PEDIATRIC NURSING APGAR SCORING

GENERAL PRINCIPLES • Heart rate

• Definition of Terms
• Respiratory effort
A. Growth: increase in size of a structure. Human • Muscle tone
growth is orderly and predictable, but not even;
it follows a cyclical pattern. • Reflex irritability
B. Development: maturation of physiologic and • Skin color
psychosocial systems to more complex state. 1 minute  initial adaptation to extrauterine life
C. Cephalocaudal: head-to-toe progression of 5 minutes  overall status
growth and development
APGAR SCORING
GENERAL PRINCIPLES INTERPRETATION

• Definition of Terms • 7 to 10  Good condition

• 4 to 6  Fair condition
D. Proximodistal: trunk-to-periphery (fingers and
toes) progression of growth and development
E. Phylogeny: development or evolution of a
species or group; a pattern of development for a • 0 to 3  In danger  resuscitation
species
F. Ontogeny: development of an individual within a Ongoing Physical Assessment
species • Vital Signs
Rates of Development • Vital statistics

A. Fetal period and infancy: the head and neurologic

• Gestational age assessment
tissue grow faster than other tissues. • Administer medications
B. Infancy and adolescence: fast growth periods
C. Toddler through school-age: slow growth periods
• Perform laboratory tests
D. Toddler and preschool periods: the trunk grows more Ongoing Physical Assessment
rapidly than other tissue.
E. The limbs grow most during school-age period. • Vital signs:
F. The trunk grows faster than other tissue during
adolescence.
– RR
• 30 to 60 bpm
NEONATAL ASSESSMENT – Apical Pulse
• Initial assessment • 110  sleeping
• 120 – 160  awake
• Ongoing assessment • 180  crying
• Physical assessment – Temperature
• Sensory assessment • 3 6  3 6 .8
– Blood Pressure
• Behavioral assessment • 80/46 mmHg
Initial Assessment • Vital Statistics:
• Airway  suctioning and O2 if needed – Weight
• Body temperature • 2,500 – 4,000 g
• Positioning  head lower than the trunk – Length
• Apgar scoring
• 18 – 21 inches
• Cord clamp  bleeding, AVA
– Head Circumference
• Voiding and meconium
• 13 – 14 inches
• Footprints and fingerprints
– Chest Circumference
• 12 – 13 inches
• Identification bands
• Mother infant bonding
Ongoing Physical Assessment
• Purulent discharge
• Gestational Age
• Congenital cataracts
– Preterm
– Term • Ears
– Postterm – Normal
• Laboratory Test • Pinna  top is horizontal line with outer
– Mother  Rh neg or blood type O cantus of the eye, flexible, cartilage present
• Blood type – Abnormal
• Bilirubin level • Low placement of ears
• Direct coomb’s test • Absent of startle reflex in response to loud
• Reticulocyte count noise
• Hct MOUTH AND THROAT
• Administer Medications
• Epstein pearl
– Vit K (Aquamephyton) • Reflexes
• .5 to 1 m g – Sucking
• IM – Gag
• Prevent transient deficiency of coagulation
factors – Extrusion
– Erythromycin ointment • Candidiasis (thrush)
• .5 % • Inability to pass NGT
• 1 to 2 cm • High pitch cry or absent
• Neisseria gonorrhea, chlamydia • Neck

PHYSICAL ASSESSMENT – Normal

• Skin • Short, thick, usually surrounded by skin folds
• Head • Tonic neck reflex
• Eyes – Abnormal
• Ears • Resistance to flexion
• Nose • Fractured clavicle
• Mouth and throat • No tonic neck reflex
• Neck • Chest

• Chest – Normal
• Genitalia • APD = TD
• Extremities • Slight sternal retractions evident during
inspiration
HEAD – Abnormal
• Asymmetry of the chest
• Eyes
• Depressed sternum
– Normal
• Color  gray GENITALIA

• Absence of tears • MALE

• Searching nystagmus – Normal

– Abnormal • Urethral opening at tip of glands penis
• Yellow sclera • Palpable testes
• Blue eyes
 – Abnormal – 1 ½ sleep and difficult to be aroused

• Hypospadias • Second Period of Reactivity

– 4 to 6 hours
• Epispadias
• FEMALE
NUTRITION

– Normal • GENERAL INFORMATION

• Labia and clitoris usually edematous – Loses 5 to 10% and regain within 10 days
• Urethral meatus behind clitoris – Gain of 28g /day  1 6 months
st

