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Information

  1. INFANT (28 DAYS TO 1 YEAR)
    1. Erikson's theory of personality development
      1. Central task: basic trust vs. mistrust; central person: primary caregiver/maternal person.
      2. Behavioral indicators
        1. Crying is only means of communicating needs.
        2. Quieting usually means needs are met.
        3. Fear of strangers at 6 to 8 months.
      3. Parental guidance/teaching
        1. Must meet infant's needs consistently—cannot "spoil" infant by holding, comforting.
        2. Neonatal reflexes fade between 4 and 6 months, replaced with increase in purposeful behavior (e.g., babbling, reaching).
        3. Fear of strangers is normal—indicates attachment between infant and primary caregiver.
        4. Child may repeat over and over newly learned behaviors (e.g., sitting or standing).
        5. Weaning can begin around the time child begins walking.
        6. Review Preventive Care Timeline and Recommended Health Screenings (Table 5.2. Child Preventive Care Timeline and Table 5.3. Recommended Health Screenings for Infants, Children, and Adolescents: Specific Conditions) with parents of infants.
      4. For additional information about behavioral concerns for each age group, see Table 5-4. Pediatric Behavioral Concerns: Nursing Implications and Parental Guidance and Table 5-5. Pediatric Sleep and Rest Norms: Nursing Implications and Parental Guidance .
    2. Physical growth (by 1 year)
      1. Height (length): 50% increase by first birthday.
      2. Weight
        1. Doubles by 4 to 7 months, triples by 1 year.
        2. Gains 5 to 7 oz/wk in first 6 months of life.
        3. Gains 3 to 5 oz/wk in second 6 months of life.
      3. Vital signs: see Table 5-6. Normal Vital Signs: Measurements and Variations with Age .
      4. Cardiac system
        1. Heart begins to function effectively.
        2. Decreased heart rate, increased blood pressure from neonatal values.
      5. Pulmonary system
        1. Predisposed to upper respiratory infections due to anatomical differences (e.g., eustachian tube is shorter and straighter in infant).
        2. Decreased respiratory rate from neonatal values.
      6. Gastrointestinal system
        1. Swallowing improves.
        2. Stomach enlarges to hold greater volume.
        3. Digests more complex foods as enzymes increase (by 4–6 months).
      7. Genitourinary system
        1. Immature; waste products poorly eliminated.
        2. Easily prone to fluid and electrolyte imbalances.
      8. Immune system
        1. Functional by 2 months.
        2. Produces IgG and IgM antibodies.
      9. Neurological system
        1. Fontanels:
          1. Anterior—open or patent through first 12–18 months.
          2. Posterior—closed by 2 months.
        2. Head circumference increases as brain grows rapidly.
        3. Neurological reflexes (e.g., Landau, parachute) appear; neonatal reflexes (e.g., Moro, rooting) disappear.
      10. Sensory
        1. Hearing improves from "quieting" to a sound, to locating a sound easily and turning toward it.
        2. Vision improves from 8 to 18 inches, to searching for hidden objects and following moving objects.
      11. Teething
        1. Generally begins around 6 months.
        2. First two teeth: lower central incisors.
        3. By 1 year: six to eight teeth.
    3. Denver II Developmental Assessment: See Table 5-7. Facts About the Denver II Developmental Assessment .
      1. Birth to 3 months
        1. Personal-social: smiles responsively, then spontaneously.
        2. Fine motor-adaptive:
          1. Follows 180 degrees, past midline.
          2. Grasps rattle.
          3. Holds hands together.
        3. Language: laughs/squeals; vocalizes without crying.
        4. Gross motor: while on stomach, lifts head 45 to 90 degrees, able to hold head steady and erect; rolls over, from stomach to back.
