Neonates birth -28days.

Infants (birth-12mts) Dramatic growth and developmental changes

• Best indicator of physical growth is steadily increasing size. Pattern of growth is down by completing a growth
chart every time infant presents at hospital. Shows increase growth, decline in growth (failure to strive) etc.
– Measure weight, length, chest and head circumference and plot on growth chart
– *Birth weight doubles by 6 months and triples by 12 months*
– Above the 97% and below the 3% indicates a growth disturbance and needs further evaluation
– See Appendix in text and/or www.cdc.gov/growthcharts
Weight: want infant NUDE (can place diaper on scale & ZERO scale)
• Make sure not to leave infant alone, will turn and fall: Safety!
• Consistent weighing times
Head circumference
• Obtain up to 36 months or as long as indicated
• Procedure: use measuring tape, above ears & eyebrows and above occipital.
• Record in kilograms (kg)

Fontanel changes: done by running hand over infants head. Have infant lye down bc if sitting gravity pushes
down.
• Posterior—closes by 2 months
• Anterior—closes by 12-18 months: monitor mostly.
• Fontanel should be charted “soft and flat”
Achievement of Milestones

• Cephalocaudal

– Gross motor skills (head control, rolling, sitting, walking) use of large muscles from head to tail; baby
learns to lift head before learning to roll over and sit.
Newborn can turn head from side to side when prone.
Almost no head lag by 3 months of age
Rolls from front to back at 4 months.
Sits leaning forward by 6 months.
Sits unsupported by 8 months.
Pulls self to standing at 9 months.
Cruises at 10-11 months, may stand alone, can sit from standing.
Walks holding on to someone’s hand at 12 months
• Proximodistal

– Fine motor ( maturation of hand & fingers) from center to periphery. First bats wt whole hand,
eventually progressing to gross grasping, then being able to pin point feeding self with spoon or fingers
(cheerios).
Strong grasp at 1 month.
Grasp reflex fades at 3 months.
Hold rattle voluntarily at 5 months.
Transfers objects hand to hand at 7 months.
At 9 months develops pincher grasp.
 Sensory development

• Sight—nearsighted at birth. Distance vision & ability to track objects by 7 months. Newborn may imitate facial
expression made by those caring for them. At 1mt can recognize by sight caring parents.
• Hearing— very well developed @ birth
• Smell—very well developed, 7days. Can differentiate mom breast milk from others.
• Taste—prefers sweet
• Touch—very sensitive, most important.
• Pain Assessment: Neonate and Infant
Facial expression, frowns, grimaces, wrinkled brow, expression of surprise
Increase in B/P, HR and possible decrease in saturation
High-pitched, tense, harsh crying
Generalized total body response in neonate and young infant
Thrashing extremities
Tremors
Older infant may rub painful area, pull away or guard the involved part

Psychosocial development

• Erickson Trust vs. Mistrust (birth-1 year)—the infant develops a sense of trust if needs are consistently met
(feeding, changing, cleaning, touching etc). If caregiver is inconsistent in meeting infant’s needs in a timely
manner, infant develops mistrust.
• Freud (psychosexual): Oral Stage (birth-18 months)—pleasure focused on oral activities (feeding, sucking)
**Remember infants R learning their environment through its senses. Taste, touch etc.
Cognitive development

• Piaget’s Sensorimotor stage: gains knowledge of the environment through the senses. 4-7mts develops object
permanence, realizes object still exist. 12mt can imitate gestures & knows how to use them correctly eg.. phone
to ear, cup to drink.

Language development

• Cooing, experimenting with sounds at 1-3mts.

• Squealing, yelling 6mt
• Attaches words to meanings, 4-5mt responds to own name & begins to response to “no”.
• Imitates speech, babbling, repeating syllables (mama, dada) by 8 months
• By 12 months uses two or three recognizable words. First word is dada instead of momma bc easier to
pronounce D’s.
• Regression can occur when energy is focused on other developmental tasks eg. Focus on crawling or walking
instead of talking. As soon as infant achieves attempt, he picks up where he left off.
Nutrition

• Breast milk the most desirable complete source for the first six months. Receives IgA from mom.
• Commercially prepared iron-fortified formula is an acceptable alternative.
• Solid foods introduced at 4 months beginning with iron-fortified cereals
• New foods introduced one-at-a-time: vegetables eg carrots, green beans →fruits (bc sweet)
• Too much [Ca] inhibits Fe absorption. No Cow Milk
• If baby has GERD & its recommended by PH, can put cereal in bottle.
Activity/Play

• Play is the work of children. Very important.

