HOLY ANGEL UNIVERSITY

School of Nursing and Allied Medical Sciences

Department of Nursing

NCM 107 – Care of the Mother, Child and Adolescent

S.Y. 2024-2025 | 1st Semester | Final Term
Module 11: Care of a Family with a Toddler

Description

This module will provide students with an understanding of the care of the family and a toddler. The
toddler period is the time of dramatic changes, both physical and psychosocial, that form the basis for
care and health teaching for this age group. The toddler period covers from 1 year up to 3 years. During
this period, children accomplish a wide array of developmental tasks and change from largely immobile
and preverbal infants who are dependent on caregivers for the fulfillment of most needs to walking,
talking young children with a growing sense of autonomy (independence). To match the needs of the
growing toddler parents must also adapt to these changes.

Learning Outcomes
LO1 Integrate knowledge and principles of toddler growth and development with application of
appropriate nursing care to the child and family.

LO3 Assess the toddler for normal growth and developmental milestones

LO4 Formulate nursing diagnosis/es that address related to growth and development of a toddler and
parental concerns.

LO5 Implement safe and quality nursing interventions related to normal growth and development of a
toddler.

LO7 Evaluate with the mother and family the health outcomes of the nurse-client relationship.

Module Outline
I. Physiologic Development
II. Motor Development
III. Freud’s Theory of Psychosexual Development
IV. Erikson’s Theory of Psychosocial Development
V. Piaget’s Theory of Cognitive Development
VI. Kohlberg’s Theory of Moral Development
VII. Nutrition of the Toddler
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VIII. Concerns and Problems Related to Normal Development of toddlers

IX. Assessment of a toddler
X. Nursing diagnosis for a toddler and family
XI. Implementation of safe and quality nursing interventions
XII. Evaluation

Module
I. PHYSIOLOGIC DEVELOPMENT

A. Weight and Height

A child gains only about 5 to 6 lb (2.5 kg) and 5 in. (12 cm) a year during the toddler period, much
less than the rate of growth during infant year. As subcutaneous, or baby fat, begins to disappear
toward the end of the second year, the child changes from a plump baby into a leaner, more muscular
little girl or boy. A toddler’s appetite decreases accordingly, yet adequate intake of all nutrients is still
essential to meet energy needs.

B. Head Circumference

HC increases only about 2 cm during the second year compared to about 12 cm during the
first year. Head circumference equals chest circumference at 6 months to 1 year of age. By 2 years,
CC should have grown greater than that of the head.

C. Body Proportion

Toddlers tend to have a prominent abdomen because, although they are walking well, their
abdominal muscles are not yet strong enough to support abdominal contents as well as they will be
able to do later. They also have a forward curve of the spine at the sacral area (lordosis). As they
become more experienced at walking, this will correct itself naturally. In addition, many toddlers
waddle or walk with a wide stance. This stance seems to increase the lordotic curve, but it keeps
them on their feet.

D. Body Systems

Body systems continue to mature

- Respirations slow slightly but continue to be mainly abdominal

- Heart rate slows from 110 to 90 beats/min

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- Blood pressure increases to about 99/64 mmHg

- The brain develops to about 90 % of its adult size

- In the respiratory system, the lumens of vessels enlarge progressively so the threat of lower
respiratory infection lessens

- Stomach secretions become more acid: therefore, gastrointestinal infections also become less
common. Stomach capacity increases to the point a child can eat three meals a day

- Control of the urinary and anal sphincters becomes possible with complete myelination of the
spinal cord, so toilet training is possible.

- Immune globulin IgG and IgM antibody production becomes mature at 2 years of age. The passive
immunity obtained during intrauterine life is no longer operative

E. Dentition

Eight new teeth (the canines and the first molars) erupt during the second year. All 20 deciduous teeth
are generally present by 2.5 to 3 years of age.