• Pseudomenstruation – Gain of 14g/day  2 6 months

nd

– Abnormal – Weight gain

• Fused labia • 2x  6 months
• Meconium in the vaginal area • 3x  1 year
• Absence of vaginal opening • 4x  2 ½ year
• DAILY NUTRIONAL REQUIREMENTS
EXTREMITIES
– Calories  100 to 200 kcal/kg
• NORMAL
– Fluid  150 to 180ml/kg
– Ten fingers and toes – CHON  2.2g/Kg  1.6g/Kg
– Full range of motion – Fat  30 to 60% of daily calories
– Nail beds are pink, with transient cyanosis
immediately after birth HIGH RISK INFANTS
– Equal brachial pulses • According to size
– Sole usually flat – LBW  < 2500g
• ABNORMAL – ELBW  < 1000g
– Polydactyly – MLBW  < 1500g
– Syndactyly  fused or webbed digits – SGA
– Yellowing of nail beds • Birth weight falls below 10 th percentile on
– Unequal gluteal folds intrauterine growth curve

– Sole covered with creases – LGA  above 90 th %

• According to age
SENSORY ASSESSMENT
– Premature
• Tactile Behaviors
– Full term
– Sensation to touch, pain and pressure – Postmature
• Olfactory behaviors
• Vision Behaviors
– Can see  7 to 12 inches
• Auditory Behaviors
• Taste Behaviors

BEHAVIORAL ASSESSMENT
• Period of Reactivity
– 30 minutes after birth
– Awake and active
– VS are increased
– Mother infant bonding  breastfeeding
• Resting Period
– 2 to 4 hours
– VS returning to baseline
 DEVELOPMENTAL THEORIES 5. Identity vs role confusion
a. 12 - 20 years
Psychosexual model (Freud) b. Significant relations: peer groups, role models
1. Oral c. Psychosocial virtues: fidelity, loyalty
a. 0-18 months d. Maladaptations & malignancies:
b. Pleasure and gratification through mouth fanaticism -- repudiation
c. Behaviors: dependency, eating, crying, biting 6. Intimacy vs isolation
d. Distinguishes between self and mother a. 20 - 25 years
e. Develops body image, aggressive drives b. Significant relations: partners, friends
2. Anal c. Psychosocial virtues: love
a. 18 months - 3 years d. Maladaptations & malignancies:
b. Pleasure through elimination or retention of feces promiscuity -- exclusivity
c. Behaviors: control of holding on or letting go 7. Generativity vs stagnation
d. Develops concept of power, punishment, ambivalence, a. 25 - 45 years
concern with cleanliness or being dirty b. Significant relations: household, workmates
3. Phallic/Oedipal c. Psychosocial virtues: care
a. 3 - 6 years d. Maladaptations & malignancies:
b. Pleasure through genitals overextension -- rejectivity
c. Behaviors: touching of genitals, erotic attachment to 8. Integrity vs despair
parent of opposite sex a. 45 years to end of life
d. Develops fear of punishment by parent of same sex, b. Significant relations: mankind or “my kind”
guilt, sexual identity c. Psychosocial virtues: wisdom
4. Latency d. Maladaptations & malignancies:
a. 6 - 12 years presumption -- despair
b. Energy used to gain new skills in social relationships
and knowledge Interpersonal Model (Sullivan)
c. Behaviors: sense of industry and mastery 1. Infancy
d. Learns control over aggressive, destructive impulses a. 0 - 18 months
e Acquires friends b. Others will satisfy needs
5. Genital 2. Childhood
a. 12 - 20 years a. 18 months - 6 years
b. Sexual pleasure through genitals b. Learn to delay need gratification
c. Behaviors: becomes independent of parents, 3. Juvenile
responsible for self a. 6 - 9 years
d. Develops sexual identity, ability to love and work b. Learn to relate to peers
4. Preadolescence
Psychosocial Model (Erikson) a. 9-12 years
1. Trust vs mistrust b. Learn to relate to friends of same sex
a. 0 - 18 months 5. Early adolescence
b. Significant relations: mother a. 12-14 years
c. Psychosocial virtues: hope, faith b. Learn independence and how to relate to opposite sex
d. Maladaptations & malignancies: 6. Late adolescence
sensory distortion- withdrawal a. 14-21 years
2. Autonomy vs shame and doubt b. Develop intimate relationship with person of opposite
a. 18 months - 3 years s ex
b. Significant relations: parents
c. Psychosocial virtues: will, determination Cognitive Theory (Piaget)
d. Maladaptations & malignancies: A. 0 - 2 years: sensorimotor
impulsivity -- compulsion -reflexes, repetition of acts
3. Initiative vs guilt B. 2 - 4 years: preoperational
a. 3 - 5 years -no cause and effect reasoning; egocentrism; use
b. Significant relations: family of symbols; magical thinking
c. Psychosocial virtues: purpose, courage C. 4 - 7 years: intuitive
d. Maladaptations & malignancies: -beginning of causation
ruthlessness -- inhibition D. 7 - 11 years: concrete operations
4. Industry vs inferiority - uses memory to learn
a. 6 - 12 years - aware of reversibility
b. Significant relations: neighborhood and school E. 11 - 15 years: formal operations
c. Psychosocial virtues: competence -reality, abstract thought
d. Maladaptations & malignancies: -can deal with the past, present and future
narrow virtuosity -- inertia
 KOHLBERG’S STAGES OF NEONATAL REFLEXES
MORAL DEVELOPMENT