• Play reflects infant’s development and awareness of the environment
• From 1 month to 1 year play is basically solitary (non-interactive).
• Develops sensory and motor skills by manipulating toys and other objects.
• Should be safe and age appropriate
Age appropriate toys

• 1-3 months
– mobile, mirror, rattle, soft toys (high-contrast patterns)
• 4-6 months
– squeeze toys, play gym, things that make noise!
• 7-9 months
– splashing bath toys, large blocks, “busy boxes”
• 10-12 months
– balls, durable books, push-pull toys, toy telephone
• All ages: soft music
Rest and sleep

• Patterns vary from infant to infant.

• First month, infants sleep when not eating.
• Three to four months, infants sleep between 9 and 11 hours at night.
• By 12 months, most infants take a morning and afternoon nap.
• Amount of sleep decreases as they grow.
Bedtime rituals should begin during infancy to prepare infant for sleep and prevent further sleep problems

Safety Concerns

• Falling off beds and down stairs.

• Aspiration of small objects (check toys for loose parts!)
• Suffocation caused by inadvertently covering nose and mouth, pressure on throat or chest, prolonged lack of air,
or strangulation.
• Poisoning from overdose of medications or ingestion of toxic household substances.
• Burns from hot liquids, foods, bath water or electrical injury.
• Motor vehicle accidents from misuse or disuse of car seats or seatbelts.
Infant fears

• When self is perceived different from caregiver (mom), separation anxiety develops—around 6 months of age
• Older infants may develop stranger anxiety at 8mts, which persists through toddlerhood.
• As infants interaction wt new places, people increases, stranger anxiety is not major.
Toddlers (1-3yrs)
• Physical growth and acquisition of new motor skills slow somewhat
• Motor skills are refined
• Cognitive growth continues
• Development of language skills are important
Physical growth

• Growth in spurts (not linear)

• Protruding abdomen and lumbar lordosis from underdeveloped abdominal muscles.
• Bowleggedness (leg muscles must bear the weight of the relatively large trunk)
• Height at 2 years is about half of expected adult height
Achievements of milestones

• Gross Motor
– 15 months
• walks without help
– 24 months
• runs
• walks up and down steps one at a time
– 36 months
• climbs well
• jumps with both feet
• pedals tricycle
• Fine Motor
– 15 months
• Builds a 2-block tower
• Scribbles spontaneously
– 18 months
• Builds 3 to 4 block tower
• Holds spoon and drinks from a cup
– 30 months
• builds 8-block tower
• copies a cross
• Toilet training is a MAJOR developmental task
Psychosocial development

• Erickson Autonomy vs. Shame & Doubt (12-36 months)—toddler achieves autonomy and self-control by testing
boundaries, separating self from parent. Exerting independence. Wants to do things for self, likes “no” even
when really means yes.

• Freud (psychosexual) Anal Stage (focus is on achieving bowel control)

Cognitive development

• Trial and error experimentation and relentless exploration.

• Begin to devise new means for accomplishing tasks through mental combinations. Builds a tower to get to
cookie jar.
• Make simple classifications
• Associate one event with a simultaneous event
• Big on imagination.
Egocentric thinking( focus is on self) also makes them difficult to share things.

Pain assessment
 • Toddler

– Loud crying
– Verbalizes words that indicate discomfort
– Attempts to delay procedure or intervention if perceived as painful
– Generalized restlessness
– Guards the site
– Touches painful area
– Fearful of staff

Language development

• Uses 50 words by 2 years

• Echolalia(repetition of words & phrases without understanding)
• Telegraphic speech( use of only essential words) “want cookie milk”
• By 30 months, a toddler can say about 300 words, use 2 to 3 word phrases
• By 36 months, vocabulary is 1000 words, can use pronouns and pleurals
TANTRUMS

• Stem from frustration associated with lack of expressive language

• Tantrums may be used to assert independence and are best dealt with by ignoring them.
• Negativism is also common. The best way to decrease the number of “No’s” is to decrease the number of
questions that can lead to a “No” response.
Nutrition

• By 12 months: usu. eat the same foods as the rest of the family
• By 18 months: physiologic anorexia (eat large amounts of foods one day and little the next) and may be picky
eaters
• Risk for aspirating small food items such as peanuts.
• Prefer to feed themselves small portions of appetizing foods.
• Do not use food as a reward or a punishment.
Limit milk to no more than 1 quart daily to help ensure intake of iron-rich foods

Activity & Play

• Toddlers engage in parallel play.

