NURS 3574 Holistic Nursing: Care of Children and Families
Exam 1 Study Guide and Blueprint
Be sure to use the learning guides provided in each module to guide your note-taking, focus, and
studying!
Understand developmental milestones

Anticipatory guidance for each milestone
Guidance During Infant's First Year First 6 Months
• Teach parents car safety with use of federally approved restraint, facing rearward, in the middle of the
back seat—not in a seat with an air bag.
• Understand each parent's adjustment to newborn, especially mother's postpartum emotional needs.
• Teach care of infant and help parents understand his or her individual needs and temperament and
that the infant expresses wants through crying.
• Reassure parents that infant cannot be spoiled by too much attention during the first 4 to 6 months.
• Encourage parents to establish a schedule that meets needs of child and themselves.
• Help parents understand infant's need for stimulation in environment.
• Support parents' pleasure in seeing child's growing friendliness and social response, especially smiling.
• Plan anticipatory guidance for safety. • Stress need for immunizations.
• Prepare for introduction of solid foods.
Second 6 Months
• Prepare parents for child's “stranger anxiety.”
• Encourage parents to allow child to cling to them and avoid long separation from either parent.
• Guide parents concerning discipline because of infant's increasing mobility.
• Encourage use of negative voice and eye contact rather than physical punishment as a means of
discipline.
• Encourage showing most attention when infant is behaving well, rather than when infant is crying.
• Teach injury prevention because of child's advancing motor skills and curiosity. • Encourage parents to
leave child with suitable caregiver to allow some free time.
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• Discuss readiness for weaning.
• Explore parents' feelings regarding infant's sleep patterns.
12 to 18 Months Old
Prepare parents for expected behavioral changes of toddlers, especially negativism and ritualism.
Assess present feeding habits and encourage gradual weaning from bottle and increased intake of solid
foods.
Stress expected feeding changes of physiologic anorexia, food fads and strong taste preferences, need for
scheduled routine at mealtimes, inability to sit through an entire meal, and lack of table manners.
Assess sleep patterns at night, particularly habit of a bedtime bottle, which is a major cause of early
childhood caries (ECC), and procrastination behaviors that delay hour of sleep.
Prepare parents for potential dangers of the home and motor vehicle environment, particularly motor
vehicle injuries, drowning, accidental poisoning, and falling injuries; give appropriate suggestions for
childproofing the home.
Discuss need for firm but gentle discipline and ways to deal with negativism and temper tantrums; stress
positive benefits of appropriate discipline.
Emphasize importance for both child and parents of brief, periodic separations.
Discuss toys that use developing gross and fine motor, language, cognitive, and social skills.
Emphasize need for dental supervision, types of basic dental hygiene at home, and food habits that
predispose to caries; stress importance of supplemental fluoride.
18 to 24 Months Old
Stress importance of peer companionship in play.
Explore need for preparation for additional sibling; stress importance of preparing child for new
experiences.
Discuss present discipline methods, their effectiveness, and parents' feelings about child's negativism;
stress that negativism is important aspect of developing self-assertion and independence and is not a sign
of spoiling.
Discuss signs of readiness for toilet training; emphasize importance of waiting for physical and
psychological readiness.
Discuss development of fears, such as darkness or loud noises, and of habits, such as security blanket or
thumb sucking; stress normalcy of these transient behaviors.
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Prepare parents for signs of regression in time of stress.
Assess child's ability to separate easily from parents for brief periods under familiar circumstances.
Allow parents to express their feelings of weariness, frustration, and exasperation; be aware that it is
often difficult to love toddlers at times when they are not asleep!
Point out some of the expected changes of the next year, such as longer attention span, somewhat less
negativism, and increased concern for pleasing others.
24 to 36 Months Old
Discuss importance of imitation and domestic mimicry and need to include child in activities.
Discuss approaches toward toilet training, particularly realistic expectations and attitude toward
accidents.
Stress uniqueness of toddlers' thought processes, especially through their use of language, poor
understanding of time, causal relationships in terms of proximity of events, and inability to see events
from another's perspective.
Stress that discipline still must be structured and concrete and that relying solely on verbal reasoning and
explanation leads to injuries, confusion, and misunderstanding.
Discuss investigation of preschool or daycare center toward completion of second year.
Guidance During Preschool Years
3 Years Old
Prepare parents for child's increasing interest in widening relationships. Encourage enrollment in
preschool.
Emphasize importance of setting limits.
Prepare parents to expect exaggerated tension-reduction behaviors, such as need for a “security blanket.”
Encourage parents to offer child choices.
Prepare parents to expect marked changes at
emotional extremes.
years old when child becomes insecure and exhibits
Prepare parents for normal dysfluency in speech and advise them to avoid focusing on the pattern.
Prepare parents to expect extra demands on their attention as a reflection of child's emotional insecurity
and fear of loss of love.
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Warn parents that the equilibrium of a 3-year-old child will change to the aggressive, out-of-bounds
behavior of a 4-year-old child.
Inform parents to anticipate a more stable appetite with more food selections.
Stress need for protection and education of child to prevent injury (see Safety Promotion and Injury
Prevention, Chapter 11).
4 Years Old
Prepare parents for more aggressive behavior, including motor activity and offensive language.
Prepare parents to expect resistance to parental authority.
Explore parental feelings regarding child's behavior.
Suggest some type of respite for primary caregivers, such as placing child in preschool for part of the day.
Prepare parents for child's increasing sexual curiosity.
Emphasize the importance of realistic limit setting on behavior and appropriate disciplinary techniques.
Prepare parents for the highly imaginative 4-year-old child who indulges in “tall tales” (to be
differentiated from lies) and develops imaginary playmates.
Prepare parents to expect nightmares or an increase in them.
Provide reassurance that a period of calmness begins at 5 years of age.
5 Years Old
Inform parents to expect a tranquil period at 5 years of age.
Help parents prepare the child for entrance into school environment.
Make certain that immunizations are up to date before child enters school.
Suggest that unemployed parental caregivers consider own activities when children begin school.
Suggest swimming lessons for the child.
Guidance During School Years
Age 6 Years
Prepare parents to expect strong food preferences and frequent refusal of specific food items. Prepare
parents to expect an increasingly ravenous appetite.
Prepare parents for emotional reactions as child experiences erratic mood changes.
Help parents anticipate continued susceptibility to illness.
Teach injury prevention and safety, especially bicycle safety.
Encourage parents to respect child's need for privacy and to provide a separate bedroom for child, if
possible.
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Prepare parents for child's increasing interests outside the home.
Help parents understand the need to encourage child's interactions with peers.
Ages 7 to 10 Years
Prepare parents to expect improvement in health with fewer illnesses but warn them that allergies may
increase or become apparent.
Prepare parents to expect an increase in minor injuries.
Emphasize caution in selecting and maintaining sports equipment and reemphasize safety.
Prepare parents to expect increased involvement with peers and interest in activities outside the home.
Emphasize the need to encourage independence while maintaining limit setting and discipline. Prepare
mothers to expect more demands at 8 years old.
Prepare fathers to expect increasing admiration at 10 years old; encourage father–child activities. Prepare
parents for prepubescent changes in girls.
Ages 11 to 12 Years
Help parents prepare child for body changes of pubescence. Prepare parents to expect a growth spurt in
girls.
Make certain child's sex education is adequate with accurate information.
Prepare parents to expect energetic but stormy behavior at 11 years old, and child becoming more eventempered at 12 years old.
Encourage parents to support child's desire to “grow up” but to allow regressive behavior when needed.
Prepare parents to expect an increase in child's masturbation.
Instruct parents that the child may need more rest.
Help parents educate child regarding experimentation with potentially harmful activities.
Health Guidance
Help parents understand the importance of regular health and dental care for the child.
Encourage parents to teach and model sound health practices, including diet, rest, activity, and exercise.
Stress the need to encourage children to engage in appropriate physical activities. Emphasize providing a
safe physical and emotional environment.
Encourage parents to teach and model safety practices.
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Guidance During Adolescence
Encourage parents to:
• Accept adolescent as a unique individual.
• Respect adolescent's ideas, likes and dislikes, and wishes.
• Be involved with school functions and attend adolescent's performances, whether it is a sporting event
or school play.
• Listen and try to be open to teenager's views even when they disagree with parental views.
• Avoid criticism about no-win topics.
• Provide opportunity for choosing options and accept natural consequences of these choices.
• Allow young persons to learn by doing, even when choices and methods differ from those of adults.
• Provide adolescent with clear, reasonable limits.
• Clarify house rules and consequences for breaking them. Let society's rules and consequences teach
responsibility outside the home.
• Allow increasing independence within limitations of safety and well-being.
• Respect adolescent's privacy.
• Try to share adolescent's feelings of joy or sorrow.
• Respond to feelings as well as words.
• Be available to answer questions, give information, and provide companionship.
• Try to make communication clear.
• Avoid comparisons with siblings.
• Assist adolescent in selecting appropriate career goals and preparing for adult roles. • Welcome
adolescent's friends into the home and treat them with respect.
• Provide unconditional love and acceptance.
• Be willing to apologize when mistaken.
Be aware that adolescents:
• Are subject to turbulent, unpredictable behavior.
• Are struggling for independence.
• Are extremely sensitive to feelings and behavior that affect them. • May receive a different message
from what was sent.
• Consider friends extremely important.
• Have a strong need to belong.
https://quizlet.com/225369138/developmental-milestones-flash-cards/
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 What to do if milestones not met
- A missed milestone could be a sign of a problem, so the doctor or another specialist will take a
closer look by using a more thorough test or exam. Your childcare provider can also be a
valuable source of information on how your child develops.


