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NCM 101 Guide
NCM 101 Guide
NCM 101 Guide
Institute of Nursing
Course Guide
CARE OF MOTHER, CHILD AND FAMILY
(Growth and Development, Infancy, Toddler)
Course Name : CARE OF MOTHER, CHILD AND FAMILY
Course Description : Principles and techniques of caring for the normal mothers, infants, children and family and the
application of principles and concepts on family and family health nursing process.
Course Credit : 4 units lecture, 4units RLE [1unit Skills Lab/3units Clinical]
Contact Hrs/sem : 72 lecture hours, 204 RLE hours (10 hrs. = 2 hrs/meeting; twice a week)
Course Objectives : At the end of the course, given actual or simulated situations /conditions involving the client (normal
pregnant woman, mother, and/or newborn baby, children and the family), the student will be able to:
1. Utilize the nursing process in the holistic care of client for the promotion and maintenance of health.
1.1 Assess with the client his/her health condition and risk factors affecting health
1.2 Identify wellness /at risk nursing diagnosis
1.3 Plan with client appropriate interventions for health promotion and maintenance of health
1.4 Implement with client appropriate interventions for Health promotion and health
maintenance taking into consideration relevant principles and techniques
1.5 Evaluate with client the progress of one’s health condition and outcomes of care.
2. Ensure a well-organized recording and reporting system
3. Observe bioethical principles and the core values (love of God, caring, love of country and of people)
4. Relate effectively with clients, members of the health team and others in work situations related
to nursing and health
CONTENTS:
Definition
a. Growth - Increase in the number and size of cells; measured in terms of quantity; Orderly and predictable but not even.
Parameters of Growth:
1. Weight
♦ is the most sensitive indicator of growth.
♦ It is measured in grams, kilograms or pounds.
♦ Doubles by 5 to 6 months
Triples by 12 months or 1 year.
Quadruples by 2 – 2 ½ years old
2. Height
♦ is measured in inches, feet or centimeters.
♦ Increases by 1 inch per month in the first six months and by ½” per month from age 7 – 12 months.
b. Development - Indicates an increase in skill or the ability to function; Viewed as a qualitative change in the child that is
demonstrated by functioning or skill and that is achieved through maturation, and learning
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EX: 1922, before insulin was discovered, children with Type I DM were left physically challenged; many of them
died. Because of Insulin therapy and good health supervision, the disease can be minimized so
children with DM may thrive and grow normally.
c. Intelligence
Children with high intelligence do not generally grow faster physically than other children but they do tend to
advance faster in skills. Occasionally, a child with HIGH INTELLIGENCE WILL FALL BEHIND IN PHYSICAL
SKILLS because he /she spends time with books or mental games, rather than with games that develop motor
skills and so does not receive practice in these areas.
2. Environment
Although a child has genetically programmed height potential, he may not grow taller because of some environmental
factors: INADEQUATE NUTRITION because of low socio-economic status. Caregiver may lack skills or not give the child
enough attention. Chronic illness
a. Socioeconomic level
HEALTH CARE and GOOD NUTRITION both cost money. Children born to low income families do not receive
adequate health supervision ( consult when severe or dying) , also immunizations, so they develop childhood
illnesses that would lead to permanent brain damage---- poor G & D.
b. Parent-child relationship
Children who are loved thrive better than those who are not. It is the QUALITY OF TIME SPENT with children
not the amount of time that is important. LOSS OF LOVE from a primary care giver ( death of a parent,
interruption of parental contact through prolonged hospitalization, divorce, absence of parent working abroad)
or inadequate parental love can interfere with child’s desire to eat, improve and advance.
c. Ordinal position in the family
First-born child, middle, youngest and only child) and size of the family has some bearing on the G & D.
FIRST/ONLY CHILD generally excel in language because conversation are mainly with adults. However, they
may not excel in other skills ( like toilet training) because there is no example to watch. Children learn by
watching other children.
d. Health
Children who are ill like those with heart diseases will have limited activity to play and active sport. The disability
due to the damage of the heart will affect the attitude of the people around the child- how disabled they think
the child is and how they treat the child.
3. Temperament
♦ usual reaction pattern of an individual or an individual’s characteristic manner of thinking, behaving or reacting to stimuli
in the environment.
♦ Inborn characteristic.
Categories Of Temperament
1. THE EASY CHILD
♦ Easy to care for
♦ Predictable rhythmicity, approach and adapt to new situations readily.
♦ Mild to moderate intensity of reaction
♦ Overall positive mood quality.
♦ 40% to 50% of children
2. THE DIFFICULT CHILD
♦ Irregular in habits
♦ Negative mood quality
♦ Withdraw rather than approach new situations.
♦ 10% of children
3. SLO W–TO-WARM-UP CHILD
♦ Overall fairly inactive
♦ Responds mildly
♦ Adapts slowly to new situations
♦ Generally negative mood
♦ 15 % of children
4. Nutrition
♦ Nutrition has become a major focus on health promotion and disease prevention.
♦ The quality of nutrition during the growing years (including prenatally) has a major influence on his/her health and
stature ( natural height).
♦ Poor maternal nutrition may limit the Growth and intelligence potential of the child at birth.
♦ Children with diets that lack essential nutrients show inadequate physical growth.
♦ Lack of energy and stamina prevents children from learning at their best intellectual level.
♦ Psychoanalytic theory suggested that personality is mostly established by the age of five. Early experiences play a large
role in personality development and continue to influence behavior later in life.
Structure of Personality
ID
▪ developed during infancy
▪ "I know what I want and I want it now!”
▪ the only component of personality that is present at birth.
▪ Operates on pleasure principle to reduce tension or discomfort. Thus, a newborn is said to be a “bundle of id”,
seeking pleasure only to satisfy needs and demands immediate gratification to find release from physiological
tension.
▪ “I know what I want and I want it now!
▪ No sense of right or wrong
▪ Derived from the unconscious level of awareness.
▪ Pleasure principle
EGO
▪ developed during toddler period
▪ "I can wait for what I want!"
▪ Reality principle
▪ balances the id and superego
▪ the result of individual’s interaction with the environment.
▪ It promotes satisfactory adjustment in relation to the environment.
▪ It is initiated when the baby recognizes the breast or as part of the environment.
▪ Operates on reality principle
SUPEREGO
▪ developed during preschool
▪ "I should not want that!”
▪ Conscience- Morality principle
▪ Develops as a person unconsciously incorporates standards and restrictions from both parents and society to guide
behaviors, thoughts, and feelings.
▪ It is blindly rigid and strictly moralistic.
▪ Emerges at around age five.
DEVELOPMENTAL THEORIES:
Theory is a system of principles that provides a framework for explaining some phenomenon.
ORAL STAGE
♦ Infants are so interested in oral stimulation or pleasure during this time.
♦ Site of gratification: mouth
♦ Activities: sucking, biting, crying, etc.
♦ for enjoyment, for nourishment, and to release tension.
Oral-Passive character
♦ weaned too early è eating, drinking, and smoking and biting nails.
♦ The individual is generally passive, needy and sensitive to rejection. They easily “swallow” other
people’s ideas.
Oral-Aggressive personality
♦ life-long desire to bite on things, such as pencils, gum, and other people have a tendency to be
verbally aggressive, argumentative, sarcastic.
Nursing significance
a. Provide oral stimulation even if the baby is placed on NPO by offering a pacifier.
b. Never discourage thumb sucking. (Breastfeeding provide more stimulation than formula because it
requires the infant to expend more energy).
ANAL STAGE
♦ Activities: Toilet training
♦ Elimination or retention of feces or urine
♦ This anal interest is a part of toddler’s self- discovery, a way of exerting independence.
♦ The child greatly enjoys holding it and letting it go.
Cues for toilet training readiness
1. Can stand, squat and walk alone.
2. Can communicate toilet needs.
3. Can maintain himself or herself dry at an interval of 2 hours.
♦ Behavior to observe: Toilet training mastered by the end of this period.
Adult Character
Anal Expulsive Personality (a.k.a. anal aggressive)
♦ little self-control, sloppy, disorganized, generous to a fault.
♦ They maybe cruel, destructive, hostile and given to vandalism and graffiti.
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PHALLIC STAGE
♦ Activity: The child may show exhibitionism and increased knowledge on both sexes.
♦ May exhibit masturbation.
♦ Pleasure through genitals
♦ Touching of genitals
♦ Erotic attachment to parent of opposite sex
♦ Develops fear of punishment (castration anxiety for boys and Penis envy for girls) by parent of same sex
♦ Usually resolve toward end of this period
♦ The Oedipus complex describes these feelings of wanting to possess the mother and the desire to replace
the father. However, the child also fears that he will be punished by the father for these feelings, a fear Freud
termed castration anxiety.
♦ Electra complex has been used to described a similar set of feelings experienced by young girls. Freud,
however, believed that girls instead experience penis envy.
♦ Behaviors to observe:
a. Exhibits interest in sex differences.
b. Exhibits preoccupation with loss of body parts and bodily injury.
c. Asks many questions related to sexuality.
1. Bookworm personality
▪ boy is harshly rejected by his mother and threatened by his father
2. Hyperfeminine belle or wall-flower
▪ girl rejected by father, and threatened by mother
3. Effeminate
▪ if boy is favored by mother over his milquetoast ( timid or submissive) father
4. Masculine and Self-centered
▪ girl is daddy’s little princess and best buddy, and mommy is relegated to a
servant role
Adult Character
♦ Promiscuous
♦ Amoral
♦ Puritanical (Doctrine of opposites)
Nursing significance
a. Accept the child fondling his or her genitalia as a normal area of exploration.
b. In case of masturbation, explain to the child that things like this must be done in a private place or
divert the attention.
c. Answer the child’s question directly and honestly as this is the right time to introduce sexuality.