      2. 4 to 6 months
        1. Personal-social: works for toy; feeds self (bottle).
        2. Fine motor-adaptive: palmar grasp, reaches for objects.
        3. Language: turns toward voice, imitates speech.
        4. Gross motor: some weight-bearing on legs; no head lag when pulled to sitting; sits with support.
      3. 7 to 9 months
        1. Personal-social
          1. Indicates wants.
          2. Plays pat-a-cake, waves bye-bye.
        2. Fine motor-adaptive: takes two cubes in hands and bangs them together; passes cube hand to hand; crude pincer grasp.
        3. Language: "dada," "mama," nonspecific, jabbers.
        4. Gross motor: creeps on hands and knees; gets self up to sitting; pulls self to standing; stands holding on.
      4. 10 to 12 months
        1. Personal-social
          1. Plays ball.
          2. Imitates activities.
          3. Drinks from cup.
        2. Fine motor-adaptive: neat pincer grasp.
        3. Language: "dada," "mama," specific.
        4. Gross motor: stands alone well; walks holding on; stoops and recovers.
    4. Nursing interventions/parental guidance, teaching:
      1. Play
        1. First year—generally solitary.
        2. Visual stimulation
          1. Best color: red.
          2. Toys: mirrors, brightly colored pictures.
        3. Auditory stimulation
          1. Talk and sing to infant.
          2. Toys: musical mobiles, rattles, bells.
        4. Tactile stimulation
          1. Hold, pat, touch, cuddle, swaddle/keep warm; rub body with lotion.
          2. Toys: various textures; nesting and stacking; plastic milk bottle with blocks to dump in, out.
        5. Kinetic stimulation
          1. Cradle, stroller, carriage, infant seat, car rides, furniture strategically placed for walking.
          2. Toys: cradle gym, push-pull.
      2. Safety
        1. Refer to Table 3-7. Infection Control When Caring for Infants, Children, and Adolescents, Table 3-8. Summary: Types of Precautions and Illnesses Requiring the Precautions , and (Table 3.9. Safety Considerations When Caring for Hospitalized Infants, Children, and Adolescents) for additional information on safety and infection control.
        2. Note: Most common accident during first 12 months is the aspiration of foreign objects.
          1. Keep small objects out of reach.
          2. Use one-piece pacifier only.
          3. No nuts, raisins, hot dogs, popcorn.
          4. No toys with small, removable parts.
          5. No balloons or plastic bags.
        3. Falls
          1. Raise crib rails.
          2. Never place child on high surface unsupervised.
          3. Use restraining straps in seats, high chairs, etc.
        4. Poisoning
          1. Check that paint on toys/furniture is lead-free.
          2. Treat all medications as drugs, never as "candy."
          3. Store all poisonous substances in locked cabinet, closet.
          4. Have telephone number of Poison Control Center on hand.
          5. pillImageInstruct in use of syrup of ipecac, if indicated. The use of syrup of ipecac is controversial in children (see Musculoskeletal and Neuromuscular Systems).
        5. Burns
          1. Use microwave oven to heat refrigerated formula only; heat only 4 oz or more for about 30 seconds. Test formula on top of your hand, not inside wrist.
          2. Check temperature of bath water; never leave infant alone in bath.
          3. Special care with cigarettes, hot liquids.
          4. Do not leave infant in sun.
          5. Cover all electrical sockets.
          6. Keep electrical wires out of sight/reach.
          7. Avoid tablecloths with overhang.
          8. Put guards around heating devices.
        6. Motor vehicles
          1. Use only federally approved car seat for all car rides; safest position is rear-facing in middle of back seat (from birth to 20 pounds, and as close to 1 year of age as possible).
