as source of
Industry vs Inferiority - school age praise and acceptance
Ind: how to do things well Syntaxic mode – 5-8 yo - logical, rational and most mature
Inf: always worried about poor or incorrect performance type of cognitive functioning; need for peers and how to deal
NI: provide opportunities for completing short projects, give w/ them
praise and rewards
Identity vs Role Confusion – adolescent
I: integrate image into a whole
R: unsure of who they are or who they can become, may
rebel
NI: provide opportunities to discuss feelings and support and
praise for decision-making

Freud’s Psychoanalytic Theory


Oral – infant
- oral stimulation for nutrition, enjoyment and release of
tension
NI: provide oral stimulation – pacifiers, breastfeeding,
thumbsucking
Anal - toddler
- elimination is a way of discovery and exerting
independence
NI: achieve bowel and bladder control even if
hospitalized
Phallic – preschool
- increased knowledge of 2 sexes
NI: accept sexual interest and answer questions about birth
or sexual difference
Latent - school age
- libido diverted to school
NI: achieve positive experiences to promote self esteem
Genital - Adolescent
- establish sexual aims and finding new love objects
NI: opportunities to relate w/ opposite sex; verbalization
about new feelings

Piaget’s Theory of Cognitive development

Sensorimotor 1 mon-24 mo
- relate through senses, separate from environment,
practical intelligence
Preoperational Thought 2-7 yo
toddler: symbolic thought, simple abstractions, literal
thinking, poor concept of time and distance, transductive
reasoning
pre-schooler: centering, egocentric, no reversibility, no
cause and effect, assimilation, role fantasy
Concrete Operational Thought 7-12 yo
- systematic reasoning
- memory to learn broad concepts and subgroups
- seriation and classification
- reversibility
- inductive reasoning (specific to general)
- conservation (7 yo – numbers; 7-8 yo quantity; 9 yo –
weight; 11 yo – volume)
Formal Operational Thought 12 yo
- solve hypothetical problems, causality, time
- talk time to sort attitudes and opinions

Kohlberg’s Theory of Moral Development


Preconventional (Level I)
Stage 1 - 2-3 yo
“mother or father says so”
punishment obedience orientation
Stage 2 - 4-7 yo
“mother says it’s wrong”
individualism/egocentrism
Conventional (Level II)
Stage 3 – 7-10 yo DEVELOPMENTAL AGE
“nice girl, nice boy”
PERIODS
Stage 4 – 10-12 yo
following rules is satisfying
“Law and Order”
Characteristics 8 mos - sits w/o support
Growth and 9 mos - pulls self to stand
Development Milestones - creeps
Reaction to Illness 10-11 mos – cruises
12 mos – stands alone; walks
INFANCY – 0-1 yo with someone’s hands
4-6 mos -2x birthweight
- 1ST 6 mos – 2 lb/mo; 2nd - 6 FINE MOTOR
mos – 1 lb/mo 1 mo - eyes to midline
1 yo - 3x birthweight 3 mos – eyes past midline
HC=CC 6-12 mos 4 mos –bring hands together
50% inc in height; 5 mos – grasps/reaches obj
- 1st 6 mos – trunk; 1 in 6 mos – holds obj in 2 hands
