NURS 207:

Promoting Pediatric Wellness

in the Family & Community
Allan J. V. Cresencia, MSN, CPN, RN
Samson Yigezu, PhD, RN
Christine Limann, BS, CPN, RN
West Coast University - Los Angeles

Theories of Development
Personality Development
Freud - Psychosexual
Erickson - Psychosocial

Mental Development
Piaget - Cognitive
Kohlberg - Moral

Erikson Stages of
Psychosocial Development
1. Infancy: Birth to 18 Months
Ego Development Outcome: Trust vs. Mistrust
Basic strength: Drive and Hope
2. Toddler: 18 Months to 3 Years
Ego Development Outcome: Autonomy vs. Shame
Basic Strengths: Self-control, Courage, and Will
3. Preschooler: 3 to 5 Years
Ego Development Outcome: Initiative vs. Guilt
Basic Strength: Purpose

Erikson Stages of Psychosocial

Development
4. School Age: 6 to 12 Years
Ego Development Outcome: Industry vs. Inferiority
Basic Strengths: Method and Competence
5. Adolescence: 12 to 18 Years
Ego Development Outcome: Identity vs. Role Confusion
Basic Strengths: Devotion and Fidelity

Theories of Development
Piaget Mental
Sensorimotor birth to
2 years
Preoperational 2 to 7
years
Concrete operations 7
to 11 years
Formal operations 11
to 15 years

Kohlberg Moral
Preconventional level
good/bad or right/wrong
Conventional level
approval by being nice
Postconventional,
autonomous, or
principled level formal
operations

Piaget Stages of Cognitive Development

Sensorimotor period Years 0-2

In this stage, infants construct an understanding of the

world by coordinating sensory experiences (such as seeing
and hearing) with physical, motoric actions.
Infants gain knowledge of the world from the physical
actions they perform on it.
An infant progresses from reflexive, instinctual action at
birth to the beginning of symbolic thought toward the end
of the stage.
Object permanence is key word.

Infant Stimulation
Newborn prefers human
face for stimulation
Visual benefit of black-andwhite objects for
stimulation
Stimulation of human voice
Importance of tactile
stimulation

Focus on Visual Objects

Fine Motor Development

Grasps object, age 2 to 3 months
Transfers object between hands, age
7 months
Pincer grasp, age 10 months
Removes objects from container, age
11 months
Builds tower of two blocks, age 12 months

Crude Pincer Grasp

Neat Pincer Grasp

Gross Motor Development

Head control
Rolls over, age 5 to 6 months
Sits alone, age 7 months
Moves from prone to sitting position, age
10 months

Head Control

Locomotion

Cephalocaudal direction of development

Crawling, age 6 to 7 months
Creeping, age 9 months
Walk with assist, age 11 months
Walk alone, age 12 months

Psychosocial Development

Eriksons phase I: developing a sense of trust

Trust vs. mistrust
Importance of caregiver-child relationship
Delayed gratification
Importance of consistency of care

Finding Hidden Object

Development of Body Image

Concept of object permanence
By end of first year, recognize that they are
distinct from parents

Viewing Own Image

Development of Sexual Identity

Hormonal influences
Infant
Parental influences on development of
sexuality

Social Development

Attachment
Reactive attachment disorder (RAD)
Separation anxiety
Stranger anxiety
Play as major socializing agent

Stranger Fear

Language Development
Crying is first verbal communication
Vocalizations
Three to five words with meaning by age
1 year

Infants Health Promotion

Promoting Infant Safety

Aspirations
Falls
Car (MVA)
Siblings
Bathing and Swimming
Childproofing

Infants Health Promotion

Nutritional Health
Recommended dietary
reference intakes
Introduction of solid
foods
Loss of extrusion reflex
Techniques for feeding
solid foods

Nutritional Health
Quantities and types of
food

Cereal
Vegetables and fruit
Meat and eggs
Table food

Chart on next slide.