Therapeutic communication to caregiver regarding milestones

Appropriate preparation of procedures based on milestones and ages
Preparing Children for Procedures
• Determine details of exact procedure to be performed.
• Review parents' and child's present understanding.
• Base teaching on developmental age and existing knowledge.
• Incorporate parents in the teaching if they desire, especially if they plan to participate in care.
• Inform parents of their supportive role during procedure, such as standing near child's head or in
child's line of vision and talking softly to child, as well as typical responses of children undergoing the
procedure.
• Allow for ample discussion to prevent information overload and ensure adequate feedback.
• Use concrete, not abstract, terms and visual aids to describe procedure. For example, use a simple line
drawing of a boy or girl and mark the body part that will be involved in the procedure. Use
nonthreatening but realistic models.*
• Emphasize that no other body part will be involved.
• If the body part is associated with a specific function, stress the change or noninvolvement of that
ability (e.g., after tonsillectomy, child can still speak).
• Use words and sentence length appropriate to child's level of understanding (a rule of thumb for the
number of words in a child's sentence is equal to his or her age in years plus 1).
• Avoid words and phrases with dual meanings (see Table 20-1) unless child understands such words.
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• Clarify all unfamiliar words (e.g., “Anesthesia is a special sleep”).
• Emphasize sensory aspects of procedure—what child will feel, see, hear, smell, and touch and what
child can do during procedure (e.g., lie still, count out loud, squeeze a hand, hug a doll). • Allow child to
practice procedures that will require cooperation (e.g., turning, deep breathing, using an incentive
spirometry).
• Introduce anxiety-inducing information last (e.g., starting an intravenous [IV] line).
• Be honest with child about unpleasant aspects of a procedure but avoid creating undue concern. When
discussing that a procedure may be uncomfortable, state that it feels differently to different people.
• Emphasize end of procedure and any pleasurable events afterward (e.g., going home, seeing parents).
• Stress positive benefits of procedure (e.g., “After your tonsils are fixed, you won't have as many sore
throats”).
• Provide a positive ending, praising efforts at cooperation and coping.

