SULTAN KUDARAT STATE UNIVERSITY

ACCESS Campus, EJC Montilla, Tacurong City

COLLEGE OF HEALTH SCIENCES

Learning Module on Care of the Mother, Child and Adolescent (Well clients)

Grabbed photo from: Hermel

Alejandre (Mother & Child Greeting
Card)

CRISTELA MARIE MARASIGAN-PELARCO,RN,RM,MAN

Compiler
 CHAPTER V. GROWTH AND DEVELOPMENT
Learning Outcomes:
At the end of this chapter, the learner will:
 Integrate theoretical approaches of growth and development across
different stages of the lifespan;
 Apply the nursing process for the promotion of normal growth and
development in different stages of the lifespan;
 Assess the normal growth and development of the family with an
infant, a toddler, a pre-schooler, a school-age child and with an
adolescent;
 Formulate nursing diagnoses for promotion of health among the family
with an infant, a toddler, a pre-schooler, a school-age child and with an
adolescent;
 Implement safe and quality nursing interventions addressing health
needs and disease prevention in different stages of growth
development;
 Conduct individual/ group health education activities based on the
priority learning needs with health promotion and disease prevention
in different stages of growth development;
 Evaluate with the client the health promotion outcomes and disease
prevention in different stages of growth development;
 Document the appropriate resources for health promotion and disease
prevention in different stages of growth development;
 Assume responsibility for life-long learning, own personal
development and maintenance of competence.

CONTENT OF THIS CHAPTER

Lesson 1: Theoretical approaches to the Growth and Development of

Children
Lesson 2: Nursing process for Promotion of Normal Growth and
Development
A. The Family with an Infant
B. The Family with a Toddler
C. The Family with a Pre-schooler
D. The Family with a School-age child
E. The Family with an Adolescent
• Assessment
• Nursing Diagnosis
• Planning and Intervention
• Evaluation
• Documentation
Lesson 3: Health Promotion and Disease Prevention in Different Stages of
Growth Development
 LESSON 1
Theoretical approaches to the Growth and
Development of Children
OVERVIEW OF GROWTH AND DEVELOPMENT

Biological, psychosocial and cognitive changes that begin during

puberty and continue throughout adolescence directly affect nutritional status
and nutrient needs. Adolescents experience dramatic physical growth and
development during puberty. As children grow, their external dimensions
increases, which in turn appreciably increases their requirements for energy,
protein, and many vitamins and minerals. Early adolescence can be described
as a period of life, in which youth undergo rapid physical, cognitive, and social
transformation.

Adolescent patients present a unique set of challenges to pediatricians.

A polite, compliant child can appear to transform into a surly, rebellious teen
before a doctor’s eyes. Adolescence can be a tumultuous time, even when it
is unfolding in a healthy manner. For this reason, and because there is so
much individual variation in adolescent development, it is usually referred to
as a unit, expressed as the sum of the numerous changes that take place
during the lifetime of an individual.

Definition of Terms

Growth: is an increase in number and size of cells as they divide and

synthesize new proteins, results in increased size and weight of the whole
or any of body part. Growth is a quantitative change.

Development: is a gradual change and expansion of the person; the all-

round expansion of the individual’s capacities through growth, maturation
and learning. Development is a qualitative change.

Normal physical growth and development

The beginning of biological growth and development during

adolescence is signified by the onset of puberty, which is often defined as the
physical transformation of a child into an adult. A myriad of biological changes
occur during puberty including sexual maturation, increases in height and
weight, completion of skeletal growth accompanied by a marked increase in
skeletal mass, and changes in body composition. The succession of these
events during puberty is consistent among adolescents. However, there may
be a great deal of deviation in the age of onset, duration, and tempo of these
events between and within individuals.

However, with increasing education needs, there is an increasing gap

between physical maturation and the ability to take on adult responsibilities.
Therefore, it is vital that health care providers who provide nutrition education
and counseling have a thorough understanding of adolescent physical and
psychosocial growth and development.

STAGES OF GROWTH AND DEVELOPMENT

To simplify analysis and discussion of the complex processes and

theories related to growth and development, researchers and theorists have
identified stages or age-groupings. These stages serve as reference points in
describing various features of growth and development (Table 1). This
chapter discusses the physical growth and cognitive, emotional, language,
and motor development specific to each stage. The following stages and age-
groupings refer to stages of childhood growth and development.

Table 1. Stages of Growth and Development

STAGE AGE
Newborn Birth to 1 month
Infancy 1 month to 1 year
Toddlerhood 1 to 3 years
Preschool age 3 to 6 years
School age 6 to 11 or 12 years
Adolescence 13 to 18 years
Middle Adult 19 to
Older Adult

Parameters of Growth

Statistical data derived from research studies of large groups of

children provide health care professionals with information about how children
normally grow. Throughout infancy, childhood, and adolescence, growth
occurs in bursts separated by periods when growth is stable or consistent.

Weight, length (or height), and head circumference are parameters that
are used to monitor growth. They should be measured at regular intervals
during infancy and childhood. The weight of the average term newborn infant
is approximately 7½ pounds (3.4 kg). Male infants are usually slightly heavier
than female infants. Usually, the birth weight doubles by 6 months of age and
triples by 1 year of age. Between 2 and 3 years of age, the birth weight
quadruples. Slow, steady weight gain during childhood is followed by a growth
spurt during adolescence.

The average newborn infant is approximately 20 inches (50 cm) long,

with an average increase of approximately 1 inch (2.5 cm) per month for the
first 6 months, followed by an increase of approximately ½ inch (1.2 cm) per
month for the remainder of the first year. The child gains 3 inches (7.6 cm) per
year from age 1 through 7 years and then 2 inches (5 cm) per year from age 8
through 15 years. Boys generally add more height during adolescence than
do girls. Body proportion changes are shown in Figure 1.
 Figure 1. Changes in body proportions with physical growth.

Head circumference indicates brain growth. The normal occipital-

frontal circumference of the term newborn head is 13 to 15 inches (32 to 38
cm). Average head growth occurs according to the following pattern: 4.8
inches (12 cm) during the first year, 1 inch (2.54 cm) during the second year;
½ inch (1.27 cm) per year from 3 to 5 years, and ½ inch (1.2 cm) per year
from 5 years until puberty. The average adult head circumference is
approximately 21 inches (53 cm).

Dentition, the eruption of teeth, also follows a sequential pattern.

Primary dentition usually begins to emerge at approximately 6 to 8 months.
Most children have 20 teeth by age 2½ years. Permanent teeth, 32 in all,
erupt beginning at approximately age 6 years, accompanied by the loss of
primary teeth. Although some parents place importance on eruption of the
teeth as a sign of maturation, dentition is not related to the level or rate of
development.

PRINCIPLES OF GROWTH AND DEVELOPMENT

Patterns of Growth and Development

Growth and development are directional and follow predictable patterns

(Boxes 1 and 2). The first direction of growth is cephalocaudal, or proceeding
from head to tail (or toe). This means that structures and functions originating
in the head develop before those in the lower parts of the body. At birth the
head is large, a full one fourth of the entire body length, the trunk is long, and
the arms are longer than the legs. As the child matures, the body proportions
gradually change; by adulthood, the legs have increased in size from
approximately 38% to 50% of the total body length.
 Box 1. Patterns of Growth and Development
Although heredity determines each individual’s growth rate, the normal
pace of growth for all children falls into four distinct patterns:
1. A rapid pace from birth to 2 years
2. A slower pace from 2 years to puberty
3. A rapid pace from puberty to approximately 15 years
4. A sharp decline from 16 years to approximately 24 years, when full
adult size is reached

Box 2. Directional Patterns of Growth and Development

A. CEPHALOCAUDAL PATTERN (Head to Toe)

Examples:
 Head initially grows fastest (fetus), then trunk (infant), then legs (child).
 Infant can raise the head before sitting and can sit before standing.

B. PROXIMODISTAL PATTERN (from the Center Outward)

Examples:
 In the respiratory system, the trachea develops first in the embryo,
followed by branching and growth outward of the bronchi, bronchioles,
and alveoli in the fetus and infant.
 Motor control of the arms comes before control of the hands, and hand
control comes before finger control.