PRECONVENTIONAL LEVEL (level 1) • Reflex: Symmetric tonic neck

• Stage 1 • Stimulus: neck flexion, neck extension

Age: 2-3
• Response:arm flexion, leg extension, arm extension,
• Description: leg flexion
– Punishment or obedience (heteronomous • Onset: birth-1month
morality)
– A child does the right things because a parent tells • Suppression: 4 mos
him or her to avoid punishment
• Stage 2
• Reflex: positive supporting
Age : 4-7 • Stimulus: tactile contact and weight bearing on sole
• Description: • Response:leg extension for supporting partial body
– Individualism, Instrumentalism, and Exchange weight

– Child carries out actions to satisfy own needs • Onset: 2 months

rather than society’s. The child does something for • Suppression: 3-7 mos, replaced by volitional standing
another if that person does something for him in
re t u rn
CONVENTIONAL LEVEL (level 2)
• Reflex: rooting

• Stage 3
• Stimulus: stroking the corner of the mouth,upper or
lower lip
Age : 7-10
• Description:
• Response:moving the tongue, mouth and head
towards the site of stimulus
– "Good boy/girl" • Onset: birth
– Orientation to interpersonal relations of mutuality • Suppression: 4 mos
– A child follows rules because of a need to be a
good person in own eyes and in the eyes of others
• Reflex: palmar grasp
• Stage 4
• Stimulus: pressure or touch on the palm, stretch of
Age : 10-12
finger flexors
• Description:
• Response:flexion of fingers
– Law and Order
• Onset: birth
– Maintenance of social order, fixed rules and • Suppression: 4-6 mos
authority
– Child follows rules of authority figures as well as NEONATAL REFLEXES
parents to keep the system working
POSTCONVENTIONAL LEVEL (level 3) • Reflex: Plantar grasp

• Stage 5 • Stimulus: pressure on the sole just distal to the

Age :older than 12 metatarsal heads

• Description: • Response:flexion of toes

– social contract, utilitarian law making perspective • Onset: birth

– child follows standards of society for the good of • Suppression: 12-18 mos
all people
• Stage 6 • Reflex: Automatic neonatal walking
Age :older than 12 • Stimulus: contact of the sole in vertical position tilting
• Descriptions: the body forward and from side to side
– Principled Conscience • Response: automatic alternating steps
– universal ethical principle orientation • Onset: birth
– child follows internalized standards of conduct • Suppression: 3-4 mos
 REFLEXES 2) respirations: 32 - 60 and irregular; neonates are
• Blinking or corneal reflex
abdominal breathers, obligate nose breathers
3) blood pressure: 75/49 mm Hg
• Pupillary reflex e. Motor development
• Doll’s eye  fixation develops
1) behavior is reflex controlled
2) flexed extremities
• Sneeze reflex f. Sensory development
• Sucking reflex
1) hearing and touch well developed at birth
2) sight not fully developed until 6 years
• Gag reflex a) differentiates light and dark at birth
• Rooting reflex  3 to 4 months
b) rapidly develops clarity of vision within 1 foot
c) fixates on moving objects
• Extrusion reflex  4 months d) strabismus due to lack of binocular vision
• Cough reflex 2. 1 - 4 months
• Babinski reflex a. Head growth: posterior fontanel closes
• Moro reflex  3 to 4 months
b. Motor development
1) reflexes begin to fade (e.g., Moro, tonic neck)
• Dance or step reflex  3 to 4 weeks 2) gains head control; balances head in sitting
position
NEONATAL SENSES 3) rolls from back to side
4) begins voluntary hand-to-mouth activity
• HEARING: c. Sensory development
– able to hear in the utero 1) begins to be able to coordinate stimuli from
various sense organs
– within hrs after birth, hearing in NB becomes 2) hearing: locates sounds by turning head and
acute visually searching
• VISION: 3) vision: follows objects 180°

