Chapter 33
The Preschooler and Family
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Promoting Optimal Growth
and Development
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The preschool period: Ages 3 to 5 years
Preparation for most significant lifestyle change:
Going to school
Cooperative interaction with other children
Experience of brief and prolonged separation
Increased attention span and memory
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2
Biologic Development
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Physical growth slows and stabilizes
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Average weight gain remains about 5 lbs/year
Average height increases 2½ to 3 inches/year
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Average weight is 30 lbs at 3 years of age
Average height is 36 in at 3 years
Most are toilet trained
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3
Gross and Fine Motor Skills
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Gross motor
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Walking, running, climbing, and jumping well
established
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•
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•
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Ride a tricycle (3 yrs)
Walk on tip toe (3 yrs)
Balance on 1 foot for a few seconds (3 years)
Skip on alternating feet, jump rope (5 years)
Fine motor
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Refinement in eye-hand and muscle coordination
Skillful manipulation (dressing, drawing)
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4
Psychosocial Development
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Developing sense of initiative vs. guilt (Erikson)
Think GUILT when you think of preschoolers!
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Chief psychosocial task of preschool period
Feelings of guilt, anxiety, and fear: May result from
thoughts that differ from expected behavior
Development of superego (conscience)
Learning right from wrong/moral development
Start becoming less egocentric
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5
Cognitive Development
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Time not completely understood
 Interpreted according to the child’s frame of reference
• Ex. Mom will be back to see you when dinner comes is better than Mom will
be back to see you at 6pm.
• Tomorrow, yesterday, next week are terms that they do not understand
Magical thinkers
 Thoughts are all powerful! Ties into their guilt!
• They think something bad about brother and then he falls off bike and
breaks arm.
• Often sees hospitalization (their own) as a punishment for doing something
wrong
Animism
 Giving inanimate objects lifelile qualities
• “Yelling” at steps when they trip
• Contributes to their fears (IV pole in corner coming alive)
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6
Development of Body Image
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Increasing comprehension of “desirable”
appearances
Poorly defined body boundaries
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Children fear that if skin is “broken,” all blood and
“insides” can leak out
Intrusive experiences are frightening
Band Aids are BIG!!!!!
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7
Social Development
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Separation-individuation process is completed
Stranger anxiety and fear of separation from
parents are overcome
Parental security and guidance are still needed
Security is derived from familiar objects
Play therapy is beneficial for working through
fears, anxieties, and fantasies
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8
Language
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Language becomes more sophisticated
Language is the major mode of communication
and social interaction
Vocabulary increases dramatically between
ages 2 and 5 years
2100 words known by 5 years and 4-5 word
sentences by age 4-5 years.
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9
Personal-Social Behavior
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Ritualism and negativism of toddlerhood
diminish
Child can dress self
Child is willing to please
Child has internalized values and standards
of family and culture
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10
Play
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Associative play
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Imitative play
Imaginative play
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Group play without rules
Imaginary playmates
Dramatic play
Mutual play
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11
Fears
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Dark
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Night lights
Rituals
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Being left alone
Animals (large dogs)
Ghosts
Objects or people associated with pain
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They get relief from familiar objects!
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Promoting Optimal Health During
the Preschool Years
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Nutrition
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Caloric requirements: Approximately
1400 to 1600 calories/day
 Fluid requirements: Approximately
100 mL/kg, depending on the activity and climate
 Food fads, strong tastes: Common
 Amount of food: Varies greatly from day to day
 Obesity in young children: Has increased dramatically
• Fruit juice 4-6oz day
• Keep milk to 24 oz day and low fat after 2 years!
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13
Sleep and Activity
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Sleep: 12 hours per night
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Infrequent naps
Waking during the night: Common
• Nightmares: Can wake them up and the remember dream
• Night terrors: they look awake but are not! Redirect to bed
• Step Brothers Sleep Walking
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Motor activity levels: Remain high
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Readiness to participate in sports
 Sedentary activity such as TV and computer time:
Should be limited
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14
Dental Health
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Eruption of deciduous teeth: Complete
Professional care and prophylaxis
Fluoride supplements
Assistance and supervision of brushing
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Flossing by parents
Tooth trauma
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If a permanent tooth is knocked they have 20 min to
get it reinserted
• Place in milk or in saliva and get to ED or dentist ASAP
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15
Safety Promotion and
Injury Prevention
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Safety education
Increase in pedestrian-motor vehicle accidents
Education concerning safety and potential
hazards
Appropriate protection
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Bicycle helmets
Protective equipment
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16
Anticipatory Guidance:
Care of Families
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Child care focus shifts from protection
to education
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Verbal explanations of how to avoid danger
Children begin questioning previous teachings of
parents
Children begin to prefer companionship
of peers
Children enter school
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17
Child Maltreatment
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Intentional physical abuse or neglect (17%)
Emotional abuse or neglect (8%)
Sexual abuse of children (9%)
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Usually by an adult
Children younger than 1 year have the highest
rate of abuse
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Child Maltreatment (Cont.)
