p.

Abdomen – umbilicus, sape, bowel sounds, hernias, liver,

Growth and Develiopment spleen, kidneys, masses/tenderness
Dr Daphne Miranda q. Genitalia
PEDIATRIC NURSING HEALTH ASSESSMENT female – stage of sexual devt, vulva, meatus, ext
genitalia, discharge, lesions
male – sexual devt stage, penis, scrotum, testes, urinary
•General considerations meatus, discharge, lesions
1. Child r. Anus – fissures, bleeding
- maintain eye contact, bend to child’s level s. Musculoskeletal – muscle size, strength, posture, body
- Use appropriate language alignment, symmetry, ROM, gait, joint mvmt, swelling,
- Allow child some warm up time redness, tenderness
- Respect child’s response, need for privacy t. Neurologic – cerebral function, cranial nerve function,
- Incorporate play DTR’s, balance and coordination
2. Family Considerations
- encourage parents participation DEFINITION
- choose quiet environment for teaching and assessment Growth
- ask open ended questions - size, cm, kg
- Focus on information needed or problem Development
- Listen attentively, respect response, provide feedback - skill
- encourage questions - complexity of function
Health History
IMPORTANCE OF KNOWLEDGE OF GROWTH AND
•Biographical data DEVELOPMENT
•Chief complaint 1. Health promotion and Illness prevention
2. Health restoration and maintenance
•Current or health status
STAGES OF GROWTH and DEVELOPMENT
•Past health A. 1st
•Review of systems Prenatal – conception – birth
B. 2nd
•Family history Neonate - birth - 28 days
Infant - 1 month - 1 yo
•Nutritional history C. 3rd
Toddler - 1 - 3 yo 1-6 yo (early childhood)
•Psychosocial history – home and family structure, school Preschool - 3 - 6 yo
and work, activity and discipline assessment, sexual and D. 4th
substance abuse assessment of adolescents School age - 6 - 12 yo (middle childhood)
Age related interview techniques Adolescence - 13 - 18 yo
Infant: speak softly, allow infant to identify you w/ a parent,
use touch PRINCIPLES OF GROWTH and DEVELOPMENT
Toddler: allow toddler to stay close to parent, focus on 1. Continuous
favorite toy or unique characteristics of child 2. Orderly and sequential
Preschooler: use simple questions and words, 3. Highly individualized
allow child to manipulate equipment, use puppets 4. Different rates
and play 5.Cephalocaudal
School age: offer explanations, teach about health, provide 6. Proximodistal
demonstrations Adolescents: maintain confidentiality, 7. Simple to complex
facilitate trust, open and honest communication, 8. Sensitive periods
nonjudgmental 9. Practice
Physical Assessment
- Complete less threatening and less intrusive procedure first FACTORS THAT AFFECT GROWTH and DEVELOPMENT
to secure child’s trust Explain actions, what child should
expect and let child manipulate equipment I. Genetics
Developmental Approaches a. Gender
a. Infant: allow infant to sit on parent’s lap, encourage b. Health
parents to hold infant, use distraction, enlist parent’s help c. Intelligence
b. Toddler: allow toddler to sit on parent’s lap, enlist parent’s d. Temperament
assistance, use play, praise cooperation
c. Preschooler: use storytelling, doll, and puppet Types of temperament
d. School age: maintain privacy, explain procedure and Easy children – even tempered, regular and predictable;
teach child about body react to stimuli positively
e. Adolescent: provide privacy and confidentiality, provide Difficult children – irritable, highly active and intense; react w/
options negative withdrawal
Head to toe assessment Slow to warm up – moody, inactive and moderately irregular;
a. Measurements react w/ mild but passive resistance
- height and weight, head circumference < 2 yo
b. General Appearance – alertness, LOC, physical Nursing Management
appearance, nutritional state, hygiene, behavior,
interaction w/ parent and nurse, overall development •Understand variations
c. Skin – color, texture, turgor, temperature, lesions, scars,