Educating parents on what developmental screening tests are for
-
One of the most essential components of a complete health appraisal is assessment of
developmental function. Screening procedures are designed to identify quickly and reliably
children whose developmental level is below normal for their age and who therefore require
further investigation. They also provide a means of recording objective measurements of
present developmental function for future reference.
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Developmental Screening Purpose:
to identify children who should receive additional assessment for potential
developmental delays
-want: earlier detection & improved child health
Performed at a set point in time
9, 18, 24 or 30 months
Results always interpreted in context
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Never in isolation
Aid to ongoing surveillance
Allow parents to express concern
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Parents have many concerns about their child's behavior and abilities.
Showing them what the child is able and not able to do helps them develop
appropriate expectations of their children. E.g., many parents think that a 1218 month old infant should understand "no" and refrain from doing things the
parent discourages. However, kids that young don't have a long attention
span or a good short or long term memory, so parents need to say "no"
thousands of times! When the parent understands this, it can change their
perception of the child from being a "bad" child to one who needs more
education!
The most obvious problems are the least common
Puts science behind identification of developmental problems
Early intervention can mitigate negative effects
We can not rely on our subjective judgment of whether a child is
developmentally normal or has a delay. We need to compare child against
established criteria for age-appropriate behavior.
If a child has a delay, the earlier they receive supportive services like physical
therapy, the better the outcome will be.
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Most pediatric professionals can easily identify a child that is clearly normal or
abnormal. It's the kids who have more subtle symptoms that are difficult to
identify. As a new nurse, you are learning normal from abnormal, so
assessment can help you gain comfort with normal and abnormal behavior.
Also, you can help parents to have appropriate expectations of their children.
Enhance the surveillance process and increase detection of delays
2 Main Types of Tools
-Parent-completed questionnaires
-Directly administered instruments
We want to engage parents to talk about their child's abilities and be able to
give guidance when parents offer opinions and concerns.
Information can be gathered via a questionnaire that the parent completes at
the visit or via specific tests the provider does during the assessment. Both
types of tools provide useful information.
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
Self concept for age levels
Development of Self-Concept
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
Self-concept is how an individual describes him- or herself. The term self-concept includes all of
the notions, beliefs, and convictions that constitute an individual's self-knowledge and that
influence that individual's relationships with others. It is not present at birth but develops
gradually as a result of unique experiences within the self, significant others, and the realities of
the world. However, an individual's self-concept may or may not reflect reality.

In infancy, the self-concept is primarily an awareness of one's independent existence learned in
part as a result of social contacts and experiences with others. The process becomes more active
during toddlerhood as children explore the limits of their capacities and the nature of their
impact on others. School-age children are more aware of differences among people, are more
sensitive to social pressures, and become more preoccupied with issues of self-criticism and selfevaluation. During early adolescence, children focus more on physical and emotional changes
taking place and on peer acceptance. Self-concept is crystallized during later adolescence as
young people organize their self-concept around a set of values, goals, and competencies
acquired throughout childhood.


Body Image
A vital component of self-concept, body image refers to the subjective concepts and attitudes that
individuals have toward their own bodies. It consists of the physiologic (the perception of one's
physical characteristics), psychological (values and attitudes toward the body, abilities, and
ideals), and social nature of one's image of self (the self in relation to others). All three of the
components interrelate with one another. Body image is a complex phenomenon that evolves and
changes during the process of growth and development. Any actual or perceived deviation from
the “norm” (no matter how this is interpreted) is cause for concern. The extent to which a
characteristic, defect, or disease affects children's body image is influenced by the attitudes and
behavior of those around them.

Infants receive input about their bodies through self-exploration and sensory stimulation from
others. As they begin to manipulate their environment, they become aware of their bodies as
separate from others. Toddlers learn to identify the various parts of their bodies and are able to
use symbols to represent objects. Preschoolers become aware of the wholeness of their bodies and
discover the genitalia. Exploration of the genitalia and the discovery of differences between the
sexes become important. At this age, children have only a vague concept of internal organs and
function

School-age children begin to learn about internal body structure and function and become aware
of differences in body size and configuration. They are highly influenced by the cultural norms of
society and current fads. Children whose bodies deviate from the norm are often criticized or
ridiculed. Adolescence is the age when children become most concerned about the physical self.
The unfamiliar body changes, and the new physical self must be integrated into the self-concept.
Adolescents face conflicts over what they see and what they visualize as the ideal body structure.
Body image formation during adolescence is a crucial element in the shaping of identity, the
psychosocial crisis of adolescence.