LATENCY STAGE
♦ Known as the “Age of Suppression”
♦ Achievement oriented years.
♦ Behaviors: sense of industry and mastery
♦ Emphasis in this period is development of skills and talents.
a. Energy is used to gain new skills and social relationship and knowledge.
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b. Suppression is normal
c. Sexual drive (libido)
▪ controlled and repressed during this period.
d. Normal homosexual
▪ interest on same sex only
Nursing significance
a. Help the child achieve positive experiences so that he/she will be ready to face the conflict of
adolescence.
GENITAL STAGE
♦ Site of gratification: genitalia
♦ Activity: Learns to establish satisfactory relationship to the opposite sex.
♦ Nursing significance: Give an opportunity to relate to the opposite sex.
♦ Resurgence of sexual drives
♦ Sexual pleasure through genitals
♦ Sexual identification
♦ Heterosexual is normal
♦ Maturation of the reproductive system
♦ Mastery of this period results in the development of the ability to love and to work
♦ Psychological theme: Maturity, creation and enhancement of life (intellectual and artistic creativity).
♦ Task: Learn how to add something to life and society.
♦ How to achieve this state: Balance both love and work.
♦ Behaviors to observe:
a. Separates from parents
b. Responsible for self
c. Develops sexual identity
d. Relationship with the opposite sex
INFANCY (0 – 18 mo.)
♦ Developmental task: Trust vs. Mistrust (learning confidence, learning to love).
♦ Trust is the foundation of all the psychosocial tasks
♦ Infants depend on the primary caregivers for all physiologic & psychological needs.
♦ The newborns react socially to caregivers by paying attention to the face or voice and by cuddling when held.
♦ They are able to interact with the environment by responding to various stimuli such as touch and sound.
♦ Mistrust develops when care is: inconsistent, inadequate, rejecting
♦ è infant becomes fearful and suspicious of the world and of people.
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TODDLERHOOD
♦ Developmental task: Learning Autonomy vs. Shame and Doubt (Self-government and independence)
♦ Activities/issues: Bodily functions, toilet training, muscle control and walking
♦ Autonomy develops when child is permitted to assert himself. They feel secure and confident.
♦ Shame and doubt develop if the child does not develop a sense of trust and/or learns his assertiveness as “is not
acceptable”.
♦ There is sense of inadequacy and self-doubt.
How to develop autonomy
1. Give an opportunity for decision making such as offering choices.
2. Encourage the child to make decisions rather than judge.
3. Toddlers begin to develop their sense of autonomy by asserting themselves with the frequent use of the
word “no”.
♦ Although they like to explore the environment, they always have a significant person nearby.
♦ Receptive & expressive language skills are developing quickly.
♦ One of the most admirable and frustrating things about two and three-year-olds is their determination.
♦ "Can do" is their motto.
♦ If we can preserve that "can do" attitude (with appropriate modesty to balance it) we are much better off as adults.
♦ Behaviors to observe
a. Shows a sense of “me”
b. Negativism
c. Ritualistic and stereotyped behavior
d. Temper tantrums
Nursing Implications:
a. Provide opportunities for decision making such as offering choices of clothes to wear or toys to play with.
b. Praise ability to make decisions rather than judging correctness of any decision.
PRESCHOOL AGE
♦ Developmental task: Initiative vs. Guilt
♦ The child learns to do basic things alone and no longer imitate the action of others.
♦ Same is true for language and fantasy activities.
How to develop Initiative
a. Initiative develops if the child is allowed the freedom to initiate small activities and to ask questions.
b. Initiative is encouraged if parents answer the child’s question ( intellectual initiative) and do not inhibit
fantasy or play activity.
c. Give an opportunity to explore new places, and events such as bringing the child to an amusement park
(exploration, adventure and discovery).
d. Guilt develops if the child is made to feel that his activity is bad or wrong.
Inhibition
▪ person will not try things because "nothing ventured, nothing lost" & particularly, nothing to feel guilty about.
Courage
▪ the capacity for action despite a clear understanding of your limitations and past failings.
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♦ Behaviors to observe
a. Starts many task; completes few
b. Very imaginative
c. Engages in fantasy play
d. Very curious, asks many questions
e. Boastful
Nursing Implications
a. Provide opportunities for exploring new places or activities.
b. Allow play to include activities including water, clay( for modeling) or finger paint.
♦ Activity: Finger painting and Modeling clay enhances imagination, creativity, and fine motor development.
♦ Virtue developed: Direction and purpose
SCHOOL-AGE PERIOD
♦ Developmental task: Industry vs. Inferiority
♦ How to develop industry: Give short assignments and projects.
♦ Virtue: Competence
♦ Develops sense of competency vs sense of inadequacy.
♦ Industry develops when a child is permitted to do things by himself and praised for the results.
♦ Interested in learning how to do things well.
♦ Inferiority develops if the child’s activities are seen as a nuisance.
♦ They begin to create & develop a sense of competence & perseverance and master skill that will help them function
in the adult world.
♦ They are motivated by activities that provide a sense of worth.
♦ These children compare themselves with others and obtain feedback from teachers & peers.
Narrow virtuosity
♦ we see this in children who aren't allowed to "be children," the ones that parents or teachers push into
one area of competence, without allowing the development of broader interests.
Inertia
♦ includes all of us who suffer from the "inferiority complexes"
♦ If at first you don't succeed, don't ever try again!
♦ Others never developed social skills -- the most important skills of all -- and so we never go out in public
Behaviors to observe:
a. Wants to learn to do things well and completely
b. Participates in variety of activities especially in school
c. Takes pride in accomplishments
Nursing Implications
a. Provide opportunities such as allowing child to assemble and complete a short project so that child feels rewarded
for accomplishment.
ADOLESCENCE
♦ Developmental task: Identity vs. Role Confusion
♦ The adolescent adjusts to changes in his or her body and seeks freedom from parents to learn who he/she is or what
kind of person he/she will be.
♦ Identity develops when there is a feeling of belongingness and being accepted by himself and others.
♦ Those who are accepted, loved & valued by family and peers generally tend to gain confidence & feel good about
themselves.
♦ Those who have difficulty forming relationships or who are perceived by peers as too different and not included
in adolescent cliques may develop less favorable self-images & low self- esteem.
♦ Role Confusion develops when the adolescent is not sure who he is or what he can do.
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To achieve Identity:
♦ Adolescents must bring together everything that they have learned about themselves as son or daughter,
as a friend, student and so on and integrate this different images of themselves as a whole that make
sense hence develop sense of self.
Nursing Implications:
a. Provide opportunities for the adolescent to discuss feelings about events important to him or her.
b. Offer support and praise for decision making
Development Of Sexuality
♦ Influenced by social and cultural aspects
♦ Being held and touched, kissed and hugged, snuggled and tickled allows babies to experience comforting,
positive physical sensations associated with being loved.
♦ The attachments established in these early years help set the stage for bonding and intimacy down the line.
Gender Awareness / Gender Identity
♦ By age 2 or 3, a child starts to develop a sense of being a male or female. Kids this age start to understand
the difference between boys and girls, and can identify themselves as one or the other.
Gender Roles
♦ Certain behaviors associated with being male or female. Gender roles are culturally derived
YOUNG ADULTHOOD
♦ Developmental task: Intimacy vs. Isolation
Intimacy
♦ ability to relate well with other people , not only with members of the opposite sex but also with one’s own
sex to form long-lasting relationship.
♦ A strong sense of personal identity is important for developing intimate relationships.
♦ Studies have demonstrated that those with a poor sense of self tend to have less committed relationships and are
more likely to suffer emotional isolation, loneliness and depression.
Behaviors to observe
a. Develop intimate relationship with another
b. Commitment to career vs avoidance of choices in relationships, work or lifestyle.
c. They face a number of experiences & changes in lifestyle as they progress towards maturity.
d. The multiple roles of adulthood may also create stress as a result of role conflict.
Nursing Significance
♦ Encourage mutual relationship and responsible sexual behavior.
MIDDLE ADULTHOOD
♦ Developmental Task: Generativity vs. Stagnation
♦ contributes to the next generation by performing meaningful work as they extend their concern to the community and
the world.
♦ Building lives, focusing on career and family.
♦ Those who are successful during this phase will feel that they are contributing to the world by being active in their
home and community.
♦ Those who fail to attain this skill will feel unproductive and uninvolved in the world.
♦ People with a sense of generativity are self-confident and better able to juggle their various lives (mother, teacher,
coach, church member).
♦ People without these sense are stagnated or self-absorbed.
♦ Those who have devoted themselves to only one role are more likely to find themselves at the end of middle age
with a narrow perspective and lack of ability to cope with change.
♦ Most important relationships: Children and community
♦ Issues: “Giving back”, helping, contributing
♦ Virtue/strength: Care and production
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LATE ADULTHOOD
♦ Developmental task: Ego Integrity vs. Despair
♦ Older adults try to make sense out of their lives as they have feelings of self- acceptance.
♦ Those who feel proud of their accomplishments will feel a sense of integrity.
♦ Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction.
♦ These individuals will attain wisdom, even when confronting death.
♦ Focused on reflecting back on life.
♦ Those who are unsuccessful during this stage will feel that their life has been wasted and will experience many
regrets. The individual will be left with feelings of bitterness and despair.