          2. Never leave stroller behind parked car.
          3. Do not allow infant to crawl near parked cars or in driveway.
  2. TODDLER (1–3 YEARS)
    1. Erikson's theory of personality development
      1. Central task: autonomy vs. shame and doubt; central person(s): parent(s)
      2. Behavioral indicators
        1. Does not separate easily from parents.
        2. Negativistic.
        3. Prefers rituals and routine activities.
        4. Active physical explorer of environment.
        5. Begins attempts at self-assertion.
        6. Easily frustrated by limits.
        7. Temper tantrums.
        8. May have favorite "security object."
        9. Uses "mine" for everything—does not understand concept of sharing.
      3. Parental guidance/teaching
        1. Avoid periods of prolonged separation if possible.
        2. Avoid constantly saying "no" to toddler.
        3. Avoid "yes/no" questions.
        4. Stress that child may use "no" even when he or she means "yes."
        5. Establish and maintain rituals (e.g., toilet training, going to sleep).
        6. Offer opportunities for play, with supervision.
        7. Allow child to feed self.
        8. Offer only allowable choices.
        9. Best method to handle temper tantrums: ignore them.
        10. Keep security object with child, if so desired.
        11. Do not force toddler to "share."
        12. Review Preventive Care Timeline and Recommended Health Screenings (see Table 5-2. Child Preventive Care Timeline and Table 5-3. Recommended Health Screenings for Infants, Children, and Adolescents: Specific Conditions ) with parents of toddlers.
      4. Additional information about behavioral concerns for each age group may be found in Table 5-4. Pediatric Behavioral Concerns: Nursing Implications and Parental Guidance and Table 5-5. Pediatric Sleep and Rest Norms: Nursing Implications and Parental Guidance .
    2. Physical growth (by 3 years)
      1. Height
        1. Slow, steady growth at 2 to 4 inches/yr, mainly in legs rather than trunk.
        2. Adult height is roughly twice child's height at 2 years of age.
      2. Weight
        1. Slow, steady growth at 4 to 6 lb/yr.
        2. Birth weight quadruples by 2.5 years of age.
      3. Vital signs: refer to Table 5-6. Normal Vital Signs: Measurements and Variations with Age .
      4. Cardiac system
        1. Heart begins to function more efficiently.
        2. Decreased heart rate, slight increase in blood pressure from infant values.
      5. Pulmonary system
        1. Mainly abdominal breathing.
        2. Lumina of bronchial vessels ↑ in size → decrease in lower respiratory system infections.
        3. Decreased respiratory rate from infant values.
      6. Gastrointestinal system
        1. Increased capacity → three-meals-a-day feeding schedule.
        2. Gastric juices increase in acidity → decrease in GI infections.
        3. Possible voluntary control of anal sphincter.
      7. Genitourinary system
        1. Bladder capacity increases; to determine bladder capacity in ounces, add 2 to the child's age (e.g., 2-year-old has a bladder capacity of 4 oz or 120 mL).