Speech patterns, stuttering, sexual curiosity, knowing gender
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Speech Problems
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-
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The most critical period for speech development occurs between 2 and 4 years old. During
this period, children are using their rapidly growing vocabulary faster than they can produce
the words. Failure to master sensorimotor integrations results in stuttering or stammering as
children try to say the word they are already thinking about. This dysfluency in speech
pattern is common during language development in children 2 to 5 years old (Nelson, 2013).
Stuttering affects boys more frequently than girls, has been shown to have a genetic link, and
usually resolves during childhood
The National Institute on Deafness and Other Communication Disorders (2010) encourages
parents and caregivers of children who stutter to speak slowly and relaxed, refrain from
criticizing the child's speech, resist completing the child's sentences, and take time to listen
attentively.
The best therapy for speech problems is prevention and early detection. Common causes of
speech problems include hearing loss, developmental delay, autism, lack of environmental
stimulation, and physical conditions that impede normal speech production (McLaughlin,
2011). Referral for further evaluation and treatment may be necessary to prevent a problem
from interfering with learning. Anticipatory preparation of parents for expected
developmental norms may allay caregiver concerns.
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Development of Sexuality
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Development of Gender Identity
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Many children experience some form of sex play during or before preadolescence as a
response to normal curiosity, not as a result of love or sexual urges. Children are
experimentalists by nature, and sex play is incidental and transitory. Any adverse emotional
consequences or guilt feelings depend on how the behavior is managed by the parents. Many
parents discourage sexual exploration, either through subtle cues or expressions of anger or
disgust at their child's behavior. These tactics clearly communicate to children that they
should not engage in such activities, discourage questions about sex, and limit the sources of
information.
Just as toddlers explore their environment, they also explore their bodies and find that
touching certain body parts is pleasurable. Genital fondling (masturbation) can occur and
involves manual stimulation, as well as posturing movements (especially in young girls) such
as tightening of the thighs or mechanical pressure applied to the pubic or suprapubic area.
Other demonstrations of pleasurable activities include rocking, swinging, and hugging
people and toys. Parental reactions to toddlers' behavior influence the children's own
attitudes and should be accepting rather than critical. If such acts are performed in public,
parents should not condone or bring attention to the behavior but should teach the child that
it is more acceptable to perform the behavior in private.
Children in this age group are learning vocabulary associated with anatomy, elimination,
and reproduction. Certain associations between words and functions become significant and
can influence future sexual attitudes. For example, if parents refer to the genitalia as dirty,
especially in the context of elimination, this association between “genitalia” and “dirty” may
be transferred to sexual functions later in life. Sex-role differences become obvious to children
and are evident in much of toddlers' imitative play. Although current research indicates that
prenatal exposure to testosterone strongly influences the individual's gender identity,
researchers also indicate that there are sensitive periods (e.g., puberty) that may also have an
influence on the development of gender identity (Berenbaum and Beltz, 2011; Hines, 2011;
Savic, Garcia-Falqueras, and Swaab, 2010). A sense of maleness or femaleness, or gender
identity, begins by 24 months old when children are able to label their own and other's
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gender (Steensma, Kreukels, de Vries, et al, 2013). Early attitudes are formed about
affectionate behaviors between adults from observing parental and other adult intimate or
sensual activities. (See also Sex Education, Chapters 12 and 14.) The quality of relationships
with parents is important to the child's capacity for sexual and emotional relationships later
in life.
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
Injury susceptibility related to developmental milestones
Birth to 4 Months Old
Major Developmental Accomplishments
Exhibits involuntary reflexes (e.g., crawling reflex may propel infant forward or backward; startle reflex
may cause the body to jerk)
May roll over
Has increasing eye–hand coordination and voluntary grasp reflex
Injury Prevention
Aspiration
Aspiration is not as great a danger to this age group, but parents should begin practicing safeguarding
early (see 4 to 7 Months Old later in this box).
Never shake baby powder directly on infant; place powder in hand and then on infant's skin; store
container closed and out of the infant's reach.
Hold infant for feeding; do not prop bottle.
Know emergency procedures for choking.
Use pacifier with one-piece construction and loop handle.
Burns
Install smoke detectors in home.
Do not use microwave oven to warm formula; always check temperature of liquid before feeding.
Check bathwater.
Do not pour hot liquids when infant is close by, such as sitting on lap.
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Beware of cigarette ashes that may fall on infant.
Do not leave infant in sun for more than a few minutes; keep exposed areas covered.
Wash flame-retardant clothes according to label directions.
Use cool-mist vaporizers.
Do not leave child in parked car.
Check surface heat of car restraint before placing child in seat.
Suffocation and Drowning
Keep all plastic bags stored out of infant's reach; discard large plastic garment bags after tying in a knot.
Do not cover mattress with plastic.
Use firm mattress and loose blankets with no pillows.
Make certain crib design follows federal regulations and mattress fits snugly—crib slats 2.375 inches (6
cm) apart.*
Position crib away from other furniture and away from radiators.
Do not tie pacifier on a string around infant's neck.
Remove bibs at bedtime.
Never leave infant alone in bath.