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Child neglect
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Physical neglect
• Deprivation of food, clothing, shelter, supervision, medical
care, and education
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Emotional neglect
• Lack of affection, attention, and emotional nurturance
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Emotional abuse or psychological maltreatment
• Destruction or impairment of child’s self-esteem
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19
Child Maltreatment (Cont.)
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Physical abuse
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Abusive Head Trauma (AHT)
Munchausen syndrome by proxy
• Factitious disorder by proxy or medical child abuse
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Factors predisposing abuse
• Parental characteristics
• Characteristics of child
• Environmental characteristics
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20
Child Maltreatment (Cont.)
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Sexual abuse
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Characteristics of abusers and victims
Initiation and perpetuation of sexual abuse
Interprofessional care of the maltreated child
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Caregiver-child interaction
History and interview
• Child physical abuse
• Neglect and emotional abuse
• Sexual abuse
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21
Childhood Communicable and Infectious
Diseases
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Infection Control
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Hand Hygiene
Standard Precautions
Transmission-Based Precautions
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Airborne
 Droplet
 Contact
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23
Communicable Diseases
Easily spread through airborne, droplet, or direct
contact
 Incidence has declined with the increase in
immunizations
 Further decreased with the use of antibiotics and
antitoxins
 Early identification of the infectious agent
 High index of suspicion for common childhood
diseases
 Primary prevention (immunizations)
 Secondary?
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Nursing Assessment in
Identification of Infection
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Recent exposure to infectious agents
Prodromal symptoms
Immunization history
History of having the disease
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Prevent Spread of Disease
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Primary prevention of disease
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Immunization
Control the spread of disease to others
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Reduce the risk of cross-transmission of organisms
Infection control policies
Hand washing
Sneeze and cough etiquette
Hygiene measures in home and school
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Prevent Complications
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Children with immunodeficiency
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Receiving steroids
Receiving immunosuppressive therapy
Malignancy
Immune disorders
• Hemolytic disease, sickle cell disease, aplastic anemia
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Lapsed or missed immunizations
Long-term complications from disease
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Varicella, pertussis, scarlet fever, diphtheria
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Nursing Priorities in Care of a Child
with a Communicable Disease
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Institute isolation precautions
Provide comfort
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Ear, nose, and throat symptoms
Urticaria
Fever
Pain
Irritability
Support the family
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COVID-19
and
children
with IDD
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People with ID are vulnerable in society because
of their dependence on support from services
and other people.
According to the CDC, those among the highest
risk for severe illness from COVID-19 are those
with disabilities, who also have an underlying
medical condition
Individuals with disabilities identified as being
most at risk for serious outcomes from COVID19 are those:
 With limited mobility who are unable to
avoid close contact with others (such as
their direct support providers and family
members)
 With difficulty following commands or
understanding preventative measures (like
hand washing and social distancing)
 Who cannot communicate signs and/or
symptoms of illness
COVID-19 presents a greater risk to people with
IDD, especially at younger ages.
CDC, 2020
IDD conditions or behaviors that increase risk
for COVID-19 negative outcomes:
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COVID-19
and children
with IDD
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Eating difficulty- can be at greater risk
because of their increased risk of potential
aspiration episodes.
Gastrointestinal – if the child engages in PICA
related activities and therefore may pose an
increased risk as the child may be touching
their mouth more with unsanitary objects.
Nutrition - diabetes
High Risk Treatments - respiratory
conditions and are among the most fragile
and susceptible to significant illnesses.