        2. Ability to "hold" urine increases.
        3. Possible voluntary control of urethral sphincter.
      8. Immune system
        1. Possible immunity from intrauterine life/maternal transfer disappears.
        2. Gradual increase in IgA, IgD, and IgE antibodies.
      9. Neurological system
        1. Anterior fontanel closed by 12–18 months.
        2. Brain increases to 90% of adult size.
        3. Progressive increase in intelligence.
        4. Myelinization of spinal cord is complete.
      10. Sensory
        1. Hearing evidences basic auditory skills.
        2. Vision shows evidence of convergence and accommodation; full binocular vision developed; visual acuity: 20/40.
      11. Teething
        1. Introduce toothbrushing as a "ritual."
        2. By 30 months: all 20 primary teeth present.
        3. First dental checkup should be between 12 and 18 months.
      12. Musculoskeletal system
        1. Lordosis: abdomen protrudes.
        2. Walks like a duck: wide-based gait, side-to-side.
    3. Denver II Developmental Assessment (see Table 5-7. Facts About the Denver II Developmental Assessment )
      1. 12 to 18 months
        1. Personal-social
          1. Imitates housework.
          2. Uses spoon, spilling little.
          3. Removes own clothes.
          4. Drinks from cup.
          5. Feeds doll.
        2. Fine motor-adaptive
          1. Scribbles spontaneously.
          2. Builds tower with two to four cubes.
        3. Language
          1. Three to six words other than "mama," "dada."
          2. Points to at least one named body part.
        4. Gross motor
          1. Kicks ball forward.
          2. Walks up steps.
      2. 19 to 24 months
        1. Personal-social
          1. Puts on clothing.
          2. Washes and dries hands.
          3. Brushes teeth with help.
        2. Fine motor-adaptive
          1. Builds tower with four to six cubes.
          2. Imitates vertical line.
        3. Language
          1. Combines two or three words.
          2. Speech partially understandable.
          3. Names picture.
        4. Gross motor
          1. Throws ball overhand.
          2. Jumps in place.
      3. 2 to 3 years
        1. Personal-social
          1. Puts on T-shirt.
          2. Can name a friend.
        2. Fine motor-adaptive
          1. Thumb wiggles.
          2. Builds tower of eight cubes.
        3. Language
          1. Knows two verbs and two adjectives.
          2. Names one color.
        4. Gross motor
          1. Balances on one foot briefly.
          2. Pedals tricycle.
    4. Nursing interventions/parental guidance:
      1. Play: toddler years—generally parallel.
      2. Toys—stimulate multiple senses simultaneously:
        1. Push-pull.
        2. Riding toys (e.g., straddle horse or car).
        3. Small, low slide or gym.
        4. Balls, in various sizes.
        5. Blocks—multiple shapes, sizes, colors.
        6. Dolls, trucks, dress-up clothes.
        7. Drums, horns, cymbals, xylophones, toy piano.
        8. Pounding board and hammer, clay.
        9. Finger paints, chalk and board, thick crayons.
        10. Wooden puzzles with large pieces.
        11. Toy record player with kiddie records.
        12. Talking toys: dolls, read-along books, phones.
        13. Sand, water, soap bubbles.
        14. Picture books, photo albums.
        15. Nursery rhymes, songs, music.
      3. Safety
        1. Refer to Table 3-7. Infection Control When Caring for Infants, Children, and Adolescents , Table 3-8. Summary: Types of Precautions and Illnesses Requiring the Precautions , and (Table 3.9. Safety Considerations When Caring for Hospitalized Infants, Children, and Adolescents) for additional information on safety and infection control.
        2. Accidents are the leading cause of death among toddlers.
        3. Motor vehicles: most accidental deaths in children under age 3 are related to motor vehicles.
          1. Use only federally approved car seat for all car rides, through age 8 or 60 lb.
          2. Follow manufacturer directions carefully.
          3. Make car seat part of routine for toddler.
        4. Drowning
          1. Always supervise child near water: bathtub, pool, hot tub, lake, ocean.
          2. Keep bathroom locked to prevent drowning in toilet.
        5. Burns
          1. Turn pot handles in when cooking.
          2. Do not allow child to play with electrical appliances.
          3. Decrease water temperature in house to avoid scald burns.
        6. Poisonings: most common in 2-year-olds.
          1. Consider every nonfood substance a hazard and place out of child's sight/reach.
          2. Keep all medications, cleaning materials, etc., in clearly marked containers in locked cabinets.
          3. pillImageInstruct in use of syrup of ipecac, if indicated by Poison Control Center (see Musculoskeletal and Neuromuscular Systems).
        7. Falls
          1. Provide barriers on open windows.
          2. Avoid gates on stairs—child can strangle on gate.
          3. Move from crib to bed.
        8. Choking: avoid food on which child might choke:
          1. Fish with bones.
          2. Fruit with seeds, pits, or "skin."
          3. Nuts, raisins.
          4. Hot dogs.
          5. Chewing gum.
          6. Hard candy.
          7. "Coin-cut" foods.