Directional growth and development are illustrated further by

myelinization of the nerves, which begins in the brain and spreads downward
as the child matures (see Box 1). Growth of the myelin sheath and other
nerve structures contributes to cephalocaudal development, which is
illustrated by an infant’s ability to raise the head before being able to sit and to
sit before being able to stand.
 A second directional aspect of growth and development
is proximodistal, which means progression from the center outward, or from
the midline to the periphery. The growth and branching pattern of the
respiratory tract illustrates this concept. The trachea, which is the central
structure of the respiratory tree, forms in the embryo by 24 days of gestation.
Branching and growth outward occur in the bronchi, bronchioles, and alveoli
throughout fetal life and infancy. Alveoli, which are the most distal structures
of the system, continue to grow and develop in number and function until
middle childhood.

Growth and development follow patterns, one of which is general to

specific. As a child matures, activities become less generalized and more
focused. For example, a neonate’s response to pain is usually a whole-body
response, with flailing of the arms and legs even if the pain is in the abdomen.
As the child matures, the pain response becomes more localized to the
stimulus. An older child with abdominal pain guards the abdomen.

Another pattern is the progression of functions from simple to complex.

This pattern is easily observed in language development. A toddler’s first
sentences are formed simply, using only a noun and a verb. By age 5 years,
the child constructs detailed stories using many complex modifiers.

The rate of growth is not constant as the child matures. Growth

spurts, alternating with periods of slow or stagnant growth, are observed
throughout childhood. Spurts are frequently seen as the child prepares to
master a significant developmental task, such as walking. An increase in
growth around a child’s first birthday may promote the neuromuscular
maturation needed for taking the first steps.

All facets of development (cognitive, motor, social/emotional, language)

normally proceed according to these patterns. Knowledge of these concepts
is useful when determining how a child’s development is progressing and
when comparing a child’s development with normal patterns.

Mastery of developmental tasks is not static or permanent, and

developmental stages do not always correlate with chronologic age. Children
progress through developmental stages at varying rates within normal limits
and may master developmental tasks only to regress to earlier levels when ill
or stressed. Also, people can struggle repeatedly with particular
developmental tasks throughout life, although they have achieved more
advanced levels of development.

Critical Periods

After birth, critical or sensitive periods exist for optimal growth and
development. Similar to times during embryologic and fetal life, in which
certain organs are formed and are particularly vulnerable to injury, critical
periods are blocks of time during which children are ready to master specific
developmental tasks. Children can master tasks outside these critical periods,
but some tasks are learned more easily during particular periods.
 Many factors affect a child’s sensitive learning periods, such as injury,
illness, and malnutrition. For example, the sensitive period for learning to walk
seems to be during the latter part of the first year and the beginning of the
second year. Children seem to be driven by an irresistible urge to practice
walking and display great pride as they succeed. If a child is immobilized, for
example, for the treatment of an orthopedic condition from age 10 months to
18 months, the child may have difficulty learning to walk. The child can learn
to walk, but the task may be more difficult than for other children.

Factors Influencing Growth and Development

1. Genetics
2. Environment
3. Culture
4. Nutrition
5. Health Status
6. Family (Parental Attitudes & Child-Rearing Philosophies)

THEORIES OF GROWTH AND DEVELOPMENT

1) Psychosexual development- Freud’s theory
2) Psychosocial development- Erikson’s theory
3) Cognitive/ intellectual development- Piaget’s theory
4) Moral development- Kohlberg’s theory
Other Theories:
5) Spiritual development- Fowler’s theory
6) Language development
7) Theory on Development of Temperament

PSYCHOSEXUAL DEVELOPMENT: FREUD’S THEORY

Sigmund Freud, often referred to as the father of psychotherapy,

developed the concepts of id, ego and superego, the psychological defense
mechanisms such as sublimation and suppression, as well as the 5 stages of
psychosexual growth and development.

a) Id –is an unconscious mechanism that operates in terms of instant

gratification and instant pleasure. Some say that infants are nothing
more than a bundle of id.
b) Ego –is the person's sense of self that provides the person with the
ability to control oneself and one's behaviors.
c) Superego –is the person's conscience.

The 5 stages of Sigmund Freud's Stages of Psychosexual

Development are:

1. The Oral Stage (Birth to 1 Year):

 During this period, the sensory area of the mouth provides the highest
sensual satisfaction for an infant by doing sucking, biting, chewing and
 vocalizing.
2. The Anal Stage (1to 3 Years):
 The toddler period, the second and third years of life, the greatest
amount of sensual pleasure is obtained from the anal and urethral
areas by defecating. At this stage the climate surrounding toilet
training.
3. The Phallic Stage (3 to 6 Years):
 During this stage, children become more interested about the genitalia
and sensitive area of the body. They recognize difference between the
sexes and become curious about dissimilarities. The oedipal stage
occurs in the later part of phallic stage, during this time the child loves
the parent of opposite sex as the provider of satisfaction.
4. The Latency Stage (6 Years to Puberty):
 During this stage, children elaborate on previously acquired traits and
skills and also form close relationship with others of their own age and
sex.
5. The Genital Stage (Puberty to Death):
 During puberty, secondary characteristics appear in both sexes with
maturation of the reproductive system and production of sex hormone.

PSYCHOSOCIAL DEVELOPMENT: ERIKSON’S THEORY

Adolescents experience dramatic biological changes related to puberty;

these biological changes can significantly affect psychosocial development.
An increased awareness of sexuality and a heightened preoccupation with
body image are fundamental psychosocial tasks during adolescence. Peer
influence is a dominant psychosocial issue during adolescence, especially
during the early stages. Young teens are highly cognizant of their physical
appearance and social behaviors, seeking acceptance within a peer group.
The desire to conform can influence food intakes among teens. The broad
chronological age range during which biological growth and development
begins and advances can become a significant source of personal
dissatisfaction for many adolescents as they struggle to conform to their
peers.

Erik Erickson proposed 8 major stages of psychosocial development

and expected tasks along the life span from infancy to old age. People,
including our own clients, who are able to resolve their age related tasks are
successfully able to progress to the next task; however, psychosocial
development can become arrested when a person is not able to achieve their
age related developmental task.

Nurses must incorporate these developmental tasks and challenges

into the plan of care and they must also modify the plan of care according to
these age related tasks. Eric Erikson's stages, developmental tasks and signs
of their lack of resolution are listed in Table 2 below as:
Table 2. Eric Erikson's stages of developmental tasks and signs of their
lack of resolution and strengths
Failures to Resolve
Stage Task Strengths
the Task
INFANCY Trust Mistrust and a failure Hope
to thrive
TODDLER Autonomy, self- Shame, doubt and a Will
control and will poor tolerance of
power frustration
PRESCHOOL Initiative, a sense Guilt and the fear of Purpose
of purpose, punishment
self-confidence,
and self-
direction
SCHOOL AGE Industry, Feelings of Competence
CHILD competence inferiority and
and self- fears that one
confidence cannot meet the
expectations of
others
ADOLESCENT Identity Role confusion, Fidelity
formation and lowered self-
a sense of self esteem and a poor
as an individual self-concept
YOUNG Intimacy, love Isolation and the Love
ADULT and affection avoidance of
relationships
including intimate
relationships
MIDDLE Generativity, Stagnation, self- Care
AGED ADULT productivity, absorption and a
and genuine lack of concern
concern for about others
others
OLDER Ego integrity, Despair and feelings Wisdom
ADULTS wisdom and the that life is without
ability to any meaning and
participate in without any sense
life with a sense of satisfaction
of satisfaction

COGNITIVE/ INTELLECTUAL DEVELOPMENT:

PIAGET’S THEORY

The early stage of adolescence is a time of great cognitive

development. At the beginning of adolescence, cognitive abilities are
dominated by concrete thinking, egocentrism, and impulsive behavior. The
ability to engage in abstract reasoning is not highly developed in most young
teens, limiting their capacity to comprehend nutrition and health relationships.
Young adolescents also lack the skills necessary to problem solve in an effort
to overcome barriers to behavior change and the ability to appreciate how
current behaviors can affect future health status. Much of modern thinking
about cognitive development in adolescence has its roots in the work of Jean
Piaget (1896 to 1980).

According to Piaget, maturation and growth have certain signposts and

adolescence marks a shift from the rule-bound, concrete methods of problem
solving during the concrete operations stage characteristic of younger children
to the greater capacity for abstraction and flexible problem solving that
characterizes formal operations. Children are born with inherited potentials for
intellectual growth, but they must develop that potential through interaction
with the environment. Upon entering what he labeled the “formal operations
stage,” early adolescents, Piaget believed, developed the ability to think more
scientifically; to design and test multiple hypotheses; and to manipulate
objects, operations, and future outcomes in their minds without having to
actually interact with physical objects. This view of cognitive development in
early adolescence has played a major role in the sequencing of curriculum in
schools. Four major stages of emotional development are:

1. Sensorimotor (Birth to 2 Years):

 In which children are primarily concerned with learning about physical
objects.
 Children progress from reflex activity through simple repetitive
behaviors to imitative behavior.
 They develop a sense of cause and effect as they direct behavior
towards objects.