II. MOTOR DEVELOPMENT

The developmental milestones of the toddler years are less numerous but no less dramatic than those of
the infant year because this is a period of slow and steady, but not sudden, growth. Toddler
development is influenced to some extent by the amount of social contact and the number of
opportunities children have to explore and experience new degrees of independence. It is strongly
influenced by individual readiness for a new skill.

Age in months Fine motor Gross motor

15 Puts small pellets into small bottles Walks alone well

Scribbles with a pencil or crayon Can seat self in chair
Holds a spoon well but may still turn it Can creep upstairs
upside down on the way to mouth
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18 No longer rotates a spoon to bring it to Can run and jump in place

mouth Can walk up and down stairs holding
on to a person’s hand or railing
Typically places both feet on one
step before advancing

24 Can open doors by turning doorknobs Walks upstairs alone, still using both
Unscrew lids feet on same step at same time

30 Makes simple lines or strokes for Can jump down from chairs
crosses with a pencil

III. FREUD’S THEORY OF PSYCHOSEXUAL DEVELOPMENT

ANAL STAGE

• Activities: Toilet training

• Elimination or retention of feces or urine

• This anal interest is a part of toddler’s self- discovery, a way of exerting independence.

• The child greatly enjoys holding it and letting it go.

Basic Concept: EGO

Major Conflict: Bowel Training

The child’s interest widens, and his main interest is focused on the anal region. Elimination takes a
new importance. He finds pleasure in both retention of feces and in defecation. This anal interest is a
part of child’s discovery of self and a way of exerting his independence The process of toilet training is
regarded as the resolution of this conflict. Toilet training is usually completed by 3 years.

IV. PSYCHOSOCIAL DEVELOPMENT (ERIK ERIKSON)

• Increases independence; better able to tolerate separation from primary caregiver

• Less likely to fear strangers

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• Able to help with dressing/undressing at 18 months; dresses self at 24 months

• Has sustained attention span

• May have temper tantrums during this period; should decrease by 2 ½ years

• Vocabulary increases from about 10 – 20 words to over 900 words by 3 years

• Has beginning awareness of ownership at 18 months; shows proper uses of pronouns by 3

years

• Moves from hoarding and possessiveness at 18 months to sharing with peers by 3 years

• Beginning of problem solving

• Toilet training is usually completed by 3 years.

• Developmental task: Learning Autonomy vs. Shame and Doubt (Self-government and
independence)

- Activities/issues: Bodily functions, toilet training, muscle control and walking

- Autonomy develops when child is permitted to assert himself. They feel secure and
confident.

- Shame and doubt develop if the child does not develop a sense of trust and/or learns his
assertiveness as “is not acceptable”

- There is a sense of inadequacy and self-doubt.

- Virtue: Will: the belief that children can act with intention, within reason and limits

How to develop autonomy

1. Give an opportunity for decision making such as offering choices.

2. Encourage the child to make decisions rather than judge.

3. Toddlers begin to develop their sense of autonomy by asserting

themselves with the frequent use of the word “no”.

• Although they like to explore the environment, they always have a significant person
nearby.

• Receptive & expressive language skills are developing quickly.

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• One of the most admirable and frustrating things about two and three-year-old is
their determination.

• "Can do" is their motto.

• If we can preserve that "can do" attitude (with appropriate modesty to balance it) we
are much better off as adults.

• Behaviors to observe

a. Shows a sense of “me”

b. Negativism

c. Ritualistic and stereotyped behavior

d. Temper tantrums

SOCIAL AND EMOTIONAL DEVELOPMENT

A. Emotional Development

Toddlers change a great deal in their ability to understand the world and how they relate to
people during the toddler years

Children who have learned to trust themselves and others during the infant year are better prepared to
do this than those who have not learned to trust themselves or others.

B. Socialization

Once already walking well, they become resistant to sitting in laps and being cuddled (a function of
independence). At 15 months – enthusiastic about interacting with people, providing these people are
willing to follow them where they want to go. At 18 months – imitate things they see 2 or more years –
become aware of gender differences and may point to other children and identify them as “boy” or
“girl”.