– focus on black and white objects 3. 5 - 6 months

– distance of 9-12 inches a. W eight: birth weight doubles; gains 3-5 oz (84-140
g) weekly for next 6 months
– pupillary reflex present at birth b. Length: gains 1/2 inch (1.25 cm) for next 6 months
• TASTE: c. Eruption of teeth begins
1) lower incisors first
– developed before birth 2) causes increased saliva and drooling
• TOUCH: 3) enzyme released with teething causes mild
diarrhea, facial skin irritation
– well developed at birth 4) slight fever may be associated with teething,
– react to painful stimuli but not a high fever or seizures
d. Motor development
• SMELL: 1) supports weight on arms
– present as soon as the nose is cleared of mucus 2) sits with support
e. Sensory development
– ability to respond to odors can be used to 1) hearing: can localize sounds above and below ear
document alertness 2) vision: smiles at own mirror image and responds
to facial expressions of others
INFANT 3) taste: sucking needs have decreased and cup
Physical tasks weaning can begin; chewing, biting, and taste
1. Neonate (Birth to 1 month) preferences begin to develop
a. W eight: 6 - 8 lb (2750 - 3629 g); gains 5 - 7 oz
(142 - 198 g) weekly for first 6 months 4. 7 - 9 months
b. Length: 20 inches (50 cm); grows 1 inch (2.5 cm) a. Teething continues
monthly for first 6 months 1) 7 months: upper central incisors
c. Head growth 2) 9 months: upper lateral incisors
1) head circumference 33 - 35.5 cm (13 - 14 inches) b. Motor development
2) head circumference equal to or slightly larger than 1) crawls; may go backwards initially
chest 2) pulls self to standing position
3) increases by 1/2 inch (1.25 cm) monthly for first 6 3) develops finger-thumb opposition (pincer grasp)
months
d. Vital signs 5. 10-12 months
1) pulse: 110 - 160 and irregular; count for a full a. W eight: birth weight tripled
minute apically b. Length: 50% increase over birth length
c. Head and chest circumference equal
 d. Teething
1) lower lateral incisors erupt
2) average of eight deciduous teeth
e. Motor development
1) walks with help or cruises
2) may attempt to stand alone
Psychosocial tasks
1. Neonatal period
a. Cries to express displeasure
b. Smiles indiscriminately
c. Receives gratification through sucking
d. Makes throaty sounds
2. 1 - 4 months
a. Crying becomes differentiated at 1 month
1) decreases during awake periods
2) ceases when parent in view
b. Vocalization distinct from crying at 1 month
1) coos, babbles, laughs; vocalizes when smiling
c. Socialization
1) stares at parents’ faces when talking at 1
month
2) smiles socially at 2 months
3) shows excitement when happy at 4 months
4) demands attention, enjoys social interaction
with people at 4 months
3. 5 - 6 months
a. Vocalization: begins to imitate sounds
b. Socialization: recognizes parents, stranger anxiety
begins to develop; comfort habits begin
4. 7 - 9 months
a. Vocalization: verbalizes all vowels and most
consonants
b. Socialization
1) shows increased stranger anxiety and anxiety
over separation from parent
2) exhibits aggressiveness by biting at times
3) understands the word “no”
5 . 1 0 - 1 2 m o n th s
a. Vocalization: imitates animal sounds, can say only
4 - 5 words but understands many more (ma, da)
b. Socialization
1) begins to explore surroundings
2) plays games such as pat-a-cake, peek-a-boo
3) shows emotions such as jealousy, affection,
anger, fear (especially in new situations)
Cognitive tasks
I n fa n t
1. Neonatal period: reflexive behavior only
2. 1 - 4 months
a. Recognizes familiar faces
b. Is interested in surroundings
c. Discovers own body parts
3. 5 - 6 months
a. Begins to imitate
b. Can find partially hidden objects
4. 7 - 9 months
a. Begins to understand object permanence;
searches for dropped objects
b. Reacts to adult anger; cries when scolded
c. Imitates simple acts and noises
d. Responds to simple commands
5. 10-12 months
a. Recognizes objects by name
b. Looks at and follow pictures in book
c. Shows more goal-directed actions
Nutrition
1. Birth to 6 months
a. Breast milk is a complete and healthful diet;
supplementation may include 0.25 mg fluoride,
400 IU vitamin D, and iron after 4 months.
b. Commercial iron-fortified formula is acceptable
alternative; supplementation may include 0.25 mg
fluoride if water supply is not fluoridated.
c. Juices may be introduced at 5-6 months, diluted
1:1 and preferably given by cup.
2. 6 - 12 months
a. Breast milk or formula continues to be primary
source of nutrition.
b. Introduction of solid foods starts with cereal
(usually rice cereal), which is continued until 18
months.
c. Introduction of other food is arbitrary; most
common sequence is fruits, vegetables, meats.
1) introduce one new food a week.
2) decrease amount of formula to about 30 oz.
as foods are added.
d. Iron supplementation can be stopped.
e. Finger foods such as cheese, meat, carrots can be
started around 10 months.
f. Chopped table food or junior food can be
introduced by 12 months
g. W eaning from breast or bottle to cup should be
gradual during second 6 months.
Play (solitary)
1. Birth to 4 months
a. Provide variety of brightly colored objects, different
sizes and textures.