- 2nd 6 mos – legs 7 mos - hand to hand transfer
2/3 brain growth 9-10 mos - pincer grasp
HR 100-120 bpm - points at obj
RR 20-30 11 mos - bangs objects
12-18 mos - Ant fontanel together
· 2 mos - Post fontanel 12 mos - throws toys
- Immune - attempts 2 tower blocks
system LANGUAGE
· 4 mos - Liquids to solids 1 mo - throaty gurgling sound
· 6 mos - Shivering 2 mos - differentiate a cry
- Tooth eruption 3 mos - squeals
· ECF 35%, ICF 40% 4 mos - coos and gurgles
Health visits – 2 weeks, 2 - moves head to sound
mos, 4 mos, 6 mos, 12 mos 5 mos - simple vowel sounds
7-8 mos - “ma” when crying
9 mos - mama, dada;
GROWTH AND understands no-no
DEVELOPMENTAL 10 mos - understands
MILESTONES gestures
GROSS MOTOR - responds to name
2 mos - 45 deg head ctrl 12 mos - obeys commands
3 mos - 90 deg head ctrl - one word other
4 mos - lifts head & chest on than mama, dada
prone PERSONAL SOCIAL
- rolls over 2 mos - social smile
5 mos - 6 mos - good head 4 mos - plays with rattle;
ctrl enjoys social interaction
- sits w/ 7 mos - feeds self w/ crackers
support - recognizes familiar
faces
8 mos - peek-a-boo Immature liver – inefficient
- stranger anxiety storage and formation of
9 mos – waves bye bye nutrients
10 mos – nursery games Extrusion reflex – until 4 mos
11 mos – holds arm or foot Calories: 100-115 kcal/kg/day
out in dressing 0-3 mos - breastmilk
12 mos – attempts to use 4-6 mos - semi-solid food
spoon; shows jealousy and Introduce one at a time
affection Start with small quantities
PLAY – solitary play Cereals, strained
1-3 mos vegetables, meat
Balloon mobiles 7-9 mos - Finger food, fluids
Mirror play 10-12 mos – 3 meals w/
Stuffed animals snacks
rattles Water – 125-150 ml/k/day
Being held from 0-6 mos
4-6 mos - 135 ml/kg/day from 6-
Squeeze toys 12 mos
Busy boxes DAILY CARE
Play gyms - bathing
7-9 mos - diaper care
Block play - care of teeth
Splashing bath toys - dressing
Cloth textured toys - sleep – 10-12 hrs/day; 1 or
Large balls more naps by 12 mos old
10-12 mos - exercise
Picture books Concerns
Large blocks - Constipation
Nesting cups - Teething – cleanliness
PLAY - thumb sucking – until
Peek-a-boo school age
Rocking - pacifiers – wean after 3
Singing games mos
Squeaky toys - head banging – begin 2nd
Pat-a-cake half of infancy to
Peek-a-boo preschool, naptime,
Feet & toes games under 15 min
Fingers & hand games - sleep problems –
Listening to stories breastfed infants wake up
Making faces sooner;
NUTRITION - spitting up
Lipase – dec until 1 yr - diaper dermatitis
Amylase – dec until 3 mos - miliaria/prickly heat –
papular, erythematous on
neck, ear, face, trunk
- baby bottle syndrome
- Loose stools – breastfed
- Colic – paroxysmal
abdominal pain, < 3 mos, inc
in formula fed
- Obesity – 32 oz formula
daily, add fiber and water to
diet
- Stranger anxiety
REACTION TO ILLNESS
Discomfort and pain
Lack of stimulation
Separation anxiety
Disruption of routine
NURSING CARE
Soothing stimulation
Toys from home
Human contact
Provide/Anticipate needs