Do not leave infant younger than 12 months old alone on adult or youth mattress or beanbag-type seats.
Motor Vehicles
Transport infant in federally approved, rear-facing car seat, preferably in back seat. Do not place infant on
seat (of car) or in lap.
Do not place child in a carriage or stroller behind a parked car.
Do not place infant or child in front passenger seat with an air bag.
Do not leave infant unattended in car.
Falls
Use crib with fixed, raised rails.
Never leave infant alone on a raised, unguarded surface.
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When in doubt as to where to place child, use floor.
Restrain child in infant seat, and never leave child unattended while the seat is resting on a raised surface.
Avoid using a high chair until child can sit well with support.
Accidental Poisoning
Poisoning is not as great a danger to this age group, but parents should begin practicing safeguards early
(see 4 to 7 Months Old later in this box).
Bodily Damage
Keep sharp or jagged objects, such as knives and broken glass, out of child's reach.
Keep diaper pins closed and away from infant.
4 to 7 Months Old
Major Developmental Accomplishments
Rolls over
Sits momentarily
Grasps and manipulates small objects Re-secures a dropped object
Has well-developed eye–hand coordination Can focus on and locate small objects
Has prominent mouthing (oral fixation)
Can push up on hands and knees
Crawls backward
Injury Prevention
Aspiration
Keep buttons, beads, syringe caps, and other small objects out of infant's reach.
Keep floor free of any small objects.
Do not feed infant hard candy, nuts, food with pits or seeds, or whole or circular pieces of hot dog.
Exercise caution when giving teething biscuits because large chunks may be broken off and aspirated.
Do not feed infant while he or she is lying down.
Inspect toys for removable parts.
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Keep baby powder, if used, out of reach.
Avoid storing cleaning fluid, paints, pesticides, and other toxic substances within infant's reach.
Know telephone number of local poison control center (800-222-1222) (usually listed in front of telephone
directory).
Suffocation
Keep all latex balloons out of reach.
Remove all crib toys that are strung across crib or play yard when child begins to push up on hands or
knees or is 5 months old.
Burns
Keep water faucets out of reach.
Place hot objects (cigarettes, candles, incense) on high surface out of child's reach. Limit exposure to sun;
apply sunscreen.
Falls
Restrain in a high chair.
Keep crib rails raised to full height.
Motor Vehicles
See Birth to 4 Months Old earlier in this box.
Accidental Poisoning
Make certain that paint for furniture or toys does not contain lead.
Place toxic substances on a high shelf or in locked cabinet.
Hang plants or place on high surface rather than on floor.
Know telephone number of local poison control center (800-222-1222) (usually listed in front of telephone
directory).
Bodily Damage
Give toys that are smooth and rounded, preferably made of wood or plastic. Avoid long, pointed objects
as toys.
Avoid toys that are excessively loud.
Keep sharp objects out of infant's reach.
8 to 12 Months Old
Major Developmental Accomplishments
Crawls or creeps
Stands holding on to furniture
Stands alone
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Cruises around furniture
Walks
Climbs
Pulls on objects
Throws objects
Picks up small objects; has pincer grasp
Explores by putting objects in mouth
Dislikes being restrained
Explores away from parent
Increasingly understands simple commands and phrases
Injury Prevention
Aspiration
Keep small objects off floor, off furniture, and out of reach of children. Take care when feeding solid table
food to give very small pieces.
Do not use beanbag toys or allow child to play with dried beans.
See also 4 to 7 Months Old earlier in this box.
Bodily Damage
See 4 to 7 Months Old earlier in this box.
Avoid placing televisions or other large objects on top of furniture, which may be overturned when infant
pulls self to standing position.
Falls
Avoid walkers, especially near stairs.*
Ensure that furniture is sturdy enough for child to pull self to standing position and cruise.
Fence stairways at top and bottom if child has access to either end.*
Dress infant in safe shoes and clothing (soles that do not “catch” on floor, tied shoelaces, pant legs that do
not touch floor).
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Suffocation and Drowning
Keep doors of ovens, dishwashers, refrigerators, coolers, and front-loading clothes washers and dryers
closed at all times.
If storing an unused large appliance, such as a refrigerator, remove the door.
Supervise contact with inflated balloons; immediately discard popped balloons and keep uninflated
balloons out of reach.
Fence swimming pools and other bodies of standing water, such as decorative fountains; lock gate to
swimming pools so that only adult can access.
Always supervise when near any source of water, such as cleaning buckets, drainage areas, toilets. Keep
bathroom doors closed.
Eliminate unnecessary pools of water.
Keep one hand on child at all times when in tub.
Accidental Poisoning
Administer medications as a drug, not as a candy.
Do not administer medications unless prescribed by a practitioner.
Return medications and poisons to safe storage area immediately after use; replace caps properly if a
child-protector cap is used.
Have poison control center number (800-222-1222) on telephone and refrigerator.
Burns
Place guards in front of or around any heating appliance, fireplace, or furnace.
Keep electrical wires hidden or out of reach.
Place plastic guards over electrical outlets; place furniture in front of outlets.
Keep hanging tablecloths out of reach (child may pull down hot liquids or heavy or sharp objects).
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
Why temper tantrums may occur
Temper Tantrums
Toddlers may assert their independence by violently objecting to discipline. They may lie down
on the floor, kick their feet, and scream at the top of their lungs. Some have learned the
effectiveness of holding their breath until the parent relents. Although holding one's breath may
cause fainting from the lack of oxygen, the accumulation of carbon dioxide will stimulate the
respiratory control center, resulting in no physical harm. Tantrums are an indication of the child's
inability to control emotions; toddlers are particularly prone to tantrums because their strong
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drive for mastery and autonomy is frustrated by adult figures or lack of motor and cognitive
skills.