  3. PRESCHOOLER (3–5 YEARS)
    1. Erikson's theory of personality development
      1. Central task: initiative vs. guilt; central person(s): basic family unit.
      2. Behavioral indicators
        1. Attempts to perform activities of daily living (ADLs) independently.
        2. Attempts to make things for self/others.
        3. Tries to "help."
        4. Talks constantly: verbal exploration of the world ("Why?").
        5. Extremely active, highly creative imagination: fantasy and magical thinking.
        6. May demonstrate fears: "monsters," dark rooms, etc.
        7. Able to tolerate short periods of separation.
      3. Parental guidance/teaching
        1. Encourage child to dress self by providing simple clothing.
        2. Remind to go to bathroom (tends to "forget").
        3. Assign small, simple tasks or errands.
        4. Answer questions patiently, simply; do not offer child more information than what the child is asking for.
        5. Normal to have "imaginary playmates."
        6. Offer realistic support and reassurance with regard to fears.
        7. Expose to a variety of experiences: zoo, train ride, shopping, sleigh riding, etc.
        8. Enroll in preschool/nursery school program; kindergarten at 5 years.
        9. Review Preventive Care Timeline and Recommended Health Screenings (see Table 5-2. Child Preventive Care Timeline and Table 5-3. Recommended Health Screenings for Infants, Children, and Adolescents: Specific Conditions ) with parents of preschoolers.
      4. Additional information about behavioral concerns for each age group may be found in Table 5-4. Pediatric Behavioral Concerns: Nursing Implications and Parental Guidance and Table 5-5. Pediatric Sleep and Rest Norms: Nursing Implications and Parental Guidance .
    2. Physical growth (by 5 years)
      1. Height and weight
        1. Continued slow, steady growth.
        2. Generally grows more in height than weight.
        3. Posture: appears taller and thinner; "lordosis" of toddler gradually disappears.
      2. Vital signs: see Table 5-6. Normal Vital Signs: Measurements and Variations with Age .
      3. Cardiac system
        1. Increased heart size (4 times larger than at birth); heart function is comparable to a healthy adult (by 5 years).
        2. Heart assumes vertical position in thoracic cavity.
        3. May hear "splitting" of heart sounds, as well as innocent murmurs on auscultation.
        4. Decreased heart rate, steady blood pressure from toddler values.
      4. Pulmonary system
        1. Increase in amount of lung tissue.
        2. Adult-like lung sounds heard on auscultation.
        3. Decreased respiratory rate from toddler values.
      5. Gastrointestinal system
        1. Continued increase in size.
        2. Position is straighter and more upright than adult stomach → more rapid emptying (defecation, vomiting).
        3. Lining still sensitive to roughage and spices.
        4. Elimination controlled.
      6. Genitourinary system
        1. Bladder remains palpable above symphysis pubis.
        2. Needs to void frequently, or "accidents" may occur despite sphincter control.
        3. Low-grade urinary tract infections common.
      7. Immune system
        1. Growth of lymphoid tissue (especially tonsils).
        2. Illnesses (especially respiratory) tend to be more localized.
        3. Continued increase in IgA and IgG.
      8. Neurological system
        1. "Handedness" (right or left) is established.
      9. Sensory
        1. Vision—far-sightedness is improving; visual acuity: 20/30.
        2. Vision and hearing screening should be conducted before kindergarten, and annually thereafter.
      10. Teeth
        1. All 20 primary or deciduous teeth ("baby teeth") should be present.
        2. Annual dental checkups; continue daily brushing.
    3. Denver II Developmental Assessment/developmental norms: see Table 5-7. Facts About the Denver II Developmental Assessment .
      1. 3 years
        1. Personal-social
          1. Dresses without help.
          2. Plays board/card games.
        2. Fine motor-adaptive
          1. Picks longer of two lines.
          2. Copies circle, intersecting lines.
          3. Draws person, three parts.
        3. Language
          1. Comprehends "cold," "tired," "hungry."
          2. Comprehends prepositions: "over," "under."
          3. Names four colors.
        4. Gross motor
          1. Pedals tricycle; hops, skips on alternating feet.
          2. Broad jumps, jumps in place.
          3. Balances on one foot.
      2. 4 years
        1. Personal-social
          1. Brushes own teeth, combs own hair.
          2. Dresses without supervision.
          3. Knows own age and birthday.
          4. Ties own shoes.
        2. Fine motor-adaptive
          1. Draws person with six body parts.
          2. Copies square.
        3. Language
          1. Knows opposite analogies (two of three).
          2. Defines seven words.
        4. Gross motor
          1. Balances on each foot for 5 seconds.
          2. Can walk heel-to-toe.
      3. 5 years
        1. Personal-social
          1. Interested in money.
          2. Knows days of week, seasons.
        2. Fine motor-adaptive
          1. Prints name.
        3. Language
          1. Counts to 10.
          2. Verbalizes number sequences (e.g., telephone number).
        4. Gross motor
          1. Attempts to ride bike.
          2. Rollerskates, jumps rope, bounces ball.
          3. Backward heel-toe walk.
    4. Nursing interventions/parental guidance:
      1. Play: preschool years—associative and cooperative.
        1. Likes to play house, "work," school, firehouse.
        2. "Arts and crafts": color, draw, paint dot-to-dot, color by number, cut and paste, simple sewing kits.