Infants Health Promotion

Development in Daily
Activities
Establishment of healthy

Nutritional Health

eating patterns
Weaning
Self-feeding
Adequate intake with a
vegetarian diet

Bathing
Diaper-area care
Use of pacifiers
Care of teeth
Dressing
Sleep patterns
Exercises

Infants Health Promotion

Parental Concerns and
Problems
Diaper dermatitis skin
condition
Miliaria sebaceous
glands
Baby-bottle syndrome
dental carries
Obesity no comment!

Baby-bottle syndrome
dental carries

Health Problems During Infancy

Chapter 13

Protein and Energy Malnutrition

Kwashiorkor
Severe protein malnutrition, especially in
children after weaning, marked by lethargy,
growth retardation, anemia, edema, potbelly,

Marasmus
A progressive wasting of the body, occurring
chiefly in young children and associated with
insufficient intake or malabsorption of food

Food Sensitivity
Cows milk allergy
Lactose intolerance

Feeding Difficulties

Regurgitation and spitting up

Reflux/GERD
Colic (paroxysmal abdominal pain)
Failure to thrive
Organic FTT
Nonorganic FTT

The Colic Carry

A Consistent Nurse in
Nonorganic FTT

SKIN DISORDERS
Diaper Dermatitis
Principal factors in development

Therapeutic management
Nursing considerations

Seborrheic Dermatitis
Chronic, recurrent, inflammatory reaction
of the skin
Scalp: cradle cap
Eyelids: blepharitis
External ear: otitis externa

Cause unknown
Nursing considerations
Head & Shoulders to wash hair 1-2 times

Atopic Dermatitis
Also called eczema
Is a category of dermatologic diseases
and not a specific etiology
Pruritic
Usually associated with allergy
Hereditary tendency

Atopic DermatitisTherapeutic Management

Hydrate the skin

Relieve pruritus
Reduce inflammation
Prevent and control secondary infection
Nursing considerations

Disorders of Unknown Etiology

Sudden infant death syndrome (SIDS)
Apparent life-threatening events
(ALTEs)
Back to Sleep campaign
Increased incidence of positional
plagiocephaly

Infants at Risk for SIDS

Unknown Etiology
Infants with one or more severe Apparent
life-threatening events (ALTEs) requiring
CPR or vigorous stimulation
Preterm infants experiencing apnea at time
of discharge from hospital
Sibling of two or more SIDS victims
History of central hypoventilation

Health Promotion of the

Toddler and Family

Biologic Development
Weight gain slows to 4 to 6 pounds per year
Birth weight should be quadrupled by
2 years of age
Height increases about 3 inches per year
Growth is steplike rather than linear

Maturation of Systems
Most physiologic systems relatively mature
by the end of toddlerhood
Upper respiratory infections, otitis media, and
tonsillitis are common among toddlers
Voluntary control of elimination
Sphincter control age 18 to 24 months

Gross and Fine Motor

Development
Locomotion
Improved coordination between ages 2 and 3
Fine motor development
Improved manual dexterity ages 12 to 15 months
Throw ball by age 18 months

Typical Toddling Gait

Psychosocial Development

Erikson: developing autonomy

Autonomy vs. shame and doubt
Negativism
Ritualization provides sense of comfort
Id, ego, superego/conscience

Promoting Optimum
Growth and Development

The terrible 2s
Ages 12 to 36 months
Intense period of exploration
Temper tantrums, obstinacy occur frequently
Developing independence vs. parental control

Piaget Stages of Cognitive

Development
Preoperational period (years 2 to 6)
Learn spatial relationships
Awareness of causal relationships between two events

the child learns to use and to represent objects by images,

words, and drawings
The child is able to form stable concepts as well as mental
reasoning and magical beliefs
Thinking is still egocentric: The child has difficulty taking
the viewpoint of other

Moral Development
Kohlberg: preconventional or premoral level
Punishment and obedience orientation
Time out is useful at this age
-1 minutes per year of age