b. Hang mobiles within 8-10 inches of infant’s face.
2. 5 - 7 months
a. Provide brightly colored toys to hold and squeeze.
b. Allow infant to splash in bath.
c. Provide crib mirror.
3. 8 - 12 months
a. Provide toys with movable parts and noisemakers;
stack toys, blocks; pots, pans, drums to bang on;
walker and push-pull toys.
b. Plays games: hide and seek, pat-a-cake.
Fears
1. Separation from parents
a. Searches for parents with eyes.
b. Shows preference for parents.
 c. Develops stranger anxiety around 6 months
(peaks at 8 months).
2. Pain
Toddler (12 months to 3 years)
A. Physical tasks: this is a period of slow growth
1. W eight: gain of approximately 11 lb (5 kg) during
this time; birth weight quadrupled by 2 1/2 years
2. Height: grows 20.3 cm (8 inches);
3. Head circumference: 19½ - 20 inches (49 - 50 cm)
by 2 years; anterior fontanel closes by 18 months
4. Pulse 110; respirations 26; blood pressure 99/64
5. Primary dentition (20 teeth) completed by 2 1/2
years
6. Develops sphincter control necessary for bowel
and bladder control
B. Psychosocial tasks
1. Increases independence; better able to tolerate
separation from primary caregiver.
2. Less likely to fear strangers.
3. Able to help with dressing/undressing at 18 months;
dresses self at 24 months.
4. Has sustained attention span.
5. May have temper tantrums during this period; should
decrease by 2 1/2 years.
6. Vocabulary increases from about 10 - 20 words to over
900 words by 3 years.
B. Psychosocial tasks
7. Has beginning awareness of ownership (my, mine) at
18 months; shows proper use of pronouns (I, me, you)
by 3 years.
8. Moves from hoarding and possessiveness at 18
months to sharing with peers by 3 years.
9. Toilet training usually completed by 3 years.
a. 18 months: bowel control
b. 2 - 3 years: daytime bladder control
c. 3 - 4 years: nighttime bladder control
C. Cognitive tasks
1. Follows simple directions by 2 years.
2. Begins to use short sentences at 18 months to 2
years.
3. Can remember and repeat 3 numbers by 3 years.
4. Knows own name by 12 months; refers to self,
gives first name by 24 months; gives full name by
3 years.
5. Able to identify geometric forms by 18 months.
6. Achieves object permanence; is aware that
objects exist even if not in view.
7. Uses “magical” thinking; believes own feelings
affect events (e.g., anger causes rain).
8. Uses ritualistic behavior; repeats skills to master
them and to decrease anxiety.
9. May develop dependency on “transitional object”
such as blanket or stuffed animal.
D. Nutrition
1. Caloric requirement is approximately 100
calories/kg/day.
2. Increased need for calcium, iron, and phosphorus.
3. Needs 16 - 24 oz milk/day.
4. Appetite decreases.
5. Able to feed self.
6. Negativism may interfere with eating.
7. Initial dental examination at 3 years.
E. Play
1. Predominantly- “parallel play” period.
2. Provide toys appropriate for increased locomotive
skills: push toys, rocking horse, riding toys or tricycles;
swings and slide.
3. Give toys to provide outlet for aggressive feelings:
work bench, toy hammer and nails, drums, pots, pans.
4. Provide toys to help develop fine motor skills, problem-
solving abilities: puzzles, blocks; finger paints,
crayons.
G. Fears: separation anxiety
1. Learning to tolerate and master brief periods of
separation is important developmental task.
2. Increasing understanding of object permanence helps
toddler overcome this fear.
3. Potential patterns of response to separation
a. Protest: screams and cries when mother leaves;
attempts to call her back.
b. Despair: whimpers, clutches transitional object,
curls up in bed, decreased activity, rocking.
c. Denial: resumes normal activity but does not form
psychosocial relationships; when mother returns,
child ignores her
Preschooler (3 to 5 years)
A. Physical tasks
1. Slower growth rate continues
a. W eight: increases 4 - 6 lb (1.8 - 2.7 kg) a year
b. Height: increases 2 1/2 inches (5-6.25 cm) a year
c. Birth length doubled by 4 years
2. Vital signs decrease slightly
a. Pulse: 90-100
b. Respirations: 24-25/minute
c. Blood pressure: systolic 85-100 mm Hg
diastolic 60-90 mm Hg
3. Permanent teeth may appear late in preschool period;
first permanent teeth are molars, behind last
temporary teeth.
4. Gross motor development
a. W alks up stairs using alternate feet by 3 years.
b. W alks down stairs using alternate feet by 4 years.
c. Rides tricycle by 3 years.
d. Stands on 1 foot by 3 years.
4. Gross motor development
e. Hops on 1 foot by 4 years.
f. Skips and hops on alternate feet by 5 years.
g. Balances on 1 foot with eyes closed by 5 years.
h. Throws and catches ball by 5 years.
i. Jumps off 1 step by 3 years.
j. Jumps rope by 5 years.
5. Fine motor development
a. Hand dominance is established by 5 years.
b. Builds a tower of blocks by 3 years.
c. Ties shoes by 5 years.
d. Ability to draw changes over this time
1) copies circles, may add facial features by 3
years.
2) copies a square, traces a diamond by 4
years.
B. Psychosocial tasks
1. Becomes independent
a. Feeds self completely.
b. Dresses self.
c. Takes increased responsibility for actions.
2. Aggressiveness and impatience peak at 4 years then