        3. Ball, rollerskate, jump rope, jacks.
        4. Swimming.
        5. Puzzles, blocks (e.g., Lego blocks).
        6. Tricycle, then bicycle (with/without training wheels).
        7. Simple card games and board games.
        8. Costumes and dress-up: "make-believe."
      2. Safety: Emphasis shifts from protective supervision to teaching simple safety rules. Preschoolers are "the great imitators" of parents, who now serve as role models.
        1. Refer to Table 3-7. Infection Control When Caring for Infants, Children, and Adolescents , Table 3-8. Summary: Types of Precautions and Illnesses Requiring the Precautions , and (Table 3.9. Safety Considerations When Caring for Hospitalized Infants, Children, and Adolescents) for additional information on safety and infection control.
        2. Teach child car/ street safety rules.
        3. Convertible safety seats should be used until child weighs at least 40 lb.
        4. Teach child not to go with strangers or accept gifts or candy from strangers.
        5. Teach child danger of fire, matches, flame: "drop and roll."
        6. Teach child rules of water safety; provide swimming lessons.
        7. Provide adult supervision, frequent checks on activity/location. Despite safety teaching, preschooler is still a child and may be unreliable.
  4. SCHOOL AGE (6–12 YEARS)
    1. Erikson's theory of personality development
      1. Central task: industry vs. inferiority; central person(s): school, neighborhood friend(s).
      2. Behavioral indicators
        1. Moving toward complete independence in ADLs.
        2. May be very competitive—wants to achieve in school, at play.
        3. Likes to be alone occasionally, may seem shy.
        4. Prefers friends and peers to siblings.
      3. Parental guidance/teaching
        1. Be accepting of the child as he or she is.
        2. Offer consistent support and guidance.
        3. Avoid authoritative or excessive demands on child.
        4. Respect need for privacy.
        5. Assign household tasks, errands, chores.
        6. Review Preventive Care Timeline and Recommended Health Screenings (see Table 5-2. Child Preventive Care Timeline and Table 5-3. Recommended Health Screenings for Infants, Children, and Adolescents: Specific Conditions ) with parents of school-age children.
      4. Additional information about behavioral concerns for each age group may be found in Table 5-4. Pediatric Behavioral Concerns: Nursing Implications and Parental Guidance and Table 5-5. Pediatric Sleep and Rest Norms: Nursing Implications and Parental Guidance .
    2. Physical growth (by 12 years)
      1. Height and weight
        1. Almost double in weight from 6 to 12 years.
        2. Period of slow, steady growth.
        3. 1 to 2 inches/yr.
        4. 3 to 6 lb/yr.
        5. Girls and boys differ in size at end of school-age years.
      2. Vital signs: refer to Table 5-6. Normal Vital Signs: Measurements and Variations with Age .
      3. Cardiac system
        1. Increased size of left ventricle (to meet demands for increased blood to growing structures).
        2. Decreased heart rate, increased blood pressure from preschool values.
      4. Pulmonary system
        1. Front sinuses develop (by 7 years).
        2. Lymphatic tissue completes growth (by 9 years).
        3. Remains well oxygenated on exertion.
        4. Continued decrease in respiratory rate from preschool values; using intercostal muscles more effectively for breathing.
