Principles of Growth and Development

 As children mature, they pass through predictable stages of

growth and development
 To establish a complete and effective nursing care plans for
children, it is essential to understand the normal growth and
development
 An understanding of growth and development helps the nurses
in achieving their goals for health promotion and disease
prevention, health restoration and maintenance
 Maturity in children involves growth in their ability to think,
to relate to people and to trust or have confidence in
themselves not just merely becoming taller and heavier as
they get older.

PRINCIPLES OF GROWTH AND DEVELOPMENT

Terms:

- Growth
- Development
- Maturations
- Cognitive development

Development

 It is defined as an increase in skills or the ability to

function (qualitative change)
 It is measured by observation, child recording (by
FREUD’S PSYCHOSEXUAL THEORY
parents description of a child progress), lab test (Denver
test II) Sigmund Freud (1856-1939)

Psychosexual development refers to developing instincts or sensual
pleasure (Freudian theory)
Psychosocial development “ Erikson’s stages of personality
development
Kohlberg’s theory of moral development is the ability to know right
from wrong and to apply this to real-life situation
 He was a physician in Australia, he worked with adults
experiencing a variety of nervous disorders. It led him to
develop the approach called psychoanalysis.
 Psychoanalysis made him believe that early childhood
experiences from the unconscious motivations for actions
in later life
He based his theory on:

Cognitive development refers to the ability to learn o understand

 His observations of he mentally ill patients he dealth
from experience acquire and retain knowledge and respond to a
with
new situation, and to solve problem (Piaget)
 The basic human needs (Maslow’s Heirarchy of
Needs)
Development task
 His note of the personality structure model
(Id,ego,superego
 Is skills or growth responsibility arising at a particular
time in an individual life.
 Children are blank pages can be shaped by learning

Basic Divisions of Childhood

Stage Age of Period

Neonate First 28 days of life
Infancy 1 month 1 year
Toddler 1-3 years
Pre-schooler 3-5 years
School age child 6-12 years
Adolescent 13-17 years
Late adolescent 18-21 years

1. The body site change in each stage according to the

changing of physical and sexual of the child
2. In each stage, both of the child and the caregiver
interact with these changes according to their culture
and education
3. The child transfer from one stage to the nest completely.
4. If the child’s transformation is not completed, the child
will be fixed in this stage as he develops in the next
stage of his life.

Stage One: Oral Phase

Infant

 The mouth is considered the specific part in this phase.

In which all functions that mouth do is important to the
infant in his first year.
Nursing Implications Nursing Information

 According to this theory, infant sucks for enjoyment or  Provide appropriate opportunities for the individual to
relief tension as well as nourishment. relate with opposite sex
 Provide oral stimulation by giving pacifiers  Allow individual to verbalize feelings about new
 Do not discourage thumb sucking relationships
 Breastfeeding may provide more stimulation than formula
feeding because it requires the infant to expend more
energy

Stage Two: Anal Phase

Toddler

 The anus is considered the specific part in this phase; in

which child begin toilet training.
 According to this theory, infant shift his interest from
the mouth to the anus region

Nursing Implications

 Help children achieve bowel and bladder control without

undue emphasis on its importance.
 If at all possible, continue vowel and bladder training
while child is hospitalized.

Stage Three: Phallic Phase

Preschool

 The genital area is considered the specific part in this

phase. In which development occur over three phases.
 Phase One: child starts to develop a strong desire to
know his own sex identity as well as the other sex
identity, and it is associated with some practices such as
masturbation, exhibitionism.

Nursing Implications

 Accept child’s sexual interest, such as fonding his or her

own genitals, as a normal area of exploration.
 Help parents answer child’s questions about birth or
sexual differences.
 Phase Two: in this phase, the development proceeds and
child starts to love his opposite sex and hate his own sex.
 For example: male child love his own mother and hate his
own father (oedipal or Oedipus comples) as well as the
female child ( Electra complex)
 Phase three; child develop a special fear from parents
because of his bad thinking, which will cause smoothing of
his feelings and transfer the hostile feelings to love
feelings.

Nursing Implications:

 The nurse must provide privacy and clear explanations

during any procedures involving the genital area

Stage Four: Latency Phase

School

 The children’s libido appears to be diverted into

concrete thinking
 They distracted in playing, school work in promoting their
skills.

Nursing Implications

 Helps a child have positive experiences so his or her self-

esteem continues to grow and the child prepares for the
conflicts of adolescence
 Provide gowns, covers and underwears at hospital: knock
the door before entering

Stage Five: Genital Phase

Adolescent

 The longest period (from adolescent to adulthood)

 The suppression in the latent phase is relieved in this
phase due to the sexual maturity resulted from the
secretions of the sex hormones
 The individual starts to establish a new sexual aims and
find a new love object with the opposite sex
What is Intelligence?

 According to Piaget, it is a basic life function that

enables an organism to adapt to its environment
 All intellectual activity is undertaken with one goal in
mind: cognitive equilibrium

Piagetian Concepts

Example:

Toddler who has never seen anything fly but birds thinks that all
flying objects are birds

STAGES OF THE THEORY

1. The sensorimotor stage (birth to 2 yrs)

2. The preoperational stage ( 2 to 7 yrs)
3. The concrete-operational stage (7 to 11 yrs)
4. The formal-operational stage (11-12 yrs and beyond)
 Chapter 29

Nursing Care of a Family with an Infant

Growth and Development

  Weight
 Height
 Head circumference
 Body proportion
 Body systems
 Teeth
 Infants grow rapidly both in size and in their ability to
perform tasks during their first year.
 Care visits schedule:
 24 weeks
 2nd month
 4th month
 6th month and
 12th month

Important of care visits:

1. Parent can ask questions about growth pattern and

developmental progress
2. Provider (nurse) can assess potential problems
3. Immunization
Motor Development
Physical Growth
 Gross motor development
Weight: birth weight doubles at 6 months
  Ventral suspension position
It triples at 1 year
  Prone position
(average 1 y/o boy weighs 10 kg (22 lb) girl 9.5 kg
  Sitting position
( 21lb)  Standing position
 Height: infants height increases during the first year by  Fine motor development
50% or grows from the average birth length (50.8 to  Thumb opposition
76.2 cm or 20-30 in)  Pincer grasp
 Head Circumference: by the end of the first year, the
brain has already reached two thirds of its adult sixe 0-1: Large reflex action
New born:
 HC= 32-36 cm (12.5-14.1 in) 1: can lift head for a while

Body Proportion 2: holds head up when prone

 The mandible becomes more prominent
 The lower jaw is prominent
 Chest circumference is equal to head circumference as early
as 6 months and in most by 12 months
 The abdomen remains protuberant until the child has been
walking well for some time
 Lengthening of the lower extremities during the last 6
months of infancy readies the child for walking and often
changes the appearance from “baby like” to “toddler like”
3: Holds head, shoulders and chest up when prone
4: turns back to front, no longer has head lag, neck righting reflex,
able to bear partial weight on feet
5: turns turn readily front to back, bears weight on forearms when
prone
6: beginning to show ability to sit

Body system 7: reaches out to be picked up, can sit alone when hands are held,
first tooth (central incisor) erupts
 Cardiovascular System:
 Heart rate slows from 120-160 beats to 100 to 8: sit securely without support
120 by the end of the first year
9: creeps or crawls (abdomen off floor)
 Lightly elevated BP from 80/40mmHg to
100/60mmHg
10: pull self to stand
 Develop a physiologic anemia 2-3 month
 Respiratory System:
11: Crulses walks with support
 Respiratory rate slows from 30-60 to 20-30
breaths/min 12: stands alone, some infant take first steps
 GI
 Ability to digest protein is present and effective Fine motor development
at birth
 Amylase, (CHO) deficient until 3 month 0-1: keeps hands fisted, able to follow object to midline with eyes
 Lipase, is decreased in amount during the entire
first year 2: holds object in few moments and drop, demonstrates social smile
 Liver immature until possibly causing inadequate
conjugation of drug 3: follow object past midline with eyes
 Extrusion reflex 3-4 (food placed on an infant’s
tongue is thrust forward and out of the mouth) 4: brings hands together and pulls clothes; thumb opposition begins
prevents eating effectively.
 Adjust to cold is mature by age 6 month 5: can grasp objects handed using whole hand
 Immune system functional at 2 months of age;
6: uses palmar grasp
produce both IgG and IgM by 1 year