The best approach toward tapering temper tantrums requires consistency and developmentally
appropriate expectations and rewards. Ensuring consistency among all caregivers in
expectations, prioritizing what rules are important, and developing consequences that are
reasonable for the child's level of development help manage the behavior. For example, a popular
time for a tantrum is before bed. Active toddlers often have trouble slowing down and, when
placed in bed, resist staying there. Parents can reinforce consistency and expectations by stating,
“After this story, it is bedtime.” Starting at 18 months old, time-outs work well for managing
temper tantrums.

During tantrums, stay calm and ignore the behavior, provided the behavior is not injurious to the
child, such as violently banging the head on the floor. Continue to be present to provide a feeling
of control and security to the child when the tantrum has subsided. During periods of no
tantrums, practice developmentally appropriate positive reinforcement.

Other suggestions for preventing tantrums include the following (Luangrath, 2011):
• Offer the child options instead of an “all or none” position.
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
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• Set clear boundaries and expectations with all caregivers.

Temper tantrums are common during the toddler years and essentially represent normal
developmental behaviors. However, temper tantrums can be signs of serious problems. Temper
tantrums that occur past 5 years old, last longer than 15 minutes, or occur more than five times a
day are considered abnormal and may indicate a serious problem (Daniels, Mandleco, and Luthy,
2012). Nurses should be alert to situations that require further evaluation.
• Ensure a consistent response to child's behavior by all caregivers.
• Praise the child for positive behavior when he or she is not having a tantrum or provide a
reward system (i.e., sticker chart).
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

Differentiate Erikson’s psychosocial stages

Each psychosocial stage has two components—the favorable and the unfavorable aspects of the
core conflict—and progress to the next stage depends on resolution of this conflict. No core
conflict is ever mastered completely but remains a recurrent problem throughout life. No life
situation is ever secure. Each new situation presents the conflict in a new form. For example,
when children who have satisfactorily achieved a sense of trust encounter a new experience (e.g.,
hospitalization), they must again develop a sense of trust in those responsible for their care in
order to master the situation. Erikson's life-span approach to personality development consists of
eight stages; however, only the first five relating to childhood are included here:
Psychosocial Development (Erikson)
The most widely accepted theory of personality development is that advanced by Erikson (1963).
Although built on Freudian theory, it is known as psychosocial development and emphasizes a
healthy personality as opposed to a pathologic approach. Erikson also uses the biologic concepts
of critical periods and epigenesis, describing key conflicts or core problems that the individual
strives to master during critical periods in personality development. Successful completion or
mastery of each of these core conflicts is built on the satisfactory completion or mastery of the
previous stage.
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
Trust versus mistrust (birth to 1 year old): The first and most important attribute to develop for a
healthy personality is basic trust. Establishment of basic trust dominates the first year of life and
describes all of the child's satisfying experiences at this age. Corresponding to Freud's oral stage,
it is a time of “getting” and “taking in” through all the senses. It exists only in relation to
something or someone; therefore, consistent, loving care by a mothering person is essential for
development of trust. Mistrust develops when trust-promoting experiences are deficient or
lacking or when basic needs are inconsistently or inadequately met. Although shreds of mistrust
are sprinkled throughout the personality, from a basic trust in parents stems trust in the world,
other people, and oneself. The result is faith and optimism.

Autonomy versus shame and doubt (1 to 3 years old): Corresponding to Freud's anal stage, the
problem of autonomy can be symbolized by the holding on and letting go of the sphincter
muscles. The development of autonomy during the toddler period is centered on children's
increasing ability to control their bodies, themselves, and their environment. They want to do
things for themselves using their newly acquired motor skills of walking, climbing, and
manipulating and their mental powers of selecting and decision making. Much of their learning
is acquired by imitating the activities and behavior of others. Negative feelings of doubt and
shame arise when children are made to feel small and self-conscious, when their choices are
disastrous, when others shame them, or when they are forced to be dependent in areas in which
they are capable of assuming control. The favorable outcomes are self-control and willpower.
Initiative versus guilt (3 to 6 years old): The stage of initiative corresponds to Freud's phallic
stage and is characterized by vigorous, intrusive behavior; enterprise; and a strong imagination.
Children explore the physical world with all their senses and powers (Fig. 3-4). They develop a
conscience. No longer guided only by outsiders, they have an inner voice that warns and
threatens. Children sometimes undertake goals or activities that are in conflict with those of
parents or others, and being made to feel that their activities or imaginings are bad produces a
sense of guilt. Children must learn to retain a sense of initiative without impinging on the rights
and privileges of others. The lasting outcomes are direction and purpose.



