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G and D--General Overview

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INTRODUCTION
This is important information because nurses are directly responsible for assuring growth & development. All children pass through predictable stages of growth & development as they mature. Parents often will ask a nurse what to expect from their child regarding developmental progress.

NURSING PROCESS OVERVIEW

Assessment should include:

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

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

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

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

Evaluation Evaluation for specific milestones must be ongoing

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to be accurate & useful because many children do not test well until school age. It also provides a chance for early detection of various problems.

IMPORTANCE OF KNOWLEDGE TO THE ROLE OF THE NURSE

Health Promotion & Illness Prevention Determining a child's developmental stage is often the primary focus of a health interview. Parents also need periodic anticipatory guidance regarding their child's development. Examples: Discussing additional home safety with a parent when a child is approaching the age for creeping. Cautioning the parents of a 1-year-old that the child's appetite may decrease during the coming year. Anticipatory guidance must be offered at the appropriate time or it's useless. Given too early it's forgotten. Given too late, issues may be ignored or addressed in a poor manner (one that is not growthenhancing)

Health Restoration & Maintenance: Caring for the sick or surgical child patient. Understanding the child's developmental stage helps in choosing the right words to explain an illness or procedures. Physical growth is another important factor to consider. Disease affects children differently at various stages of growth.

PRINCIPALS OF GROWTH AND DEVELOPMENT

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Children do not merely grow taller & heavier. Maturing involves growth in ability to perform skills, to think, to relate to people, to trust, to have confidence in oneself. Growth - refers to increase in physical size such as weight & height (quantitative change). Development (maturation) - refers to increase in skill or ability to function & it is measured by observing a child's ability to perform a specific task (qualitative change). Psychosexual development (Freud) - refers to developing instincts or sensual pleasure. Psychosocial development (Erikson) - refers to personality development Moral development (Kohlberg) refers to growing to know right from wrong. Cognitive development (Piaget) - refers to the ability to learn & understand from experience, acquire & retain knowledge, respond to new situations & solve problems. It is measure by intelligence tests & observation of the child. Patterns Neurologic tissues (spinal cords and brain - mature by 2-5 years) and lymphoid tissue (spleen, thymus, lymph nodes & tonsils) grown rapidly during infancy & childhood. The reproductive system shows little growth until puberty. There are several principals of growth & development you must remember: Growth and development are continuous processes from the day we are conceived until death. Growth and development proceed in an orderly sequence. Different children pass through the predictable stages at different rates. All body systems do not develop at the same rate. Development is cephalocaudal (from head to toe). Development proceeds from proximal to distal body parts. Development proceeds from gross to refined motor skills. There is an optimum time for initiation of experiences or learning.
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Neonatal reflexes must be lost before development can proceed A great deal of skill and behavior is learned by practice.

FACTORS INFLUENCING GROWTH AND DEVELOPMENT

Genetics (ex: temperament) & environmental (ex: nutrition) influences are the two primary factors in determining a child's pattern of growth & development. Genetics Can influence learning style and temperament Gender - On average females are born weighing & measuring less than males. Girls begin their puberty growth spurt 6 months to a year earlier than boys. Health - A child who inherits a genetically transmitted disease may not grow as rapidly or develop as fully as the healthy child Intelligence - Children with high intelligence tend to advance faster in skills & may fall behind in physical skills because they spend more time with books or such than developing motor skills. Temperament Refers to the usual reaction pattern of a person or their manner of thinking, behaving or reacting to stimuli in the environment. Nursing Research has shown significant correlation between infant temperament & postpartum depression Reaction Patterns - There are nine characteristics of a reaction pattern & include the following: Activity Level - Child may have a high or low activity level or in between, all are normal. Rhythmicity - Child may have a regular rhythm, have a predictable schedule of doing things or Child may have an irregular rhythm, always changing their routines day to day. Approach - Child approaches new situations
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without apprehension, in an unruffled manner or Child approaches anything new with withdrawal and crying. Adaptability - Refers to the ability to adapt to something new over time. An example here is that one child may cry on its first tub bath but get use to it by the 3rd bath or another child never seems to adapt to the tub bath and cry's for months over the tub bath. Intensity of the reaction - Some children react to situations crying loudly, thrashing their arms & such while others have mild or low-intensity reactions to stress. Distractibility - Children who are easily distracted are easier to manage, others who cannot be distracted are considered stubborn & willful. Attention Span and Persistence - Refers to ability to remain interested in a project or activity. Some children will play alone with a toy for hours while others will play no more than 1-2 minutes with each toy. Threshold of Response - Refers to how intense the level of stimulation has to become to receive a response. A child with a low threshold needs little stimulation to get a reaction & a child with a high threshold needs intense stimulation to get a reaction. Mood Quality - Child who is always laughing and happy is said to have a positive mood quality.