– They play alongside not with others.
• Imitation is one of the most common forms of play.
• Gross motor skills can be enhanced with push-pull toys.
• Short attention span causes them to change toys frequently.
• Appropriate toys should
– have no detachable or small parts
– Encourage imitation, language development and gross and fine motor skills.
• Examples:
– dolls, housekeeping toys, play phones, rocking horses, ride-on toys, finger paints, large puzzles, large
blocks.
Sleep and Rest

• Total sleep requirements decrease during second year of life to about 12 hours daily.
• Most toddlers nap once a day until the end of the 2nd or 3rd year.
Sleep problems are common and may result from fears of separation, establish sleeping rituals to decrease it.
Safety Concerns

• falls
• drowning
• aspiration
• poisoning
• suffocation
• burns
• motor vehicle
• other accidental injuries
Fears of Toddlers

• Fear of losing parents

– Separation anxiety
• Fear of strangers
– Stranger anxiety
• Loud noises
• Strange animals
The Dark!
Preschoolers
• Healthy preschooler is slender, graceful, agile and has good posture.
• Height
– Average growth 2.5 to 3 inches/year
– Average 4 year old is 40.5 inches tall
• Weight
– Average weight gain 5 pounds per year
– Average 4 year old weighs 37 pounds
Milestones

Gross Motor
• 3 years
– rides a tricycle
– climbs stairs alternating feet,
– stands on one foot at a time for a few seconds
– broad jumps
• 4 years
– skips
– hops on one foot
– catches a ball
– goes down stairs alternating feet
• 5 years:
– skips on alternate feet
 – throws and catches a ball
– jumps rope
– balances on alternate feet with eyes closed
Fine Motor
• 3 years
– constructs a 3 block bridge
– copies a circle
– draws a cross.
• 4 year
– laces shoes
– copies a square
– traces a diamond
– draws a three part stick figure.
• 5 years:
– ties shoes
– uses a scissors well
– add 7-9 parts to a stick person
– print a few letters and numbers
– prints her/his first name
Psychosocial Development

• Erickskon’s Initiative vs. Guilt (3-5 years)—preschoooler develops sense of initiative by succeeding in activities,
planning, making up games, etc

• Freud’s Phallic Stage (conflict with same-sex parent, love of opposite sex parent)

Cognitive Development

• Uses transductive reasoning (attributes cause and effect relationships to events coinciding in time, even though
the events may be unrelated) eg.. jane broke clock cause she walked into room..
• Unable to see viewpoint of others
• Uses many words appropriately, but lacks real knowledge of their meaning eg..dam
• Preschoolers exhibit magical thinking and believe their thoughts are all powerful
• They may feel guilty and responsible for their “bad” thoughts, which sometimes coincide with a wished event

Pain assessment

• Preschooler
– Fears bodily harm
– May think pain is punishment for some deed or thought
– Cries, kicks
– Describes location and intensity in simple words
– Regression in earlier behavior
– Withdrawal
– Denies pain
• unsure and afraid of what intervention may occur
– Cultural practices may reflect child’s reaction to pain
Language Development

• Average 3-year-old says 1000 words, speaks in 3 to 4 word sentences and talks incessantly.
• May acquire 10-20 new words per day
• Average 4 year-old says 1500 words, tells exaggerated stories, and sings simple songs
Age 4 is the peak age for “Why” questions. Why, why why why all day long!!!
Are fascinated by death and dying!!!

Nutrition

• May be picky eaters

• Many 3- and 4-year-olds are restless and/or fussy at mealtimes
• 5-year-old is influenced by food habits of others
• Focus on the “social” aspects of eating, including conversation, manners, willingness to try new foods and help
with meal preparation
Activity & Play

• Preschoolers’ play is associative (ie, interactive and cooperative with sharing)

• Need contact with age mates
• Imitative, imaginative, and dramatic play are important
• Imaginary friends are common
• Activities should promote growth and motor skills such as running, jumping and climbing
Rest & Sleep

• Preschoolers sleep 11 to 13 hours per day

• Many preschoolers need an afternoon nap until age 5
• Sleep problems are common and include nightmares, night terrors, difficulty settling down after a busy day,
extending bedtime rituals to delay sleep
• Eliminate daytime nap, if it seems to interfere with nighttime sleep
• Continue bedtime rituals with relaxation time before bedtime to help child settle down
• Security object and night-light help
Safety Concern

• Less prone to accidents, but are at risk for the same type of injuries and require many of the same type of safety
precautions
• Parents and other caretakers need to emphasize safety measures
• Preschoolers listen to adults and can understand and heed precautions
Fears