      5. Gastrointestinal system
        1. Higher metabolic rate requires adequate food and fluids to ensure nutrition and hydration.
        2. Food retained in stomach for longer periods of time.
      6. Genitourinary system
        1. Bladder capacity increase continues.
        2. Kidneys mature.
        3. Less likely to have fluid and electrolyte (F/E) imbalance as increased conservation of water occurs.
      7. Immune system
        1. Growth of lymphoid tissue increases, then plateaus, then decreases.
        2. Continued improvement noted with body's increased ability to localize infections.
      8. Neurological system
        1. Central nervous system matures.
        2. Myelinization continues → increase in both fine motor-adaptive and gross motor skills.
      9. Sensory
        1. Vision: 20/20 vision well established between 9 and 11 years.
        2. Should be screened for vision/hearing annually, usually in school.
      10. Teeth
        1. Begins to lose primary teeth around sixth birthday.
        2. Eruption of permanent teeth, including molars; 28 permanent teeth (by 12 years).
        3. Dental screening annually, daily brushing.
      11. Pubescence (preliminary physical changes of adolescence)
        1. Average age of onset: girls at 10, boys at 12.
        2. Beginning of growth spurt.
        3. Some sexual changes may start to occur.
    3. Developmental norms
      1. 6 to 8 years
        1. Dramatic, exuberant, boundless energy.
        2. Alternating periods: quiet, private behavior.
        3. Conscientious, punctual.
        4. Wants to care for own needs but needs reminders, supervision.
        5. Oriented to time and space.
        6. Learns to read, tell time, follow map.
        7. Interested in money—asks for "allowance."
        8. Eagerly anticipates upcoming events, trips.
        9. Can bicycle, swim, play ball.
      2. 9 to 11 years
        1. Worries over tasks; takes things seriously, yet also developing sense of humor—likes to tell jokes.
        2. Keeps room, clothes, toys relatively tidy.
        3. Enjoys physical activity, has great stamina.
        4. Very enthusiastic at work and play; has lots of energy—may fidget, drum fingers, tap foot.
        5. Wants to work to earn money: mow lawn, baby-sit, deliver papers.
        6. Loves secrets (secret clubs).
        7. Very well behaved outside own home (or with company).
        8. Uses tools, equipment; follows directions, recipes.
        9. By 12th birthday: paradoxical stormy behavior, onset of adolescent conflicts.
    4. Nursing interventions/parental guidance:
      1. Play
        1. Wants to win, likes competitive games.
        2. Prefers to play with same-sex children.
        3. Enjoys group, team play.
        4. Loves to do magic tricks and other "show-off " activities (e.g., puppet shows, plays, singing).
        5. Likes to collect things: cards, compact discs.
        6. Does simple scientific experiments, computer games.
        7. Has hobbies: needlework, woodwork, models.
        8. Enjoys pop music, musical instruments, videos, posters.
      2. Safety (see Table 3-7. Infection Control When Caring for Infants, Children, and Adolescents )
        1. As passenger: use specially designed car restraints until age 8 or 60 lbs, then safety belts. Teach child not to distract driver.
        2. As pedestrian: teach bike, street safety.
        3. Teach how to swim, rules of water safety.
        4. Sports: teach safety rules.
        5. Adult supervision still necessary; serve as role model for safe activities.
        6. Teach about "stranger danger" and online safety.
        7. Suggest Red Cross courses on first aid, water safety, babysitting, etc.
        8. Refer to Table 3-7. Infection Control When Caring for Infants, Children, and Adolescents , Table 3-8. Summary: Types of Precautions and Illnesses Requiring the Precautions , and (Table 3.9. Safety Considerations When Caring for Hospitalized Infants, Children, and Adolescents)for additional information on safety and infection control.
  5. ADOLESCENT (12–18 YEARS)
    1. Erikson's theory of personality development
      1. Central task: identity vs. role confusion; central person(s): peer group.
      2. Behavioral indicators
        1. Changes in body image related to sexual development.
        2. Awkward and uncoordinated in the beginning.
        3. Much interest in opposite sex: girls become romantic.
        4. Wants to be exactly like peers.
        5. Becomes hostile toward parents, adults, family.
        6. Concerned with vocation, life after high school.
      3. Parental guidance/teaching
        1. Offer firm but realistic limits on behavior.
        2. Continue to offer guidance, support.
        3. Allow child to earn own money, control own finances.
        4. Assist adolescent to develop positive self-image.
        5. Review Preventive Care Timeline and Recommended Health Screenings (see Table 5-2. Child Preventive Care Timeline and Table 5-3. Recommended Health Screenings for Infants, Children, and Adolescents: Specific Conditions ) with parents of adolescents.