**Categories of Temperament:
The Easy child - has predictable rhythmicity, approach & adapt to new situations, mild to moderate intensity of reaction, overall positive mood quality. Rated by parents in 40%-50% of children. The Difficult Child - is irregular in habits, has a negative mood quality, and withdraws from new situations. Rated by parents in 10% of children. Slow-to-Warm-Up Child - is overall fairly inactive, responds only mildly & adapts slowly to new situations with a general negative mood. Rated by parents in 15% of children. Mixed Group Child

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(Be careful with such 'labeling' ladies & gentlemen J )

Nursing Implications Regarding Temperament

Parents should be talked to about reactivity patterns because they tend to persist. They need to understand that it is their child's method of coping, such understanding can help parent's accept & respect the child as individual. A child who is slow to adapt may need to have a procedure explained several times to be able to accept it. Mild or intense reactivity patterns influence how the child will react to pain - for example the child who has acute pain barely makes a sound versus the child with mild pain screams & cry loudly. Temperament can also influence breastfeeding. An important fact for a new breastfeeding mom. New research has found a significant correlation between infant temperature and postpartum depression.

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Environment Can include stress (teach coping methods such as listening to music play). Inadequate nutrition due to low socioeconomics, inadequate care giver skills and attention, chronic illness (resulting in decreased appetite) and endocrine disorders which can be regulated with diet or medications (from the external environment). Socioeconomic Level Food costs money, a child in a low-income family may not receive proper nutrition. Health care costs money, therefore poor health supervision could result in no immunizations, which has many implications. Parent-Child Relationship
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Front Page

Erikson's 8 Stages of Development

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Children who are loved thrive better than those who are not. It is the quality of time not the amount. Cultural norms in the family play a role in when a child is expected to achieve particular development milestones. Ordinal Position of the Family The position of a child in the family will have some bearing on his or her growth and development. Health Diseases can come from environmental sources and influence growth and development. Treating a child as if he or she is sick or vulnerable to sickness refers to - fragile child syndrome. Nutrition Quality of a child's nutrition prenatally and during the growing years influences their external health and stature. Poor maternal nutrition can limit growth and intelligence. Poor nutrition limits the body's ability to resist infection. Lack of calcium can lead to rickets (shortening or bowing of long bones). And lack of vitamins can lead to vision impairment and poor healing. Establishing healthy eating patterns early on life can contribute to better health in the adult years. The tendency for being overweight may be inherited but being overweight early in life can also play a role. Fat intake does not need to be restricted for the first 2 years of life. A percentage of fat is needed for myelination of nerves. Whole-grain cereals & raw fruits such as apples provide fiber. Olestra, a synthetic fat should not be used by children because fat-soluble vitamins may be excreted with this product. Too much sugar can result in dental caries & obesity. Soft drinks, candy & chocolate are empty calorie foods. Salt/sodium should be moderate. Salt is an acquired taste. If it is not introduced to a

Growth & Development: General Overview

Growing Old in a New Age >>A video instructional series on aging for college and high school classrooms and adult learners; 13 one-hour video programs and coordinated books Learn about the impact of aging on both society and individuals as 75 diverse elders relate their experiences. The four ways that age is measured chronologically, biologically, psychologically, and socially are the basis for discussing the quality of life in later years. The series examines common misconceptions about aging and provides a springboard for analyzing new roles for elders, intergenerational alliances, resource allocation, and artificial attempts to prolong life. These programs are particularly useful for students of psychology, gerontology, sociology, family studies, human development, and health sciences.

Produced by The University of Hawaii Center on Aging. 1993.