Nursing Significance
♦ Accept their bodily limitations but encourage them to share their wisdom and explore the philosophy
of life and death.
♦ Most significant relationship: Mankind
♦ Virtue Developed: Wisdom and Generosity of the spirit
DEVELOPMENT OF SELF-ESTEEM
♦ Self esteem refers to the extent to which we like, accept or approve of ourselves or how much we value
ourselves
Four Major Factors that Influence Self esteem Argyle (2008)
1. Reaction of others
♦ Admire us = Positive self esteem or Avoid us = negative
2. Comparison with others
♦ If friends appear to be more successful, happier = negative BUT if they are less successful
than us = Positive
3. Social roles
♦ Some social roles carry prestige (doctor, airline pilot) = Positive
♦ Other roles carry stigma (prisoner, unemployed)= Negative
4. Identification
♦ We identify with the positions we occupy, the roles we play and the groups we belong to.
Level 1. Pre-conventional Morality Level II. Conventional Morality Level III. Postconventional Morality
Stage 1. Obedience and Punishment Stage 3. Good Interpersonal Stage 5. Social contract &
Stage 2. Individualism and Exchange Relationships Individual Rights
(The good boy/good girl attitude) Stage 6. Universal Principles
Stage 4. Maintaining the Social Order (Principled conscience)
(Law and order morality) Stage 7. Transcendental Morality or
Morality of Cosmic Orientation
INFANCY
Definition of terms
a. Infancy - is the period from one month to 1 year of age
b. Developmental milestones – are major markers of growth and development that serve as the basis for assessing
developmental delay or advancement
c. Gross Motor – ability to accomplish large body movements
d. Fine Motor - ability to coordinate hand movement.
4. GIT
♦ GIT matures gradually though liver is still immature
♦ Deciduous teeth erupts at 6 mos.
5. Endocrine System
♦ Kidneys and the endocrine are still immature
6. Neurologic and Sensory System
♦ At 6 mos, can shiver in response to cold & adipose tissues are developed to serve as insulation
7. Immune System
♦ Functional at 2 months.
♦ At 1 yr. able to produce both :
a. IgG for natural passive immunity
b. IgM - bactericidal for gram negative bacteria
c. IgA (against respiratory pathogens)
d. IgE (for hypersensitivities)
e. IgD (immunologic role still under investigation) are not plentiful till pre-school age.
8. Sensory changes:
a. Neonatal:
♦ hearing and touch well developed at birth; sight not fully developed until 6 years
b. 1 -4 months
♦ Begins to coordinate stimuli from various sense organs; hearing; locates sound by turning head
and visually searching; binocular vision developing; beginning hand-eye coordination, hand
regard, prefers human face; follows objects 180 degrees. Ability to accommodate is equal to
adult
c. 5 – 6 months
♦ With organized depth perception at 6 months; can localize sounds above and below ear; with
difficulty establishing eye coordination at six months; smiles at own mirror image and
responds to facial expression of others; sucking needs have decreased; chewing, biting,
and taste begin to develop.
d. 7 – 9 months
♦ Can fixate on small objects; depth perception has matured hence can perform transferring object
from one hand to the other.
e. 10 – 12 months
♦ Able to follow rapidly moving objects; visual acuity is 20/50 or better; binocularity is well
established. Beginning of object permanence. Can easily locate sound in any direction and
turn towards it.
DEVELOPMENTAL MILESTONES:
Motor development
♦ is the process of learning, controlling and integrating muscular responses
a. Neonatal Period
♦ Motor development: mainly reflex controlled, lifts head momentarily, with moro reflex
b. 1 – 4 months
♦ Gross: reflexes begin to fade; gains head control start of neck righting reflex, rolls from back to
side; begins voluntary head to mouth activity; gains head control beyond the plane of the
body at 3 months; rolls from back to side
♦ Fine: begins voluntary hand to mouth activity; At 2 mos. holds objects momentarily then drops;
hands held open not in fists. At 4 mos. brings hands together and pull to their clothes;
beginning thumb apposition; fingers are used in scooping and raking motion. Palmar and
plantar grasp disappear
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c. 5 – 6months
♦ Gross: Parachute reflex starts to develop; Intentional rolling over; willfully turning over from
abdomen to back at five months, and back to abdomen at six months. Sits with support
♦ Fine: Increased manipulative skill; can grasp and let go voluntarily; plays with toes as objects; can
hold spoon and can feed himself with much spilling
d. 7 – 9 months
♦ Gross: At seven months, sits alone with hands held forward. Bounces with enjoyment in standing
position. Sits independently at 8 months. At 9 months, goes from prone to sitting upright,
can creep, crawl, pulls self to standing position
♦ Fine: Can transfer toy from one hand to the other; develops finger thumb apposition; uses crude
pincer grasp; preference for dominant hand is evident; diminished ineffective grasping at 8
months due to advanced eye-hand coordination.
e. 10 – 12 months
♦ Gross: creeps with abdomen off floor; walks with help or cruises; may attempt to stand alone; can
sit down from upright position
♦ Fine: 10 months, the pincer grasp is sufficiently established to enable infants to pick up a raisin
and other finger goods. Uses one finger to point to objects; offers object to people but can’t
release them. By 11 months, they put objects into a container and like to remove them. By
age 1, infants try to build a tower of two blocks but fail, drink in a cup and pull up socks. Can
draw a straight line using a crayon.
LANGUAGE DEVELOPMENT
COGNITIVE DEVELOPMENT BY JEAN PIAGET : Sensorimotor : Neonatal Period - reflexive behavior only
a. 1 – 4 months : Primary circular Reaction
♦ Activities related to the body, repetitive behavior ♦ Discovers own body parts
♦ Recognizes familiar faces ♦ Totally narcissistic being
♦ Is interested in surroundings
b. 4 - 8 months: Secondary circular reaction
♦ Further separation of self from environment. ♦ Beginning object permanence
♦ Able to imitate selective activity from several events. ♦ Idea of quality and quantity.
♦ Awareness of before and after the sequence of events. ♦ Can find partially hidden objects
♦ Beginning recognition of symbols as type of communication.
c. 8 – 12 months: Coordination and Secondary Reactions
♦ Concept of object permanence advancing.
♦ Actively searches for hidden objects
♦ Associates symbols with events but classification is based on own experience.
♦ Distinguishes objects from related activity and perceives them as objects.
♦ Distinguishes end products from their means; attempts to remove barriers to achieve the end. Actively
searches for hidden objects.
♦ Comprehends meaning of words and simple commands.
♦ Know that gestures have certain meaning (bye-bye, kiss ).
♦ Associates bye-bye with “Daddy going to work”.
♦ Able to put objects in container.
♦ Works to get toy that is out of reach.
♦ Ventures away from parents to explore surroundings.
SOCIAL DEVELOPMENT:
♦ Infants social development is influenced by their reflexive behavior, such as the grasp and eventually and depends
primarily on the interaction between them and the principal caregiver.
♦ Attachment of parent and child begins before birth and increasingly becomes significant until the first year of life
♦ Infant’s first means of verbal communication is crying, a biologic sign that conveys a message of urgency and signals
displeasure.
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EMOTIONAL DEVELOPMENT
a. The infant usually reacts by crying and kicking. Trust is an integral part of infant’s total development.
b. An infant learns to trust others through the relief of his basic needs (Erickson’s Theory)
TEMPERAMENT
♦ The infant’s temperament or behavioral style influences the type of interaction that occurs between the child and
parents and other family members.
♦ The more dissonance (lack of harmony) between the child’s temperament and the parent’s ability to accept and deal
with the behavior, the greater the risk for subsequent parent-child conflicts.
Punishment
♦ a consequence that results from a breakdown in discipline, from the child’s disregard of the rules that were
learned.
♦ Parents should instill some sense of discipline early in life because part of it involves setting safety limits and
protecting others or property.
1. Parents begin with negative voice and stern eye contact.
2. Time out commensurate with the child’s abilities
3. Parents should provide safe alternatives, putting away dangerous household items during
exploratory period
4. Give consistent discipline and nurturing
5. Alternative child care arrangements
♦ Basic types of care: in-home care, parent’s or caregiver’s home (family daycare) and center-based care usually in
a daycare center.
6. Thumb sucking and use of pacifier
♦ Thumb sucking starts in utero, shown by sonogram and sucking blisters.
♦ Thumb sucking should be stopped at school age.
♦ Thumb sucking may begin at 3 months peaks at about 18 months.
♦ An infant who completes feeding and still seems restless and discontent, and who actively searches for something
to put on his mouth may need a pacifier.
♦ Parents should attempt to wean the infant from pacifier anytime after 3 months and when the sucking reflex is
fading at 6 to 9 months
♦ The best approach is to be certain an infant has adequate sucking pleasure and then ignore thumb sucking
7. Teething
♦ A physiologic process with some discomfort as the crown of the tooth breaks through the periodontal membrane.
♦ Giving frozen teething ring or ice cube wrapped in a cloth
The following manifestations are not normal during tooth eruption :
a. High fever c. Diarrhea
b. Seizures d. Vomiting
♦ Check articles within baby’s reach to be sure that they are safe to chew or edible as teething infants tend to place
almost any object in the mouth
♦ Give frozen teething ring or ice cube
wrapped in a cloth
8. Maternal deprivation - is the term used for an infant’s lack of a warm relationship
♦ Infants deprived from maternal care by their own mothers or by an adequate mother substitute lack all that goes
with love and seldom perceive sufficient stimulation to promote normal development.