C. Language Development

Toddlerhood is a critical time for language development, although even this varies among children
because to master language, children need practice time. To learn other

words, children need to be exposed to words through conversation and having books read to them.
Language develops quickest if parents respect what toddlers have to say so children grasp the use and
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purpose of language. Watching television promotes little learning in toddlers because the activity is
passive, and it is difficult to discern how language causes action. The American Academy of Pediatrics
recommends severely limiting television viewing until at least 2 years of age.

Urge parents to encourage language development by naming objects as they play with their child or
when they give the toddler something. This helps children grasp the fact that words are not meaningless
sounds but that they apply to people and objects and have uses.

Always answering a child’s questions is another good way to do this. Answers are simple and brief
because they have such a short attention span. Still other toddlers do not develop language readily
because they are not called on to use it (It is readily given to them). Reading allowed is another
effective way to strengthen vocabulary. Pointing to the pictures and describing what the picture shows.
Children learn language from imitating what they hear. Enunciation should be good. Pronouns are
difficult for children to use correctly (I, me, him, her). They often interchange words from both
languages.

Language Development

15 months – 4 to 6 words

18 months – 7 to 20 words; uses jargoning; names one body part

24 months – 50 words; two-word sentences (noun or pronoun and verb) such as “Daddy go” or
“dog talks”

30 months – verbal language increasing steadily; knows full name; can name one color and
holds up finger to show age

PLAY

• Parallel play, children play beside other children, not with them or side-by-side play.

1.They should have similar toys

2. They enjoy toys they can play with by themselves and that require actions

• Those toys that they can control give them a sense of power in manipulation, which is an expression
of autonomy.

•15 months – can stack 2 blocks; enjoys being read to; drops toys for adult to recover (exploring sense
of permanence) put in, take out stage
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•18 months – imitates household chores; begins parallel play; walks securely enough to enjoy pull toys

•24 months – parallel play evident

•30 months – spends time playing house; imitating parents’ actions; play is “roughhousing” or active

•Examples of appropriate toddler toys:

1. Pull-push toys

2. Blocks

3. Assortment of balls

4. Picture books

5. Play Doh with simple tools (craft sticks and wooden rollers)

6. Containers, scoops, sifters, and other objects for sand and water play

7. Toys and props for dramatic play like scarves, hats, a toy telephone, stuffed animals, and
generic baby dolls

8. Large pegged-top puzzles

9. A small climbing structure

V. PIAGET’S THEORY OF COGNITIVE DEVELOPMENT

As a toddler, a child enters the final stages of Piaget’s sensorimotor thought and the beginning
of the pre-operative period at approximately 12 months

A. Stage 5 (12-18 months)

Piaget describes this stage as “Little scientists” because of their interest in trying to discover
new ways to handle objects or new results that different actions can achieve “Trial and
error” ball rolls = crawls to retrieve.

• Knows own name by 12 months; refers to self;

• Able to identify geometric forms by 18 months

• Achieves object permanence

• Uses “magical” thinking; believes own feelings affect events

• Experiments by trial and error

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• Uses ritualistic behavior

• May develop dependency on “transitional object”

• Insatiable curiosity about the environment.

• Uses all sensory cues for exploration.

• Ventures away from parents for longer periods.

• Uses physical skills to achieve a particular goal.

• Can find hidden objects, but only in the first location.

• Able to insert round objects into a hole.

• Fits smaller objects into each other (nesting).

• Gestures “up” and “down”.

• Puts objects into containers and takes them out.

• Realizes that out of sight is not out of reach, opens doors and drawers to find objects.

• Gains comfort of parents voice even if not visible

B. Stage 6 (18 to 24 months)

• Toddlers are able to try out various actions mentally rather than having to actually
perform them. The beginning of problem solving or symbolic thought.

• Pre logical reasoning = wrong conclusions and faulty judgment. I like ice cream so she
also likes ice cream

• Deferred imitation – able to remember an action and imitate it later

• Object permanence becomes complete

• End of toddler period – pre operational thought and uses assimilation – uses toys in the
wrong way (toy hammer = instead of pounding with it, she may shake it to see if it
rattles)

C. Preoperational Thought period ( Preconceptual) 2 to 3 years

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• Children become more symbolic

• Can arrive at answers mentally instead of thorough physical attempt.