edema, tatoos •Provide parents information
d. Hair – distribution, characteristics, lice
e. Nails – texture, shape, color, condition
•Provide health education esp for families of children w/
illness
f. Lymph nodes – swelling. Mobility, temperature,
tenderness •Assess development
g. Head – size, shape, symmetry, fontanelles
h. Eyes – visual acuity FACTORS THAT INFLUENCE GROWTH AND
i. Ears – hearing acuity DEVELOPMENT
j. Nose and sinuses – discharge, tenderness II. Environment
k. Mouth – tooth eruption, condition of hums, lips, teeth, a. Socioeconomic level
palates, tonsils, tongue, buccal mucosa b. Parent-Child Relationship
l. Neck – suppleness and range of motion c. Ordinal position in the family
m. Chest – shape, breasts, discharge, lesions d. Health
n. Lungs – breath sounds
o. Heart – sounds, murmurs, rubs THEORIES OF GROWTH AND DEVELOPMENT
Developmental task
 Stage 2 - 4-7 yo
- skill or growth responsibility arising at a particular time “mother says it’s wrong”
in an individual’s life individualism/egocentrism
- foundation of accomplishment of future tasks Conventional (Level II)
Stage 3 – 7-10 yo
Erickson’s Theory of Psychosocial Development “nice girl, nice boy”
Trust vs Mistrust -infant
T: safe environment; dependable people Stage 4 – 10-12 yo
M: suspicious, fearful, shun emotional involvement following rules is satisfying
NI: provide primary caregiver and visual stimulation “Law and Order”
Autonomy vs Shame and Doubt – toddler Postconventional (level III)
A: build on new motor and mental abilities, take pride in Stage 5 & 6 - >12
accomplishments following standards for everyone’s good
S: doubt and stop trying
NI: provide opportunities for decision making and give “Social Contract”
praises “Principled conscience”
Initiative vs Guilt – preschool
I: how to do things Harry Sullivan
G: limited brainstorming and problem-solving skills Prototaxic mode – infancy – need for bodily contact and
NI: provide opportunities for exploration, answer questions love; anxiety d/t unmet needs
and do not inhibit fantasy Parataxic mode – 2-5 yo - parents viewed as source of
Industry vs Inferiority - school age praise and acceptance
Ind: how to do things well Syntaxic mode – 5-8 yo - logical, rational and most mature
Inf: always worried about poor or incorrect performance type of cognitive functioning; need for peers and how to deal
NI: provide opportunities for completing short projects, give w/ them
praise and rewards
Identity vs Role Confusion – adolescent DEVELOPMENTAL AGE PERIODS
I: integrate image into a whole
R: unsure of who they are or who they can become, may Characteristics
rebel Growth and Development Milestones
NI: provide opportunities to discuss feelings and support and Reaction to Illness
praise for decision-making
INFANCY – 0-1 yo
Freud’s Psychoanalytic Theory
Oral – infant •4-6 mos -2x birthweight
- oral stimulation for nutrition, enjoyment and release of - 1ST 6 mos – 2 lb/mo; 2nd - 6 mos – 1 lb/mo
tension 1 yo - 3x birthweight
NI: provide oral stimulation – pacifiers, breastfeeding, HC=CC 6-12 mos
thumbsucking 50% inc in height;
Anal - toddler - 1st 6 mos – trunk; 1 in
- elimination is a way of discovery and exerting - 2nd 6 mos – legs
independence
NI: achieve bowel and bladder control even if
•2/3 brain growth
hospitalized •HR 100-120 bpm
Phallic – preschool
- increased knowledge of 2 sexes •RR 20-30
NI: accept sexual interest and answer questions about birth 12-18 mos - Ant fontanel
or sexual difference · 2 mos - Post fontanel
Latent - school age - Immune system
- libido diverted to school · 4 mos - Liquids to solids
NI: achieve positive experiences to promote self esteem · 6 mos - Shivering
Genital - Adolescent - Tooth eruption
- establish sexual aims and finding new love objects · ECF 35%, ICF 40%
NI: opportunities to relate w/ opposite sex; verbalization
about new feelings
•Health visits – 2 weeks, 2 mos, 4 mos, 6 mos, 12 mos
Piaget’s Theory of Cognitive development