3. Nutrition
0-3 months Seven to Ninth-month old
a. Feed only on breast milk or formula for first year a. Introduce finger foods and cup when an infant
b. Always hold infant when feeding and never prop is able to sit up.
bottle when feeding. b. Have infant join family at mealtimes.
c. Limit water intake to ½ oz at a time. c. Allow self-feeding with observation to prevent
d. Avoid use of honey or corn syrup. choking.
e. Allow non-nutritive sucking. d. Offering fluids after solids.
e. Introduce limited amounts of diluted juice in a cup.
f. Avoid sugary deserts and soda.
Four to Six-month old Tenth to Twelfth-month old
a. Introduce solid foods without added salt or sugar a. Offer 3 meals and healthy snacks.
and iron-fortified cereal. b. Begin to wean from bottle and beginning
b. Introduce one food at a time, waiting 5 to 7 days table foods.
between new items. c. Avoid fruit drinks and flavored milk.
c. Avoid use of juice or sweetened drinks. d. Avoid infant to feed self with spoon.
d. Introduce the food before the formula or breast e. A newborn’s stomach can hold approximately
feeding when an infant is hungry 2 tablespoons (30 ml). By 1 year, stomach
e. Introduce small amounts of new foods (1 -2 tsp at can hold no more than approximately 1 cup
a time). (240 ml).
f. Use of spoon only.
g. Respect infant food preferences : a child cannot be Suggested Schedule for Introduction of Food
expected to like all new tastes well equally ♦ 5-6 months iron-fortified cereal mixed with breast
h. Use only minimal to no salt and sugar on solid milk, orange juice or formula
foods to minimize the number of additives Rationale: aids in preventing iron-deficiency
i. Remember that the extrusion reflex is present for anemia; the least allergenic type of food;
the first 4-6 months of life so any food placed on an easily digested food
an infants tongue will be pushed away ♦ 7 months- Vegetables
j. To prevent aspiration., do not place food in bottles Rationale: good source of vitamin A;
with formula adds new texture and flavors to diet
k. Introduce foods with a positive , ‘you’ll like this ♦ 8 months- Fruits
attitude” Rationale : best source of vitamin c, good source
of vitamin A; adds new texture & flavors to diet
♦ 9 months - meat
Rationale: Good source of protein, iron, & Vit. B
♦ 10 months- egg yolk
Rationale: Good source of iron
e. A moody baby
f. A still-developing nervous system
3. Spitting up
♦ The peak age for spitting up – also known as reflux – is 4 months.
♦ Breastmilk oversupply or forceful let-down
♦ Food sensitivities
♦ Babies with Gastroesophageal Reflux Disease (GERD)
♦ Caused by teething
a. Smaller, more frequent feedings can be easier to digest.
b. Positioning baby in a semi-upright or sitting position when breastfeeding,
c. Fussy, reluctant feeders: try lots of skin to skin contact, breastfeeding in motion (rocking, walking),
in the bath or when baby is sleepy.
d. Ensure good latch to minimize air swallowing.
e. Allow baby to completely finish one breast (by waiting until baby pulls off or goes to sleep) before
you offer the other.
4. Weaning
Supplementary Feedings
♦ Feedings provided in place of breastfeeding
♦ may include expressed or banked breast milk
Complementary Feedings
♦ Feedings provided in addition to breastfeeding after 6 months
♦ A NB’s stomach holds 30 ml but a 1 yr. old hold 240 ml.
♦ Needs 100 ml / kg BW due to rapid growth
When is the Infant Ready for Solid Foods :
1. He is nursing every 3-4 hrs. taking more than 32 oz. of formula a day and does not seem satisfied
2. When extrusion reflex fades (3-4 mos.) and sucking reflex is diminished
3. Biting movement begins at 3 mos. while chewing movement begin at 7-9 mos.
4. Able to keep his head in a steady, upright position
5. Sitting well when supported to swallow well
6. Curiosity about what the family is eating
Principles in giving complementary feeding:
1. Introduce one solid at a time every 5 days:
a. To help discern possible food allergy
b. Helps establish sense of trust because it minimizes the number of new experiences in any
one day.
2. Feed the first solid food with infant held in parent’s arm to minimize the amount of stress associated
with it.
3. An infant’s introduction to solid food should be a pleasant experience
4. A small serving is all that an infant will take at first
5. A new food should be offered before his formula.
6. The feeder should be calm, patient, gentle, and pleasant in her approach to the infant.
Sequence of foods to offer
1. Pureed or semi-liquid food
2. Strained or mashed food
3. Small pieces of finger foods
♦ Offer 2 to 4 ounces of water per day in a sippy cup
5. Baby Bottle syndrome
♦ Tooth decay in infants and very young children
♦ Happens when sweetened liquids or those with natural sugars (like milk, formula, and fruit juice) cling to an
infant’s teeth for a long time.
♦ Bacteria in the mouth thrive on this sugar and make acids that attack the teeth
NCM 101: MCN (G & D, Infancy, Toddler) Elizabeth Fernandez-Haciñas Page | 37
a. Wipe the baby's gums with a clean gauze pad or washcloth after each feeding.
b. Begin brushing your child's teeth, without toothpaste, when his or her first tooth comes in.
If you choose to use toothpaste, use a fluoride-free one.
c. Clean and massage gums in areas without teeth.
d. Floss once all the baby teeth have come in.
e. Make sure your child is getting enough fluoride, which helps lessen cavities. If your local water
supply does not contain fluoride, ask your dentist or doctor if you need to use a supplement.
f. Schedule regular dental visits by your child's first birthday. Dentists also offer special sealant
coatings, which can help prevent tooth decay in children.
g. Don't fill bottles with sugar water and soft drinks. Bottles are for milk, water, formula, and special
electrolyte-containing solutions when the child has diarrhea . Juices, mixed half and half with
water to avoid empty calories, are a way to interest your child in a "sippy cup." Soft drinks
are not recommended for children, as they have no nutritional value.
h. Never allow your child to fall asleep with a bottle containing anything but water.
i. Never give your child a pacifier dipped in anything sweet.
j. Reduce the sugar in your child's diet, especially between meals.
6. Constipation
♦ babies 0 to 4 months of age poop on average three to four times a day, and after the introduction of
solid foods, that reduces to approximately one bowel movement per day.
♦ milk-protein allergy or intolerance, dairy in mom's diet that's passed through the breast milk.
♦ A change in formula or in Mom's diet
♦ fruits and veggies, such as pears and broccoli
7. Loose Stools
♦ An infection with a virus, bacteria, or parasite.
♦ Babies can pick up these germs through contact with unclean food or water or when they touch germy
surfaces and then put their hands into their mouths.
♦ A food allergy or sensitivity to medicines
♦ Drinking too much fruit juice
8. Poisoning
3. Care of teeth
♦ Deciduous teeth, baby teeth, temporary teeth, milk teeth
♦ 20 temporary or deciduous teeth
♦ The last of the permanent teeth to appear are called “third molars,” or “wisdom teeth.”
They usually begin to erupt—pushing their way through the gums—between ages 17 and 21 years.
4. Dressing
5. Sleep
Sleep Problems
♦ Breast-fed infants tend to wake up more often than formula fed infants because breast milk is easily digested
NCM 101: MCN (G & D, Infancy, Toddler) Elizabeth Fernandez-Haciñas Page | 38
Newborns (0-3 months) ……….… 14-17 hrs / day Teenagers (14-17) ……………………… 8-10 hrs / day
Infants (4-11 months) ……….…… 12-15 hrs / day Younger adults (18-25) ………………….. 7- 9 hrs / day
Toddlers (1-2 years) ……….……. 11-14 hrs / day Adults (26-64) …………………………….. 7- 9 hrs / day
Preschoolers (3-5) ………….……. 10-13 hrs / day Older adults (65+) ………………………… 7-8 hrs / day
School age children (6-13) …….… 9-11 hrs / day
6. Play
♦ Infants learn many things thru play
1. Infants practice motor skills
2. General coordination of movement and specific coordination of hand-eye movements
3. Infants learn to relate to objects and people
4. Express their feelings and ward off frustrations
5. Play is important in the development of the child’s personality
Essential factors in the selection of toys:
1. Should be safe for the child’s use
2. Should be washable
3. Easy to handle
4. Smooth with rounded edges, no sharp points
5. Not too heavy
a. Never leave an infant on a raised/unprotected surface, such as a bed or couch, even the child is in an infant
seat. If a child sleeps in a crib, the rails should be 2 3/8 in. apart.
b. Place a gate at the top and bottom of stairways
c. Do not allow an infant to walk with a sharp object in the hands or mouth (it could pierce the throat in a fall).
d. Be sure crib sides are raised and locked before walking away from the crib.
e. Ensure that the space between the mattress and headboard is small enough to trap the child’s head.
3. Safety with Siblings
a. Parents should be reminded that children below 5 years of age are not responsible enough or knowledgeable
enough about infant to be left unattended with them.
b. They might introduce an unsafe toy or engage in a play that is too rough for the infant.
c. The preschoolers might be jealous of a new baby that they physically harm the infant if left alone.
4. Suffocation
a. Allow no plastic bags within the infant’s reach.
b. Do not use pillows in a crib.
c. Store unused appliances such as refrigerators or stoves with the door removed.
d. Buy a crib that is approved for safety (spacing of siderails is not over (2 3/8 inch) 6 cm apart
e. Remove constricting clothing such as bib from neck at bedtime.
5. Drowning
♦ Do not leave infants alone in a bath tub or unsupervised near water (even buckets of cleaning water).