7: transfers objects hand to hand

10: uses pincer grasp (thumb and finger) to pick up objects

12: holds cup and spoon well, helps to dress (pushes arm into
sleeve) can hold crayon

Typical Eruption pattern of Decidous Teeth Reflexes

2: grasp reflex fading

3: landau reflex develops
4: stepping fading
6:moro and tonic neck reflex fading
12: landau reflex fade
 Rooting reflex
 Baby’s cheek is stroked
 They respond by turning their head towards the
stimulus
 They start sucking, thus allowing for
breastfeeding
 When corner of mouth is touched lower lips is
lowered, tongue moves towards the point
stimulated
 When finger slides away head turns to follow it
 When center of lips is stimulated lip elevates
 Plantar/grasp reflex
 Placing objects or finger beneath the toes causes
curling of toes around the object
 Present at 32 weeks of gestation
 Disappears at 9-12 months
Clinical significance
 This reflex is referred to as the readiness tester
 Integrates at the same time that independent gait first
becomes possible
 Sucking/swallowing reflex
 Touching lips or placing something in baby’s mouth
causes baby to draw liquid into mouth by creating
vacuum with lips, cheeks and tongue
 Babinski’s reflex
 Stimulus consists of a firm painful stroke along the
lateral boarder of the sole from feet to toe
 Response consists of movement ( flexion or extension)
of the big toe and sometimes movement (fanning) of
the other toes
 Present at birth, disappears at approx. 9-10 months
 Presence of reflex later many indicate disease
 Parachute reflex
 Reflex appears at about 6-9 months and persists
thereafter
 Elicited by holding the child in ventral suspension and
suddenly lowering him to the couch
 Arms extend as a defensive reaction
Clinical significance
 Absent or abnormal in children with cerebral palsy
 Would be asymmetrical in spastic hemiplegia
 Doll’s eye reflex (Oculocephalic reflex)
 Passive turning of the head of the newborn leaves the eye
“behind”
 A distinct time lag occurs before the eyes move to a new
position in keeping with the head position
 Disappears at within a week or two of birth
 Failure of this reflex to appear indicates a cerebral lesion
 Gallant’s reflex
 Firm sharp stimulation along sides of the spine with the
fingernails or a pin procedures contraction of the
underlying muscles and curving of the back
 Response is easily seen when the infant is held upright and
the trunk movement is unrestricted
 Best seen in the neonatal period and thereafter gradually
fades
Socialization and language
2: makes cooing sounds, differentiates cry
3: loughs out loud
6: may say vowel sounds (oh-oh)
7: shows beginning fear of strangers
8: fear of strangers peaks
9: says first word (da-da)
12: says two words plus ma-ma and da-da
Play
0-1: Enjoys watching face of primary caregiver, needs play time in
prone position
2: enjoys bright colored mobiles
3: spends time looking at hands, “tummy time” important during the
day
4: needs space to practice turning
5: handles rattles well
6: enjoys bathtub toys, rubber ring for teething
7: likes objects that are good size for transferring
8: enjoys manipulation, rattles, and toys of different textures
9: needs safe space for creeping
10: play games like patty-cake and peek-a-boo
11: crusing can be main activity
12: likes toys that fit inside each other (pot and pans)
SOLITARY PLAY
Senses Development
 VISION
 1ST month see object in the midline directly in front of
closer than (46 cm)
 Binocular vision 2nd month focus well, so encourage and teach
parent to make a point of eye to eye contact for vision and
socialization
 Up until 6 months infants may experience difficulty in
establishing eye coordination but after 3 months, if eyes
still cross should be examined by a physician
 HEARING
 1st month hearing is demonstrated
 10 months, infants recognize their name and listen acutely
when spoken to
 By 12 months. Infants can easily locate sound in any
direction and turn toward it
 A vocabulary of two words plus “mama” and “dada” also
demonstrates an infant can hear
 TOUCH
 An infant needs to be touched to experience skin to skin
contact
 To handle infants with assurance and gentleness
 Advised parents to cuddle an infant next to their bare chest
( skin to skin contact)
 Clothes should feel comfortable and soft
 Diapers should be dry rather than wet. Teach parents
 TASTE
 Infants have taste by turning away from or spitting out a
taste
 SMELL
 Infants can smell accurately within 1 or 2 hours after birth
 They respond to an irritating smell by drawing back from it
 They enjoy and learn early in life to identify the familiar
smell of breastmilk
 Teach parents keep irritating odors out of the child’s
environment
Emotional development
 Cognitive development
 Primary circular reaction
 Secondary circular reaction
 Object permanence
1st month socialization, learning how to interact with others, is an
extensive phenomenon
6 weeks of social smile, it is a major milestone
Major milestone for assessing
 a- Vision
b- Motor control
c- Intelligence

4 month crying when playing person leave him

6 month recognize stranger from care giver

8 month stranger anxiety (eight month anxiety)

12 months, most children have overcome their fear of strangers

and responds when approached

 Primary Circular Reaction by the 3rd month of life, an infant

explores objects by grasping them with the hands or by
mouthing them
 Secondary Circular Reaction 6 month can initiate pleasurable
sensations
 Coordination of Secondary Schema infants of 10 months
discover object permanence, r become aware an object out of
Nursing Diagnoses: Infant Growth and Development
sight still exists. Infants are ready for peek-a-boo once they
gained the concept of permanence
 Ineffective breastfeeding related to maternal fatigue
 Disturbed sleep pattern (maternal) related to baby’s
need to nurse every 2 hours
 Health seeking behaviors related to adjusting to
parenthood
 Delayed growth and development related to lack of
stimulating environment
HEALTH PROMOTION OF AN INFANT AND FAMILY  Ineffective role performance related to new
responsibilities within the family
1. Promoting Achievement of Development Task: Trust vs.
Mistrust (Erikson) HEALTH PROMOTION: ACHIEVEMENT OF DEVELOPMENTAL
2. Promoting Infant Safety TASK
 Aspiration prevention
 Fall prevention Trust versus mistrust
 Car safety
 Safety with siblings  Met needs
 Bathing and swimming safety  Routines
 Childproofing  Rituals
3. Promoting Nutritional Health of an Infant  Consistent caregiver
 Recommended dietary allowance for an infant
 Introduction of solid food (between 4 to 6 months)
chewing 7-9 months. Introduce food one at a time
every (3-4 days to identify any allergies)
 Quantities and types of food (cereal, vegetables,
Chapter 30
fruit, meat and eggs)
 Establishment of healthy eating patterns Nursing Care of a Family with a Toddler
 Weaning 6-9 month
 Self-feeding 6 month Growth and Development of Toddler
 Vegetarian diet (continue breastfed or ingest an iron
fortified formula Physical Growth
4. Promoting Infant Development in daily Activities
 Bathing  Weight, height, head circumference, and body mass index
 Diaper area care  Body contour
 Care of teeth  Body systems
 Dressing  Teeth
 Exercise (early morning and late afternoon outside)
 Sleep (10-12 hours night and several naps) Children in this age (1-2 years) have a growing sense of autonomy
5. Promoting Healthy Family Functioning (a primary task of (independence).
parents during the infant’s need to meet that need)
Parents must also grow during this period
PARENTAL CONCERNS AND PROBLEMS RELATED TO
NORMAL INFANT DEVELOPMENT The parent’s task is