Development of Body Image

Refer to body parts by name
Avoid negative labels about physical
appearance
Recognize sexual differences by age 2

Development of Sexuality
Exploration of genitalia is common
Gender roles understood by toddler
Playing house or pirates

Social Development
Differentiation of self from mother and from
significant others
Separation
Individualization

Language
Increasing level of complexity
Increasing ability to understand

Personal Social Behavior

Toddlers develop skills of independence
Skills for independence may result in tyrannical,
strong-willed, volatile behaviors
Skills include feeding, playing, and dressing and
undressing self

Playing Dress-Up

Transitional Objects Provide

Security

Play
Magnifies physical and psychosocial
development
Parallel play
Imitation
Locomotive skills
Tactile play

Coping with Concerns Related to

Normal Growth and
Development

Toilet training
Sibling rivalry
Temper tantrums
Negativism
Regressive behavior

Toilet Training

Assessing Readiness
for Toilet Training

Voluntary sphincter control

Able to stay dry for 2 hours
Fine motor skills to remove clothing
Willingness to please parents
Curiosity about adults or siblings toilet
habits
Impatient with wet or soiled diapers

Promoting Optimum Health

During Toddlerhood
Nutrition
Phenomenon of physiologic anorexia

Sleep and activity

Dental health

Regular dental exams

Removal of plaque
Fluoride
Low-cariogenic diet

Toothbrushing

Injury Prevention

Motor vehicle injuries: car seat safety

Drowning
Burns
Poisoning
Falls
Aspiration and suffocation
Bodily damage

Forward-Facing Convertible
Seat

Matches Are a Potentially

Deadly Hazard

Plastic Caps for Electrical Sockets

Storage of Cleaning Agents

Health Promotion of the

Preschooler and Family

PROMOTING OPTIMUM
GROWTH AND DEVELOPMENT
Preschool period
3 to 5 years of age
Refining tasks mastered in
toddlerhood

Biologic Development
Physical growth rate slows and stabilizes
during preschool years
Physical proportions change

Slender but sturdy

Graceful, agile
Posture erect
Males and females similar in size and proportion

Gross Motor Behavior

By 36 months:
Walking, running, climbing, jumping

By age 4 years:
Skips and hops on one foot
Catches ball

By age 5 years:
Skips on alternate feet, jumps rope, learns to skate
and swim

4-Year-Old Hops on One Foot

Psychosocial Development:
Erikson
Developing a sense of initiative
Initiative vs. guilt
Development of superego (conscience)
(Freud)

Cognitive Development: Piaget

Preoperational phaseages 2 to 7
Preconceptual phase: ages 2 to 4
Intuitive thought: ages 4 to 7
* Causality
*Time
*Magical thinking
*Logical thinking

Moral Development: Kohlberg

Preconventional (premoral)
Punishment and obedience orientation: ages
2 to 4
Nave instrumental orientation: ages 4 to 7

Preschoolers Enjoy Friends

Spiritual Development
Parental influences
Concrete representation of spiritual beings
Development of conscience related to
spiritual development

Development of Body Image

Increasing awareness of self and others
Poorly defined body boundaries
Poor understanding of internal anatomy

Development of Sexuality

Sexual identity
Sexual beliefs
Sex typing
Gender behaviors
Sexual exploration of children is main health
concern

Social Development
Individuation-separation process
Effects of prolonged separation (such as
hospitalization)

Language
Ages 4 to 5: four- and five-word
sentences
Age 6: understand all parts of speech;
identify opposites

Preschooler Dressing Himself

Personal-Social Behavior
Self-assertion is a major theme
Independent in dressing, eating, toileting by
ages 4 to 5
Desire to please
Internalized values--conscience & morals
More secure with new sibling arrival at this
age

Play

Associative play
Make up rules as they go along
Imitation
Imaginary playmates
Mutual play with parents