6. Animal Bites
♦ Do not allow an infant to approach a strange dog
♦ Supervise play with family pets.
7. Poisoning
a. Never present medication as a candy
b. Buy medications in containers with safety caps: put away immediately after use
c. Never take medications in front of infants. Place all medications and poisons in locked cabinets
d. Never leave medication in a pocket or hand bag.
e. Use no lead-based paint in any area of the home.
f. Hang plants per set on high surfaces
g. Post telephone number of the poison control center by telephone.
8. Burns
a. Test warmth of formula and food before feeding
b. Do not smoke or drink hot liquids while holding an infant
c. Use sunscreen on a child over 6 months when in direct sunlight; limit the sun exposure to less than 30 min.
d. Monitor infants near candles
e. Keep electric wires and cords out of reach; Cover electrical outlets with safety plugs
f. Keep sharp jagged objects out of child’s reach
g. Keep diaper pins closed
9. Car Safety
a. Never transport unless an infant is buckled into an infant car seat in the back seat of the car.
Be aware of the proper technique for placing an infant in a car seat.
b. Infants up to 20 lbs should be placed in rear-facing seats in the back because an inflating front-seat airbag
could suffocate the infant.
c. Do not be distracted by an infant while driving.
d. Do not leave an infant unattended in a parked car (can become dehydrated form excess heat or can
be abducted).
10. Bodily damage
a. Keep sharp jagged objects out of child’s reach.
b. Keep diaper pins closed.
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11. Immunizations
♦ a measure of preventing communicable disease
♦ our immune system helps the body fight germs by producing substances to combat them. Once it does, the
immune system "remembers" the germ and can fight it again.
♦ Vaccines contain germs that have been killed or weakened. When given to a healthy person, the vaccine
triggers the immune system to respond and thus build immunity.
Obstacles faced by family with regards to immunization
1. Belief: immunization causes fever
2. Ignorance: some parents are not aware of the importance of immunization
3. Lack of money: although health centers give free immunization, some vaccines are not available in
the health centers.
Kinds of Immunization:
1. BCG 4. Measles Vaccine
2. DPT 5. Hepa Vaccine
3. Polio Vaccine 6. Others
Diphtheria, Measles
Hemophilus
Pertusis Pneumo Mumps Hepatitis Papilloma
Hepa B Influenza Rotavirus Influenza
Tetanus coccus Rubella A Virus
Type B
Polio Chicken Pox
On birth
1st Dose
in hosp.
2nd
1 mo.
Dose
2 mo. 1st Dose 1st Dose 1st Dose 1st Dose
4 mos 2nd Dose 2nd Dose 2nd Dose 2nd Dose
3rd Dose
6 mos 3rd Dose Addition 3rd Dose 3rd Dose
Starting
of bOPV
from
12 mos 4th Dose 4th Dose 3rd Dose 1st Dose 6mos
18 mos 1st Dose two
24 mos 2nd Dose doses,
6 yrs followed
(Grade 2nd Dose by one
1) dose per
7 yrs year
(Grade Booster before the
2) influenza
13 yrs Booster 3 Doses season
(without (girls
Grade 8) Polio) only)
From 3 to 6 months 8 cm
From 6 to 9 months 5 cm
From 9 to 12 months 3 cm
NCM 101: MCN (G & D, Infancy, Toddler) Elizabeth Fernandez-Haciñas Page | 41
Middle of infancy CC = HC
TODDLER
Toddler
♦ a child whose age is from 1 year old to 3 years old
♦ The toddler period is marked primarily by increasing strength and skill in performance
CHARACTERISTICS OF TODDLERHOOD:
1. A true foundation of age
♦ Many behavior patterns, attitudes and emotional expressions are established
♦ It is a critical period in setting the pattern for personal and emotional adjustments
2. Age of rapid growth and change
♦ They grow physically and psychologically
♦ Change in height and weight; develop interests and attitudes
♦ There is development of body control (Sitting, standing, walking)
3. Age of decreasing dependency
♦ Begins to do things himself
♦ Rebellion against being treated as a baby
♦ A protest comes in forms of angry outbursts and crying when independence is denied
4. Age of increased individuality
♦ Develop along lines suited to their interests and abilities
♦ Individuality is shown in appearance and in patterns of behaviors
♦ No longer thrive on same food or same schedules of eating and sleeping
5. Beginning of socialization
♦ Able to understand many things and communicate needs and wants
♦ Show desire to become part of groups and start protesting when left alone
♦ Try to win the attention of others by all means
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♦ Exhibit attachment behavior and develops strong emotional ties with their mothers
6. Beginning of sex-role typing
♦ Begins stereo-typed toys
7. Appealing age
♦ Babies are disproportionate and are appealing because of the big heads, protruding abdomens, small thin
limbs and tiny hands and feet
♦ When they are dressed in baby clothes and wrapped in baby-blankets, they become even more appealing
♦ Their helplessness and dependency make them more appealing
8. Beginning of creativity
♦ Because of lack of muscle coordination and their inability to control their environment, babies are incapable of
doing anything that can be regarded as creative.
♦ They are learning however in these early months of life to develop interests and attitudes that lay the foundations
of later creativity.
9. A hazardous age
♦ The physical hazards are illness, accidents, disabilities and death. Psychological hazards are disinterests and
negative attitudes
b. Fine Motor:
♦ By age 15 months, they can drop a pellet into a narrow-necked bottle. Scribbles voluntarily with a pencil
or a crayon; holds a spoon well but still turns upside down on the way to the mouth; Casting or
throwing objects and retrieving them become an almost obsessive activity,
♦ By 18 months, spoon no longer rotates; they can throw a ball overhand without losing their balance. turns
doorknob; unscrew lids.
♦ Ability to build tower of blocks: 3 blocks; 24 months - 6-7 blocks; 30 months – a tower of eight or more;
♦ 36 months – copies circle, uses scissors, button and unbuttons.
♦ Provide toys to help develop fine motor skills, problem solving abilities
♦ At 15 months:Names familiar objects; 4 to 6 words undress, point 2 – 3 body part;
♦ 24 months: use 2 – 3 word phrases
♦ 30 months – gives first and last names
♦ 36 months – Tells stories, talks non-stop, 500 – 900 vocabularies
Importance of play
1. Physical development
♦ Develop and exercise muscles of the body.
2. Social development
♦ Enjoys parallel play
♦ Explore relationships between objects and how to control them.
♦ See themselves as part of the community and develop skills to participate, especially language.
3. Therapeutic value
♦ Helps child release emotional tension
♦ Uses symbols and make-believe in play.
4. A means of education
♦ Learns to know color, shapes, sizes, texture of play materials.
♦ Expand understanding of object permanence (hide-and-seek activity)
5. Develops a beginning understanding of moral values
Factors in selecting toys for toddler
1. Consider toddler’s likes and dislikes
2. Toddler’s like to pull and push toys and enjoys pedal propelled toys
3. Consider toddlers’ being imaginative
4. Should be safe
5. No sharp edges
6. No rough edges
7. No small, removable parts nor flammable
8. Should not be lead painted
Examples of appropriate toddler toys
1. Pull-push toys
2. Blocks
3. Assortment of balls
4. Picture books
5. Play Doh with simple tools (craft sticks and wooden rollers)
6. Containers, scoops, sifters, and other objects for sand and water play
7. Toys and props for dramatic play like scarves, hats, a toy telephone, stuffed animals, and generic
baby dolls
8. Large pegged-top puzzles
9. A small climbing structure
CONCERNS OF TODDLERS
1. Toilet training
♦ one of the biggest tasks the toddler must achieve, during this period.
♦ Important development levels that must be reached before toilet training begins: one physiologic, and 2 cognitive
Markers of readiness:
a. Can stand, squat and walk alone
b. Can communicate toilet needs
c. Can maintain himself/herself dry for an interval of 2 hours
PROMOTION OF HEALTH
1. Safety measures
A. Motor Vehicle Accidents
1. Always use a car seat
2. Keep child safe in strollers and carts
B. Burns
1. Have and maintain smoke detectors
2. Plan and practice escape routes
3. identify dangers in the home and remove them or block child’s access to them
4. Prevent children from getting near firecrackers or fireworks
5. Keep toddler out of the sun; if not, cover child's skin with hats and clothing. Protect any bare skin with a
small amount of sunscreen.
6. Small bodies can develop heat exhaustion much more quickly than adults. Do not keep child out in warm
weather for long periods, and keep water or other drinks on hand.
C. Drowning
1. Supervise all baths at all times
2. Deal with water hazards and teach swimming safety
3. Keep pools and hot tubs safe
4. Empty all buckets and coolers when not in use
5. Keep toilet lids down, and consider securing them with safety latches.
D. Falls
1. Don't allow your child to walk or run with objects in his or her mouth.
2. Avoid using baby walkers. Children can fall down stairs and get hurt. An activity center is a better choice.
3. High chairs should have a wide, stable base and make sure the high chair is locked in the upright position
before use. Use the safety straps, and supervise your child at all times while he or she is in the high chair.
4. Changing tables should have a railing on all sides that is 2 in. (5.1 cm) high. Always use the safety strap,
and keep one hand on your child. Have diapers and other items handy, but keep them out of your child's
reach.