2. Pre-operational (2 to 4 Years):
 The predominant characteristic of the preoperational stage of
intellectual development is ego centrism, which in this sense doesn’t
mean selfishness the inability to put oneself in the place of another.
 Children are preoccupied with symbols in language, dreams and
fantasy.

3. Intuitive phase (4 to 7 Years):

 Children begin to elaborate concepts and to make simple associations
between ideas.
 They are only beginning to deal with problems of weight, length, size
and time.
 Reasoning is also transductive because 2 events occur together, they
cause each other or knowledge of one characteristic is transferred to
another.

4. Concrete operation (7 to 11 Years):

 In this, children move into the abstract world, mastering numbers and
relationships.
 At this age thought becomes increasingly logical and coherent.
  Children are able to classify sort, order, and otherwise organize facts
about the world to use in problem solving.

5. Formal operation (11 to 15 Years):

 In which they tackle purely logical thought, thinking about their own
thinking as well as that of others.
 Formal operational thought is characterized by adaptability and
flexibility.
 Adolescents can think in abstract terms, use abstract symbols and
draw logical conclusion from a set of observations.

MORAL DEVELOPMENT: KOHLBERG’S THEORY

The study of moral development is somewhat controversial because it

places morality under a scientific lens, implying a social and biologic basis for
moral behavior. Moral development described by Lawrence Kohlberg is based
on cognitive developmental theory. He observed, not every individual reaches
the same end. Kohlberg postulates 6 stages of potential moral development
which is organized in 3 levels:

1. Pre-conventional Level:
 The pre-conventional level of normal development parallels the
preoperational level of cognitive development and intuitive thought.
 They avoid punishment and obey without question those who have the
power to determine and enforce the rules and labels.

2. Conventional Level:
 At the conventional stage children are concerned with conformity and
loyalty. They value the maintenance of family, group or national
expectation regardless of consequence.
 One earns approval by being nice, obeying the rules and maintaining
the social order are the correct behavior. This level is correlated with
the stage of concrete operation in cognitive development.

3. Post-conventional Level:
 At the post conventional level the individual has reached the cognitive
stage of formal operation.
 Correct behavior tends to be defined in terms of general individual
rights and standards that have been examined and agreed by the
entire society.

SUMMARY OF MAJOR THEORIES FOR GROWTH &

DEVELOPMENT

Many theorists have attempted to organize and classify the complex

phenomena of growth and development. No single theory can adequately
explain the wondrous journey from infancy to adulthood. However, each
theorist contributes a piece of the puzzle. Theories are not facts but merely
attempts to explain human behaviour. Table 3 compares and contrasts
theories discussed in the text. The chapters on each age-group provide
further discussion of these theories.

Table 3. Summary of Theories on Stages of Growth and Development

Piaget’s Freud’s Stages of Erikson’s Kohlberg’s Stages
Periods of Psychosexual Stages of of Moral
STAGES
Cognitive Development Psychosocial Development
Development Development
INFANCY Period 1 Oral Stage Trust vs. Mistrust Premorality or
(Birth-2 yr): Preconventional
Sensorimotor Morality,
Period Stage 0 (0-2 yr):
Naivete and
Egocentrism
Reflexive Mouth is a sensory Development of No moral sensitivity;
behavior is used organ; infant takes a sense that the decisions are made
to adapt to the in and explores self is good and on the basis of what
environment; during oral passive the world is good pleases the child;
egocentric view substage (first half when consistent, infants like or love
of the world; of infancy); infant predictable, what helps them and
development of strikes out with reliable care is dislike what hurts
object teeth during oral received; them; no awareness
permanence. aggressive characterized by of the effect of their
substage (latter hope. actions on others.
half of infancy). “Good is what I like
and want.”
TODDLERHOOD Period 2 (2-7 yr): Anal Stage Autonomy vs. Premorality or
Preoperational Shame and Preconventional
Thought Doubt Morality,
Stage 1 (2-3 yr):
Punishment-
Obedience
Orientation
Thinking remains Major focus of Development of Right or wrong is
egocentric, sexual interest is sense of control determined by
becomes anus; control of over the self and physical
magical, and is body functions is body functions; consequences: “If I
dominated by major feature. exerts self; get caught and
perception. characterized by punished for doing it,
will. it is wrong. If I am not
caught or punished,
then it must be right.”
PRESCHOOL Phallic or Initiative vs. Guilt Premorality or
AGE Oedipal/Electra Preconventional
Stage Morality,
Stage 2 (4-7 yr):
Instrumental
Hedonism and
Concrete Reciprocity
Genitals become Development of Child conforms to
focus of sexual a can-do attitude rules out of self-
curiosity; superego about the self; interest: “I’ll do this
(conscience) behavior for you if you do this
develops; feelings becomes goal- for me”; behavior is
of guilt emerge. directed, guided by an “eye for
competitive, and an eye” orientation.
imaginative; “If you do something
initiation into bad to me, then it’s
gender role; OK if I do something
characterized by bad to you.”
purpose.
SCHOOL AGE Period 3 (7-11 Latency Stage Industry vs. Morality of
yr): Concrete Inferiority Conventional Role
 Operations Conformity,
Stage 3 (7-10 yr):
Good-Boy or Good-
Girl Orientation
Thinking Sexual feelings Mastering of Morality is based on
becomes more are firmly useful skills and avoiding disapproval
systematic and repressed by the tools of the or disturbing the
logical, but superego; period culture; learning conscience; child is
concrete objects of relative calm. how to play and becoming socially
and activities are work with peers; sensitive.
needed. characterized by
competence.
Morality of
Conventional Role
Conformity,
Stage 4 (begins at
about 10-12 yr): Law
and Order Orientation
Right takes on a
religious or
metaphysical quality.
Child wants to show
respect for authority,
and maintain social
order; obeys rules for
their own sake.
ADOLESCENCE Period 4 (11 yr- Puberty or Genital Identity vs. Role Morality of Self-
Adulthood): Stage Confusion Accepted Moral
Formal Principles,
Operations Stage 5: Social
Contract Orientation
New ideas can Stimulated by Begins to Right is determined
be created; increasing develop a sense by what is best for
situations can be hormone levels; of “I”; this the majority;
analyzed; use of sexual energy process is exceptions to rules
abstract and wells up in full lifelong; peers can be made if a
futuristic force, resulting in become of person’s welfare is
thinking; personal and paramount violated; the end no
understands family turmoil. importance; child longer justifies the
logical gains means; laws are for
consequences of independence mutual good and
behavior. from parents; mutual cooperation.
characterized by
faith in self.
ADULTHOOD Intimacy vs.
Isolation
Development of
the ability to lose
the self in
genuine
mutuality with
another;
characterized by
love.
MIDDLE Generativity vs. Morality of Self-
ADULTHOOD Stagnation Accepted Moral
Principles,
Stage 6: Personal
Principle Orientation
Production of Achieved only by the
ideas and morally mature
materials through individual; few people
work; creation of reach this level; these
children; people do what they
characterized by think is right,
care. regardless of others’
 opinions, legal
sanctions, or
personal sacrifice;
actions are guided by
internal standards;
integrity is of utmost
importance; may be
willing to die for their
beliefs.
OLDER Ego Integrity vs. Morality of Self-
ADULTHOOD Despair Accepted Moral
Principles, Stage 7:
Universal Principle
Orientation
Realization that This stage is
there is order achieved by only a
and purpose to rare few; Mother
life; Teresa, Gandhi, and
characterized by Socrates are
wisdom. examples; these
individuals transcend
the teachings of
organized religion
and perceive
themselves as part of
the cosmic order,
understand the
reason for their
existence, and live for
their beliefs.

SPIRITUAL DEVELOPMENT: FOWLER’S THEORY

According to Fowler, faith is a human universal that is expressed

through beliefs, rituals and symbols specific to religious tradition. It is
multidimensional and a way of learning about life. Spirituality affects the whole
person mind, body and spirit. The stages of development of faith are:

1. Stage ‘0’- Undifferentiated:

 This stage of development encompasses the period of infancy during
which children have no concept of right or wrong, no beliefs and no
convictions to guide their behavior.