TODDLER – 1 –3 yo
TODDLER – holding on,
letting go
Slowed growth
Wt gain 5-6 lbs (2.5 kg) - 3 words other
BW quadruples 2.5 yo than dada, mama
5 in (12 cm) 18 mos - uses phrases
Baby fat disappears 2 yo - short sentences; 2-3
brain 90 % adult size words; 300 words
CC > HC; inc by 2 cm - pronouns
HR 90 bpm - points to one body
BP 99/64 part
TODDLER 2 ½ - full name
Protruberant abdomen 3 yo - speaks fluently using
bowlegged longer sentences
Stomach capacity increases - tells stories
Control of urinary and anal - plurals
sphincters PERSONAL/SOCIAL
IgG and IgM 15 mos - pats pictures
20 deciduous teeth - imitates
housework
GROWTH AND 18 mos - turns page 2-3 at a
DEVELOPMENTAL time
MILESTONES - uses spoon
Gross 2 yo - removes garments
15 mos – walks alone well - toilet trained by day
18 mos – run and jump in (2-3 yrs old)
place 3 yo - dry by night (3-4 yrs
- walk up & down stairs old)
holding on to railing - washes and dries
- seat self in chair hands
24 mos – walks up & down NUTRITION
stairs one step at a time Decrease in appetite/
2 ½ yo – tiptoes, jumps Physiologic anorexia
3 yo - throws balls, rides picky eaters, food jags
tricycles Milk – 1L/day
- stands on 1 foot 1, 300 kcal/day
momentarily Single food instead of
Fine motor mixtures
15 mos - 2 tower blocks, Allow self feeding
scribbles Allow choice between 2 types
18 mos – 3-4 tower blocks of food
24 mos – vertical stroke Offer finger food
30 months – 8 tower blocks Risk of aspiration
LANGUAGE PLAY - parallel play
15 mos - vocalizes wants - imitation
- jargon Babbling and talking
Ball games Sibling rivalry
Clay Discipline
Listening to music -consistent, planned, private,
Listening to stories initiated after behavior
Large blocks Separation anxiety – 18 mos
Making music and noise Transitional objects
Push and Pull toys
Puppet play REACTION TO ILLNESS and
Scribbling NURSING
Stack-and-dump toys INTERVENTIONS
DAILY CARE
- dressing – can put on socks, fear of separation - Assure of
underpants, undershirt parents return
- sleep – 8-12 hours sleep w/ phases: protest, despair,
1 nap detachment
- bathing Defense mech: Regressive
- care of teeth behaviors - reassurance
CONCERNS Nutrition – allow finger food
Toilet Training Dressing changes – allow to
bowel control – 18 mos pull off tape
daytime bladder ctrl – 2- Medication – allow choices of
3 yo “chaser” after oral medication
nighttime bladder ctrl – Hygiene – allow choice of
3-4 yo bathtime toy, allow to put
CONDITIONS: toothpaste
1. control of sphincters Pain – allow to express pain
2. cognitive understanding Stimulation
3. delay immediate Elimination – continue potty
gratification training
4. mature nervous system Rest – allow choice of toy at
* Should not be initiated bedtime
during times of stress
Negativism
Temper Tantrums –
“extinction”
Accidents
Rituals
Egocentrism
Fears: loss of parents, loud
noises, going to sleep, large PRE SCHOOL 3-5 yo
animals PRE SCHOOL
Future body build apparent
Increased skeletal growth
Handedness LANGUAGE
5 yo - may have permanent 3 ½ yo - knows sex
teeth - counts to 3 or more
Tonsils inc in size - 900 words
IgG and IgA increases 4 yo - exaggerates and boasts
PRE SCHOOL - 1, 500 words
- why questions
HR 85 bpm 5 yo- talks constantly
BP 100/60 - 2, 100 words
3 - 5 kg/yr PERSONAL/SOCIAL
2 - 3.5 in/yr 3 ½ yo - dresses w/
Frequent voiding supervision
- separates more easily
from mother
GROWTH AND yo – buttons up
DEVELOPMENTAL 4 ½ - dresses w/o
MILESTONES supervision
Gross 5 yo – uses a knife, spoon
3 1/2 yo - stands on 1 foot 5 fork; focus on social
sec aspects of eating
- upstairs on 1 foot/step; NUTRITION
down 2 feet /step Slow/Steady growth
4 – 4 ½ - climbs stairs Decreased appetite
- hops on 1 foot, skip Reject vegetables, mixed
- catch ball dishes, liver
5 yo – heel to toe walk Offer small servings
- skips Alternate foot and Discourage “grazing” – eating
runs small amounts of non
- throw and catch a ball, nutritious food
jump rope, balance on Healthy snack food
alternate feet PLAY – associative play
FINE MOTOR Dress up clothes
3 yo – copies circle, imitates Housekeeping toys
cross Dolls and other toys for
4 –4 1/2 pretending
- draws man w/ 3 parts Bikes and climbing toys
- copies square, trace Paper and crayons
diamond simple crafts
- lace shoes Large blocks
5 yo - copies triangle and DAILY CARE
diamond - accidents – bicycle
- writes alphabet, first safety, seat belts
name
- dressing – choose own - dressing change – allow
clothes to measure, cut tape, see
- sleep – 11-13 h per incision site
day; resist taking naps - medication – allow to
- exercise – very active choose “chaser”
- bathing – can wash and - hygiene – allow choice of
dry hands; need toys, wash hands and face
supervision - pain – allow pain
- care of teeth – expression, handle syringe,
independent brushing; 1st analgesic
dental visit - stimulation
CONCERNS
- imitation
- Oedipus and electra
complex
- gender roles – need
exposure to parents of
opposite sex
- Socialization – capable of
sharing
- Discipline – “time out”
- Common fears – dark,
mutilation/castration,
separation, animals, ghosts
- Telling tales
- Imaginary friends
- sharing – define limits and
teach property rights