Sensorimotor 1 mon-24 mo
GROWTH AND DEVELOPMENTAL MILESTONES
- relate through senses, separate from environment,
practical intelligence GROSS MOTOR
2 mos - 45 deg head ctrl
Preoperational Thought 2-7 yo
toddler: symbolic thought, simple abstractions, literal 3 mos - 90 deg head ctrl
4 mos - lifts head & chest on prone
thinking, poor concept of time and distance, transductive
reasoning - rolls over
5 mos - 6 mos - good head ctrl
pre-schooler: centering, egocentric, no reversibility, no
cause and effect, assimilation, role fantasy - sits w/ support
8 mos - sits w/o support
Concrete Operational Thought 7-12 yo
- systematic reasoning 9 mos - pulls self to stand
- creeps
- memory to learn broad concepts and subgroups
- seriation and classification 10-11 mos – cruises
12 mos – stands alone; walks with someone’s hands
- reversibility
- inductive reasoning (specific to general)
FINE MOTOR
- conservation (7 yo – numbers; 7-8 yo quantity; 9 yo –
weight; 11 yo – volume) 1 mo - eyes to midline
3 mos – eyes past midline
Formal Operational Thought 12 yo
- solve hypothetical problems, causality, time 4 mos –bring hands together
5 mos – grasps/reaches obj
- talk time to sort attitudes and opinions
6 mos – holds obj in 2 hands
7 mos - hand to hand transfer
9-10 mos - pincer grasp
Kohlberg’s Theory of Moral Development - points at obj
Preconventional (Level I) 11 mos - bangs objects together
Stage 1 - 2-3 yo 12 mos - throws toys
“mother or father says so” - attempts 2 tower blocks
punishment obedience orientation LANGUAGE
1 mo - throaty gurgling sound Water – 125-150 ml/k/day from 0-6 mos
2 mos - differentiate a cry - 135 ml/kg/day from 6-12 mos
3 mos - squeals DAILY CARE
4 mos - coos and gurgles - bathing
- moves head to sound - diaper care
5 mos - simple vowel sounds - care of teeth
7-8 mos - “ma” when crying - dressing
9 mos - mama, dada; understands no-no - sleep – 10-12 hrs/day; 1 or more naps by 12 mos old
10 mos - understands gestures - exercise
- responds to name Concerns
12 mos - obeys commands - Constipation
- one word other than mama, dada - Teething – cleanliness
PERSONAL SOCIAL - thumb sucking – until school age
2 mos - social smile - pacifiers – wean after 3 mos
4 mos - plays with rattle; enjoys social interaction - head banging – begin 2nd half of infancy to
7 mos - feeds self w/ crackers preschool, naptime, under 15 min
- recognizes familiar faces - sleep problems – breastfed infants wake up sooner;
8 mos - peek-a-boo - spitting up
- stranger anxiety - diaper dermatitis
9 mos – waves bye bye - miliaria/prickly heat – papular, erythematous on neck,
10 mos – nursery games ear, face, trunk
11 mos – holds arm or foot out in dressing - baby bottle syndrome
12 mos – attempts to use spoon; shows jealousy and - Loose stools – breastfed
affection - Colic – paroxysmal abdominal pain, < 3 mos, inc in formula
PLAY – solitary play fed
1-3 mos - Obesity – 32 oz formula daily, add fiber and water to diet
- Stranger anxiety
•Balloon mobiles REACTION TO ILLNESS
•Mirror play Discomfort and pain
Lack of stimulation
•Stuffed animals Separation anxiety
Disruption of routine
•rattles NURSING CARE
•Being held Soothing stimulation
Toys from home
4-6 mos Human contact
•Squeeze toys Provide/Anticipate needs