Preschoolers Enjoy a Sense of

Accomplishment

Preschoolers Enjoy Imaginative and

Imitative Play

Coping with Concerns Related to

Normal Growth and
Development

Preschool and
Kindergarten Experience

Learning group cooperation

Peer group experiences
Readiness for academics
Preparing the child

Sex Education
Find out what the child knows and thinks
Be honest with responses
Understanding the broader concept of
sexuality
Resources:
Sexuality Information and Education Council of
the United States (SIECUS)
American Academy of Pediatrics (AAP)

Aggression
Definition: behavior to hurt person or destroy
property
Frustration
Modeling
Reinforcement
Professional help for parenting

Fears
Night terrors
Animism: ascribing lifelike
characteristics to inanimate objects
Techniques to overcome fears

PROMOTING OPTIMUM
HEALTH DURING THE
PRESCHOOL YEARS

Nutrition
Nutritional requirement approximately
90 kcal/kg
Fluid requirement approximately 100
ml/kg daily
MyPyramid application to preschoolers
Concerns about childhood obesity

Choosing Healthy Foods

Assist in Food Preparation

Sleep and Activity

Sleep average is 12 hours per night for
preschool
Sleep problems
Sleep rituals help establish routine &
consistency

Dental Health
Eruption of primary teeth is complete in
preschoolers
Need assistance with toothbrushing
Routine prophylaxis including fluoride
supplements

Injury Prevention

Poisoning
Drowning
Pedestrian motor vehicle injuries
Seat belts
Bicycle helmets
Emphasis on protection and education
for safety

Health Problems of Early

Childhood

Infectious Disorders
Communicable diseases
Incidence has declined with increase of
immunizations
Further decreased with use of antibiotics
and antitoxins

Nursing Assessment in
Identification of Infection

Recent exposure to infectious agents

Prodromal symptoms
Immunization history
History of having the disease

Prevent Spread of Disease

Primary prevention of the disease
Immunization

Control spread of disease to others

Reduce risk of cross-transmission of
organisms
Infection control policies
Hand washing

Caution for Compromised Children

Children with immunodeficiency
Receiving steroid therapy
Other immunosuppressive therapies
Generalized malignancies
Immunologic disorder

Risk for complications from communicable diseases,

especially varicella (chickenpox) and erythema
infectiosum (EI)
Risk for viremia from varicella zoster virus

Chickenpox

Agent: varicella zoster virus

VZG also causes herpes zoster (shingles)
VZIG treatment for children at risk
Transmission: direct contact, droplet, and
contaminated objects
Incubation: 2 to 3 weeks
Communicability: 1 day before eruption until
all lesions crusted

Erythema Infectiosum
(Fifth Disease)
Agent: human parvovirus
Rash in three stages:
Slapped face appearance disappears in
1 to 4 days
Maculopapular rash on extremities; lasts 7 days or
more
Rash subsides but reappears if skin irritated or
traumatized by heat, cold, friction, etc.

Roseola
Agent: human herpesvirus type 6
Incubation: 5 to 15 days
Persistent high fever for 3 to 4 days;
otherwise appears well
After fever subsides, rash appears
Rash first on trunk, then face and extremities

Rubeola (Measles)
Agent: virus
Transmission: secretions, droplets
Incubation: 10 to 20 days; communicability
from 4 days before to 5 days after appearance
of rash
Koplik spots appear 2 days before rash

Mumps

Agent: paramyxovirus
Transmission: via droplet or direct contact
Incubation: 14 to 21 days
Fever, headache, malaise, followed by
parotitis
May cause orchitis and meningoencephalitis

Pertussis (Whooping Cough)

Agent: Bordetella pertussis

Transmission: droplet or direct contact
Incubation: 6 to 20 days
Cough: short rapid coughs followed by
crowing or whoop sound
Complications: pneumonia (usual cause of
death)

Rubella (German Measles)

Agent: rubella virus
Transmission: direct contact or indirect
contact with article freshly contaminated with
nasopharyngeal secretions, blood, stool, or
urine
Incubation: 14 to 21 days
Complications: rare; greatest danger is
teratogenic effect on fetus

Scarlet Fever

Agent: group A hemolytic streptococci

Transmission: droplet or direct contact
Incubation: 1 to 7 days
Complications: carditis, peritonsillar abscess,
glomerulonephritis

Scarlet Fever (Cont.)