• Imaginary monsters
• Strangers and “strange” people
• Animals they are not familiar with
• Loud noises
• The dark
• Pain (can remember painful experiences)
• Bodily mutilation** realize can hurt, so fear harm. Fall & scape their knee so make a scene about blood
OMG!!
School-AGE 6-12yrs
Physical growth
• Girls grow faster than boys and commonly surpass them in height and weight
• During preadolescence (10-13 years), a child commonly experiences rapid and uneven growth
• Average school-age child grows 2 inches/year.
• Average school-age child gains 4.5 to 6.5 lbs per year.
Milestones

Gross Motor
• bicycling
• roller skating, roller-blading, skateboarding
• progressively improved running and jumping
• swimming
Fine motor

• Greater dexterity for crafts and video games

• computer competence
printing in earlier years, cursive in later years

Psychosocial development

• Erickson’s Industry vs. Inferiority (6-12 years)—gain a sense of industry by success with activities outside the
home (school, sports, etc). Inferiority develops when failures are not met with support & encouragement.
Adults job to still encourage even when child fails.

• Freud’s Latency Stage –developing social skills with activities with same-sex friends (ex: Brownies/Girl Scouts,
Cub Scouts/Boy Scouts)

Cognitive development

• Stage of concrete operations, marked by inductive reasoning, logical operations, and reversible concrete
thought
• Specific characteristics include:
– transition from egocentric to objective thinking (seeing another’s point of view, asking questions)
– difficulty dealing with remote, future or hypothetical matters developing various mental classifying and
ordering activities eg.. cant perceive time, “are we there yet”?
• Typical activities of a child at this stage;
– collecting and sorting objects (baseball cards, dolls, cards)
– ordering items according to size, shape, weight, and other criteria
– considering options and variables when problem solving
Pain assessment

– Able to describe pain and quantity

– Has an awareness of death
– Stiff body posture
 – Withdrawal
– Procrastinates or bargains to delay procedures

Language & social development

• Develops formal adult articulation patterns between ages 7 and 9.

• Radius of significant others expands to include school mates and instructive adults.
• Peer relationships gain new importance. But mom still authorian.
• Engages in tasks and activities that he/she can carry through to completion.
• Gains self-esteem and develops body-image
Activity & play

• Play becomes more competitive and complex during this time.

• Characteristic activities include team sports, secret clubs (same gender), scouting and other organizations,
complex puzzles, collections, reading, hero worship and “gang” activities.
• Rules and rituals are important aspects of play and games. Rules are really important!!. Will tell on anybody who
breaks them.

Rest & sleep

• Sleep requirements vary, but typically range from 8 to 9.5 hours/night.

• Bedtime should be firmly established and adhered to on school nights.
• Reading before sleep may set up and facilitate a positive bedtime pattern.
• Children may be unaware of fatigue; if allowed to remain up, they will wake up still usual time but will be in bad
mood next day.

Safety Concern

• Learn to accept more responsibility for personal health care and injury prevention.
• Learn safety rules with regards to activities.
• Because of increased motor ability and independence, they are at increased risk for serious injury.
• Parents should continue to provide guidance for new situations and threats to safety, eg…inappropriate
touching.
• Should receive education about the use and abuse of alcohol, tobacco, and other drugs.

Fears

• Common fears include:

– failure at school
– bullies
– intimidating teachers
– kidnapping
– death: they understand that person is gone, “until next thanksgiving”.
• will ask multiple questions, but as long as they are answered and issue is not avoid the topic is drop once they
are satisfied.

Adolescents
Physical growth
• Girls
– puberty begins between ages 8 and 14 and usually is completed within 3 years
– Girls grow 2 to 8 inches and ceases at about 16 or 17
– On average, girls gain between 15 and 55 lbs.
Boys
– puberty begins between ages of 9 and 16 and is completed by age 18 or 19
– Boys grow 4 to 12 inches and growth ceases between ages 18 and 20
– On average, boys gain between 15 and 65 lbs.
• Hormonal influences cause important developmental changes
– body mass reaches adult size
– sebaceous glands become active
– sweat glands become fully functional
– hair growth in the axillae, genital and anal areas
– body hair assumes characteristic distribution
– development of secondary sex characteristics

Psychosocial development

Erickson: Identity vs. Role Confusion

• Early (11-14 yrs) develop sense of identity by adjusting to bodily changes, conforming to peer norms, mastering
skills within peer groups, defining boundaries with authority figures.

• Middle (14-16 yrs) continue adjusting to body changes, interested in attracting opposite sex, time of greatest
conflict with parents & authority figures. Relationship is all consuming.

• Late (17-20 yrs) have mature sexual identity, feels secure with body image, roles within peer groups clearly
defined, has idealistic career goals

Cognitive development

• Develop abstract reasoning.