2. Stage ‘1’-Intuitive Projective:

 Toddlerhood is primarily a time of imitating the behavior of others.
 Children imitate the religious gestures and behavior of others without
comprehending any meaning or significance to the activities.

3. Stage ‘2’-Mythical Literal:

 In this period, spiritual development parallels cognitive development
and is closely related to children’s experiences and social interactions.
 Good behavior is awarded and bad behavior is punished.

4. Stage ‘3’-Synthetic Convention:

 As children approach adolescence, however they become increasingly
aware of spiritual disappointment.
  They recognize that prayers are not always answered and may begin
to abandon or modify some religious practices.

5. Stage ‘4’-Individuating Reflexive:

 Adolescence becomes more aware of the emotion, personality,
patterns, behaviours, ideas, thoughts and experience of self and
others.
 They begin to compare the religious standards of their parents. Self-
concept is how an individual describes himself or herself.
 The term self-concept includes all the notions, beliefs and convictions
that constitute an individual’s relationship with others.

LANGUAGE DEVELOPMENT THEORY

 The ability to communicate is a significant factor in a child’s intellectual,

emotional and social development. Language is a complex system of
grammatical and semantic properties. Children are able to understand
language before they are able to speak it.
 The steps of prelingual speech are the same for all children. Reflex,
vocalizations, babbling, imitation of sounds and verbal utterance.
 The child’s articulation or ability to pronounce words correctly so that they
are understood develops along with language ability. Articulation skills
require the coordination of the tongue and lower jaw.
 Vocabulary or semantic development, progresses from infancy throughout
life. The most dramatic vocabulary development takes place between 18
months & 3 years of age.
 A single child develops language earlier than those with siblings. Girls
learn language and speak earlier than boys.

Language Development Milestones

Here is what to expect at different ages from infancy until school age in
a typically developing child (one who is not advanced or delayed in language
development).

First Year
 3 months: Makes cooing and gurgling sounds
 6 months: Babbles and makes sing-song sounds
 12 months: Babbles with inflection, which sounds like talking; says first
word

At 18 Months
 Says eight to 10 words others can understand
 Has a vocabulary of about five to 40 words, mostly nouns
 Repeats words heard in conversation
 Uses “hi,” “bye,” and “please” when reminded

At 2 Years
 Has a vocabulary of 150 to 300 words
  Uses two- to three-word sentences, usually in noun-verb combinations,
such as "Dog bark," but also using inflection with combinations like
"More cookie?"
 Refers to self by name and uses “me” and “mine”

At 3 Years
 Uses three- to five-word sentences
 Asks short questions, usually using "what" or "where"
 Has a vocabulary of about 900 to 1000 words

At 4 Years
 Has a vocabulary of about 1,500 to 2,500 words
 Uses sentences of five or more words

At 5 Years
 Identifies some letters of the alphabet
 Uses six words in a sentence
 Uses “and,” “but,” and “then” to make longer sentences

By age 6, a child's language begins to sound like adult speech, including the
use of complex sentences, with words like "when," for example. However,
children tend not to use sentences with "although" and "even though" until
about age 10.

THEORY ON DEVELOPMENT OF TEMPERAMENT:

STELLA CHESS AND ALEXANDER THOMAS

TEMPERAMENT
 Constitutionally based individual differences in emotion, motor,
reactivity and self-regulation that demonstrate consistency across
situations and over time.
 It is biologically based; Heredity, neural and hormonal factors affect
response to the environment.
 This can be modulated by environment factors; parental response.

Stella Chess and Alexander Thomas are credited with the

development of the 9 temperamental qualities which include:
1. Activity level
2. Sensitivity and reactions to external stimuli
3. Adaptability
4. Level of Intensity
5. Distractibility
6. Approach/Avoidance and Withdrawal
7. Persistence
8. Regularity and organization
9. Mood
SUMMARY POINTS:

 Adolescence is a complex developmental process that varies substantially,

both individually and culturally and the divisions of development are
arbitrary.
 They are psychosocial, psychosexual, moral, cognitive and spiritual. They
all usually progress together in the process of maturation and learning.
 Knowledge of growth and development is important to the nurse to
observe the sequence of developmental behavior of each child and also
helps to plan better care to the baby.
 In addition, it is significant for nurses and caretakers to find out any delay
in growth and developmental milestones of children, so that early detection
of abnormalities can be rectified with prompt therapy.
 As, when adolescent development is successful, the result is a biologically
mature individual equipped with a sense of an independent self, the
capacity to form close peer and group relationships, and the cognitive and
psychological resources to face the challenges of adult life.
 LESSON 2
Nursing process for Promotion of Normal
Growth and Development
OVERVIEW OF NURSING PROCESS FOR NORMAL GROWTH
AND DEVELOPMENT

This is important information because nurses are directly responsible

for assuring growth & development. All children pass through predictable
stages of growth & development as they mature. Parents often will ask a
nurse what to expect from their child regarding developmental progress.

Assessment should include:

 Height & weight should be measured & plotted on a standard growth
chart for children - at all visits.
 Focus history & observation on development milestones, major
markers of normal development.
 24-hour recall of nutrition intake
 Description of school & play behaviors
 Developmental stage is assessed through observation & listening
carefully to how the child describes self, or parents describe the child.

Nursing Diagnoses
 These vary. Please consult any Nursing Diagnosis book.

Planning
 Planning should include considering all aspects of the child's health
(holistic care) including physical, emotional, cultural, cognitive, spiritual,
nutritional & social aspects.
 Each child's progress is unique.
 A child cannot be forced to achieve milestones faster than that child's
own timetable will allow.
 Through anticipatory guidance a child can be encouraged to reach his
or her maximum developmental potential.
 Privacy issues must be considered with adolescents.

Implementation to foster growth & development:

 Encourage age-appropriate self-care.
 Suggest age-appropriate toys or activities to parents (most toys labeled
with age can be played with earlier than age on the package).
 Role modeling by the nurse is an important intervention for children &
families (Ex: Problem solving is more effective than acting out).

Evaluation
 Evaluation for specific milestones must be ongoing to be accurate &
useful because many children do not test well until school age. It also
provides a chance for early detection of various problems.
 ASSESSMENT OF DEVELOPMENTAL MILESTONES:
NORMAL PEDIATRIC MILESTONES

The development of a child mostly takes place in the early years of his
life. At this stage, parents are still overwhelmed with how fast babies grow and
develop. Parents take much time and patience in picking the best resource to
understand a child’s development. Therefore, lots of questions are thrown in
the air for the nurse to answer. Some questions prove to be challenging, and
it is important for nurses to be able to know the normal developmental
milestones like the back of their hands.

The first word, smile, and roll over are called developmental
milestones. The child can tick off a milestone on his growing list of firsts
depending on how he play, speak, move, and learn. While it is always
emphasized that children develop at their own pace, developmental
milestones are there to shed light on the general changes that should be
expected as the child ages.

General Domains of Developmental Milestones

Domain #1: Normal Motor Development
Domain #2: Normal Language Development
Domain #3: Cognitive Development
Domain #4: Social Development

GENERAL PRINCIPLES OF DEVELOPMENTAL MILESTONES

For excellent developmental assessment and surveillance, nurses

must know the general principles of developmental milestones. The four key
domains that should be periodically assessed include motor development,
language development, cognitive (problem-solving), and psychosocial skills.

Development occurs in an orderly, predictable, and intrinsic manner.

For example, development proceeds from head to toe in a proximal to distal
fashion. Reactions to stimuli develop from general into more specific and
goal-directed reactions. Children gain independence from early years of total
dependence.

Lastly, both intrinsic and extrinsic factors can affect development.

Some examples of intrinsic factors are physical characteristics, health state,
temperament, and genetic attributes. On the other hand, extrinsic factors
include personalities of family members, economic status, learning
experiences in the environment, and cultural setting to which the child is
born.

Domain #1: NORMAL MOTOR DEVELOPMENT

Motor milestones can both be assessed through history interview and

observation. Evaluating gross motor development usually involves neuro
maturational markers like primitive reflexes and postural reactions.
 For example, Moro reflex is one primitive reflex that is present at birth
and disappears usually between 3-6 months of age. If the baby has stronger
and more sustained primitive reflexes, a CNS injury might be considered. On
the other hand, parachute reaction is one postural reaction that is acquired.
This actually helps the body become oriented in space through interplay of
visual, proprioceptive, and vestibular adjustment done by cerebral and
cerebellar brain structures. Delayed development of postural reactions can
signify CNS damage.

On the other hand, fine motor skills involve the use of small muscles of
the hands. The control progresses from the use of proximal muscles to the
distal muscles. As the baby improves on balance during sitting and moving,
the hands become more focused on manipulation of objects.