• Can not view one object as necessarily being different from another

• Child is egocentric and unable to see the viewpoint of another.

• Able to use assimilation or change situation to fit thoughts

• Displays static thinking.

• Concept of time is now, and ,the oncept of distance is only as far as he can see.

• They draw conclusions from obvious facts they see (prelogical reasoning)

The key features of the preoperational stage:

1. Centration - the tendency to focus on only one aspect of a situation at one time

2. Egocentrism - child's inability to see a situation from another person's point of view. Each
child is absorbed in its own private world and speech is egocentric. The main function of
speech at this stage is to externalize the child’s thinking rather than to communicate with
others

3. Symbolic Representation - the ability to make one thing - a word or an object - stand for
something other than itself. Pretend (or symbolic) play is common in toddlers. They often
pretend to be people they are not (e.g. superheroes, policeman), an may play these roles
with props that symbolize real life objects. Children may also invent an imaginary playmate

4. Animism - the belief that inanimate objects (such as toys and teddy bears) have human
feelings and intentions.

VI. KOHLBERG MORAL DEVELOPMENT

Pre-Conventional Stage
Stage 1: Punishment and Obedience
• Rules are obeyed to avoid punishment
• Consequences of acts determine whether they are good or bad
• The child does right because the parent tells him/her to avoid punishment.
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• The child is good because the parent said the child must be, not that it is right to be good.
• Children see morality as something external to themselves, as that which the big people say
they must do.
• Nursing implication:
1. Child needs help to determine what are right actions.
2. Give clear instructions to avoid confusion

VII. NUTRITION
Because growth slows abruptly after the first year of life, a toddler’s appetite is usually less than an
infant. children who ate hungrily 2 months earlier now may sit and play with their food. Teach parents
to place a small amount of food on a plate and allow their child to eat it and ask for more rather than
serve a large portion that the child cannot finish.
Allow self-feeding, a major way to both strengthen independence in a toddler and improve the
amount of food consumed. Offering Finger foods and a choice between two types of food helps
promote independence while exposing children to varied foods. Children usually prefer to eat the same
type of food over and over because of the sense of security this offers

• Sedentary children = 1,000 kcal daily

• Active = 1,400 kcal daily
• Needs protein and carbo; avoid sugar to prevent obesity

• Fats should generally not be restricted for children under 2 years old however, children over 2
years old should consume no more than 30% of total daily calories from fat.

• Adequate calcium and phosphorus intake is important for bone mineralization

• Milk should be whole milk until 2 years

VIII. CONCERNS AND PROBLEMS RELATED TO NORMAL TODDLER DEVELOPMENT

A. Toilet training

• one of the biggest tasks the toddler must achieve, during this period.
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• Important development levels that must be reached before toilet training begins: one
physiologic, and cognitive

Markers of readiness:

a. Can stand, squat and walk alone

b. Can communicate toilet needs

c. Can maintain himself/herself dry for an interval of 2 hours

Stages of Toilet Training:

a. Bowel control – 18 months

b. Daytime bladder control – 2 ½ yrs of age

c. Nighttime bladder control – 3 yrs

Play or smear with feces – they have become fully aware of body excretions but have no adult
values toward them it is the same as the modelling clay they play with

Management:

a. Provide with play substances of similar texture

b. Change diaper immediately after defecation

c. Do not scold or punish the child

B. Ritualistic behavior

Repetetive phenomena, such as rituals and rigid routines frequent between the ages of
two and four yers old. Engaging in repetetive behavior may be a toddler’s way of trying to
establish predictability and order iina world where they have little to no control or
understanding of the world around them, which can be anxiety provoking. It can be reduced by
setting rules and guidelines, and not letting the child to be over dependent.