      4. Additional information about behavioral concerns for each age group may be found in Table 5-4. Pediatric Behavioral Concerns: Nursing Implications and Parental Guidance and Table 5-5. Pediatric Sleep and Rest Norms: Nursing Implications and Parental Guidance .
    2. Physical growth (by 18 years)
      1. Height and weight
        1. Adolescent growth spurt lasts 24 to 36 months.
        2. Growth in height commonly ceases at 16 to 17 years in girls, 18 to 20 years in boys.
        3. Boys gain more weight than girls, are generally taller and heavier.
      2. Vital signs approximately those of the adult (see Table 5-6. Normal Vital Signs: Measurements and Variations with Age ).
      3. Cardiac system
        1. Increased heart size and strength to near-adult values.
        2. Decreased heart rate, increased blood pressure from school-age values.
      4. Pulmonary system
        1. Lungs increase in size to near-adult levels, but not as rapidly as other body systems (may explain lack of energy).
        2. System is "mature" by 12 years.
        3. Continued decreased respiratory rate from school-age values.
      5. Gastrointestinal system
        1. Continued need for increased calories.
      6. Genitourinary system
        1. Fully developed; bladder can hold 700 mL.
      7. Immune system
        1. Fully developed; infections become increasingly rare in an adolescent who is healthy.
        2. Lymphoid tissue matures and regresses.
      8. Neurological system
        1. Fully developed.
      9. Sensory
        1. Fully developed.
      10. Teeth: 32 permanent teeth by 18 to 21 years.
      11. Sexual changes
        1. Girls
          1. Changes in nipple and areola; development of breast buds.
          2. Growth of pubic hair.
          3. Change in vaginal secretions.
          4. Menstruation—average onset between 12 and 13 years of age; range 8 to 15 years.
          5. Growth of axillary hair.
          6. Ovulation.
        2. Boys
          1. Enlargement of genitalia.
          2. Growth of pubic, axillary, facial, and body hair.
          3. Lowering of voice.
          4. Production of sperm; nocturnal emission ("wet dreams").
    3. Developmental norms
      1. Motor development
        1. Early (12–15 years)—awkward, uncoordinated, poor posture, decrease in energy and stamina.
        2. Later (15–18 years)—increased coordination and better posture; more energy and stamina.
      2. Cognitive
        1. Academic ability and interest vary greatly.
        2. "Think about thinking"—period of introspection.
      3. Emotional
        1. Same-sex best friend, leading to strong friendship bonds.
        2. Highly romantic period for boys and girls.
        3. May be moody, unpredictable, inconsistent.
      4. Social
        1. Periods of highs and lows, sociability and loneliness.
        2. Turmoil with parents—related to changing roles, desire for increased independence.
        3. Peer group is important socializing agent—conformity increases sense of belonging.
        4. Friendships: same-sex best friend advancing to heterosexual "relationships."
    4. Nursing interventions/parental guidance:
      1. Play
        1. School-related group activities and sports.
        2. Develops talents, skills, and abilities.
        3. Television—watches soap operas, romantic movies, sports.
        4. Develops interest in art, writing, poetry, musical instrument.
        5. Girls: increased interest in makeup and clothes.
        6. Boys: increased interest in mechanical and electronic devices.
      2. Safety (see Table 3-7. Infection Control When Caring for Infants, Children, and Adolescents )
        1. Motor vehicles (cars and motorcycles)—as passenger or as driver.
        2. Encourage driver education; serve as positive role model.
        3. Teach rules of safety for water sports.
        4. Teach about "stranger danger" and online safety.
        5. Wants to earn money but still needs guidance: advocate safe job, reasonable hours.