Table 4. Gross Motor and Fine Motor Development Milestones

Age Milestones
GROSS MOTOR MILESTONES
Birth Turns head side to side
Lifts head when lying prone
2 months
Head lags when pulled from supine position
Rolls over
4 months No head lad when pulled from supine position
Pushes chest up with arms
Sits alone
6 months
Leads with head when pulled from supine position
Pulls to stand
9 months
Cruises
12 months Walks
FINE MOTOR MILESTONES
Birth Keeps hands tightly fisted
3-4 months Brings hands together to midline and then to mouth
4-5 months Reaches for objects
Rakes objects with whole hand
6-7 months
Transfers object from hand to hand
Uses immature pincer (ability to hold small object
9 months
between thumb and index finger)
Uses mature pincer (ability to hold small object between
12 months
thumb and the index finger)

Red flags in motor development include:

1. persistent fisting beyond 3 months which indicate neuromotor
problems;
2. early rolling over, early pulling to stand instead of sitting, and persistent
toe walking which may all indicate spasticity; and
 3. early hand dominance (before 18 months of age), which may signify
weakness of the opposite upper extremity associated with hemiparesis.

Domain #2: NORMAL LANGUAGE DEVELOPMENT

Language is the single best indicator of intellectual potential.

Language is the ability to communicate with symbols. It is often mistaken as
synonymous with speech, the latter being defined as a vocal expression of
language. This is the domain with the most number of delays.

It is also interesting to note that a child can usually understand 10

times (receptive language) as many words as he or she can speak
(expressive language). The first two (2) years of life is the time for optimal
language acquisition.

Table 5. Basic Language Development Milestones

Age Milestone
Attunes to human voice
Birth
Develops differential recognition of parents’ voices
Cooing (runs of vowels), musical sounds (e.g. ooh-ooh, aah-
2-3 months
aah)
Babbling (mixing vowels with mixed consonants) [e.g. ba-
6 months
ba-ba]
Jargoning (e.g. babbling with mixed consonants, inflection,
9-12 months and cadence)
Begins using mama, dada (nonspecific)
12 months 1-3 words, mama and dada (specific)
20-50 words
18 months
Beginning to use two-word phrases
Two-word telegraphic sentences (e.g. mommy come)
2 years
25-50% of child’s speech should be intelligible
Three-word sentences
3 years
More than 75% of the child’s speech should be intelligible

Domain #3: COGNITIVE DEVELOPMENT

This domain talks about thinking, memory, learning, and problem-

solving. By evaluating problem solving and language milestones, infant
intelligence can be estimated. There is a poor correlation between gross
motor skills and cognitive potential.

Table 6. Cognitive Development Concepts

Age Concept
Object permanence (people and objects continue to exist
9 months
even when an infant cannot see them). This ability to
 maintain an image of a person is the reason why
separation anxiety (6-18 months) develops when a loved
one leaves the room.
Cause and effect (understanding which actions cause
9-15 months
certain results).
1-3 years Magical thinking

Domain #4: SOCIAL DEVELOPMENT

It refers to the ability to interact with people and the environment. It is

dependent on cultural and environmental factors.

Table 7. Social Development Milestones

Age Concept
Attachment (bonding with a primary caregiver begins at
12-36 months birth and empathy development is critical during this
period).
A sense of self and independence (process of separation
15 months
and individuation begins).
Social play (exhibit parallel play during the first 2 years of
12-24 months
life).

In the grand scheme of things, it is essential for nurses to understand

normal development as well as the variations that are considered acceptable
so nurses can recognize pathologic patterns and developmental delays.
Prompt planning and intervention will then be instituted for children who may
benefit from referral to early intervention programs.

ROLE OF NURSES ACROSS THE LIFESPAN OF GROWTH &

DEVELOPMENT

Undoubtedly, life-span developmental scientists do not specifically

consider health education of well individuals with respect to disease
prevention, risk reduction, and health promotion efforts or to health promotion,
maintenance, and rehabilitation measures for persons who are acutely and
chronically ill. The application and translation of developmental characteristics
to the teaching and learning aspects of healthcare delivery are the
responsibility of nurses and other healthcare providers.

Nurses must be knowledgeable and educated about expected age

related changes and age specific characteristics and needs of clients across
the life span so that they can modify the care of their client's accordingly.
Health professionals should be able to identify knowledge deficits and assess
learning needs among staff members by observing how well and how
consistently their nursing care is modified according to their clients' age
specific characteristics and needs. Similarly, the need to identify knowledge
deficits and assess the learning needs among their clients and family
members across the life span in terms of their knowledge about expected age
related changes and age specific characteristics and needs.

For example, neonates and infants receive communication with the

touch or a coup by an adult and they enjoy colorful things like a mobile;
infants and toddlers must not be given any small toys or toys that can
disassemble into small parts because they are in the oral stage of
development where they place objects in the mouth which places them at risk
for aspiration and death; adolescents are rebellious and they want to be with
and accepted by their peers. Adults enjoy socialization and activities like
different sports and an exercise regimen; while older adults may be in need of
activities such as those in an elder day care center and reminiscence therapy.

When a staff or client/family learning need is assessed, the nurse then

plans, implements and evaluates the teaching that is given specific to the
learners' needs. For example, a middle aged man caring for an elderly parent
may have the need to learn about the safety needs of the elderly and new
parents may need education related to age appropriate toys and car seats.

The following is a summary of the developmental stages and their

general characteristics in the four stages of childhood in relation to the
physical, cognitive, and psychosocial maturational levels indicative of learner
readiness is summarized in Table8.

Table 8. Summary of Developmental Stages and their General

Characteristics
Learner Age/Level General Characteristics
INFANCY-TODDLERHOOD
Approximate age: Birth-2 years Dependent on environment
Needs security
Cognitive stage: Sensorimotor Explores self and environment
Natural curiosity
Psychosocial stage: Trust vs. Mistrust
(Birth-12 months)
Autonomy vs. Shame
and Doubt (1-2 year)
EARLY CHILDHOOD
Approximate age: 3-5 years Egocentric
Thinking pre-causal, concrete, literal
Cognitive stage: Preoperational Believes illness self-caused and punitive
Limited sense of time
Psychosocial stage: Initiative vs. Guilt Fears bodily injury
Cannot generalize
Animistic thinking
Centration, Separation anxiety
Motivated by curiosity
Active imagination, prone to fears
Play is his/her work
MIDDLE AND LATE CHILDHOOD
Approximate age: 6-11 years More realistic and objective
Understands cause and effect
Cognitive stage: Concrete operations Deductive/inductive reasoning
Wants concrete information
Psychosocial stage: Industry vs. Inferiority Able to compare objects and events
Variable rates of physical growth
Reasons syllogistically
Understands seriousness and
consequences of actions
Subject-centered focus
Immediate orientation
ADOLESCENCE
Approximate age: 12-19 years Abstract, hypothetical thinking
Can build on past learning
Cognitive stage: Formal operations Reasons by logic and understands
scientific principles
Psychosocial stage: Identity vs. Role Future orientation
confusion Motivated by desire for social
acceptance
Peer group important
Intense personal preoccupation,
appearance extremely important
Feels invulnerable, invincible/immune to
natural laws
YOUNG ADULTHOOD
Approximate age: 20-40 years Autonomous
Self-directed
Cognitive stage: Formal operations Uses personal experiences to enhance
or interfere with learning
Psychosocial stage: Intimacy vs. Isolation Intrinsic motivation
Able to analyze critically
Makes decisions about personal,
occupational, and social roles
Competency-based learner
MIDDLE-AGED ADULTHOOD
Approximate age: 41-64 years Sense of self well-developed
Concerned with physical changes
Cognitive stage: Formal operations At peak in career
Explores alternative lifestyles
Psychosocial stage: Generativity vs. Self- Reflects on contributions to family and
absorption and society
Stagnation Re-examines goals and values
Questions achievements and successes
Has confidence in abilities
Desires to modify unsatisfactory aspects
of life
OLDER ADULTHOOD
Approximate age: 65 years and over Cognitive changes
Decreased ability to think abstractly,
Cognitive stage: Formal operations process information
Decreased short-term memory
Psychosocial stage: Ego integrity vs. Increased reaction time
Despair Increased test anxiety
Stimulus persistence (after image)
Focuses on past life experiences
Sensory/ Motor deficits
Auditory changes (Hearing loss)
Visual changes (Farsighted, Lenses
become opaque)
Psychosocial changes
Decreased risk taking
Selective learning
Intimidated by formal learning
 LESSON 3
Health Promotion and Disease Prevention in
Different Stages of Growth Development
NEONATE (1 – 4 weeks)