C. Negativism

Negativism signals the transition from babyhood to childhood. It is the child’s way of
asserting herself - seeing how it feels to make decisions on her own and part of making these
decisions is disagreeing with her parents that they are separate individuals from the parents
with separate needs.
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Management:

a. Offer your child a choice of limited options: "Do you want a cheese sandwich or a
peanut butter sandwich for lunch today?" rather than "What do you want for
lunch today?"

b. Use as few commands as possible, and insist on obedience only when absolutely
necessary.

c. Emphasize the positive. "We will have a treat later" works much better than "You
cannot have a cookie now." Negative statements from you can prompt negative
behavior from your child.

d. Limit the number of questions asked of the child. Making statements instead of
asking questions can avoid a great many negative responses.

e. Make a statement not a question

D. Discipline

Discipline is setting rules and road signs so children know what is expected of them. Punishment is
a consequence that results from a breakdown in discipline, from the child’s disregard of the rules that
were learned. Parents should instill some sense of discipline early in life because part of it involves
setting safety limits and protecting others or property

General rules to follow when teaching discipline:

a. Parents need to be consistent

b. Rules are learned best if correct behavior is praised rather than the wrong behavior
punished.

c. Timeout is a technique of helping children learn that actions have consequences. To

use it effectively, parents need to be certain that their child understands the rule they
are trying to enforce.

d. Give warning first before giving a time out. The length of time is 1 min per year of
age.
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E. Separation anxiety

Separation anxiety begins at about six months of age and persists throughout the preschool
period. A child becomes fearful and nervous when away from home or separated from a loved one,
usually a parent or other caregiver, to whom the child is attached.
Stages of Separation Anxiety

A. Protest – clinging to parents, pleading for parents to stay

B. Despair – child is hopeless and becomes quiet, withdrawn, apathetic

C. Detachment – lack of protest when parents leave but if parents reappear, child may ignore

Prevention:

1. Reduce anxiety in the child.

2. Develope a sense of security in the child and the caregivers.

3. Educate the child and family/caregivers about the need for natural separations.

4. Reinforce a child's independence and self-esteem through support and approval.

5. Say goodbye firmly.

F. Temper tantrums

The frontal lobe of your toddler’s brain (the part that controls logic, reasoning, planning,
judgment, self-control, and emotional processing) is underdeveloped. Toddler feels frustrated and angry
that he can’t do something, but he can’t mentally process those feelings. He lacks the self-control
necessary to keep those emotions in check and he certainly can’t express his feelings verbally, (in a more
socially acceptable way) the way an adult would. Therefore, he resorts to kicking and shrieking and
throwing things, because those are skills he does have.

Causes:

a. When tired
b. Unrealistic request by a parent
c. If parents are saying NO frequently
d. Response to difficulty making choices or decisions or to pressure from certain activities
Management:
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a. Give your toddler choices, when possible.

b. Institute a countdown before a transition takes place: “3 more books, and then it’s
bedtime” or “5 more minutes to play trucks, and then we have to stop and eat lunch”.
c. Avoid attempts to reason with your toddler. Remember, your toddler is not a creature of
logic. calmly and firmly offer a short explanation that he can understand and then repeat it
as necessary.
d. Remain calm and consistent. If your toddler sees that she is not able to get a rise out of
you, she will probably calm down faster. It is also important that you remain firm and
consistent – avoid giving in to your toddler’s demands when she’s throwing a tantrum.
e. Avoid overtiredness. Try to watch for your toddler’s sleep cues. Is she rubbing her eyes?
Yawning? Looking glassy-eyed? If so, then get her to bed quickly. It is worth repeating: an
exhausted toddler is more likely to throw a whopper of a tantrum before nap time or
bedtime than a toddler who’s well-rested. So try to stay ahead of the overtiredness, and
make sure she is getting the rest she needs.

G. Sibling Rivalry

It can be tough for a toddler to welcome a new baby into his domain. As siblings get older, they
may show their jealousy by arguing, name-calling, teasing, pushing, and occasionally fighting. But the
toddler won't understand his feelings of jealousy, or what he can do about that annoying newborn. He
just wants attention, and may react by misbehaving or even regressing.