Industry versus inferiority (6 to 12 years old): The stage of industry is the latency period of
Freud. Having achieved the more crucial stages in personality development, children are ready
to be workers and producers. They want to engage in tasks and activities that they can carry
through to completion; they need and want real achievement. Children learn to compete and
cooperate with others, and they learn the rules. It is a decisive period in their social relationships
with others. Feelings of inadequacy and inferiority may develop if too much is expected of them
or if they believe that they cannot measure up to the standards set for them by others. The ego
quality developed from a sense of industry is competence.
Identity versus role confusion (12 to 18 years old): Corresponding to Freud's genital period, the
development of identity is characterized by rapid and marked physical changes. Previous trust in
their bodies is shaken, and children become overly preoccupied with the way they appear in the
eyes of others compared with their own self-concept. Adolescents struggle to fit the roles they
have played and those they hope to play with the current roles and fashions adopted by their
peers, to integrate their concepts and values with those of society, and to come to a decision
regarding an occupation. An inability to solve the core conflict results in role confusion. The
outcome of successful mastery is devotion and fidelity to others and to values and ideologies.
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
Piaget’s cognitive stages
Cognitive Development (Piaget)
Jean Piaget (1969), a Swiss psychologist, developed a stage theory to better understand the way a child
thinks. According to Piaget, intelligence enables individuals to make adaptations to the environment that
increase the probability of survival, and through their behavior, individuals establish and maintain
equilibrium with the environment. Each stage of cognitive development is derived from and builds on
the accomplishments of the previous stage in a continuous, orderly process. This course of development
is both maturational and invariant and is divided into the following four stages (ages are approximate):
Sensorimotor (birth to 2 years old): The sensorimotor stage of intellectual development consists of six
substages that are governed by sensations in which simple learning takes place (see Chapter 9 and
Chapter 11). Children progress from reflex activity through simple repetitive behaviors to imitative
behavior. They develop a sense of cause and effect as they direct behavior toward objects. Problem
solving is primarily by trial and error. They display a high level of curiosity, experimentation, and
enjoyment of novelty and begin to develop a sense of self as they are able to differentiate themselves from
their environment. They become aware that objects have permanence—that an object exists even though
it is no longer visible. Toward the end of the sensorimotor period, children begin to use language and
representational thought.
Preoperational (2 to 7 years old): The predominant characteristic of the preoperational stage of
intellectual development is egocentrism, which in this sense does not mean selfishness or selfcenteredness but the inability to put oneself in the place of another. Children interpret objects and events
not in terms of general properties but in terms of their relationships or their use to them. They are unable
to see things from any perspective other than their own; they cannot see another's point of view, nor can
they see any reason to do so (see Cognitive Development, Chapter 12). Preoperational thinking is
concrete and tangible. Children cannot reason beyond the observable, and they lack the ability to make
deductions or generalizations. Thought is dominated by what they see, hear, or otherwise experience.
However, they are increasingly able to use language and symbols to represent objects in their
environment. Through imaginative play, questioning, and other interactions, they begin to elaborate
concepts and to make simple associations between ideas. In the latter stage of this period, their reasoning
is intuitive (e.g., the stars have to go to bed just as they do), and they are only beginning to deal with
problems of weight, length, size, and time. Reasoning is also transductive—because two events occur
together, they cause each other, or knowledge of one characteristic is transferred to another (e.g., all
women with big bellies have babies).
Concrete operations (7 to 11 years old): At this age, thought becomes increasingly logical and coherent.
Children are able to classify, sort, order, and otherwise organize facts about the world to use in problem
solving. They develop a new concept of permanence—conservation (see Cognitive Development [Piaget],
Chapter 14); that is, they realize that physical factors (such as, volume, weight, and number) remain the
same even though outward appearances are changed. They are able to deal with a number of different
aspects of a situation simultaneously. They do not have the capacity to deal in abstraction; they solve
problems in a concrete, systematic fashion based on what they can perceive. Reasoning is inductive.
Through progressive changes in thought processes and relationships with others, thought becomes less
self-centered. They can consider points of view other than their own. Thinking has become socialized.
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Formal operations (11 to 15 years old): Formal operational thought is characterized by adaptability and
flexibility. Adolescents can think in abstract terms, use abstract symbols, and draw logical conclusions
from a set of observations. For example, they can solve the following question: If A is larger than B and B
is larger than C, which symbol is the largest? (The answer is A.) They can make hypotheses and test them;
they can consider abstract, theoretic, and philosophic matters. Although they may confuse the ideal with
the practical, most contradictions in the world can be dealt with and resolved.
Parenting Styles, Day Care
Communication and Language Development
Differences between
 Infant
 Toddler
 Preschool/school age
 Adolescent
Infancy
Because they are unable to use words, infants primarily use and understand nonverbal communication.
Infants communicate their needs and feelings through nonverbal behaviors and vocalizations that can be
interpreted by someone who is around them for a sufficient time. Infants smile and coo when content and
cry when distressed. Crying is provoked by unpleasant stimuli from inside or outside, such as hunger,
pain, body restraint, or loneliness. Adults interpret this to mean that an infant needs something and
consequently try to alleviate the discomfort by meeting their physical needs, speaking softly, and
communicating through touch.
Infants respond to adults' nonverbal behaviors. They become quiet when they are cuddled, rocked, or
receive other forms of gentle physical contact. They receive comfort from the sound of a soft voice even
though they do not understand the words that are spoken. Until infants reach the age at which they
experience stranger anxiety, they readily respond to any firm, gentle handling and quiet, calm speech.
Loud, harsh sounds and sudden movements are frightening.
Early Childhood
Children younger than 5 years old are egocentric. They see things only in relation to themselves and from
their point of view. Therefore focus communication on them. Tell them what they can do or how they
will feel. Experiences of others are of no interest to them. It is futile to use another child's experience in an
attempt to gain the cooperation of small children. Allow them to touch and examine articles they will
come in contact with. A stethoscope bell will feel cold; palpating a neck might tickle. Although they have
not yet acquired sufficient language skills to express their feelings and wants, toddlers can effectively use
their hands to communicate ideas without words. They push an unwanted object away, pull another
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person to show them something, point, and cover the mouth that is saying something they do not wish to
hear.
Everything is direct and concrete to small children. They are unable to work with abstractions and
interpret words literally. Analogies escape them because they are unable to separate reality from fantasy.
For example, they attach literal meaning to such common phrases as “two-faced,” “sticky fingers,” and
“coughing your head off.” Children who are told they will get “a little stick in the arm” may not be able
to envision an injection (Fig. 4-3). Therefore, use simple, direct language rather than phrases that might be
misinterpreted by a small child.
FIG 4-3 A young child may take the expression “a little stick in the arm” literally.
School-Age Years
Younger school-age children rely less on what they see and more on what they know when faced with
new problems. They want explanations and reasons for everything but require no verification beyond
that. They are interested in the functional aspect of all procedures, objects, and activities. They want to
know why an object exists, why it is used, how it works, and the intent and purpose of its user. They
need to know what is going to take place and why it is being done to them specifically. For example, to
explain a procedure such as taking blood pressure, show the child how squeezing the bulb pushes air
into the cuff and makes the “arrow” move. Let the child operate the bulb. An explanation for the
procedure might be as simple as, “I want to see how far the arrow moves when the cuff squeezes your
arm.” Consequently, the child becomes an enthusiastic participant.
School-age children have a heightened concern about body integrity. Because of the special importance
they place on their body, they are sensitive to anything that constitutes a threat or suggestion of injury to
it. This concern extends to their possessions, so they may appear to overreact to loss or threatened loss of
treasured objects. Encouraging children to communicate their needs and voice their concerns enables the
nurse to provide reassurance, to dispel myths and fears, and to implement activities that reduce their
anxiety. For example, if a shy child dislikes being the center of attention, ignore that particular child by
talking and relating to other children in the family or group. When children feel more comfortable, they
will usually interject personal ideas, feelings, and interpretations of events.
Adolescence
As children move into adolescence, they fluctuate between child and adult thinking and behavior. They
are riding a current that is moving them rapidly toward a maturity that may be beyond their coping
ability. Therefore, when tensions rise, they may seek the security of the more familiar and comfortable
expectations of childhood. Anticipating these shifts in identity allows the nurse to adjust the course of
interaction to meet the needs of the moment. No single approach can be relied on consistently, and
encountering cooperation, hostility, anger, bravado, and a variety of other behaviors and attitudes is
common. It is as much a mistake to regard an adolescent as an adult with an adult's wisdom and control
as it is to assume that a teenager has the concerns and expectations of a child.
Interviewing an adolescent presents some special issues. The first may be whether to talk with the
adolescent alone or with the adolescent and parents together. If the parents and teenager are together,
talking with the adolescent first has the advantage of immediately identifying with the young person,
thus fostering the interpersonal relationship. However, talking with the parents initially may provide
22
insight into the family relationship. In either case, give both parties an opportunity to be included in the
interview. If time is limited (such as during history taking), clarify this at the onset to avoid appearing to
“take sides” by talking more with one person than with the other.
Privacy and confidentiality are of great importance when communicating with adolescents because it is
consistent with developmental maturity and autonomy. Explain to parents and teenagers the legal and
ethical protections and limits of confidentiality. Nurses need to know and understand the state and
federal consent and confidentiality laws pertaining to adolescent circumstances, such as suspected abuse,
alcohol or other drug use, suicidal or homicidal ideation, contraceptive care, pregnancy, sexually
transmitted infections, and sexual assault (Broner, Embry, Gremminger, et al, 2013).
Another dilemma in interviewing adolescents is that two views of a problem frequently exist: the
teenager's and the parents'. Clarification of the problem is a major task. However, providing both parties
an opportunity to discuss their perceptions in an open and unbiased atmosphere can, by itself, be
therapeutic. Demonstrating positive communication skills can help families with adolescents to
communicate more effectively (see Nursing Care Guidelines box).
Vital signs and weight