Stage of Development:
 Trust vs. Mistrust
 Trust: ability to believe in and rely on others
 Mistrust: may be evidenced as failure to thrive

Physical:
 Cannot support weight of head
 Anterior and posterior fontanels not yet closed
 Immature heat regulation
 Receding jaundice; umbilical stump healing
 Immature immune system, still has passive immunity from mother
 CNS must be stimulated for proper growth and development

Cognitive/ Intellectual:
 Limited: cerebral function not fully established
 Behavior is reflexive in nature
 Learns through sensory stimulation

Psychosocial:
 Development of trust and is dependent on others
 Bonding with parents or primary caregiver

Fears/Stressors:
 Fears: none evidenced at this time
 Major stressor: physical immaturity
 Other stressors: lights, noises, handling

Safety:
 Support head and neck when moving/carrying; protect fontanel
 Monitor body temperature, maintain environment
 Wash hands; avoid exposing to infections
 Position on back or side; avoid use of pillows, thick/tight clothing or
dressings that can constrict the diaphragm
 Never leave alone unless in a crib with side rails up and locked
 Semi-reclined, rear-facing position car seat in back seat for child up to
20 pounds or 27 inches
 Suspected child abuse, neglect, or unsafe situation must be reported

General Age Specific Care:

 Encourage parents to stay close, promote bonding and participation in
care
 Limit the number of caregivers.
 Swaddling increases feeling of security and comfort.
Health Promotion & Patient Education Plan:
 Directed at primary caregiver with emphasis on Activity of Daily Living
(ADLs), preventive care, immunizations, nutrition, bonding, exposure to
infection and safety
 Assess parents’ knowledge of and comfort level in caring for the
neonate

INFANCY (4 weeks – 1 year)

Stage of Development:
 Trust vs. Mistrust
 Trust = ability to believe in and rely on others
 Mistrust may be evidenced as failure to thrive

Physical:
 Obligatory nose breather
 Poor temperature control and sensitive to fluid loss
 Immature immune system
 Moves from gross motor to fine motor
 Can raise head, roll over and bring hand to mouth
 Reflexes diminish and intentional actions begin
 Can crawl, stand, and even walk alone or with help

Cognitive/Intellectual:
 Learns through sensory stimulation and by imitation
 Limited ability to communicate needs or problems
 Recognizes and differentiates primary caregiver from others
 Mimics sounds and able to put 2 words together verbally
 Manipulates objects in the environment

Psychosocial:
 Development of trust and dependent on others
 Bonding to parents, develops relationships within the family
(siblings/grandparents)
 Begins communication and emotional connection with others
 Smiles and repeats actions to elicit response from others (peek-a-
boo/pat-a-cake)

Fears/Stressors:
 Major fears: separation from primary caregiver, unfamiliar situations,
strangers
 Stressors: loud noises, bright lights, sudden environmental changes
 Parental anxiety may be transmitted to infant

Safety:
 Unable to recognize dangers and should not be left alone
 Puts objects in mouth - keep small objects and medicines out of reach
 Place on back or side; protect fontanels; prevent heat loss
 Avoid use of pillows, thick bed clothes or tight clothing/dressings that
 can constrict the diaphragm
 Protect from falls; side rails always up and safety strap on
stroller/highchair
 Semi-reclined, rear-facing position car seat in the back seat for child up
to 20 pounds or 27 inches
 Suspected child abuse, neglect, or unsafe situation must be reported

General Age Specific Care:

 Encourage parents to stay close; promote bonding and participation in
care
 Limit the number of caregivers in contact with infant
 Maintain comfortable environment (soft light, warm, noise control)
 Give familiar objects for comfort

Health Promotion & Patient Education Plan:

 Directed at primary caregiver/ parents.
 Emphasis on preventive care, immunizations, nutrition, bonding, and
safety

TODDLER (1 - 3 years)

Stage of Development:
 Autonomy vs. Shame and Doubt
 Autonomy = self-control over motor abilities and body functions
 Works to master the physical environment while maintaining self-
esteem

Physical:
 Has 4– 6 teeth; may continue teething; eats 3 meals/day; feeds with
cup and spoon; feeds independently by 3 years; gains 4–6 lbs/year
 Walks by 15 months; runs and climbs by 2 years; stacks blocks,
scribbles and enjoys age appropriate toys
 Needs 10-12 hrs. of sleep/night plus a daytime nap

Cognitive/Intellectual:
 Toilet training should be started
 Parallel play with others
 Can differentiate familiar people from others
 Learns through senses, exploration, discovery, and imitation
 Thinking is concrete, literal, and egocentric; short attention span and
limited memory capability; follows simple commands

Psychosocial:
 Self-control and will power, developing sense of independence but
remains very dependent on parents for safety, security, and approval
 Knows right from wrong
 Is uninhibited, energetic, seeks attention, positive reinforcement, and
approval
 Impulsive; moods change quickly; has little self-control over behavior
 Needs the security of routine and is upset by environmental and activity
 changes

Fears/Stressors:
 Major fear: separation from parents/caregivers, may be intense
 Hospital environment/strangers/procedures may evoke terror response
 Stressors: loss of control, restriction of movement

Safety:
 Energetic and curious nature may lead to unsafe explorations;
accidents may occur as autonomy increases
 Keep side rails up
 Chemicals and medications should be kept out of reach
 Choking on objects is a threat
 Forward-facing-only car seat for children at least one-year-old and
weight of 20 pounds
 Suspected child abuse, neglect, or unsafe situation must be reported

General Age Specific Care:

 Encourage parental presence and participation with care
 Prepare child for procedures; use distraction techniques and Child Life
Services
 Offer choices when ones exist
 When hospitalized, may have difficulty sleeping or nightmares
 Speak at eye level with the child and maintain eye contact

Health Promotion & Patient Education Plan:

 Directed at primary caregiver/parents and child immediately before
procedures
 Child safety is an extremely important area to teach parents of
toddlers. Young parents may be unaware of safety hazards and may
need help in learning ways to childproof their home.
 Toilet training also occurs at this age. By teaching various ways to toilet
train, and by continuing to emphasize individual rates of development,
health educators can help parents toilet train children with realistic
expectations and lessened stress
 Give toddler brief, simple and concrete explanations in words they can
understand; give one direction at a time; use of play to facilitate
learning and to decrease anxiety (dolls/puppets/storybooks)

PRE-SCHOOL (3 - 5 years)

Stage of Development:
 Initiative vs. Guilt
 Initiative tasks include exploring, seeking answers, distinguishing
between sexes
 Needs balance between needs for exploration and necessary limits on
behavior

Physical:
 Should grow 4-5 lbs and 2 - 3 inches per year
  All primary teeth should be present and eats three meals a day
 Neuromuscular, gross and fine motor skills refined (i.e. balance
improved, greater muscular strength, jumps in place, walk on tip toes,
stands on one foot and hops, draws/copies a circle)
 Able to feed and dress self
 Bowel/bladder patterns established

Cognitive/Intellectual:
 The “why” stage: wants to know the cause and purpose of everything
 Unable to think abstractly; still concrete, literal, magical, and egocentric
thinkers with difficulty differentiating reality from fantasy
 Short attention span
 Oriented to the present only – unable to comprehend anticipatory
explanations

Psychosocial:
 Able to tolerate brief separation from parents when explanation given
 Egocentric, but is increasingly aware of self vs. others
 Beginning sexual discrimination
 Learning to play in groups; imitates adults
 Home rituals/habits are important
 Likes to pretend; ascribes living qualities to inanimate objects
 Needs praise/encouragement; feels guilty if disappoints parents/makes
mistakes

Fears/Stressors:
 Fear of the unknown, of the dark, of mutilation, bodily injury, or being
left alone
 Stress and illness may cause regression and separation anxiety

Safety:
 Needs constant supervision
 Accidents and injuries remain a threat due to curiosity and exploration;
keep medications and small objects out of reach
 Car seat or booster seat when riding in an automobile
 Suspected child abuse, neglect, or unsafe situation must be reported

General Age Specific Care:

 Encourage parental presence and participation with care as much as
possible while in hospital setting
 Prepare child for procedures within 5 minutes of procedure; use
distraction techniques; praise and rewards after procedures
 Utilize Child Life services to assist in explanation of procedures,
equipment and to offer distraction.
 Offer choices when ones exist
 When hospitalized, may have difficulty sleeping or nightmares

Health Promotion & Patient Education Plan:

 Directed at primary caregiver and pre-schooler
 Pre-schooler is very interested in knowing why things are being done to
 them - answer questions quickly, honestly, using concrete words they
understand, not abstract statements; use of dolls/puppets/storybooks
to facilitate learning and decrease anxiety; honesty is especially
important.
 Teaching topics for parents of pre-school children include
understanding the importance and role of play, dealing with sexual
curiosity, beginning school adjustment, and handling eating and
sleeping problems.