 Teething  To support their child’s growing independence with

 Thumb-sucking patient and sensitivity
 Use of pacifiers  To learn methods for handling the child’s frustrations
 Sleep problems that arise from the search for autonomy.
 Constipation
Physical Growth begins slow, while developmental tasks is rapid
 Loose stools
 Colic
1. Weight:
 Spitting up
 Child gain only about 2.5 kg (5-6 pounds) per year
 Diaper dermatitis
 The subcutaneous fat starts to disappear at the end of
 Baby bottle tooth decay syndrome
the second year
 Obesity in infant
 They show decrease appetite, so adequate intake of all
nutrients is still essential to meet energy needs.
 Weight is calculated for children from 1-5 years of age
by the equation (age 2+8)
2. Height: child gain 12 cm (5 inches) per year
 Height is calculated for children from 1-5 years of age by
the equation (age 5+80)
3. Head Circumference
  Equals or less than chest circumference at 6 months to 1
year of age
 By 2 years chest circumference has grown greater than
that of the head
 It increases only about 2 cm during the second year
4. Body Contour
 Toddlers tend to have a prominent abdomen
 Toddlers have a forward curve of the spine at the sacral
area (lordosis)
 Toddlers walk with a wide distance between their feet.
Body systems continue to mature during this time:
 Respiration slow slightly but continue to be mainly
abdominal
 The heart rate slows 90 bpm; BP increases to about
99/64 mm Hg
 The brain develops to about 90% of its adult size
 Stomach secretions become more acid
Developmental milestones
 Language development
 Emotional development
- Autonomy
- Socialization
- Play behaviour
 Stomach capacity increases to the point a child can eat
three meals a day
 Control of the urinary and anal sphincters becomes
possible with complete myelination of the spinal cord.
 IgG and IgM antibody production becomes mature at 2
years of age
 The passive immunity obtained during intrauterine life is
no longer operative
 Teeth: eight new teeth (the canines and the first
molars ) erupt during the second year
 All 20 deciduous teeth are generally present by 2.5 to 3
years of age
Language Development
 A child who is 2 years old should talk two-word and noun-
verb simple sentences
 A word that is used frequently by toddlers is “No” which
reflect their autonomy development
Toddlers use it to when
 They are refusing a task
 They do not understand it
 They practice a sound that they have notices has potent
effects on those around them
Language develops most quickly if parents:
 Respect what toddlers have to say
 Make conversation with toddler
 Answering their questions (simple and brief)
 Naming objects as they play with their child
 When they give their toddler something, they must name
it
 Children should not be made to name an object before
they can have it. They should say the word in right way
 The toddler learn language from imitating what they hear
 Pronouns are difficult to use, up to 3.5-4 years to
recognize
Emotional Development
Autonomy versus shame or doubt.
 They start to do what they want because they want that
and they can do it
Socialization
 15 month-old children are excited about interacting with
people
 By 18 months, toddlers imitate the things they see a
parent doing
 Children become aware of gender differences and may
point to other children and identify them as boy or girl
Play Behavior
 Side by side play (parallel play)
 Caution parents that if two toddlers are going to play
side, they must provide duplicate toys or an argument
over one toy is likely to occur.
 The toddlers enjoy toys that require action (dolls that
can be squeezed, pulled)
Health promotion of a toddler
 Toddlers tend to develop many upper respiratory and ear
infections, it is recommended to have a schedule visits
15-18-24 months of life
 This scheduled visits provides an opportunity for health
promotion and early detection of any growth and
development delays.
Promoting Toddle Safety
 Accidents are the major cause of death in children of all
ages
 Accidental ingestions (poisoning) are the type of accident
that occurs most frequently in toddlers (medication and
cleaning products)
 Other accidents that occur frequently in toddlers include
motor vehicle accidents, burns, falls and playground
injuries
Activities to ensure toddler safety
13 to 18 months
 Supervising child outdoors
 Educating child about dangers of throwing, hitting
 Preventing access to electrical outlets, chords
 Securing gates and doors
 Maintaining water heater temperature at 120 to 130 F.
25 to 36 months
 Instructing child on dangers of weapons and fires, and
also how to get help when feeling scared or in danger
 Selecting toys carefully
 Storing matches and lighters out of child’s reach
 Instructing child about stranger danger and good
touch/bad touch supervising child closely when in public
settings
Lead Screening
 All children between the ages of 6 months and 6 years
should be tested periodically for the presence of too
much lead in their body (lead poisoning)
 Elevated lead levels are caused by eating, chewing, or
sucking n objects (such as windowsills, paint chips, or
furniture) that are covered with lead-based paint. Or
colored print in newspapers; old water pipes.
 Lead is toxic to body tissue, ingestion of it can lead to
serious damage to the brain and nervous system, kidneys,
and red blood cells
 Levels as low as 5 ug/dL can cause learning and
behavioural problems
 10ug/dL standard to define lead toxicity
 High levels may result in seizures, cognitive challenges,
coma and even death
 Beginning symptoms of lead poisoning include irritability,
headache, fatigue, and abdominal pain
Promoting Nutritional Health of a Toddler
 A toddler’s appetite becomes lesser than the infant
 They should consume 1,000-1,400 kcal daily
 Protein and carbohydrate needs are often easily met
during the toddler period
 Diets in high in sugar should be avoided (to prevent
toddler obesity)
 Fats should generally not be restricted for children
under 2 years old
 Adequate calcium and phosphorus intake is important for
bone mineralization
Teaching, Toddler Nutrition
13 to 18 months
 Discontinuation bottle feeding
  Offering of textured solids as small portions and
frequent feedings
 Continued used of spoon and self-feeding Discipline
 Avoidance of force feeding
 Use of healthy snacks  Discipline means setting rules or road signs so children
know what is expected of them
19-24 months  Punishment is a consequence that results from a
breakdown in discipline, from the child’s disregard of the
 Use of drinking water for thirst rules that were learned
 Limitation of fluids before meals  Timeout is technique of helping children learn that
 Inclusion of foods high in iron and protein actions have consequences. To use timeout effectively,
 Regularity of meal times parents first need to be certain their child understand
the rule they are trying to enforce: for instance, if you
25 to 36 months hit your brother, you’ll have timeout.

 Healthy food choices for the child, including raw and
cooked vegetables
 Healthy snacks between meals, foods from all food
groups, and iron-fortified cereals use of small portions
 Limitation of fat content in foods
 Avoidance of high sugar cereals
 Child participation in food preparation
 Avoidance of food as a reward
Promoting Toddler Development in Daily Activities
Dressing
 Toddler try to dress themselves but most of time in
wrong way
 Instruct parents to give up from perfection in order to
enforce the child’s sense of autonomy.
Growth and Development of a Toddler
Developmental milestone
Cognitive development
Negativism
 As part of establishing their identities as separate
individuals, toddlers typically go through a period of
extreme negativism
 They do not want to do anything a parent wants them to
do
 Their reply to every request is a very definite “no”
 Parent need some help to realize this is not only a normal
phenomenon of Toddlerhood but also a positive stage in
development
 This change indicates their toddlerhood has learned he
or she is a separate individual with separate needs.
Separation Anxiety
 Fear of being separated from parents begins at about 6
months of age and persists throughout the preschool
period
 This universal fear of this age group is known as
separation anxiety. For this reason, toddlers have
difficulty accepting being separated from their primary
caregiver