• Develops the capacity for true formal thought.
• Systematic approach to problems

Pain assessment

– Perceives pain at a physical, emotional and mental level

– Understands cause and effect
– Describes pain and quantifies pain intensity
– Increased muscle tension
– Withdrawal and decreased motor activity
Nutrition

• Readily available nutritious snacks provide good insurance for a balanced diet.
• Milk and protein needed in sufficient amounts to promote bone and muscle growth.
• Maintaining adequate intake may be difficult because of such factors as
– busy schedules
 – influence of peers
– easy availability of fast foods
– fatty, empty calorie foods
• Common dietary deficiencies include
– iron, folate, and zinc.

Activity & Play

• Sports, camping, fishing gear, movies, video games, computer games, radios, MP3, compact disks, models,
collectibles, and personal telephones.
• Older adolescents are interested in the independence and status represented by being able to drive.

Rest & Sleep

• Common sleep interferences:

– rapid growth
– overexertion in activities
– tendency to stay up late
• In an attempt to “catch up”, adolescents sleep late at every opportunity. Sleep till noon & stay up till 3am.

Safety Concerns

• Establish rapport, be respectful

• Allow to handle equipment
• Provide detailed explanation of what child will experience during exam or procedure, and why it is necessary.
– Teach about procedures a day or two in advance
• unsafe use of equipment
• improper use of firearms
• swimming and diving accidents
• sports injuries
• sunburn (use of sunscreen should be encouraged)
• smoking and use of drugs (should be discouraged)
• Problem-solving should be taught to decrease use of physical violence as a coping mechanism.
• Adolescents engage in sexual activity
– for pleasure
– to satisfy drives and curiosity
– as a means of conquest or power
– to express and receive affection
– in response to peer pressure
• Accurate information must be provided on
– Pregnancy (stressing that both male and female partners are responsible for contraception)
– transmission of and protection against sexually transmitted diseases
– “no” means “no”
Fears

• Common fears of adolescents: very concerned with image!!

– relationships with persons of the opposite sex
– homosexual tendencies
 – school failure
– being “different”
– ability to assume adult roles “OMG pregnancy”
Nursing interventions • Roll back to front

• Sit unassisted
• Anticipatory Guidance
– Promoting development through Play • Walk
• Atraumatic Care
• Lose Babinski reflex
– Child Life
• Health Teaching • Write first name
– Promoting Nutrition
• Birth weight double
– Promoting Safety
• Half of adult height
Assessment
• Front-facing car seat
• Infant birth-12mtsDon’t forget the fontanel
• Drive
• th
Capillary refill is the 5 vital sign

• Developmental assessment—observe for achievement of milestones

– Much assessment data can be gathered by observing from across the room

– Think about what is most important in your exam

– Remember you will have little cooperation from older infant

– Do least invasive first; most invasive last

• Let child stay in parent’s lap or asleep if possible

• Auscultate respiratory rate one full minute DO NOT Assess by using hand on belly, have to LISTEN

• Auscultate apical pulse 1 full minute

• Assess breath sounds, heart tones, bowel sounds. Sounds are readily transmitted throughout all fields due to
thin chest wall. Transmitted= can hear throughout body.

• Complete the physical assessment

• Obtain blood pressure and temperature last***Routinely BP measurement is introduced at 3yrs of age.***

• < 90days old take rectal temp!!

• A decreased BP is a late stage sign, infant going into shock, Capillary Refill (decreased pulses R 1 st sign)

• Don’t forget the fontanel

• Capillary refill is the 5th vital sign

Toddler assessment

• Establish rapport with caregiver, then child

• Allow parent to hold child during exam

• Get what is most important first—you will get less cooperation as the assessment goes on

• Follow assessment sequence for infants

• Routine blood pressure measurement introduced at 3 yrs.

Teach about procedures immediately before

Preschooler approach to assessment

• Demonstrate on doll or teddy bear

• Allow to handle equipment

• Simple explanations, DO NOT LIE

• May proceed from head to toe

• Save invasive procedures for last

• Be mindful of your word choices

• Teach child about procedures a few hours before

School-age appoarch to assessment

• Establish rapport, be respectful

• Allow to handle equipment

• Provide detailed explanation of what child will experience during exam or procedure, and why it is necessary.

– Teach about procedures a day or two in advance

Adolescent approach to assessment

• Provide privacy

• Presence of parents/caregivers may affect history-taking

• Assessments and procedures

– Provide detailed explanations

– Teach a week beforehand when possible

• Listen to adolescent’s concerns and encourage open communication