SCHOOL AGE (5 - 12 years)

Stage of Development:
 Industry vs. Inferiority
 Industry = interest in developing a sense of self through engaging in
tasks and refining skills/doing work; task mastery involves self-
confidence, perseverance, self-control, cooperation, recognition
 Inferiority = feelings of inadequacy and fears

Physical:
 Seasonal growth spurts in Spring and Fall; should gain 5-6 pounds per
year; some clumsiness may occur as a result of growth spurts
 Baby teeth replaced with permanent teeth
 Increased muscle mass and strength; neuromuscular skills and
balance improved
 Despite wide variations, early signs of puberty may appear

Cognitive/Intellectual:
 Increased comprehension; thinking is concrete, literal, and specific;
logical and more deductive reasoning begins; understands cause and
effect; solves problems
 Functions in present; begins understanding the past and can foresee
future consequences; tells time and plans ahead
 Increased understanding of death and it’s finality
 May be reluctant to ask questions or admit they don’t understand

Psychosocial:
 Same-sex peers more important than family; influenced by non-parent
adult idols
 Learns gender appropriate behavior, attitudes, and roles
 Rules are important to them
 Behavior controlled by expectations, regulations, anticipation of praise
or blame; begins questioning parental authority; needs
praise/encouragement from adults
 Wants control over privacy

Fears/Stressors:
 Great fear of the unknown, pain, bodily injury, mutilation, separation
from caregivers and friends, death, loss of control, failure to live up to
expectations or disappointing significant others
 Resents forced dependence and lack of privacy
  Views illness/pain with guilt and/or as punishment

Safety:
 Peer pressure may influence child to act with poor judgment; takes
risks/dares
 Safety helmets for biking/skateboarding; seat belts will replace
car/booster seats
 Independent behavior may cause ingestion or overdose of available
medications
 Suspected child abuse, neglect, or unsafe situation must be reported

General Age Specific Care:

 Encourage parental presence and participation with care as much as
possible
 Prepare child for procedures ahead of time.
 Allow participation in discussions/decision making and expression of
feelings and fears.
 Provide privacy
 Define and reinforce behavior limits; offer choices when ones exist
 Continue schooling

Health Promotion & Patient Education Plan:

 Directed at primary caregiver and/or school age child
 Explain procedures in advance with correct terminology in simple terms
 Detailed information enhances the child’s sense of control and
independence

ADOLESCENT (13 - 18 years)

Stage of Development:
 Identity Formation vs. Identity/role confusion
 Identity Formation = need to establish a stable sense of self, who they
are, where they fit in, where they are going
 Tasks include: independence from parents to establish their role in
society; establishing relationships with members of opposite sex;
coping with body changes; development of sexual identity and self-
concept

Physical:
 Adult weight achieved
 Rapid changes in terms of height and sexual characteristics
 May need more rest and sleep due to rapid growth
 Permanent teeth; increased body hair and blemishes

Cognitive/Intellectual:
 Increased abilities for logical, abstract, deductive thought, and
analytical reasoning; understands hypothetical situations; forms own
opinions
 Limited understanding of body structures and functions
 Gains introspection
  Self-esteem grows internally
 Development of occupational identity
 Doesn’t like to ask questions which make them appear “stupid”

Psychosocial:
 Concerned about how they appear to others
 Develops sexual identity; relationships with opposite sex take on new
meaning; peer group important; interest in slang words particular to
peer group
 Often question or rebel against authority figures and may criticize
parents
 Needs time to adjust and cope with events; may need (but not request)
adult support to cope effectively
 Unaware of own mortality; feel invincible and that nothing will happen
to them

Fears/Stressors:
 Major concerns: appearance, school performance, loss of control,
separation or lack of acceptance from peers, being different
 Physical changes associated with illness or injury may be threatening

Safety:
 Peer pressure may influence to act with poor judgment; takes
risks/dares
 Use of automobiles; risk of accidents increases for self and others
 Suicide is third-highest cause of death; Sexually Transmitted Diseases
(STDs) and depression is at a high level
 May experiment with drugs, cigarettes, alcohol, and sexual activity
 Any suspected abuse, neglect, or unsafe situation must be reported

General Age Specific Care:

 Involve adolescent in care with participation in decision making; needs
control over events involving them; choice whether parent is present
 Define and set limits firmly when necessary; offer choices when ones
exist
 Respect privacy and opinions; interview directly; may need to separate
from parent
 Continue schooling

Health Promotion & Patient Education Plan:

 Inquire if they want parents present during teaching sessions
 Use patient’s preferred method of education (visual, auditory, etc.); give
scientific explanations using body diagrams, models or videotapes
 Encourage questions and verbalization of feelings
 Provide education about cigarettes, alcohol, drugs, and STDs

YOUNG ADULT (19 - 44 years)

Stage of Development:
  Intimacy vs. Isolation
 Intimacy = reaching out and using one’s self to form a commitment to
an intense, lasting relationship with another person
 Isolation = manifested with poor self-esteem and withdrawal

Physical:
 Biological maturity is complete
 Brain cell development peaks
 Women see most significant changes during pregnancy and lactation

Cognitive/Intellectual:
 Wide range of life experiences assist in developing adult intellectual
capacities
 Reaches peak intelligence, memory, and abstract thought
 Forms their own opinions and makes independent decisions
 Chooses vocation; receives appropriate education

Psychosocial:
 Resolving issues from adolescence; establish personal identity, values,
attitudes, interests, and acceptance of self
 Develop adult roles and responsibilities at work, home, and society
 Comes to terms with sexuality and preferences
 Develops and maintains friendships and intimate love relationship

Fears/Stressors:
 Loss of independence; loss of job due to illness/injury
 Separation from spouse/significant others, children, and friends
 Balancing roles of career, marriage, and child-rearing simultaneously
 Challenges: managing growing number of responsibilities at home,
work, school, or community

Safety:
 Major cause of death related to accidents, suicide, and homicides
 Seat belt use in automobiles
 Stress and depression may be experienced
 STD is a risk due to experimentation with various lifestyles; encourage
condoms
 Promote recreational and personal safety habits
 Suspected domestic violence, abuse, or unsafe situations must be
reported

General Age Specific Care:

 Should receive at least one thorough health assessment yearly (screen
for STDs, hypertension, and cholesterol levels); smoking cessation
counseling/program if applicable
 Treat with respect; encourage decision-making and self-care
 Don’t be judgmental; support decisions you may not make
 Involve the individual with plan of care and decision making.
 Explore the impact of hospitalization or illness on work, job, family and
other commitments.
  Encourage visits from significant others
 Never use terms of endearment (honey, sweetie, darlin’)

Health Promotion & Patient Education Plan:

 Include significant other in education
 Use patient’s preferred method of education (visual, auditory, etc.)