 Deferred imitation
Temper Tantrums
 Preoperational thought
 Assimilation  Almost every toddler has a temper tantrum at one time
or another. The child may kick scream, stamp feet, shout,
Parental Concerns During the Toddler Year
NO, lie on the floor, flail arms and legs and bang the head
against the floor
 Toilet training
 Children may even hold their breath until they become
 Ritualistic behaviour
cyanotic and fall to the floor.
 Negativism
 Discipline
Nursing Diagnosis: Toddler growth and development
 Separation anxiety
 Temper tantrums  Deficient knowledge related to best method of toilet
training
Toilet Training
 Risk for injury related to impulsiveness of toddler
 Interrupted family process related to need for close
 Toilet training is an individualized task for each child. It
supervision of 2 year old
should begin and be completed according to a child’s
 Readiness for enhanced family coping related to parent’s
ability to accomplish it, not according to a set schedule.
ability to adjust to new needs of child
 Before children can begin to be toilet trained, they must
have reached three important developmental levels, one
physiologic and the other two cognitive
1. They must have control of rectal and urethral sphincters,
usually achieved at the time they walk well.
2. They must have a cognitive understanding of what it
means to hold urine and stools until they can release
them at a certain place and time.
3. They must have a desire to delay immediate gratification
for a more socially accepted action.

Temper Tantrums

 Temper tantrums occur most often when children are:

1. Tired
2. May be a response to an unrealistic request by a parent
3. May occur if parents are saying “no” too frequently with
regard to such

Temper Tantrums Management

1. Try to determine the reason for the behaviour

2. Be certain it seems like a tantrum, not something more
3. Think through what you do when the child has a tantrum
 Don’t give either material r emotional bribes
 Don’t punish the child
 Don’t demonstrate adult behaviour in managing temper
tantrums
  A definite change in body contour occurs during the
preschool years
 The wide gait, prominent lordosis, and protuberant
abdomen of the toddler change to slimmer, taller, and
much more childlike proportions
 Contour changes are so definite that future body type
ectomorphic (slim body build) or endomorphic (large body
build) becomes apparent. Handedness begins to be
obvious.
 A major step forward is a child’s ability to learn
extended language, which is achieved not only by motor
but also by cognitive development.

Body Systems

 Lymphatic tissue begins to increase in size, particularly

the tonsils, and levels of IgG antibodies increase.
 These changes tend to make preschool illnesses more
localized
 Physiologic splitting of heart sounds may be present for
the first time on auscultation.
 Innocent heart murmurs may also be heard for the first
time. Due to the changing size of the heart in reference
to the thorax as the chest reach adult proportions.
 Pulse rate decreases to about 85 bpm
 Blood pressure holds at about 100/60 mm Hg
 The bladder is easily palpable above thr symphysis pubis;
voiding is frequent enough (9 or 1 times a day)
 Muscles are noticeably stronger and make activities such
as gymnastics possible
 Many children at the beginning of the period exhibit genu
valgus (knock-knees) this disappears with increased
skeletal growth at the end of the preschool period.

Weight

 Average weight gain 4.5 lb (2 kg) a year

Height

 An increase of about 2 to 3.5 inches (6 to 8 cm ) a year

on average

Head circumference

 Is not routinely measured at physical assessment on

children over 2 years of age

Teeth

 Children have all 20 decidous teeth by 3 years of age

generally

Language Development

 3 year old child has a vocabulary of about 900 words

 These are used to ask questions constantly, up to 400 a
day, mostly how and why questions
 A child needs simple answers to such questions to
encourage curiosity, vocabulary building, and questioning
 They enjoy participating in mealtime conversation and
imitate language exactly