a b a te .
3. Gender-specific behavior is evident by 5 years.
4. Egocentricity changes to awareness of others; rules
become important; understands sharing.
C. Cognitive development
1. Focuses on one idea at a time; cannot look at entire
perspective.
2. Awareness of racial and sexual differences begins.
a. Prejudice may develop based on values of
parents.
b. Manifests sexual curiosity.
c. Sexual education begins.
d. Beginning body awareness.
3. Has beginning concept of causality.
4. Understanding of time develops during this period.
a. Learns sequence of daily events.
b. Is able to understand meaning of some
time-oriented words (day of week,
month, etc.) by 5 years.
5. Has 2000-word vocabulary by 5 years.
6. Can name 4 or more colors by 5 years.
7. Is very inquisitive (why?, why? why?).
D. Nutrition
1. Caloric requirement is approximately 90
calories/kg/day.
2. May demonstrate strong taste preferences.
3. More likely to taste new foods if child can assist in the
preparation.
F. Play
1.Predominantly associative play
2. Enjoys imitative and dramatic play.
a. Imitates same-sex role functions in play.
b. Enjoys dressing up, dollhouses, trucks, cars,
telephones, doctor and nurse kits.
3. Provide toys to help develop gross motor skills:
tricycles, wagons, outdoor gym; sandbox, wading
pool.
4. Provide toys to encourage fine motor skills, self-
expression, and cognitive development: construction
sets, blocks, carpentry tools; flash cards, illustrated
books, puzzles; paints, crayons, clay, simple sewing
sets.
5. Television, when supervised, can provide a quiet
activity; some programs have educational content.
G. Fears
1. Greatest number of imagined and real fears of
childhood during this period.
2. Fears concerning body integrity are common.
a. Magical and animistic thinking allows children to
develop many illogical fears (fear of inanimate
objects, the dark, ghosts).
School-age (6 to 12 years)
A. Physical tasks
1. Slow growth continues.
a. Height: 2 inches (5 cm) per year
b. W eight: doubles over this period
c. At age 9, both sexes same size; age 12, girls
bigger than boys
2. Dentition
a. Loses first primary teeth at about 6 years.
b. By 12 years, has all permanent teeth except final
molars.
3. Bone growth faster than muscle and ligament
development; very limber but susceptible to bone
fractures during this time.
4. Vision is completely mature; hand-eye coordination
develops completely.
5. Gross motor skills: predominantly involving large
muscles; children are very energetic, develop greater
strength, coordination, and stamina.
6. Develops smoothness and speed in fine motor control.
B. Psychosocial tasks
1. School occupies half of waking hours; has cognitive
and social impact.
a. Readiness includes emotional (attention span),
physical (hearing and vision), and intellectual
components.
b. Teacher may be parent substitute, causing
parents to lose some authority.
2. Morality develops
a. Before age 9 moral realism predominates: strict
superego, rule dominance; things are black or
white, right or wrong.
b. After age 9 autonomous morality develops:
recognizes differing points of view, sees “gray”
areas.
3. Peer relationships
a. Child makes first real friends during this period.
b. Is able to understand concepts of cooperation and
compromise (assist in acquiring attitudes and
values); learns fair play vs competition.
c. Help child develop self-concept.
d. Provide feeling of belonging.
4. Enjoys family activities.
5. Has some ability to evaluate own strengths and
weaknesses.
6. Has increased self-direction.
7. Is aware of own body; compares self to others;
modesty develops.
C. Cognitive development
1. Period of industry
a. Is interested in exploration and adventure.
b. Likes to accomplish or produce.
c. Develops confidence.
2. Concept of time and space develops.
a. Understands causality.
b. Masters concept of conservation: permanence of
mass and volume; concept of reversibility.
c. Develops classification skills: understands
relational terms; may collect things.
d. Masters arithmetic and reading.
D. Nutrition
1. Caloric needs diminish in relation to body size: 85
kcal/kg.
2. “Junk” food may become a problem; excess sugar,
starches, fat.
3. Obesity is a risk in this age group.
4. Nutrition education should be integrated into school
program.
E. Play
1. Rules and ritual dominate play; individuality not
tolerated by peers; knowing rules provides sense of
belonging; “cooperative play.”
2. Team play: games or sports
a. Help learn value of individual skills and team
accomplishments.
b. Help learn nature of competition.
3. Quiet games and activities: board games, collections,
books, television, painting
4. Athletic activities: swimming, hiking, bicycling, skating
G. Fears:
more realistic fears than younger children; include
death, disease or bodily injury, punishment; school
phobia may develop, resulting in psychosomatic
illness.
Adolescent (12 to 19 years)
A. Physical tasks
a. Girls: height increases approximately 3 inches/year;
slows at menarche; stops around age 16.
b. Boys: growth spurt starts around age 13; height
increases 4 inches/year; slows in late teens.