E. Poisoning
1. Wash your hands and working surfaces while preparing food
2. Cook foods to safe temperatures, and refrigerate foods promptly
3. Identify any products that could harm the child when eaten or inhaled.
4. Store these products out of your child's reach.
5. Children may chew on contaminated paint flakes or painted objects.
6. Use a carbon monoxide detector, and have your furnace checked each year.
7. Protect the child from second hand smoke, mold, and other indoor air pollutants
F. Choking
♦ Child can choke on things smaller than 1.25 in. (3.2 cm) in diameter and 2.25 in. (5.7 cm) long. These
include button batteries and coins.
1. Keep items like these out of your child's reach.
2. Learn to recognize signs of choking (a child who is choking can't talk, cry, breathe, or cough)
G. Strangulation And Suffocation
1. Keep cords for blinds and drapes out of child's reach.
2. Cords with loops should be cut and given safety tassels instead.
3. Never use accordion-style gates. A baby or young child may trap his or her head in the gate and may
strangle.
4. Make sure that furniture does not have cut out portions or other areas that can trap your child's head.
NCM 101: MCN (G & D, Infancy, Toddler) Elizabeth Fernandez-Haciñas Page | 49
5. Always lock car doors, and keep the keys out of your child's sight and reach.
6. If you are storing an old refrigerator or freezer, remove the door.
7. Do not let your child play with plastic sacks, and keep them out of his or her reach. Many children like to
play with sacks and put them over their heads.
8. Cribs should have less than 2.4 in. (60 mm) of space between slats.
9. Playpens should have spaces in the mesh material that do not exceed 0.25 in. (0.6 cm) across. Wooden
slats should measure less than 2.4 in. (60 mm) apart.
10. Grown up children can get tangled in mobiles or may use larger toys
2. Nutrition
Specific suggestions for feeding toddlers:
a. Serve food in small portions. Child likes plain food and eats one food at a time.
b. Chop or cut the food into small pieces
c. Diet for each day should include the following: Toddlers should consume at least 1,300 kcal daily
c.1. meat and fish – one serving, one egg daily or cheese
c.2. liver – one or more servings a week.
c.3. green and yellow vegetables – two or more servings a day
c.4. citrus fruits, raw or cooked – fruit two or more servings a day (one could be citrus or tomato juice)
c.5. cereal and bread enough to meet his caloric needs
c.6. butter or margarine
c.7. milk 16 ounces to a maximum of 1 quart or part of which may be used in cooking or on cereals
d. Satisfy the child’s appetite with nutritious foods and avoid offering him candy cake, ice cream and the like.
Nutritious snacks may be given between meals.
e. Give vitamins as suggested by the physician
f. Since child is growing less rapidly, he may eat less than he did at the end of the first year.
Don’t force him to eat.
g. High sugar should be avoided.
h. Fats should generally not be restricted for children under 2 years old however children over 2 years old
should consume no more than 30% of total daily calories from fat.
i. Adequate calcium and phosphorus intake is important.
j. Milk should be whole milk until 2 years
3. Daily physical care:
a. Bath should be given as part of his care
b. Prevention of tooth decay in the deciduous dentition is important
c. Clothing should be light and bright colored with large easily managed buttons, straps placed where child can
reach them
d. Amount of sleep the toddler needs depends upon his health, age, emotional tension and activity during the day.
PRESCHOOLER
♦ The Preschooler is a child from 4 to 6 years old
THE CHARACTERISTICS OF A PRESCHOOLER
1. A toy age
♦ The age of playing with toys most of the time
2. A pre gang age
♦ The child is learning the foundations of social behaviour. This learning prepares him for the more highly organized
social life of the school.
3. The Pre school age
♦ The period preceding the child’s entry into school.
4. An Exploratory age
♦ They want to know what their environment is and how it works, how it feels, and how they can be a part of it. Child
NCM 101: MCN (G & D, Infancy, Toddler) Elizabeth Fernandez-Haciñas Page | 50
Age 4 Age 5
▪ color recognition of primary colors ▪ Learns to balance
▪ Triples in height ▪ Jumps in rope
▪ Jump ▪ Eruption of permanent dentition
▪ Goes up and down in stairs ▪ Imaginative play
▪ Uses scissors perfectly ▪ Imitates the triangle
▪ Imitates square ▪ Prints letters
▪ Ties his shoe laces ▪ Draws a man
▪ Writes his name ▪ Hammers nails
▪ Draws 3 parts of the body ▪ Dresses himself/herself alone
▪ 1500 vocabularies
▪ Able to tell tales
COGNITIVE DEVELOPMENT
♦ Preoperational: Intuitive thought
♦ lack sight to view themselves as others see them or put themselves in another’s place, so they feel they are always
right. This causes them to argue with forcefulness believing they are always 100% correct.
♦ They are not yet aware of the property of conservation.
Imitation
♦ Preschoolers need free rein to imitate the roles of the people around them. Hence role playing should be fun and
need not be accurate.
♦ They generally imitate activities they see their parents performing at home
♦ They learn new words by introducing the other self of the parents at work such as: photocopier, secretary, lawyer,
sales clerk and the like.
LANGUAGE DEVELOPMENT
♦ The 3-year old child has a vocabulary of 900 words.
♦ These are used to ask questions constantly, mostly “how”, and “why”.
Examples: “Why is snow cold?”
“How do worms hear?”
“What does your tongue do?”
♦ They need simple answers, so curiosity, vocabulary building and questioning are encouraged, and also the depth of
child’s understanding is deceptive
♦ They would just follow what has been told to them but then return and ask why it was so.
♦ Preschoolers imitate language exactly, so if they hear less-than-perfect language, that is the language pattern they
adopt.
♦ They may imitate and use “bathroom language” if not corrected.
♦ Preschoolers are egocentric so they define objects in relation to themselves.
PLAY
♦ Preschoolers do not need so many toys. Their imaginations are keener than they will be at any other time in their
life, so they enjoy games that use imitation such as playing
♦ They imitate what they see parents doing: eating meals, mowing the lawn, cleaning the house, washing, ironing
arguing and so forth.
♦ They pretend to be teachers, firefighters, cowboys, store clerks. They have imaginary friends. These exist until they
formally begin schooling.
♦ Four and 5-year-olds divide their time between rough-housing and imaginative/imitative/associative play.
SOCIALIZATION
♦ Since 3-year-olds are capable of sharing, they play with other children their age much more agreeably than do
toddlers, which is why preschool period is a sensitive and critical time for socialization.
♦ Children at age 4 are involved in arguments more than they did at age 3, especially as they become more certain of
their role in the group.
♦ Five-year-olds begin to develop “best” friendships perhaps on the basis of who they walk with to the school, or who
lives closest to them
Fantasy
♦ Preschoolers begin to differentiate cartoon characters from real
♦ Children are fond of imitating and pretending to be something ore someone else, a fantasy role: like rabbit,
batman, superman.
♦ Parents should be encouraged to support the fantasy but still reassuring the child that she/he is still herself/
himself, the difference between the child and the role.
♦ Children should have preschool skills such as: being able to retell a simple story, able to recognize letters in
their names, trace the shapes of letters and numbers on paper, following simple instructions, matching
rhyming sounds, properly holding a pencil and listening to a story with a group, new social experiences like
taking turns and being in school for an entire day, interacting with new friends
2. Sex education
a. Open the door to sex education by teaching your child the proper names for his or her sex organs, perhaps
during bath time.
b. If your child points to a body part, simply tell him or her what it is. This is also a good time to talk about
which parts of the body are private.
c. When your child asks questions about his or her body — or yours, take the questions at face value, and
offer direct, age-appropriate responses.
♦ Sex education isn't a single tell-all discussion. Instead, take advantage of everyday opportunities to discuss
sex.
3. Gifted children
♦ The range for average intelligence is 85 to 115
♦ Children whose IQ scores are at least 120 to 130 are considered gifted.
♦ Some gifted children realize they're "different" from their peers. This can make them feel isolated and
withdrawn. It may also make them targets for bullying. They may begin to feel intensely frustrated because
they can think more rapidly than they can express themselves, verbally or physically.
♦ If child appears unusually angry or frustrated, consider consulting a mental health professional.
4. Aggression
♦ The preschooler is learning a lot of new skills and she can easily become frustrated with everything she is
trying to accomplish
♦ Child is tired and hungry or maybe if she feels resentful or neglected on top of everything else. She doesn’t
quite know what to do about it, so she responds by biting, hitting, or throwing a tantrum.
d. Pain
♦ Some fears are a result of concrete experiences but some is due to their developing imagination.
a. Approach the fear in steps.
b. Explain, expose, and explore.
c. Use love objects. These can offer an anxious child lasting reassurance
d. Problem-solve together.
e. Practice through pretend play
PROMOTION OF HEALTH
1. Promoting Preschooler Safety
a. Keeping Children Safe, Strong and FREE
b. Warn child never to talk to a stranger.
c. Teach child to call for help in case of emergency.
d. Describe what a police officer looks like and express that a police officer can help in emergency situation.
e. Explaining about secrets
f. Explaining that bullying behavior from other children is not to be tolerated but reported so they can receive help
managing it.
g. Wearing safety helmet when riding a bicycle
2. Nutritional Needs
♦ Would be based on the food pyramid.
♦ Caution should be made, since vitamins for this period are made in such a way that they are attractive, and
should be kept in a safe place far from children’s reach.
3. Promoting Preschoolers in Daily Activities
a. Dressing
♦ have difficulty in buttons, prefer bright and printed clothes that oftentimes mismatch.
b. Sleep
♦ Sleep 12 hours a night
♦ They don’t take a nap no matter how tired they are
♦ Are afraid of the dark
♦ Night waking from nightmares or night terrors reaches its peak.