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child or is moderate they do not develop a desire for heavily salted foods. Protein - is essential for growth with its amino acids. Carbohydrates - provide the main fuel, especially for the neurological system (i. e. your brain) and the actively growing brain cells of infants and toddlers. Fats - are needed for myelination of nerve fibers in infants. Also provide energy and insulation. Vitamins - do not produce energy but that help the cells to do so. ADE & K can only be absorbed in the presence of fat molecules. Thus another need for some fat in the diet. Water-soluble vitamins (B complex & C) cannot be stored in the body and must be taken daily. Minerals - are needed to build new cells and regulate body processes i.e. calcium. Macronutrient - is a (major) mineral that you need more than 100mg of daily. Micronutrient - is a (minor) mineral that you need less than 100mg of daily. Trace minerals - are only needed in small amounts. Careful assessment and family education are needed for families who practice vegetarian diets to ensure adequate nutrition for growth during childhood. May review details in a dietary book.

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SELECTED THEORIES OF DEVELOPMENT

A developmental task is a skill or a growth responsibility arising at a particular time in an individual's life.

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Freud's Psychoanalytic Theory

Describes child development as psychosexual stages in which interests become focused on a particular body site. Infant - Oral phase - Infant sucks for enjoyment or relief of tension, as well as for nourishment. Toddler - Anal phase - Children find pleasure in both the retention and defecation of feces; Part of self-discovery and a way of exerting independence. Preschooler - Phallic phase - Children may show exhibitionism; Leads to increased knowledge of the two sexes. School-Age Child - Latent phase - Libido (energy) appears to be diverted into concrete thinking. Adolescent - Genital phase - Establish of new sexual aims and finding of new love objects. Criticisms of Freud - Based theory on observations of the mentally ill or what people should do to avoid mental illness. This theory looks at illness rather than wellness, which limits its applicability to the promotion of health.

Erikson's Theory of Psychosocial Development

Stresses the importance of culture and society on personality development. Where Freud looked at ways that mental illness develops, Erikson looked at actions that lead to mental health and describes eight stages across a life span. At each stage there is conflict between two opposing forces. Infant - Trust vs. mistrust - or learning confidence or learning to love. Infants whose needs are met i.e. discomforts quickly removed, who are cuddled, fondled, played with, and talked to view the world as safe & people as helpful & dependable. Those with unmet needs develop distrust and become fearful and suspicious of the world and people. Trust vs. mistrust arises again at each successive stage of development. Toddler - Autonomy vs. shame - autonomy meaning self-governance or independence builds on children's new motor & mental abilities. Children take pride in new accomplishments and want to do things independently. Toddlers need to do what
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they are capable of doing & will develop a sense of being able to control muscle & impulses. Toddlers are independent people. Caregivers who are impatient and do everything for them enforce a sense of shame and doubt. If they aren't allowed to do they doubt their ability to do. Preschooler - Initiative vs. guilt - Learning initiative is learning how to do things. Children can initiate motor activities of various sorts on their own. Giving freedom & opportunity to initiate motor play i.e. running, bike riding, sliding, wrestling, or play with materials such as finger paints, sand, water & modeling clay; Parent's answering questions; Not inhibiting creative or fantasy play, all enforce their sense of initiative. If they are made to feel their motor activity is bad, questions are bothersome, play is silly or stupid they may develop guilt instead. School -Age Child - Industry vs. inferiority - Here children are interested in doing things well. They want to know if they are doing a good job or doing it right. Children who are encouraged, praised and rewarded develop a sense of accomplishment and thus a sense of industry. Parents who view activities as mischief or don't show appreciation for their child's work may develop a feeling of inferiority. Children whose sense of industry has been destroyed at home may be revitalized by a committed teacher or nurse. Adolescent - Identity vs. role confusion - At this time adolescent must integrate all the different images of themselves i.e. son, daughter, friend, student, scout and so on into a whole that makes sense. If they are unable to do this they experience role confusion & are unsure of the kind of person they are. They may seek a negative identity preferable to no identity at all. The Young adult - Needs to achieve a sense of intimacy as opposed to isolation - Intimacy means they can relate well with other people and form long-lasting relationships. The Nursing implications: Women without a sense of intimacy may have more difficulty accepting a pregnancy & beginning to love a newborn child. The Middle Age person - Needs to develop a sense of generatively in which they extend their concerns to the community and outside world. Those whose develop this are able to juggle their various lives and are self-confident. Those without this sense
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become stagnated or self-absorbed. The nursing implications: Women without a sense of generatively may have more difficulty accepting a pregnancy & a new role of childbearing & childrearing. Criticisms of Erikson's Theory Is that life does not occur in easily divided stages.