c. Boys double weight between 12 and 18, related to
increased muscle mass.
d. Body shape changes
1) boys become leaner with broader chest.
2) girls have fat deposited in thighs, hips, and
breasts; pelvis broadens.
e. Apocrine glands cause increased body odor.
f. Increased production of sebum and plugging of
sebaceous ducts causes acne.
4. Sexual development: girls
c. Development of secondary sex characteristics and
sexual functioning under hormonal control
d. Breast development is first sign of puberty.
1) bud stage: areola around nipple is
protuberant.
2) breast development is complete around the
time of first menses.
5. Sexual development: boys
a. Development of secondary sex characteristics,
sex organs and function under hormonal control.
b. Enlargement of testes is first sign of sexual
maturation; occurs at approximately age 13, about
1 year before growth spurt.
c. Scrotum and penis increase in size until age 18.
d. Reaches reproductive maturity about age 17, with
viable sperm.
e. Nocturnal emission: a physiologic reflex to
ejaculate buildup of semen; natural and normal;
occurs during sleep (child should not be made to
feel guilty; needs to understand that this is not
enuresis).
f. Masturbation increases (also a normal way to
release semen).
g. Pubic hair continues to grow and spread until mid
20s .
h. Facial hair; appears first on upper lip.
i. Voice changes due to growth of laryngeal,
cartilage.
j. Gynecomastia: slight hypertrophy of breasts due to
estrogen production; will pass within months but
causes embarrassment.
B. Psychosocial tasks
1. Early adolescence: ages 12-14 years
a. Starts with puberty.
b. Physical body changes result in an altered self-
concept.
c. Tends to compare own body to others.
d. Early and late developers have anxiety regarding
fear of rejection.
e. Fantasy life, daydreams, crushes are all normal,
help in role play of varying social situations.
f. Is prone to mood swings.
g. Needs limits and consistent discipline.
2. Middle adolescence: ages 15-16 years
a. Is separate from parents (except financially).
b. Can identify own values.
c. Can define self (self-concept, strengths and
weaknesses).
d. Partakes in peer group; conforms to values/fads.
e. Has increased heterosexual interest;
communicates with opposite sex; may form “love”
relationship.
3. Late adolescence: ages, 17-19 years
a. Achieves greater independence.
b. Chooses a vocation.
c. Participates in society.
d. Finds an identity.
e. Finds a mate.
f. Develops own morality.
g. Completes physical and emotional maturity.
C. Cognitive development
1. Develops abstract thinking abilities.
2. Is often unrealistic.
3. Is capable of scientific reasoning and formal logic.
4. Enjoys intellectual abilities.
5. Is able to view problems comprehensively.
D. Nutrition
1. Nutritional requirements peak during years of
maximum growth: age 10-12 in girls, 2 years later in
boys
2. Appetite increases.
3. Inadequate diet can retard growth and delay sexual
maturation.
4. Food intake needs to be balanced with energy
expenditure.
5. Increased needs include calcium for skeletal growth;
iron for increased muscle mass and blood cell
development; zinc for development of skeletal and
muscle tissue and sexual maturation.
F. Activities: DISADVANTAGE
group activities predominate (sports are important);
activities involving opposite sex by middle  Cost
adolescence.  Greater preparation and effort
G. Fears  Hands  clean
1. Threats to body image: acne, obesity
2. Injury or death
 Requires refrigeration and storage
3. The unknown  No transfer of maternal antibodies
Child’s Response to Death
 Doesn’t benefit mother physiologically
1. toddlers - may insist on seeing a significant other long
IMMUNIZATION
after that person’s death.
2. Preschoolers - See death as temporary; a type of • BCG
sleep or separation.
3. School-age – See death as a period of immobility.
– Infants
- Feel death is punishment. • .05 ml
4. Adolescents - Have an accurate understanding of
d e a th .
• Intradermal
• Right deltoid
ADVANTAGE
BREAST FEEDING
– School Entrants
Readily available • .1 m l
Economical • Intradermal
Promotes facial muscles, jaw and teeth • Left deltoid
Mother infant bonding • DPT
Reduced incidence of allergies – 6, 10 and 14 weeks
Reduced incidence of maternal breast cancer – .5 m l
Transfer of maternal antibodies – Intramuscular
• Ig A – Upper outer portion of the thigh
• Lactoferrin • Hepatitis
• Lysozyme – 6, 10, and 14 weeks
• Leukocytes – .5 m l
• Macrophages – Intramuscular
DISADVANTAGE – Upper outer portion of the thigh
 Prevents other from feeding the infant • OPV
 Limits paternal role in feeding – 6, 10 and 14 weeks
 Compels the mother to monitor her diet carefully – 2 drops
 Maybe difficult to a working mother – Mouth
 Digest quickly  more feeding • Measles
ADEQUATE ??? – 9 months
• Wets 6 to 8 diapers a day – .5 m l
• Gaining weight – Subcutaneous
BOTTLE FEEDING – Left outer part of the upper arm
ADVANTAGE • Vitamin A Contraindication:
 Permits the father to feed – Fever
 Mother  medications – Compromise Immune system
 Fewer feedings – Seizure disorder must be controlled
 Feeding  public  embarrassment – Never give gluteal
 •
INFANCY (0 to 1 yr)