Conjunctivitis
Newborns: chlamydia, gonorrhea or herpes
simplex virus
Infants: may be sign of tear duct obstruction
Children: causes are bacterial (most
common), viral, allergic, or foreign body

Intestinal Parasitic Diseases

Ascariasis (common roundworm)

Hookworm
Strongyloidiasis (threadworm)
Giardiasiscaused by a protozoon

Ingestion of Injurious Agents

Cosmetics and personal care products

Cleaning products
Plants
Foreign bodies, toys, and miscellaneous
substances
Hydrocarbons (gasoline)

Principles of Emergency
Treatment
Poison control center
Call first, before initiating any interventions

Assessment
Gastric decontamination
Induce vomiting, absorb toxin, or perform gastric
lavage depending upon agent ingested

Prevent recurrence

Heavy Metal Poisoning

Mercury toxicity (less frequently)
* Air & water pollutant from coal plants, etc
Most common is lead ingestion
*Most common by peeling lead-based paint
*Micro particles of lead contaminate bare soil
*Can be inhaled or ingested
*Affects renal, hematologic, and neurologic
systems developing brain and nervous
are especially vulnerable

Effects of Lead on Body

Systems

Lead Poison Diagnosis

Rarely symptomatic
Venous blood sample of 10 mcg/dl
Screening for lead poisoning at ages
1 and 2 years
Chelation therapy with calcium disodium
edetate (EDTA) and succimer (DMSA)
Prognosis

Child Maltreatment
Intentional physical abuse (22%) or
neglect (54%)
Emotional abuse (4%) or neglect
Sexual abuse of children (8%)

Types of Neglect
Physical neglect
Deprivation of food, clothing, shelter,
supervision, medical care, and education

Emotional neglect
Lack of affection, attention, and emotional
nurturance

Emotional abusedestroy or impair childs

self-esteem

Munchausens Syndrome by
Proxy
Caregiver fabricates signs and symptoms of
illness in child (the proxy) to gain attention
from medical staff
Child may undergo needless and painful
procedures and treatments10% of cases
may be fatal to the child

Factors Predisposing
to Physical Abuse
Parental characteristics
Social isolation, poor support systems
Parental low self-esteem and less
adequate maternal functioning

Child Characteristics
Predisposing to Physical Abuse
Compatibility between childs and parents
temperament and parents ability to deal with
behavioral style
Removing the child victim from the home
may place other siblings at risk for abuse

Environmental Characteristics
Chronic stress
Divorce, poverty, unemployment, poor
housing, substance abuse, frequent relocation,
crowded living conditions
Child abuse can occur in any socioeconomic
population

Sexual Abuse
Defined as: the use, persuasion, or coercion
of any child to engage in sexually explicit
conduct or simulation of such conduct for
producing visual depiction of such conduct, or
rape, molestation, prostitution, or incest with
children

Characteristics of
Abusers and Victims
Typical abuser is a male the victim knows but
may be ANYONE
All socioeconomic backgrounds

Nursing Care of the

Maltreated Child
Identify abusive situations as early as possible
History pertaining to the incident
Evidence of maltreatment
Pattern or combination of indicators that arouse
suspicion and further investigation
Protect child from further abuse

References
Hockenberry, M. J. (2005). Wongs Essentials
of Pediatric Nursing 8th ed. St. Louis,
Missouri: Elsevier Mosby.
Jordan, D. N.(2005). Nursing 202 Lecture #1
Power Points. Los Angeles, CA.
Pillitteri, A. (2007). Maternal & Child Health
Nursing: Care of the Childbearing &
Childrearing Family 5th ed. Philadelphia, PA:
Lippincott Williams & Wilkins.