Normal variations
Rate of weight gain, when doubles, triples
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24
25
26
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Play


Types of play
Play appropriate for age
28

Physical Examination (PE)
 How does PE differ with age group…head to toe? Atraumatic first?
 Normal and abnormal
 Fontanel
 Weight and other growth parameters
 Susceptibility to infection
 Education to parents on differences of children’s PE and character
Nutrition


Food patterns for age level
Food choices for age level
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30
31
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Adolescents:
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Anticipatory guidance

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Safety by age level
Counseling concepts by age level
Teaching for age level: how to involve age groups (think of teaching model)
Toilet training readiness and counseling
Day care facilities
Aggressive behaviors risk factors
Temperament of child
Health Problems

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
ALTE
SIDS
Child maltreatment

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
Colic
Sleep problems
Poisoning
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The Hospitalized Child

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

Attachment stages with hospitalization
Child stressors with hospitalization
Family stressors with hospitalization
Sibling reactions to hospitalization
How to support children and families through hospitalization
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Pain Assessment and Management




Pain assessment scales for each age/developmental range
Nonpharmacologic strategies for pain management
Limited value of physiologic measurement
Side effects of opioid pain management
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Approximate numbers of questions per topic:
6
Pediatric Perspectives
5
Health Assessment & Developmental Screening
2
Communication
15
Infant G & D
6
Health Problems of Infants (Colic, SIDS, ALTE)
8
Pain Assessment and Management
8
Hospitalized Child
14
Toddler G & D
13
Preschooler G & D
6
Health Problems of Young Children (Sleep Problems, Poisoning, Child Maltreatment)
2 (5) Dosage Calculation (3 calculations in one, 2 calculations in the other)
75 TOTAL
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