•
C - urious

•
I – ron supplement (4 to 6 months), immunization
H – ighly imaginative
•
•
N – o choking hazard
O – bserve for initiative VS guilt
•
•
F – ear of stranger peaks at 8 months
O – ff limits to the kitchen (risk for poisoning and burn)
•
•
A – llow to use a pacifier if NPO
L – oss of body part is a common fear
• N – ote the weight changes

•
PRESCHOOL
T – rust V.S. mistrust
•
•
M - u ti l a ti o n
S – olitary play
• A – associate play, abandonment

•
TODDLER (1 to 3yr)

•
G - uilt

•
T – alk to the child at simple terms
I – nitiative, imaginary playmate, imagination
•
•
O – ffer choices to the child to provide some control
C – urious  “Y”
• D – on’t leave alone near the bathtub or swimming
pool SCHOOL AGE ( 6 to 12 yr)

• D – oubt and shame V.S. Autonomy • S – ame sex stage

• L – earns about death @ age 3 • C – ompetitive play

• E – limination pattern • H – eroworship

• R – rituals and routines • O – bserve for industry VS inferiority

• O – ff limits to vehicles
• P – ush-pull toys (mobile), parallel play (forget
• L – oss of control is a common fear
sharing)

• R – rituals and routines (eyes and consistency),

• E – xplain procedurse
regression • R – egression is common
• A – utnomy VS shame and doubt, accidents (death)

• I – nvolve parents
• D – eath (bogeyman), honesty  funerals and burials

• S – eparation anxiety
• I – ndustry VS inferiority (collections)

• E – limination and explore

• M – odesty (privacy)

COMMON ACCIDENTS
• P – eers (own sex)
P – revent further absorption
O – ff, shower or wash off
• L – oss of control  hospitalization, encourage
decision making
I - dentify
S - upport • E - xplaination of procedures
O – ngoing safety education
N – otify local poison control center ADOLESCENT (12 to 18 yr)

PRESCHOOL (3 to 6 yr) • P – eer group  activities, peer pressure

• P – lay is associative/cooperative • A – ltered body image  don’t want to be seen

• R – gression is common
different

•
•
I – dentity – image  college or career
E – xplain procedures
•
•
R – ole diffusion
S – ame age group for room assignment
• S – eparation from peers