♦ Needs a night light.
c. Exercise
♦ Active period.
♦ They receive a great deal of exercise, Rough-housing, love time-honored games.
d. Bathing
♦ Fond of taking a bath but are not paragons of neatness.
e. Care of teeth
♦ Deciduous teeth should be preserved to protect the dental arch.
f. Night grinding
♦ Bruxism
♦ grinding the teeth at night
♦ usually to release tension, “letting go”
SCHOOLER
♦ 6 – 12 YEARS OLD
CHARACTERISTICS OF A SCHOOLER
1. Troublesome Age
♦ no longer willing to do what they are told
NCM 101: MCN (G & D, Infancy, Toddler) Elizabeth Fernandez-Haciñas Page | 56
BIOLOGIC DEVELOPMENT
♦ Weight: doubles over this period
♦ Height: 2 inches per year
♦ Height increases to 1-2 inches (2.5-5 cm)
♦ At age 9, both sexes - same size;
♦ Age 12, girls bigger than boys
♦ Adult vision level is achieved; hand-eye coordination develops completely
♦ IgA and IgG reach adult levels, and lymphatic tissue continues to grow up until age 9.
♦ By 10 years of age, brain growth is complete, so fine motor coordination becomes more refined.
♦ Innocent heart murmurs are heard due to extra blood crossing the heart valves.
♦ Pulse rate decreases to 70-80 bpm;
♦ Blood pressure rises to about 112/60 mmHg
PHYSICAL GROWTH
♦ Dentition
▪ loses first primary teeth at about 6 years
▪ by 12 years, has all permanent teeth except final molars
▪ Malocclusion with teeth mal alignment may result if the eruption of the permanent teeth and growth of the jaw do
not correlate with final head growth.
♦ Bone growth faster than muscle and ligament development
♦ Posture becomes more erect
MOTOR DEVELOPMENT
♦ Gross motor skills
▪ predominantly involving large muscles
▪ children are very energetic
▪ develop greater strength, coordination, and stamina
♦ Fine motor development
▪ Develops smoothness and speed in fine motor control
MORAL DEVELOPMENT: Level II: Conventional Stage 3: Good Interpersonal Relationship: Good Boy/Girl Attitude
♦ Taking turns is fair, stealing is not.
♦ They lie to disguise that they have been involved in an action that is not nice.
♦ When asked why it is wrong to steal, “because it is not nice or fair”.
TWELVE-YEAR OLD
Physical
♦ coordination improves
Psychosocial
♦ A sense of humor is present
♦ is social and cooperative
SOCIAL DEVELOPMENT
♦ Daily relationship with age-mates provides the most important social interaction of school- aged children.
♦ They practice or mimic adult roles.
♦ Explore the social environment.
♦ They have sense of initiative.
♦ They learn to share, & discover,
♦ Learning is fun and adventure,
♦ Doing things is more rewarding than watching things being done.
♦ Children become increasingly sensitive to social norms and pressure of the peer groups.
♦ Interaction to peers lead to the formation of intimate friendships with same sex peers
LANGUAGE DEVELOPMENT
EMOTIONAL DEVELOPMENT
1. Children enter this period with the ability to trust others and with a sense of respect for their own worth.
2. There’s sense of autonomy
♦ Can accomplish small tasks independently.
♦ They practice or mimic adult roles.
♦ Explore the social environment.
3. They have sense of initiative.
♦ They learn to share
♦ Discover learning is fun and adventure
♦ Doing things is more rewarding than watching things being done.
♦ High-protein foods include lean red meat, chicken, turkey, seafood, eggs, dairy foods, peanut butter, soy
products, legumes, nuts and seeds.
Carbohydrates
♦ the main source of energy.
♦ Children ages 1 and older consume at least 130 grams of carbohydrates every day.
♦ Choose carbohydrates from whole grains, milk products, fruits, vegetables and legumes instead of refined
grains and added sugars
Fats, especially omega-3 fatty acids
♦ are important for child’s cognitive development.
♦ Children ages 4 and older consume 25 to 35 percent of their daily calorie intake from fats, especially mono-
and poly unsaturated fats found in vegetable oils, avocados, peanut butter, hummus, nuts and seeds. Foods
high in omega-3 fatty acids include purified fish oils, canola oil, walnut oil, walnuts, soybeans, soybean oil,
algal oil, flaxseeds, flaxseed oil and pumpkin seeds.
Calcium
♦ found in dairy products and dairy-free calcium-fortified beverages, iron in meats and iron-fortified grains,
vitamin A found in fruits, vegetables and dairy products, vitamin D in fish and dairy products and iodine,
which is abundant in seafood, dairy products, enriched grains and iodized salt.
2. Help child brush their teeth with fluoride toothpaste twice a day
3. Serve healthy meals and snacks
4. Take your child to the dentist for regular cleanings and check-ups.
5. Ask your dentist about dental sealants
3.d. Hygiene
1. Teach handwashing
2. Use handkerchief when sneezing and coughing
♦ Germs travel far and wide. A sneeze travels up to 100 miles per hour and can send 100,000 germs
into the air.
3. Remind child not to touch their eyes or pick their nose.
♦ Germs are easily transmitted into the body through the mucous membranes in the eyes, the nose,
and the mouth.
4. Dental Hygiene
♦ Get the child into the habit of flossing and brushing the tongue, the insides of the cheeks and roof of
mouth
3.e. Bath Time
♦ Many parents find that evening baths are the best way to relax a child before bed.
ADOLESCENT
♦ 12 to 18 years old
PUBERTY
♦ a transitional period between the juvenile state and adulthood during which a growth spurt occurs
♦ secondary sexual characteristics appear, fertility is achieved, and psychological changes take place
♦ A girl has entered this period when she begins to menstruate, and a boy when he begins to produce spermatozoa
♦ These events occur between 11 and 14 years
♦ Follows same pattern for all races and cultures
♦ Related to hormonal changes
Stages of Puberty
1. Pre-pubescent (“Maturing”)
♦ overlaps the closing year or two of childhood
♦ one who is no longer a child but not yet an adolescent
♦ secondary sex characteristics begin to appear but the reproductive organs are not yet fully developed
2. Pubescent (“mature”)
♦ occurs at the dividing line between childhood and adolescence
♦ criteria of sexual maturity appear - menarche in girls and first nocturnal emission in boys
♦ secondary sex characteristics continue to develop and cells are produced in the sex organs
3. Post pubescent
♦ overlaps the first year or two of adolescence
♦ secondary sex characteristics become well developed and the sex organs begin to function in a
mature manner
4. A time of rapid growth and change
♦ “adolescent growth spurt” rapid changes lead to confusion, feelings of inadequacy and insecurity, and in many
cases to unfavorable behavior
5. A negative phase
♦ negative attitudes and behavior are characteristic mainly of the early part of puberty and the worst of the
negative phase is over when the individual becomes sexually mature
Major Milestones of Development
♦ Onset of puberty and the cessation of body growth; Physiologic growth and development of adult coordination occur.
♦ Initially, the gain in physical growth is mostly in weight, leading to stocky appearance of prepubescence, è thin, gangly
appearance of late adolescence.
♦ Fast period of growth
♦ Results in change in body structure, development of secondary sex characteristics, and reproductive maturity
♦ Girls: height increases approximately 3 inches/yr; slows at menarche; stops around age 16
♦ Vital signs approach adult norms
SEXUAL MATURATION
♦ At a set point in brain maturity, the hypothalamus transmits an enzyme to the anterior pituitary gland to begin
production of gonadotropic hormones, which activate changes in testes and ovaries and produce puberty.
♦ Time of the onset of puberty varies widely, between 10-14 years of age.
♦ Sexual maturation in girls occurs between 12 and 18 years old
♦ Sexual maturation in boys, between 14 and 20 years old.
ADOLESCENCE
♦ A period of rapid growth and development.
♦ A period of intense physical, physiologic, and psychosocial changes usually beginning and ending in the second
decade of life.
Substages of adolescence
1. Early Adolescence – 10 to 14 years
♦ aware of their rapidly changing bodies and start to worry about their physical appearance.
♦ They might experience shyness, blushing, modesty, and a greater interest in privacy.
♦ May feel invincible and start to engage in risky behaviors such as smoking and alcohol use.
♦ Characterized by sexual curiosity, usually expressed through admiration of celebrities, teen idols, and
musicians.
2. Middle Adolescence - 15 to 17 tears
♦ extremely concerned with how they look, and they think others are concerned too.
♦ They spend a large amount of time grooming, exercising, and modifying their physical appearance.
♦ Dressing and acting like adults is not always enough so they begin to concentrate on behaviour associated
with adult status – smoking, drinking, using drugs, and engaging in sex are some examples. They believe
that this behavior will create the image they desire.
8. A dreaded age
♦ adolescent teenagers being sloppy, unreliable individuals who are inclined towards destructiveness and
antisocial behaviour has led many adults who must guide and supervise the lives of young adolescents to
dread this responsibility and to be unsympathetic in their attitudes towards adolescents.
♦ it creates much friction with their parents and places a barrier between them and their parents which prevents
them from turning to their parents for help in solving their problems.
9. Late adolescence is also a gang age
♦ Group standards is far more important to older children than individuality eg:- in dress, speech and behaviour
older children want to be as nearly like their gang mates as possible.
According to the World Health Organization (WHO)
♦ Adolescent age ranges from 10 to 19 years of age.
♦ Young people range from 10 to 24 years of age.