Chapter 31

Physical growth
Preschools are egocentric, they define objects related to
- Height, weight, body mass, and head circumference themselves.
- Teeth
What can be done to promote language development:
Assessing Average Preschool
 Engage in play and bath with language
 The preschool period includes ages 3, 4, and 5 years  Converse using descriptions, simple questions and
 Physical growth slows considerably during this period, expansion
personality and cognitive growth are significant.  Use playful songs
 Most children of this age want to do things for  Use correct names
themselves, which puts them at risk of injury  Ask open ended questions
 Parent’s role is to promote the safety for their child  Express feelings in words
because they still need help.
Play
Physical Growth
 Preschools enjoy games that use imitation
  Many pre-schoolers have imaginary friends as a normal
part of having an active imagination
 Four and 5 year olds divide their time between rough-
housing and imitative play
 Five year olds are also interested in group games or songs
they have learned in nursery school or preschool.
Emotional development
Developmental tasks
- Initiative
- Imitation
- Fantasy
- Oedipus and electra complexes
- Gender roles
- Socialization
1. Initiative
 The developmental task of the preschool years, according
to Erikson, is to form a sense of initiative versus guilt
 A child with a well-developed sense of initiative has
discovered that learning new things is fun
 To gain a sense of initiative, pre-schoolers need exposure
 A wide variety of experiences and play materials so they
can learn as much about the world as possible.
2. Imitation
 Pre-schoolers need free restraint to imitate the roles of
the people around them. Role playing should be fun and
does not have to be accurate
 Parents should help and engage in playing or activity but
should not ask the child to imitate them
3. Fantasy
 Pre-schoolers begin to make differentiation between
fantasy and reality
 Becomes afraid that they have lost their own identity or
have become “stuck” in their fantasies
 So the parents should not both supporting the fantasy
and yet reassuring a child she is still himself.
4. Gender roles
 They should exposure to an adult of opposite gender
specially the single parent. So they become familiar with
opposite gender roles.
5. Socialization
 A child who live with other child or exposed to other
children than his parent, have more socialization than
other child who live just with his parents
 Although 4 year olds continue to enjoy groups, they may
become involved in an argument more than they did at age
3.
 Five year olds begin to develop best friendships.
6. Oedipus and Electra Complexes
 An Oedipus complex refers to the strong emotional
attachment a preschool boy demonstrates toward his
mother
 An electra complex is the attachment of a preschool girl
to her father.
Cognitive Development
 Because pre-schoolers do not have mental substitution
skills, they feel they are always right
 Also, pre-schoolers are not yet aware of the property of
conversation
Moral and Spiritual Development
 Children of preschool age determine right from wrong
based on their parents rule
 They have little understanding of the rationale for these
rules or even whether the rules are consistent.
 Preschoolers begin to have an element concept of God if
they have been provided some form of religious training.
Belief in an outside force aids in the development of
principles.
Nursing Outcome Evaluation
4 years old
 Walking, climbing, jumping, and running
 Riding a tricycle or bicycle with training wheels
 Building a tower of 10 blocks
 Drawing a person with 3 parts
 Using short paragraphs with sentences of 4 or 5 words
 Distinguishing fantasy from reality
 Giving first and last name
 Singing a song
5 years old
 Walking, climbing, jumping, and running with coordination
 Dressing self independently
 Drawing a person with head, body, arms, and legs
 Copying a triangle or square
 Counting using fingers
 Speaking in short paragraphs, with recognition of most
alphabet letters
 Giving own address and phone number
 Following rules of interactive peer games
Preschooler Promoting Safety
 By age 4, children may project an attitude of
independence and the ability to take care of their own
needs.
 They still need supervision to be certain they do not
injure themselves or other children.
 Because pre-schoolers imitate adult rules so well they
may imitate taking medicine if they see family members
doing so
 A good rule for parents is never to take medicine in front
of children.
Keeping Children Safe, Strong, and Free
Preschool age is a good time to educate children about their
safety, which includes:
 Warning a child never to talk with or accept a ride from a
stranger
 Teaching a child how to call for help in an emergency
(yelling or dialling the emergency number)
 Describing what police officers look like and explaining
that police officers can help in an emergency situation.
 Explaining the good secret and the bad one.
Motor Vehicle and Bicycle Safety
Head injury is the major cause of death in the preschool age.
Educate parents to put their children in the back with seat belts
on.
Promoting Nutritional Health
 Offering small servings of food is a good idea, so a child
is not overwhelmed by the amount on a plate.
 Encourage parents to make snacks nutritious
 Teach parents to make mealtime a happy and enjoyable
part of the day foe everyone
Promoting the Preschool in Daily Activities
Dressing;
 Dressed themselves
 Exposure to experience to choose their clothes
 They may have mismatched clothes
Sleep:
 They do not want nap at morning
 Refuse sleep because fear of dark
 Night walking from nightmares reaches its peak. This
means that prechoolers may need a night light.
Exercise:
 The preschool period is an active phase
Bathing:
 As needed, day over day
Care of teeth
 The tooth brush should be started
  Drink fluoridated water or receive a prescribed oral
fluoride supplement
 Try to decrease candy and sweet intake
Night Grinding
Grinding the teeth at night ( usually during sleep), is a habit of
many young children. It can be caused by:
 Present of tension
 Child anxiety
 Child with cerebral palsy of spasticity of jaw muscles
Discipline
 Pre-schoolers have opinions on things such as what they
want to eat, where they want to go, and what they want
to wear
 This may bring them into opposition with their parents.
So timeout is a good technique to correct behaviour for
parents throughout the preschool years.
 Beating should be never use as a disciple method can be
used such as letting the child taking responsibilities of
his own action
Possible Unintentional Injury
 Motor vehicles
 Falls
 Drowning
 Animal bites
 Poisoning
 Burns
 Community safety
Parental Concerns During the Preschool Years
Common Fears of the Preschooler
 Because preschoolers’ imagination is so active, this can
lead to a number of fears
 Fears of dark, mutilation, and separation or abandonment
are all very real to a pre-schooler.
FEAR OF DARK
 The tendency to fear the dark is an example of a fear
heightened by a child’s vivid imagination: a stuffed toy by
daylight becomes a threatening monster in the dark.
 Children awaken screaming because of nightmares. They
may be reluctant to go to bed or to go back to sleep by
themselves unless a light is left on.
FEAR OF MUTILATION
 Fear of mutilation is also significant during the
preschool age, as revealed by the intense reaction of
a pre-schooler to even a simple injury such as falling
and scraping a knee.
 A child cries afterward not only from the pain but
also from the sight of the injury
 Part of this fear arises because pre-schoolers do
not know which body parts are essential and which
ones like an inch of scrapped skin can be easily
replaced.
FEAR OF SEPARATION
 Fear of separation continues to be a major concern for
pre-schoolers.
 Their sense of time is still so distorted
 Relating time and space to something a child knows such
as meals, television shows, or a friend’s house, is most
effective.
 For example, stating “mommy will pick you up from
preschool after you have had your snack” or showing a
child the work site might be more comforting
Behavior variations
TELLING TALL TALES
 Stretching stories to make them seem more interesting
is a phenomenon frequently encouraged in this group
 Caution parents not to encourage this kind of storytelling
but instead help a child separate fact from fiction by
saying
 ”That’s a good story, but now tell me what really
happened”. This conveys the idea a child has not told the
truth, yet does not squash imagination or initiative.
IMAGINARY FRIENDS
 Many pre-schoolers have an imaginary friend who plays
with them.
 Parents can help their pre-schooler separate fact from
fantasy about their imaginary friend by saying, “ I know
rasha is not real, but if you want to pretend, I’ll set place
for her.” This response helps a child understand what is
real and what is fantasy without restricting a child’s
imagination or creativity.
DIFFICULTY SHARING
 Sharing is a concept that first comes to be understood
around the age of 3 years. Before this, children engage in
parallel play
 Around 3 years of age children begin to understand that
some things are theirs, some belong to others, and some
can belong to both. For the first time, they can stand in
line to wait for a drink, take turns using a shovel at a
sandbox, and share a box of crayons.
 Sharing does not come easily, however; children who are
ill or under stress have even greater difficulty with it
than usual.
 Assure parents that sharing is a difficult concept to
grasp and that, as with most skills, preschoolers need
practice to understand and learn it."
 Defining limits and exposing children to these three
categories (mine, yours, ours) helps them determine
which objects belong to which category.
REGRESSION
 Some preschoolers, generally in relation to stress, revert to
behavior they previously outgrew,
 Help parents understand that regression in these
circumstances is normal, and a child's thumb sucking is little
different from the parents' reaction to stress (smoking many
cigarettes, nail biting, overeating), to make it easier for them
to accept and understand.
 Removing the stress is the best way to help a child discontinue this
behavior.
SIBLING COMPETITION
 Jealousy of a brother or sister may first become evident
during the preschool period, partly because this is the
first time that children have enough vocabulary to
express how they feel (know a name to call) and partly
because preschoolers are more aware of family roles and
how responsibilities at home are divided.
 parents find the problem of jealousy is bigger than they
anticipated and welcome a few suggestions about how to
provide more time for their preschooler during the day
and which activities a preschooler would especially enjoy.
BROKEN FLUENCY
 Developing language is such a complicated process that
children from 2 to 6 years of age typically have some
speech difficulty that parents may interpret as
stuttering
 A child may begin to repeat words or syllables, saying, "I-
I- I want a n-n-new spoon spoon-spoon." This is called
broken fluency (repetition and prolongation of sounds,
syllables, and words).
 It is often referred to as secondary stuttering because a
child begins to speak without this problem and then,
during the preschool years, develops it.
 It is a part of normal development and if accepted as
such, will pass it is resolved most quickly
Broken Fluency resolved quickly if parents follow few simple rules
 Do not discuss in the child's presence that he or she is
having difficulty with speech.
 Listen with patience rather than interrupt or ask the
child to speak more slowly or to start over.
  Always talk to the child in a calm, simple way to role
model slow speech.
 Protect space for the child to talk if there are other
children in the family
 Do not force a child to speak if he or she does not want
to,
 Do not reward a child for fluent speech or punish for
nonfluent speech
Preparing for a New Sibling
 Introduction of a new sibling is such a major happening
that parents need to take special steps to be certain
their preschooler will be prepared.
 There is no rule as to when this preparation should begin,
but it should be before the time a child begins to feel
the difference the new baby will make. This is perhaps
when the mother first begins to look pregnant.
Preparing a Child for School
 At the end of the preschool period, children will begin a
formal school experience as they enter kindergarten.
SEX EDUCATION
 Children during the preschool age become acutely aware
of the difference between boys and girls
 Explanations should be just as simple: boys look different
from girls
 An important part of sex education for pre-schoolers is
teaching them to avoid sexual abuse, such as not allowing
anyone to touch their body unless they agree it is all
right.
School Age Child
 The term “school age” is commonly refers to children
between ages of 6 to 12
 Although these years represent a time of slow physical
growth, cognitive growth and development continue to
proceed at rapid rates.
 Children of school age may also be more influenced by the
attitudes of their friends than previously.
Physical Growth
 General growth is slow until puberty. The child show
progressive lower in growth in height and rapid again in
weight
 School age children’s annual average weight gain is
approximately 1.3 to 2.2 kg. the increase in height is 2.5
to 5 cm.
 As the eye globe reaches its final shape about this same
time, an adult vision level is achieved.
 At 6 year 117 cm and 22kg in weight
 At 12 year 150 cm and 44 kg
 Posture becomes more erect. Lordosis and knock-knee
appearance disappear.
 Scoliosis may become apparent for the first time in late
childhood
 By 10 years of age, brain growth is complete, so fine
motor coordination becomes refined.
Physiological Growth
 Vital signs T: 37 degree Pulse 70-80 bpm
 BP:112/60 Respiration 20 Breath/min
 GIT mature to digest food
 Kidney system mature to concentrate urine 30 cc or ml
per hour
 Circulatory system heart beat are shifts from fourth to
fifth intercostals space
 Neurological system are improved memory and ability to
understand
 Immunological sysystem: the main function of this system
is elimination of substance that are foreign to the body.
So lymphoid tissue reach of greater amount in school
than adult.
 IgG and IgA reach adult levels
 Lymphatic tissue continues to grow up until about age
9frontal sinuses develop at about 6 years, so sinus
headache becomes a possibility (before that, headache in
children is rarely caused by a sinus infection).
The left ventricle of the heart enlarges to be strong enough to
pump blood to the growing body
 the innocent heart murmurs may become apparent due to
the extra blood crossing heart valves
 maturation of the respiratory system leads to increased
oxygen-carbon dioxide exchange
Mental Development
 At 6 year: count to 20, obey command as open door, know
right arm
 At 7 year read clock
 At 8 year know month, days, number count from 1-20
 At 10-12 year write short letter to friends, use
telephone read story, books
Vocalization
 At 6 year: talk full sentence
 At 7 year: orient time and place, season, month
 At 8 year: understand past, present future
 At 10-12 year: vocabulary depend on intelligent
Development of sexuality in the school age
 School age is a process of resolving oedipal situation
 Less egocentric direct his energy to others
 Child engage in activities they receive satisfaction
 Failure lead to sense of inferiority or inadequacy
Sexual Maturation
 Puberty is provoked in this period in response to
gonadotropin hormones
 Sexual maturation in girls occurs between 12 and 18
years; in boys, between 14 and 20
 Prepubertal girls usually taller, by about 2 inches ( 5 cm)
or more, than preadolescent boys because their typical
growth spurt begins earlier.
Concern of boys
 Boys are aware of increasing genital size. Hypertrophy of
breast tissue (gynecomastia) can occur in prepuberty,
most often in heavy boys.
 They become worried about their chest and facial hair
that not appear yet, so they must be assured that this
hair will be developed latterly in the puberty years.
 As seminal fluid is produced, boys begin to notice
ejaculation during sleep, termed nocturnal emissions.
Concern of Girls
 A girl notices the change in her pelvic contour when she
tries on a skirt or dress from the year before and
realizes her hips are becoming broader.
 She may misinterpret this finding as a gain in weight and
a tempt a crash diet. She can be reassured that broad
bone structure of the hips is part of an adult female
profile
 Girls are usually conscious of breast development. Breast
development is not always symmtrical
 Preparation for menstruation is important preparation
for future childbearing and for the girl’s concept of
herself as a woman
  Most girls have some menstrual irregularity during the
first year or two after menarche( the start of
menstruation)
 Girls also need to know that vaginal secretions will begin
to be present.
 By 7 years this has been called the server “eraser year”
because children are never quiet content with what they
have done
 By 8 years, children’s eyes are developed enough so they
can read regularize type.
 By age 9, their writing behind to look mature and less
awkward
 Older school-age children begin to evaluate their
teachers ability