MIDDLE ADULT (45 - 65 years)

Stage of Development:
 Generativity vs. Stagnation
 Generativity = concern about providing for others that is equal to
concern about providing for oneself; guiding the next generation;
contributing to humanity
 Stagnation = self-absorption

Physical:
 Slowing of physiologic functions and possibility of chronic health issues
 Increased height, muscle mass/tone/subcutaneous fat, near vision
(presbyopia), nerve conduction, ability to hear high-pitched sounds;
skin begins to dry
 Inability for tissue regeneration
 Decreased bone density and strength
 Atrophy of reproductive system; hormone production decreases;
menopause

Cognitive/Intellectual:
 Time of maximum command of self and influence over others
 Forms own opinions; makes numerous decisions; may hold highest
status job
 Life experiences provide continued learning; reflects on and
reassesses life
 Understands reality of death

Psychosocial:
 “Sandwich generation” – concurrent responsibilities for children and
aging parents (especially for women) o Maintaining contact with, but
letting go of parental authority over, children o Meeting needs of aging
parents o Additional supports may be needed
 Achieving financial and emotional security
 Finding new sources of satisfaction
 Preparing for retirement

Fears/Stressors:
 Loss of control and values important to the family; dependency on
others
 Loss of youth, vitality, sexual appeal
 Work and social status; disenchantment with work
 Heavy financial responsibilities; makes major life decisions
  Balancing roles and responsibilities of career, family, and friends
 Loneliness as children leave home; caregiver role for elderly parents
 Menopause for women
 Death; death of spouse

Safety:
 Risk for heart attack, stroke, and fractures
 Suspected domestic violence, abuse, or unsafe situations must be
reported

General Age Specific Care:

 Respect their decisions; allow as much control over their care as
possible
 Never use terms of endearment (honey, sweetie, darlin’)
 Allow verbalization of fears and concerns
 Need regular physicals and health care screenings
 Involving the significant other with plan of care
 Provide privacy
 Provide for mobility and functional needs

Health Promotion & Patient Education Plan:

 Include significant other and family in education
 Use patient’s preferred method of education (visual, auditory, etc.)
 Cardiovascular health; weight bearing exercises

OLDER ADULT (65 – 85)

Stage of Development:
 Ego Integrity vs. Despair
 Ego Integrity = accepts life and self as they are
 Despair = remorse about what could have been

Physical:
 Diminished function; muscle atrophy; brittle bones; stiff joints;
fragile/dry skin
 Cardiovascular: ↓ cardiac force, cardiac output, and arterial elasticity
 Lungs more rigid, ↓ oxygen exchange
 Loss of teeth
 ↓ ability to fight infection
 ↓ sensory function and balance
 Sleep pattern irregularity

Cognitive/Intellectual:
 Performs cognitive tasks more slowly due to: ↓ visual, auditory, and
tactile acuity o slower motor responses to sensory stimuli o short term
memory losses
 Needs time to process information and link events
 Intellectual ability tends to decline depending on use
Psychosocial:
 Coping with adjustments necessitated by advanced age, illness,
disability
 Reviews life’s accomplishments and deals with loss
 Confronts their own mortality and death of spouse, friends, and
associates

Fears/Stressors:
 Loss or death of spouse, adult children, and friends
 Declining mental and physical health; social isolation
 Diminished self-relevance of values important to family
 Loss of independence or increased dependency on others

Safety:
 ↑injury risks due to physical and cognitive impairments; may be unable
to recognize dangers; increased risk for falls
 Unfamiliar environment and presence of strangers may cause
confusion and/or agitation and falls
 Suspected elder abuse, neglect, or unsafe situations must be reported

General Age Specific Care:

 Preserve dignity and autonomy as much as possible
 Involve family with plan of care
 Encourage reminiscence and validating concerns.
 May require re-orientation to environment, time, and day
 Injury prevention precautions (fall prevention, skin integrity
maintenance)
 May require increased use of assistive devices (canes, walkers,
wheelchairs)
 Never use terms of endearment (honey, sweetie, darlin’)
 Provide adequate lighting and ensure adequate warmth due to ↓heat
regulation

Health Promotion & Patient Education Plan:

 May require longer time to learn; ensure use of communication aids
(hearing aid, eyeglasses)
 Face patient and speak slowly and distinctly; do not shout
 Include significant other/family members in education and decision
making
 Allow verbalization of fears and concerns

THE OLD-OLD ADULT > (85 or more years)

Stage of Development:
 Ego Integrity vs. Despair
 Ego Integrity = accepts life and self as they are
 Despair = remorse about what could have been
 Fastest growing segment of the population

Physical:
  Diminished function; muscle atrophy; brittle bones; stiff joints;
fragile/dry skin
 Cardiovascular: ↓ cardiac force, cardiac output, and arterial elasticity
 Lungs more rigid,
 ↓oxygen exchange
 Loss of teeth
 ↓ ability to fight infection
 ↓ sensory function and balance
 Sleep pattern irregularity

Cognitive/Intellectual:
 Performs cognitive tasks more slowly due to:
 ↓ visual, auditory, and tactile acuity o slower motor responses to
sensory stimuli o short term memory losses
 Needs time to process information and link events
 Intellectual ability tends to decline depending on use

Psychosocial:
 Coping with adjustments necessitated by advanced age, illness,
disability
 Reviews life’s accomplishments and deals with loss
 Confronts their own mortality and death of spouse, friends, and
associates

Fears/Stressors:
 Loss or death of spouse, adult children, and friends
 Declining mental and physical health; social isolation
 Diminished self-relevance of values important to family
 Loss of independence or increased dependency on others

Safety:
 ↑ injury risks due to physical and cognitive impairments; may be unable
to recognize dangers; increased risk for falls
 Unfamiliar environment and presence of strangers may cause
confusion and/or agitation and falls
 Suspected elder abuse, neglect, or unsafe situations must be reported
General Age Specific Care:
 Preserve dignity and autonomy as much as possible
 Involve family with plan of care
 Encourage reminiscence and validating concerns.
 May require re-orientation to environment, time, and day
 Injury prevention precautions (fall prevention, skin integrity
maintenance)
 May require increased use of assistive devices (canes, walkers,
wheelchairs)
 Never use terms of endearment (honey, sweetie, darlin’)
 Provide adequate lighting and ensure adequate warmth due to ↓ heat
regulation
Health Promotion & Patient Education Plan:
 May require longer time to learn; ensure use of communication aids
(hearing aid, eyeglasses)
 Face patient and speak slowly and distinctly; do not shout
 Include significant other/family members in education and decision
making
 Allow verbalization of fears and concerns

SUMMARY POINTS:
 In order to plan and implement individualized approaches to health
promotion and interventions, the nurse must take age and developmental
level into account.
 When working with children, you must assess cognitive and psychosocial
development. This will influence the level of the health promotion
strategies chosen and help identify whether parental or peer involvement
would facilitate learning. If psychomotor skills are part of the learning need,
you must determine whether the child has enough physical maturation to
realistically perform the skill.
 When assessing an adult, emphasis on the developmental stages is
different than when assessing a child. The average adult possesses
cognitive capacities to learn, so assessing the precise level of cognition
becomes less important. It is important to assess current knowledge about
the content area. Assess physical skills by focusing on past experience
with skills and the adult’s feelings about manipulative competencies. This
helps to determine the amount and type of practice that will be needed to
master psychomotor skills.
 Assessment of older adults needs to focus on the physical changes
experienced by a given individual. Psychosocial assessment is also
important in working with adult age groups.
 In working with the elderly patient, you may feel overwhelmed trying to
teach a patient and family when the frail elderly person may have multiple
medical problems and more than 10 medications, and is dependent in
several activities of daily living.
 Yet these patients and families need the most interventions, education and
support you can provide. Through careful assessment of developmental
factors, selection of teaching strategies that are age-appropriate, and
compensation where needed to overcome normal deficits seen with aging,
you can plan and implement effective patient teaching.
 REFERENCES:

Belagavi, Dayanand (2019). Theories of growth and development in

pediatrics: A review. Journal of Paediatrics and Nursing Science, July-
September, 2019; 2(3):63-66. Accessed from:
https://www.innovativepublication.com/media/journals/IJPNS-2-3-63-
66.pdf
Butkus, S.C. (2015). Maternal-neonatal nursing made incredibly easy! Third
edition. Copyright 2015. Wolters Kluwer Health | Lippincott Williams &
Wilkins.
Carley, Jerry (2011). Nursing Growth and Development Overview. Accessed
from: http://nursing--growth-and-
development.pbworks.com/w/page/10228855/G%20and%20D--
General%20Overview
Developmental Stages and Transitions: NCLEX-RN. Registered RN.Org.
Updated September 22, 2020. Accessed from:
https://www.registerednursing.org/nclex/developmental-stages-
transitions/
Health Promotion for the Developing Child. Nurse Key. Accessed from:
https://nursekey.com/health-promotion-for-the-developing-child/
Lewis, Louise (2015). Fundamentals of Midwifery: a textbook for students.
First edition published © 2015 by John Wiley & Sons, Ltd
Murray, Sharon S. (2014). Foundations of Maternal-Newborn and Women’s
Health Nursing, Sixth Edition. Copyright © 2014, 2010, 2006, 2002,
1998, 1994 by Saunders, an imprint of Elsevier Inc.
Pillitteri, Adele. (2010). Maternal and child health nursing: Care of the
childbearing and childrearing family; 6th edition.
Tabangcora, Iris Dawn (2017). Maternal and Child Health Nursing –
Development Milestones: Normal Pediatric Development Milestones.
Last updated on January 19, 2017. Retrieved from:
https://nurseslabs.com/normal-pediatric-developmental-milestones/