•Busy boxes TODDLER – 1 –3 yo

TODDLER – holding on, letting go
•Play gyms
7-9 mos •Slowed growth
•Block play •Wt gain 5-6 lbs (2.5 kg)
•Splashing bath toys •BW quadruples 2.5 yo
•Cloth textured toys •5 in (12 cm)
•Large balls •Baby fat disappears
10-12 mos
•brain 90 % adult size
•Picture books •CC > HC; inc by 2 cm
•Large blocks •HR 90 bpm
•Nesting cups •BP 99/64
PLAY
TODDLER
•Peek-a-boo •Protruberant abdomen
•Rocking •bowlegged
•Singing games •Stomach capacity increases
•Squeaky toys •Control of urinary and anal sphincters
•Pat-a-cake •IgG and IgM
•Peek-a-boo •20 deciduous teeth
•Feet & toes games
GROWTH AND DEVELOPMENTAL MILESTONES
•Fingers & hand games Gross
•Listening to stories •15 mos – walks alone well
•Making faces •18 mos – run and jump in place
NUTRITION - walk up & down stairs holding on to railing
Lipase – dec until 1 yr - seat self in chair
Amylase – dec until 3 mos
Immature liver – inefficient storage and formation of nutrients •24 mos – walks up & down stairs one step at a time
Extrusion reflex – until 4 mos
Calories: 100-115 kcal/kg/day •2 ½ yo – tiptoes, jumps
0-3 mos - breastmilk
4-6 mos - semi-solid food
•3 yo - throws balls, rides tricycles
- stands on 1 foot momentarily
Introduce one at a time Fine motor
Start with small quantities
Cereals, strained vegetables, meat •15 mos - 2 tower blocks, scribbles
7-9 mos - Finger food, fluids
10-12 mos – 3 meals w/ snacks •18 mos – 3-4 tower blocks
 Accidents
•24 mos – vertical stroke Rituals
•30 months – 8 tower blocks Egocentrism
Fears: loss of parents, loud noises, going to sleep, large
LANGUAGE
animals
•15 mos - vocalizes wants
- jargon Sibling rivalry
- 3 words other than dada, mama Discipline
-consistent, planned, private, initiated after behavior
•18 mos - uses phrases Separation anxiety – 18 mos
•2 yo - short sentences; 2-3 words; 300 words Transitional objects
- pronouns REACTION TO ILLNESS and NURSING INTERVENTIONS
- points to one body part
•2 ½ - full name fear of separation - Assure of parents return
phases: protest, despair, detachment
•3 yo - speaks fluently using longer sentences Defense mech: Regressive behaviors - reassurance
- tells stories Nutrition – allow finger food
- plurals Dressing changes – allow to pull off tape
PERSONAL/SOCIAL Medication – allow choices of “chaser” after oral medication
Hygiene – allow choice of bathtime toy, allow to put
•15 mos - pats pictures toothpaste
- imitates housework Pain – allow to express pain
•18 mos - turns page 2-3 at a time Stimulation
Elimination – continue potty training
- uses spoon
Rest – allow choice of toy at bedtime
•2 yo - removes garments
- toilet trained by day (2-3 yrs old) PRE SCHOOL 3-5 yo
PRE SCHOOL
•3 yo - dry by night (3-4 yrs old) Future body build apparent
- washes and dries hands Increased skeletal growth
NUTRITION Handedness
•Decrease in appetite/ Physiologic anorexia 5 yo - may have permanent teeth
Tonsils inc in size
•picky eaters, food jags IgG and IgA increases
PRE SCHOOL
•Milk – 1L/day
HR 85 bpm
•1, 300 kcal/day BP 100/60
•Single food instead of mixtures 3 - 5 kg/yr
2 - 3.5 in/yr
•Allow self feeding Frequent voiding
•Allow choice between 2 types of food
•Offer finger food Gross
GROWTH AND DEVELOPMENTAL MILESTONES