Age Boys Girls

9-11 Prepubertal weight gain Breast: elevation of
occurs papilla with breast bud
formation; areolar
diameter enlarges Play
11-12 Sparse growth of Straight hair along the
straight, downy, slightly labia. Vaginal epithelium  Play continues to be rough at age 6 years
pigmented hair at base becomes cornified  By 7 years of age, children require more props for play
of penis than when they are younger.
Scrotum becoming pH of vaginal secretions  To be a police officer, a 7 year old needs a badge and
textured; growth of acid; slight mucous gun, whereas before a pointed finger sufficed.
penis and testes begins vaginal discharge present  Most girls and boys of this age also enjoy helping in the
Sebaceous gland Sebaceous gland kitchen with jobs such as making cookies and salads or
secretion increases secretion increases frosting cakes
 8 year olds like table games but hate to lose, so they
Perspiration increases Perspiration increases
tend to avoid competitive games
Dramatic growth spart
 9 year old play hard. They wake in the morning squeeze in
some activity before school and plan something the
moment they arrive home again
Teeth
 Many 10 year olds spend most of their time playing hand-
 Deciduous teeth are lost and permanent teeth erupt held or television remote control games. Boys and girls
during the school-age period at 6 years of age play separately at age 10, although interest in the
 The average child gains 28 teeth between 6 and 12 years opposite sex is apparent
of age: the central and lateral incisors; first, second, and  Eleven and 12 year old children enjoy dancing to popular
third cuspids; and first and second molars music and playing table games and are accommodating
enough to be able to play with younger siblings who need
Socialization the rules modified to their advantage.

 Six year old children play in groups, but when they are
tired or under added stress, they prefer one-to-one
contact Language Development
 Seven year olds are increasingly aware o family roles and
 6 year old talk in full sentences, using language easily and
responsibility. Promises must be kept, because 7 year
with meaning
olds view them as definite, firm commitments. Child
 Most 7 years old can tell the time in hours, but they may
aware to family, family roles, responsibilities, less
have trouble with concepts such as “half”
resistance, less stubborn
 At about age 9, they use swear words to express anger or
 Eight year olds actively seek the company of other child.
just to show other children they are growing up.
They like the reward system.
 By 12 years of age, a sense of humor is apparent. They
 Nine year olds take the values of their peer group very
can carry on an adult conversation, although stories are
seriously
limited because of their lack of experience.
 Although 10 year olds enjoy groups, they also enjoy
privacy. Girls become increasingly interested in boys and
Emotional Development
vice by 11 years of age
 Twelve year olds feel more comfortable in social
 They should have learned to share, to have discovered
situations than they did the year before
that learning is fun and on adventure, and have learned
that doing things is more important and more rewarding
Developmental Milestone
than watching things being done.
Gross Motor Development

 At the beginning of the school age period (age of 6)

Learning to Live with Others
children endlessly jump and hop. They have enough
coordination to walk a straight line. Many can ride a
 A good time to urge children to learn compassion and
bicycle.
thoughtfulness toward others is during the early school
 6 year old. Gender differences usually begin to manifest
years
in play: there are “girls games” such as dressing dolls, and
 Learning to give a present without receiving one in return
“boy games,”
or doing a favour without expecting a reward is also a
 A 7 year old appears quiets
part of this process
 The movement of 8 year olds are more refined than
 Children may show empathy toward others as early as 20
those of younger children, they ride a bicycle well and
months, but gain cognitively they cannot relate others
enjoy sports such as gymnastics, soccer, and football
experiences to their own until about 6 years of age.
 Nine year olds are on the go constantly, as if they always
have a deadline to meet
 By 10 years of age, they are more interested in
perfecting their athletic skills than they were previously Promoting School-Age Safety
 Twelve year olds fall into activities with intensity and
concentration School age children are ready for time on their own without direct
adult supervision