Professional Visits- could be at greater risk of
contracting the virus if these visits take place
at hospitals or clinical offices where they
may be exposed to more people with
illnesses
Escude, 2020
Intestinal Parasitic Diseases
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Giardiasis- parasite
 Waterborne disease (dirty water spread through person to person contact
• Causes watery diarrhea, cramping, bloating
 Therapeutic management
• Dx with stool samples
• Usually gets better on own or antibiotic therapy (Flagyl)
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Enterobiasis (Pinworms)
 Diagnostic evaluation: swallow or inhale egg
• Hx intense peri-anal itching worse at night
• Tape test
 Therapeutic management
• Anti-parasite meds
 Mebendazole
 Albendazole (Albenza)
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Conjunctivitis: direct contact
Newborn Etiology
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Chlamydia trachomatis
Neisseria gonorrheae
Chemical (24 hours p birth)
Blocked tear duct
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Child Etiology
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Viral
Bacterial
Allergic
Foreign body
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Conjunctivitis s/s
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Pink or red sclera
Excessive tearing
Yellow-green purulent discharge from eyes (if
bacterial)
Crusting of eyes in the morning (if bacterial)
Swollen conjunctiva
Treatment: antibiotic ointment or drops for
bacterial, antihistamine for allergic
Fifth Disease
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Also known as parvovirus B19 or erythema
infectiosum
Spread: droplet or blood
Symptoms: fever, runny nose headache then a
red rash develops on face “slapped cheek” and
a maculopapular rash on extremities
Droplet precautions
Limited; symptomatic treatment
B19 can be toxic to fetus
Fifth Disease
Measles (Rubeola)
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Spread: direct contact, droplet
Communicability: 4 days before to 5 days after
the rash appears
Prodromal symptoms:
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Mild to moderate fever
Conjunctivitis
Fatigue
Cough, runny nose, sore throat
Rash: KOPLIK spots in mouth then red rash that
begins at top of head and works its way down
Vitamin A can lessen symptoms
Complication: pneumonia, encephalitis, otitis
Measles
Varicella
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Aka: chicken pox
Spread: direct contact, droplet, contaminated
objects
Incubation- 2-3 weeks
Communicability: 1 day before lesions appear
until ALL lesions are crusted over
Symptoms: prior to rash there is fever, fatigue,
headache, loss of appetite then macules form on
trunk and spread. Progress to papules, then
vesicles and crust
Varicella
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Immunocompromised children at risk for serious
complications
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If exposed but no symptoms consider giving the
vaccine
If starting to have symptoms Acyclovir
Treatment; symptomatic if not
immunocompromised
Complications: bacterial infection of skin,
encephalopathy, pneumonia, bleeding problems
Varicella
Nursing Considerations for Chicken Pox
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Emphasize good hand washing
Antipyretic for fever (NO ASPIRIN!!)
Antihistimine for itching
Analgesics for pain
Fluids
Rest
Notify daycare/school of infectious disease
Isolation: Airborne/contact: varicella
 Droplet: fifths disease, mumps, pertussis, rubeola
 Standard: conjunctivitis, mononucleosis
Skin Infections
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Bacterial
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Viral
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Staphylococci or streptococci
Common to have viral exantham with viral infection in
childhood
Fungal
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Ringworm
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43
Skin Infections (Cont.)
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Bacterial infections
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Increase in community-acquired methicillin-resistant
Staphylococcus aureus (MRSA) infections
Abscess formation
Severity varies with skin integrity, immune and
cellular defenses
Examples are impetigo contagiosa, pyoderma,
cellulitis
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Bacterial Skin Infections
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Impetigo
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Abscess
Viral Skin Infections
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Most communicable diseases of childhood have
a characteristic rash
Examples
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Rubeola, rubella
Verrucae
Herpes simplex types I and II
Varicella zoster
Molluscum contagiosum
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Fungal Skin Infections
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Superficial infections that live on the skin
Also known as dermatophytoses
Transmission from person to person or from
infected animal to human
Examples
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Tinea capitis
 Tinea corporis
 Tinea pedis
 Candidiasis (oral, diaper, vaginal)
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47
Tinea Infections
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48
Scabies
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Caused by scabies mite as female burrows into
the epidermis to deposit eggs and feces
Inflammation occurs 30 to 60 days later
Management
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Topical treatment: Permethrin 5% or lindane
Oral treatment: Ivermectin if body weight is more
than 15 kg
Nursing implications
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Scabies
Pediculosis Capitis (Head Lice)
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Very common, especially in school-age children
Scalp itching is the most common symptom
Adult louse lives 48 hours without a human host;
female louse has a life span of 30 days
Females lay eggs (nits) at the base of the hair shaft
Nits hatch in 7 to 10 days
Treatment is pediculicides and removal of nits
Nursing implications

Surveillance and education (home remedies)
 Preventing spread and recurrence
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Head Lice
Infections Transmitted by
Anthropods
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Rickettsial disorders are transmitted by bites from
infected fleas, deer ticks, and mites
Lyme disease is the most common tick-borne
disorder in the United States
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Three stages of illness
 Diagnosed by a characteristic rash (erythema migrans)
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Management involves early treatment with
antibiotics
Nursing implications are prevention and education
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53
Erythema Migrans (Lyme disease)
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