♦ Youth encompasses ages 15 to 24 years
PHYSICAL GROWTH
♦ Most girls are 1 to 2 inches (2.4 – 5 cm) taller than boys coming into adolescence and generally stop growing within
3 years from menarche. Thus, those girls menstruating at 10 years of age may reach their adult height by age 13.
♦ Boys: growth spurt starts around age 13; height increases 4 inch/yr, slows in late teens
♦ Boys double weight between 12 and 18, related to increased muscle mass
♦ Body shape changes
Girls Boys
Weight 13 – 55 lb ( 7 – 25 kg) 15 – 65 lb (7 – 30 kg)
Height 2 – 8 in ( 5 – 20 cm) 4 – 12 in (10 – 30 cm)
Age ( years) 16 or 17 18 - 20
CONCERNS OF ADOLESCENCE
1. Sexuality and Sexual Activity
2. Hazing
3. Substance Abuse
SAFETY ISSUES
♦ Accidents are leading cause of death: motor vehicle accidents, sports injuries, firearms accidents
♦ Safety measures include education about proper use of equipment and caution concerning risk taking
♦ Drug and alcohol use may be a serious problem
♦ Adolescent characteristics of poor impulse control and recklessness make prevention complex
NUTRITIONAL NEEDS
♦ Nutritional requirements peak during years of maximum growth: age 10 – 12 in girls, 2 years later in boys
▪ Boys require an average of 2,800 calories per day.
▪ Girls require an average of 2,200 calories per day.
♦ Appetite increases
♦ Inadequate diet can retard growth and delay sexual maturation
♦ Food intake needs to be balanced with energy expenditure
♦ Increased needs include calcium for skeletal growth;
iron for increased muscle mass and blood cell development;
zinc for development of skeletal and muscle tissue and sexual maturation
COMMON PROBLEMS
a. Hypertension d. Body piercing & Tattoos g. Gender discrimination j. Acne
b. Poor Posture e. Rebellion h. Dealing with peer pressure k. Obesity
c. Fatigue f. Menstrual Irregularities i. Suicides
PHYSICAL APPEARANCE/PHYSIOLOGICAL
♦ Musculo-Skeletal System
♦ At 19 – 30, maximum physiologic and motor function and stamina is reached.
♦ At 25, skeletal growth is completed
NCM 101: MCN (G & D, Infancy, Toddler) Elizabeth Fernandez-Haciñas Page | 70
Vit D– to metabolize calcium Vit B6 – Catalyzes synthesis of heme portion ofheme molecule
Vit C - to increase iron absorption Thiamin – counteracts poor appetite and regulate normal nerve
Vit E – for solubility of RBC function
Vit C & E – Retard cellular aging Vit B12 and Folacin – for normal blood formation
Copper – Facilitates hemoglobin formation Zinc – improves taste acuity and wound healing
2. Rest and Sleep
Rest - to cease activity, taking a break, usually the person is awake through that time.
Nap - to sleep briefly. Anywhere from 5 minutes to 2 hrs.
Sleep - eyes closed and not conscious of goings on around you this can last a few moments to many hours.
♦ During this time body, mind and energy are rejuvenated through this version of relaxation.
♦ Young adults should have 5 or 7 – 8 hours of sleep
Factors that determine need for rest and sleep:
a. Emotional and physical status
b. Occupation and amount of physical activity
Stages of sleep
1. REM (Rapid Eye Movement) sleep
♦ when dreaming occurs
♦ occur in 79 -90 min cycle that increases as the night progresses
2. NREM – Non Rapid Eye Movement
Stage 1 - transition from wakefulness to sleep in 5 min.
♦ drowsy and relaxed with fleeting thoughts, somewhat aware of the environment, can be easily
awakened and may think he has been awake .
Stage 2 – beginning of deeper sleep; ( 40 – 50% of total sleep time)
♦ more relaxed but easily awakened.
Stage3–period of progressively deeper sleep begins 30- 40 mins after sleep onset
♦ muscles more relaxed, difficult to awaken
Stage 4 - very deep sleep; ( occurs 40 min after stage 1)
♦ rests and restores body physically
♦ very relaxed, seldom moves, difficult to arouse
♦ responds slowly if awakened
♦ sleep-walking and enuresis may occur
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MIDDLE ADULT
♦ 45 years to 65 years
CHARACTERISTICS OF MIDDLE ADULTHOOD
1. A dreaded period
♦ unfavorable stereotypes, traditional beliefs concerning mental and physical deterioration, emphasis on youth
2. A time of transition
♦ change in virility (male), change in fertility (women), changed roles, physical condition, interests
♦ Crisis: parenthood crisis, dealing with aging parents, death of a spouse
3. A time of stress
♦ somatic due to physical evidence of aging, cultural due to high value placed on youth, vigor and success,
economic due to financial burden of educating children & providing status symbols for family members,
psychological due to death of spouse, departure of children, boredom with marriage, sense of lost hope and
approaching death
NCM 101: MCN (G & D, Infancy, Toddler) Elizabeth Fernandez-Haciñas Page | 74
4. A “dangerous age”
♦ (men) “middle age revolt”; promiscuous act, alcoholism; (women) hormonal upset due to menopause; physical
breakdown: overwork, overworry, careless living; mental illness, suicides; alcoholism, substance abuse
5. An “awkward age”
♦ “no longer young nor are they yet old”; stands between the younger “Rebel generation” and the “Senior citizen
Generation”; have no recognized place in society → inconspicuous; psychological – death of spouse;
departure of children; boredom with marriage; sense of lost hope and approaching death
6. A time of achievement
♦ time for financial and social success, authority and prestige; “Command Generation”- Norm bearers, decision
makers, lives in a youth oriented society controlled by the middle-aged
7. A time of evaluation
♦ evaluate accomplishments in light of earlier aspirations and the expectations of others; coming to terms of ones
fantasies
8. Evaluated by a double standard
♦ standard for men and standard for women; physical changes: men- distinguished, women – middle age spread;
approve way for the two sexes to age: stay young and active, “grow old gracefully”- “rocking chair philosophy”
9. A time of “empty nest”
♦ children no longer live under parental roof; Crises: family centered home → pair-centered home; more traumatic
for women
10. Time of boredom
♦ one of the unhappy periods of life
Nursing responsibilities:
a. Chew food well
b. Eat smaller portions
c. Eat in a pleasant & unhurried atmosphere
d. Avoid eating when overtired
2. Rest, sleep, exercise for better maintenance & to modify and retard aging process
PROMOTION OF HEALTH
1. Regular physical examination 5. Work through emotional & family concerns related to middle age
2. Pursuit of leisure activity 6. Affirm the worth of self as a middle and aged Person
3. Use of relaxation technique 7. Prepare for possible accidents/illness
4. Prepare for the later years 8. Confront developmental tasks
HEALTH PROBLEMS
a. Obesity c. Substance abuse
b. Chronic diseases d. Cancer
4. Deprivation theory
5. Wear-and- Tear theory
C. Physiologic Theories
♦ Explains aging on the basis of a breakdown of an organ system or impairment in neuroendocrine
or physiologic control mechanism
1. Biological Clock theory
2. Immune theory
D. Psychosocial Theories
♦ Lifestyle, personality and environmental factors also influence longevity
1. Continuity theory
2. Activity theory
3. Symbolic Interaction theory
4. Disengagement theory
a. Powerlessness
♦ characterized by feelings of no control or a sense that one’s actions will have no significant impact on an
outcome
b. Hopelessness
♦ A subjective state in which an individual sees limited or unavailable alternatives or personal choices and is
unable to mobilize energy on own behalf
8. Sensory deprivation
9. Sleeplessness
Melatonin
♦ important to regulate normal sleep cycles
♦ noted to induce sedation and lower core body temperature
AREAS OF PREPARATION
CHRONIC ILLNESS
FOR OLD AGE
1. Alzeimer’s 5. Cardiovascular Diseases 1. Health
2. Arthritis a. Hypertension 2. Retirement
3. Osteoporosis b. Coronary Artery Disease (Angina; MI) 3. Use of leisure time
4. Respiratory Diseases c. Congestive Heart Failure 4. Financial independence
a. Pneumonia d. Cerebro Vascular Disease (CVA) 5. Social contacts
b. Tuberculosis e. Peripheral Vascular Disease 6. Role changes
7. Life patterns
References:
Hockenberry, Wilson. Wong’s Nursing Care for Infants and Children. 8th ed. Elsevier Pte Ltd. 2010
Pilliteri, Adelle. Maternal and Child Health Nursing. 5th ed. Lippincott Williams and Wilkins. 2010
Kozier and Erbs. Fundamentals of Nursing. 8th ed. Pearson Prentice Hall. 2010
Wilson, David. Wong’s Clinical Manual of Pediatric Nursing. 8 th ed. St. Louis, Mo.Mosby. 2012
Wong’s Nursing Care of Infants and Children. 9th ed. St. Louis, Mo.Mosby. 2011
Cantrell, Mary Ann. Pediatric Nursing. New York: McGraw-Hill. 2011
Pilliteri, Adele. Maternal and Health Nursing: Care of the Childbearing and Childrearing Family. 6 th ed. Philadelphia: Wolters
Kluwer Health. Lippincott Williams & Wilkins. 2010
Grading System:
Quiz ----------------------- 40 %
Requirements ---------- 20 %
Concept Exams ------- 40 %
100 %
Prepared by :
ELIZABETH FERNANDEZ-HACIÑAS, RN, MAN, RM, Ed.D.
Lecturer
Cp # 09178197345
Consultation day : Th-F : 2:00 pm-4:00pm
Room : Consultation Room