Promoting Nutritional Health

Fine Motor Development
 Most school age children have good appetites, although
 By 6 years, easily tie their shoelaces. They can cut and any meal is influenced by the day’s activity
paste well and draw a person with good detail
  School age children need breakfast to provide enough
energy to get them through active mornings at school.
 Most children are hungry after school and enjoy a snack
when they arrive home
Needs
 Sleep and rest
 Bathing
 Nutrition
 Exercise and activity
 Dental health
 Education
 Sex education
 Religious education
Promoting Development of a School Age Child in Daily Activities
Dress
 Although school age children can fully dress themselves,
they are not good at taking care of their clothes until
later in the school age years
 This is the right age to teach the children the
importance of caring for their own belongings
Sleep
 Younger school age children typically require 10 to 12
hours of sleep each night, and older ones require about 8
to 10 hours
 Night time terrors may continue during the early school
years and may actually increase during the first grade as
a child reacts to the stress of beginning school.
Exercise
 Exercise need not involve organized sports. It can come
from nighborhood games, walking with parents, or bicycle
riding
Hygiene
 Children of 6 or 7 years of age still need help in
regulating the bath water temperature and in cleaning
their ears and fingernails
 By age 8, children are generally capable of bathing
themselves but may not do it well because they are too
busy to take the time or because they do not find bathing
as important as their parents do
Care of teeth
 School age children should visit a dentist atleast twice
yearly for a checkup, cleaning, and possibly a fluoride
treatment to strengthened and harden the tooth enamel.
Health Problems of School Age
1. Phobia from school manifested by vomiting abdominal
pain, regression
2. Learning difficulties: reading and writing problems
3. Behaviour problems: Lying, cheating, stealing
4. Sexual problem
5. Nutritional problems
6. Communicables disease as hepatitis
7. Allergy as asthma, sinusitis, streptococcal infection
8. Dental problems
9. Skeletal problems as bone fracture and scoliosis
10. Accident electric shock, drowning, motor accident
Growth and Development of Adolescence
 Adolescence is the period between 12 and 18 to 20 years,
a time that serves as a transition between childhood
and adulthood.
 It can be divided into an early period (13 to 14 years), a
middle period (15 to 1b years), and a late period (17 to
20 years).
Physical growth
 The major milestones of development in the adolescent
period are the onset of puberty.
 Adolescents both growth rapidly and mature dramatically
during this period
 At first the gain in physical growth is mostly in weight,
feadinq to the stocky, slightly obese appearance of
prepubescence: later comes the thin, tall appearance of
late adolescence.
 Individual gain about 30 to 50% of adult weight during
adolescence
 On average, girls gain between (7-25 kg) on the other
hand boys gain (7-30 kg)
Height
 Growth stops with closure of the epiphyseal lines of long
bones. This occurs at about 16 or 17 years of age in
females and about 18 to 20 years of age males
 Girls grow 5-20 cm. and cease at about age 16-17
 Boys grow 10-30 cm. ane ceases at about age 18-20
 Pulse rate and respiratory rate decrease slightly (to 70
bpm and 20 breaths/min respectively), and blood
pressure increases slightly (to 120/70 mmHg), reaching
adult levels by late adolescence
Teeth
 Adolescents gain their second molars at about 13 years
of a e and their third molars (wisdom teeth) between lg
and 21 years of age.
Puberty
 Puberty is the stage at which the individual first becomes
capable of sexual reproduction.
 A girl has entered puberty when she begins to
menstruate (12 to 18) a boy enters puberty when he
begins to produce spermatozoa (14-20)
 Puberty: period of rapid physical maturation involving
hormonal & bodily changes that occur primarily during
early adolescence
 Menarche: girl's first menstruation, occurs at
approximately age 12 to 13, but has been declining an
average of about 4 months per decade for past century.
 Key factor in puberty’s occurrence is body mass-body
weight approximating 106 (plus or minus 3 pounds) can
trigger menarche.
 Puberty's determinants include nutrition, health,
heredity & body mass
Growth and Development of an Adolescent #2
 Developmental milestones
 Play or recreation
 More adult forms of recreation
 Team loyalty becomes intense
 Much time talking with peers, face to face or
electronically
 Part-time job
 Charitable endeavors
Vital Signs:
Temperature= 97.5-98.6 degree F
Apical rate= 55-90 bpm (PR 60-100)
Respirations= 12-20 breaths/min
Blood pressure= 121/70 mmHg (average)
Secondary Sex Changes
• The secondary sex characteristics that begin in the late school-
age period continue to develop during adolescence.
Gender differences:
 Girls experience increase in height, weight, breast
development, and pelvic girth with expansion of the
uterine tissue. Menarche (onset of the menstrual period)
Typically occur about 2.5 years after secondary sex
characteristics begin
  Boys experience increase in height, weight, muscle mass,
penis and testicle. Nocturnal emission of seminal fluid is
an overt sign of puberty.
Tanner stages of male sexuality maturity
 13-15 pubic hair abundant and curly, testes, scrotum, and
penis enlarginq further, axillary hair present, facial hair
fin and-downy, voice change happen.
 15-16 genitalia adult, facial and body hair present sperm
production mature.
 16-17 pubic hair may extend along medial aspect of
thighs, testes. scrotum, and penis adult size, may have
some degree of facial acne (gynecomastia faded)
 17-18 end of skeletal growth.
Pubic hair (male & female) development:
I- stage I is the prepubertal stage.
2- stage 2 is characterized by sparse, long, straight downy
hair.
3- stage 3 is characterized by darker, curly hair that is
sparse over the entire pubis.
4- stage 4 is characterized by dark, curly, and abundant hair
in the pubic hair in pubic area only.
5- stage 5 is characterized by an adult pattern.
Developmental changes resultiæ from hormonal . influences:
Body mass increase to adult size.
 Sebaceous glands are activated.
 Eccrine sweat glands become fully functional.
 Apocrine sweat glands undergo development.
 Body hair is distributed in a characteristics adult-like
pattern.
Hormonal Changes
 Hormones: powerful chemical substances secreted by
endocrine glands & carried through body by bloodstream
 Hypothalamus: structure in higher portion of brain that
monitors eating, drinking & sex
 Pituitary gland: important endocrine gland controls
growth & regulates other glands
 Gonads: sex glands - testes in males & ovaries in female
Two primacy classes of hormones
 Androgens: male sex hormones
 Estrogens: female sex hormones
 Testosterone: androgen plays important role in male
pubertal development
 Estradiol: estrogen plays important role in female
pubertal development
Major Endocrine Glands Involved in Pubertal Change
Pituitary gland The
Developmental Task: Identity Versus Role Confusion In late
adolescence, the task is to form a sense of intimacy or form
close relationships with persons of the opposite as well as the
same sex. It is the concentration on these two tasks that leads to
typical adolescent behavior
The four main areas in which adolescents must make gains to
achieve a sense of identity
1. Accepting their changed body image
2. Establishing a value system or what kind of person they want to
be
3. Making a career decision
4. Becoming uncontrolled by their parents
• If young people do not achieve a sense of identity, they develop
a sense of role confusion or can have little idea what kind of
person they are
Body Image
 Adolescents who developed a strong sense of industry
during their school-age years have learned to solve
problems and are best equipped to adjust to their new
body image.
 Nurses who care for adolescents can do much to educate
them about their bodies and help them to accept the
changes that mark maturity.
Self-Esteem
 Like body image, self -esteem may undergo major
changes during the adolescent years and can be
challenged by all the changes that occur during
adolescence, including:
1. Changes ain one's body and physiologic functioning
2. Changes .in feelings and emotional focus
3. Changes 'in social relationships ( including relationships with
both family and friends)
4. Changes 'in family and school expectations
All of these factors can have an effect on an adolescent's feelings
about himself or herself sometimes resulting in crisis.
Value System
 Adolescents develop values through talking to peers.
They also need an attentive adult ear , someone who will
listen to their fears, hopes, dreams, and the pressure
they feel to be somebody, the pressure Of wanting to do
something and yet not knowing what or how.
Career Decisions
 Part of the feeling of knowing what kind of person you
are is knowing what kind of job you can do.
 Because of the thousands of opportunities available today
makinq a career decision becomes more and more
difficult.
Emancipation from Parents
 Emancipation from parents can become a major issue
during the middle and late adolescent years or two
reasons. Some parents may not yet be readv for their
child to be totally independent. and some adolescents
may not yet be sure they want to be on their own.
 They may fight bitterly for a right- for example, to stay
out until midnight or later on a weekend- then never use
the privilege once they have gained it.
Sense of Intimacy
 Once adolescents have achieved a sense of identity in
early or mid-adolescence, they are ready to work on a
second developmental task that of achieving a sense of
intimacy (erikson, 1993 The ability to form intimate
relationships is the sense of trust, the first
developmental task in infancy.
Cognitive Development
 The final stage of cognitive development, the stage of
formal operational thought begins at the age 12 or 13
 years and grows in depth over the adolescent years
(piaget, 1969). This step involves the ability to think in
abstract terms and use the scientific method to arrive at
conclusions
Moral and Spiritual Development
 Because adolescents enlarge their thought processes to
include formal reasoning, they are able to respond to the
question, “why is it wrong to steal from your neighbor’s
house?” with “ it would hurt my neighbour by requiring
him to spend money to replace what I stole rather than
with the immature response of the school age.
Promotion of an Adolescent and Family
Promoting Adolescent Safety
 Accidents, most commonly those involving motor
vehicles are the leading cause of death among
adolescents.
Promoting Nutritional Health for an Adolescent
 Adolescents may always feel are hungry. experiencing If
adolescents so much growth eating they habits are
unsupervised, they tend to eat faddish or quick snack
foods rather than more nutritionally sound ones because
of both hunger and peer pressure. Some adolescents
turn away from the five pyramid food nourished despite
their large intake.
Promoting Development of an Adolescent in Daily Activities
• Maintaining adequate nutrition to support rapid adolescent
growth is essential to continued healthy development
• Adequate sleep, hygiene, and exercise are also important and
should become an adolescent's responsibility rather than the
parents'.
• Parents can, however, encouraqe adolescents to engage in
healthy patterns of riving—primarily through role modeling.
Dress and Hygiene
 Adolescents are capable of total self-care and, because
of their body awareness may even be overly conscientious
about personal hygiene and appearance.
Sleep
 Although it is widely believed adults need 8 hours of
sleep a night some need more and others can adjust to
considerably less. Protein synthesis occurs most readily
during sleep. Because adolescents are buildinq so many
new cells, adolescents may need proporfionately more
sleep than school -age children during this time.
Exercise
 Adolescents need exercise every day both to maintain
muscle tone and to provide an outlet for tension.
Parental Concerns During the Adolescent Years #1
 Health problems
 Hypertension
 Poor posture
 Body piercing and tattoos
 Fatigue
 Menstrual irregularities
 Acne
 Obesity
Parental Concerns During the Adolescent Years #2
 Sexuality and sexual activity
 STDs
 Pregnancy
 Homosexuality
 Date rape
 Stalking
 Hazing or bullying
Parental Concerns During the Adolescent Years #3
 Substance use disorders
 Depression and self-injury
Common Health Problems of an Adolescent
Poor posture
 Many adolescent demonstrate poor posture, a tendency
to round shoulders and a shambling, slouchy walk. This is
due in part to the imbalance of growth, the skeletal
system growing a little more rapidly than the muscles
attached to it.
 Poor posture particularly seems to develop in adolescents
who reach adult height before their peers. They slouch
to appear no taller than anyone around them
 Girls especially may slouch to diminish the appearance of
their breast size if they are developing more rapidly than
their friends
 This also can occur from carrying backpacks that are too
heavy.
Body Piercing and Tattoos
 Body piercing and tattoos are becoming a mark of
adolescence. Both sexes have ears, lips, chins, navels,
and breasts pierced and filled with ear rings, or tattoos
applied to arms, legs, or their central body.
 These acts have become a way for adolescents to make
a statement I am different from you"). Be certain
they know the symptoms of •infection at a piercing or
tattoo site ( redness, warmness, drainage, swelling, mild
pain) and to report these to a health care provider if
they occur.
Fatigue
 So many adolescents comment they feel fatigued to
some degree that this can be considered normal for the
age group.
 Because fatigue may be a beginninq symptom of disease,
however , it is important be investigated as a legitimate
concern and not underestimated.
 Assess an adolescent’s diet, sleep patterns, and activity
schedules, because all can contribute greatly to fatigue.
Menstrual Irregularities
 Menstrual irregularities can be a major health concern
of adolescent girls as they learn to adjust to their
individual body cycles.
 Dysmenorrhea is painful menstruation, it was thought to
be mainly psychological, needing no treatment other than
reassurance that it was a normal phenomenon and
something women should endure.
 Today, it is known that the pain is caused by the release
of prostaglandins in response to tissue destruction
during the ischemic phase of the menstrual cycle.
Prostaglandins release causes smooth muscle contraction
in the uterus
 Dysmenorrhea can also be a symptom of an underlying
illness such as PID, uterine myomas (tumors) or
endometriosis (abnormal formation of endometrial
tissue)
Management of dysmenorrhea
1. Warm bath
2. Heating pads applied to abdomen
3. Exercise
4. Good posture
5. Mild analgesic
6. Diuretics to relieve fluid retention  3 leading causes of death in adolescence: accidents,
suicide, & homicide
7. Psychotherapy  Suicide is deliberate self -injury with the intent to end
one's life. Successful suicide occurs more frequently in
Pre-menstrual syndrome: immediately preceding menstruation as males than in females, although more females apparently
attempt suicide than males (about 8:1)
 Nervous tension
 Depression Sexually Transmitted Diseases
 Irritability
 Leg pain  Teenagers tend to believe that:
 Anxiety  Sexually transmitted diseases (STD) always
 Headache happen to someone else.
 Tender abdomen and breast  STDs Can be easily cured without any harm done
 These symptom lead to poor achievement in schools and  STDs are too horrible for a nice young person to
emotional upset even hear about.