Piaget's Theory of Cognitive Development

Include the Sensorimotor Stage, Preoperational Thought, Concrete Operational Thought & Formal Operational Thought. Piaget defines stages of cognitive development Sensorimotor Stage Infant - Babies relate to the world through the senses, using only reflex behavior. As infants progress they learn the concept that people are entities separate from their environment. Learn that objects in the environment are permanent & continue to exist even though they are out of sight or changed in some way (infants know their parents exist and will return to them). Eight-month anxiety - is when the infant continues to cry for their parents because they know their parents still exist even when out of sight As infants further progress they demonstrate goal-directed behavior and actively seek new experiences. It is important to have enough stimulating objects around for exploring so that experimenting & learning can proceed in this way. Preoperational Thought Toddler - Toddlers begin to develop some cognitive skills such as symbolic thought and egocentric thinking. During preoperational thought children are able to use symbols to represent objects. Preschooler - Develop intuitive-thought, a tendency to look at an object and see only
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one of its characteristics (referred to as centering). An example of centering is a child observes that their medicine tastes bad but does not understand it will also help them. Preschool thinking is also influenced by role fantasy, or how children would like something to turn out. They also use assimilation, taking information and changing it to fit their existing ideas. They believe wishes are as real as facts, that dreams are as real as daytime happenings and perceive animals & even inanimate objects as being capable of thought & feeling. Later they learn accommodation (they change their ideas to fit reality rather than the reverse). Egocentrism is also strong during this period (perceiving their own thoughts & needs as better or more important than those of others). Concrete Operational Thought School-Age Children - are able to discover concrete solutions to everyday problems and recognize cause-and-effect relationships. Reasoning during school age tends to be inductive, proceeding from specific to general. Formal Operational Thought Adolescents - Are capable of thinking in terms of possibility, such as what could be, rather than limited to what already is. This makes it possible for adolescents to use scientific reasoning. Criticisms of Piaget's Theory He only used a small sample of subjects, his own children.

Kohlberg's Theory of Moral Development

Is a theory on moral reasoning or the way that children gain knowledge of right and wrong. Recognizing these stages can help identify how a child may feel about their illness & whether the child can be depended on to carry out self-care activities such as self-administered medicine.
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Preconventional (Level I) About 2-7 years old Infants - have little concept but they do learn that when they do certain actions, parents give affection and approval. To support this caregivers should give praise when infants do what they are asked to do. The average infant is trying hard to please but probably falls short due to immaturity. Infants who have developed a sense of trust are better able to develop a spiritual orientation in future years & thus be bound by a moral conscience. Toddlers - reason for doing the 'right thing' is centered most strongly in mother or father 'saying so', rather than spiritual or societal motivation. However, they may not obey requests from people other than their parents as they do not view their authority at the same level (may be necessary for parents to reinforce instructions). Preschoolers - tend to 'do good' out of selfinterest rather than out of true intent to do good or because of a strong spiritual motivation. Children at this age imitate what they see, so if they see less-than-perfect role modeling, they may copy these wrong actions & assume those actions are correct. Because of egocentrism, a preschooler will do things for others only in return for things done for him or her. Ex: Lie still while I change your dressing and then we'll play in the playroom when I'm through. Conventional (Level II) About 7-12 years old School-age Child - enters the conventional development stage, the level at which many adults function. Young school-age children may lie about their actions to disguise that they have been involved in an action that is not 'nice.' This age group may have trouble following self-care measures reliably when out of a nurses or parent's sight, because they feel it is necessary to obey rules only when the rules can be clearly enforced. Postconventional (Level III) Greater than 12 years old Adolescents - are capable of internalizing standards of conduct (they do what they think is right regardless of whether they have social rules). They are capable of
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carrying out self-care measures even when someone else is not present & are capable of understanding the importance of measures to themselves & that certain things should simply be done because they are right. Criticisms of Kohlberg's Theory Challenged as being male-oriented research because original research was done entirely on boys. (See Susan Gilligans In a Different Voice. Additionally see Susan Hoff Sommers The War on Boys)

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