Mangement:

a. Tell the toddler about the approaching birth

b. Ask the toddler for help and advice

c. Explain what's going to happen once the baby arrives

d. Spend time with the toddler

e. Let the toddler get involved in the preparations

f. Be prepared for aggression

g. Involve the toddler in looking after the baby

h. Don't compare the children

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i. Teach the toddler to resolve conflicts on his own

IX. ASSESSMENT OF A TODDLER

Whether a child is seen for a routine check-up or has come to a healthcare center because
of a specific health concern, assessment begins with a careful health history. Asking parents about a
toddler’s ability to carry out activities of daily living offers assessment information not only on the
child’s developmental progress but also offers important clues about the child-parent relationship.
Because parents see their children daily, they are the best source of information and opinion on
when a child seems to be acting “out of sorts” or “different”.

Careful observation is another crucial element of the nursing assessment of a toddler, although
toddlers may not show typical behavior at a healthcare visit.

X. NURSING DIAGNOSIS

Nursing diagnosis related to growth and development of toddlers usually focuses on the
parents’ eagerness to learn to learn more about the parameters of normal growth and development or
issues of safety or care. Examples of nursing diagnoses are:

• Health-seeking behaviors related to normal toddler development

• Deficient knowledge related to the best method of toilet training

• Risk for injury related to impulsiveness of the toddler

• Interrupted family process related to need for close supervision of a 2-year-old

• Readiness for enhanced family coping related to the parents’ ability to adjust to the new
needs of the child

• Risk for imbalanced nutrition, more than body requirements, related to fast food choices

• Disturbed sleep pattern related to lack of bedtime routine

XI. IMPLEMENTATION OF SAFE AND QUALITY NURSING INTERVENTIONS

To help parents resolve a concern during the toddler period, focus largely on family
education and anticipatory guidance. Urge them to establish realistic goals and outcomes so they can
meet the rapidly changing needs of their toddler and learn to cope with typical toddler behaviors.
Otherwise, parents can expect too much of a toddler and grow frustrated instead of enjoying being a
parent of a child this age.
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When teaching about typical toddler behavior, teach parents that a good rule is to think of a
toddler as a visitor from a foreign land who wants to participate in everything the family is doing but
doesn’t know the customs or the language.

Also teach parents not only how to approach a current problem but also how to learn adequate
methods for resolving similar situations that are sure to arise in the future. If parents do not learn
methods that can be applied throughout their child’s growing years, they may win battles but loose
wars. Health visits provide opportunities to help parents learn healthier coping techniques as well as a
time to demonstrate effective communication skills so parents can improve their interactions with their
child.

XII. EVALUATION
Expected outcomes must be evaluated frequently during the toddler period because
children change so much and learn so many new skills during this time that their abilities and
associated parental concerns can change from day to day. Examples of expected outcomes include:

• Parents state the child maintains a consistent bedtime routine within the next 2
weeks

• Parents state they have childproofed their home by putting a lock on kitchen
cupboards by the next clinic visit

• Grandmother states she has modified usual activities to conserve strength to care
for toddler granddaughter by 1 weeks’ time

References
Silbert-Flagg, J. (2022). Maternal and child health nursing: Care of the childbearing and
childbearing family (9thed.). Philadelphia, PA: WoltersKluwer.
Credits and Quality Assurance

Prepared: Recommending Approval:

MELANIE C. TAPNIO, MAN, RN, LPT DENMARK D. GABRIEL, MSN, RN, LPT
Assistant Professor Assistant Professor & Chairperson, Nursing Program

Reviewed by:
Approved by:
LEONARDO S. ANGELES, JR., PhD, MAN, RN, LPT
Assistant Professor & OBE Facilitator ELMER D. BONDOC, PhD, MAN, RN
Dean
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School of Nursing and Allied Medical Sciences
Department of Nursing
School of Nursing and Allied Medical Science