Acne Eating disorder

 Acne is a self -limiting inflammatory disease that
involves t e sebaceous g an s a empty into hair shafts
( the pilosebaceous unit mainly of the face and shoulders.
 It is the most common skin disorder of adolescence,
occurrinq slightly more frequently in boys than girls. The
peak age for the lesions to occur in girls is 4 to 17 years:
for boys, 16 to 19 years.
 Although not proven, genetic factors may play a part in
their development Cigarette smoking may also increase
the number of Inflammatory lesions.
 Eating disorder are complex, involving genetic,
inheritance, physiological factors, cognitive factors and
environmental experiences
 Anorexia nervosa: is disorder that involve voluntary
refusal to eat, accompanied by severe loss of body weight
without an organic cause
 Bulimia: individual consistently follow binge and purge
eating pattern (episodes of binge eating followed by self-
inducing vomiting.

Therapeutic Management

 The goal of therapy for acne is threefold: (1) decrease

sebum formation, 2 prevent comedones, and (3) control
bacterial proliferation.

Obesity

 Most overweight adolescents have obese parents,

suggesting that both inheritance and environment play
a part in the development of adolescent obesity.
 Most obese adolescents continue to be obese adults. It
can be difficult for adolescents to learn to like
themselves (achieve a sense of identity) if they do not
like their reflection in a mirror.

Substance abuse:

 refers to the use of chemicals to improve a mental state

or induce euphoria,
 This is so common among adolescents that as many as
50% of high school seniors report having experimented
with some form of drug use occurs in adolescence from a
desire to expand consciousness or to feel more
confident and mature
 It also can be a response to peer pressure or a form of
adolescent rebellion. This type of rebellion is more
emotionally charged than acts such as staying out late or
wearing clothing other than those approved by parents,
because is not only harmful but also illegal.

Assessment of Substance Abuse

 If adolescents trust health care personnel, they will

generally admit they have engaged in drug
experimentation. Some common findings on the health
history that suggest an adolescent is abusing some
substance are

1. Failure to complete assignments in school

2. Demonstration of poor reasoning ability

3. Decreased school attendance

4. Frequent mood swings

5. Deteriorating physical appearance

6. Recent change in peer group

7. Expressed negative perceptions of parents

Concerns Regarding Attempted Suicide

Leading Causes of Death in Adolescence.