- Regression –reaction to
stress
- Sibling rivalry
- sex education
- pre-school center
- broken fluency
- swearing
- High energy level
- Curiosity
REACTIONS/CONCERNS IN
ILLNESS AND NURSING
INTERVENTIONS
- nutrition – food in
animal/alphabet shapes School Age 7 – 11 yo
SCHOOL AGE
3-5 lb/yr playing w/ gang important;
1-2 in /yr eyes fully developed
10 yo – brain growth complete GROWTH AND
Adult vision DEVELOPMENTAL
Abundant tonsillar and MILESTONES
adenoid tissue 8 yo – script writing
“innocent” heart murmurs 9 yo – all activities done w/
HR 70 bpm gang
BP 112/60 - hero worship; adult
28 permanent teeth articulation;
Pubertal onset 10 yo – more improved
SECONDARY SEX coordination
CHARACTERISTICS - well mannered w/
Female breast devt adults
St 1 (prepubertal) 11 yo – active but awkward
St 2 – breast buds - mixed sex activities
St 3 – further enlargement of 12 yo – coordination improves
breasts and areola; no - joins organizations
separation of contours PERSONAL/SOCIAL/PLAY
St 4 – breast mound Competitive play and
St 5 – adult configuration recreational activities
Male genitalia devt Hobbies and personal
St 1 – prepubertal interests
St 2 – enlargement of testes Arts and crafts
and scrotum; rugae, Biking
reddening of scrotum Board games
St 3 – further enlargement, Clubs
lengthening of penis Collecting items
St 4 – increase length and Chess
width of penis, devt of Comic Books – ability to read
glans, darkening of scrotum one of most significant skills
St 5 – adult configuration NUTRITION
Good appetite
GROWTH AND May go on food jags
DEVELOPMENTAL Food w/ high nutritional value
MILESTONES - more calories and
6 yo – skip, jump, tumble, nutrients
hop, ride bicycle, walk a - hungry after school – give
straight line; first molars snacks and make
7 yo – central incisors; sexual mealtimes enjoyable
differences seen in play; quiet DAILY CARE
play - dressing – influenced
8 yo – improved coordination; by peers
- sleep – 8-12 hrs; no - Death and disability,
naps immobilization - Still need
- exercise – games, bike comfort
riding, walking - Unknown events &
- hygiene – 8 yo – procedures - Allow to
capable of bathing alone help
- care of teeth – 2x yearly w/ care & treatment
visit to the dentist; brush - Loss of ctrl &
daily independence - Give
* 6 yo – eruption of choices
permanent teeth - Loss of contact w/
- safety – bicycle, school peers - Allow visits
bus safety, prevention of - Disruption of school - Talk
falls and sports injuries about interests
CONCERNS - concerns over modesty
- problems w/ articulation nutrition – allow choices
– disappears 9 yo - dressing – ask opinions
- Sex education on bulk of dressing and
- Stealing – 7 yo – where to apply tape
importance of money - medicine – teach name
- Violence/terrorism – and action, allow to
education;reassurance choose form if possible
- School anxiety and - body injury, pain – allow
phobia, bullying, intimidating expression of pain, explain
teachers, something bad source and cause
happening to parents - stimulation
- Recreational drug and
alcohol use
- Obesity
- nocturnal enuresis and
encopresis (stool leakage;
boys > girls)
REACTION TO ILLNESS
AND NURSING
INTERVENTIONS
Cause of illness – external
forces; aware of
significance of different
illnesses
Defense mech: reaction ADOLESCENT 13-18 yo
formation ADOLESCENT
Girls taller than boys 2-8 in,
15-55 lbs
Growth stops 16-17 yo - Acne
Boys grow 4-12 in and gain - Body piercing
15-65 lbs - Fatigue - emotional
Growth stops 18-20 yo fatigue
Heart and lung size increase - Menstrual irregularities
more slowly - Sexuality and sexual
HR 70 bpm activity
RR 20 breaths/min - Poor posture
BP 120/70 - Stalking – educate girls
ADOLESCENT - Substance abuse
Androgen inc sebaceous - Suicide
gland activity resulting in - runaways
acne - discipline – firm, limit
Apocrine glands inc activity setting
13 yo – 2nd molars REACTION TO ILLNESS
PUBERTY – capable of AND NURSING
sexual reproduction INTERVENTION
Secondary sexual Defense mech: Denial and
characteristics displacement
GROWTH AND Main issue – body image –
DEVELOPMENTAL educate and Allow
MILESTONES participation in tx decisions;
13 yo – sports compassionate understanding
15 yo - enjoys privacy Fears loss of control and
- stays in room independence - Respect
16 yo - part time job privacy and confidentiality
- charitable causes Fears injury and pain -
NUTRITION Provide opportunities for
- faddish diet self expression
- give responsibility for Separation from peers and
food planning lack of emotional support -
- increased calories, Ca, Approach w/ caring and
protein understanding, age
DAILY CARE compatible roommate,
- dressing and hygiene Phone at bedside
- care of teeth - Nutrition – food
- sleep – need more preferences
sleep - Dressing – final
- exercise – daily appearance of dressing,
CONCERNS and time for changing
- Socialization – falling in - Medicine – choice for
love injection site, teach name
- Obesity; Diseases – HPN and action
- Rest – time and length
of rest periods
- Hygiene – respect
modesty, extent of self care
- Pain – allow pain
expression, ask for
analgesics
- stimulation

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