•Risk of aspiration 3 1/2 yo - stands on 1 foot 5 sec

PLAY - parallel play - upstairs on 1 foot/step; down 2 feet /step
- imitation 4 – 4 ½ - climbs stairs
- hops on 1 foot, skip
•Babbling and talking - catch ball
5 yo – heel to toe walk
•Ball games - skips Alternate foot and runs
•Clay - throw and catch a ball, jump rope, balance on
alternate feet
•Listening to music FINE MOTOR
3 yo – copies circle, imitates cross
•Listening to stories 4 –4 1/2
•Large blocks - draws man w/ 3 parts
- copies square, trace diamond
Making music and noise - lace shoes
•Push and Pull toys 5 yo - copies triangle and diamond
- writes alphabet, first name
•Puppet play LANGUAGE
3 ½ yo - knows sex
•Scribbling - counts to 3 or more
•Stack-and-dump toys - 900 words
4 yo - exaggerates and boasts
DAILY CARE
- 1, 500 words
- dressing – can put on socks, underpants, undershirt
- sleep – 8-12 hours sleep w/ 1 nap - why questions
5 yo- talks constantly
- bathing
- care of teeth - 2, 100 words
PERSONAL/SOCIAL
CONCERNS
3 ½ yo - dresses w/ supervision
•Toilet Training - separates more easily from mother
bowel control – 18 mos 4 yo – buttons up
daytime bladder ctrl – 2-3 yo 4 ½ - dresses w/o supervision
nighttime bladder ctrl – 3-4 yo 5 yo – uses a knife, spoon fork; focus on social aspects
CONDITIONS: of eating
1. control of sphincters NUTRITION
2. cognitive understanding Slow/Steady growth
3. delay immediate gratification Decreased appetite
4. mature nervous system Reject vegetables, mixed dishes, liver
* Should not be initiated during times of stress Offer small servings
Negativism Discourage “grazing” – eating small amounts of non
Temper Tantrums – “extinction”
nutritious food
Healthy snack food •St 2 – enlargement of testes and scrotum; rugae, reddening
PLAY – associative play of scrotum

•Dress up clothes •St 3 – further enlargement, lengthening of penis

•Housekeeping toys •St 4 – increase length and width of penis, devt of glans,
darkening of scrotum
•Dolls and other toys for pretending •St 5 – adult configuration
•Bikes and climbing toys
GROWTH AND DEVELOPMENTAL MILESTONES
•Paper and crayons 6 yo – skip, jump, tumble, hop, ride bicycle, walk a straight
•simple crafts line; first molars
7 yo – central incisors; sexual differences seen in play; quiet
•Large blocks play
DAILY CARE 8 yo – improved coordination; playing w/ gang important;
- accidents – bicycle safety, seat belts eyes fully developed
- dressing – choose own clothes GROWTH AND DEVELOPMENTAL MILESTONES
- sleep – 11-13 h per day; resist taking naps 8 yo – script writing
- exercise – very active 9 yo – all activities done w/ gang
- bathing – can wash and dry hands; need - hero worship; adult articulation;
supervision 10 yo – more improved coordination
- care of teeth – independent brushing; 1st dental visit - well mannered w/ adults
CONCERNS 11 yo – active but awkward
- imitation - mixed sex activities
- Oedipus and electra complex 12 yo – coordination improves
- gender roles – need exposure to parents of opposite sex - joins organizations
- Socialization – capable of sharing PERSONAL/SOCIAL/PLAY
- Discipline – “time out” Competitive play and recreational activities
- Common fears – dark, mutilation/castration, separation, Hobbies and personal interests
animals, ghosts •Arts and crafts
- Telling tales
- Imaginary friends •Biking
- sharing – define limits and teach property rights •Board games
- Regression –reaction to stress
- Sibling rivalry
•Clubs
- sex education •Collecting items
- pre-school center •Chess
- broken fluency
- swearing •Comic Books – ability to read one of most significant skills
- High energy level NUTRITION
- Curiosity Good appetite
REACTIONS/CONCERNS IN ILLNESS AND NURSING May go on food jags
INTERVENTIONS Food w/ high nutritional value
- nutrition – food in animal/alphabet shapes - more calories and nutrients
- dressing change – allow to measure, cut tape, see - hungry after school – give snacks and make mealtimes
incision site enjoyable
- medication – allow to choose “chaser” DAILY CARE
- hygiene – allow choice of toys, wash hands and face - dressing – influenced by peers
- pain – allow pain expression, handle syringe, analgesic - sleep – 8-12 hrs; no naps
- stimulation - exercise – games, bike riding, walking
- hygiene – 8 yo – capable of bathing alone
School Age 7 – 11 yo - care of teeth – 2x yearly visit to the dentist; brush
SCHOOL AGE daily
* 6 yo – eruption of permanent teeth
•3-5 lb/yr - safety – bicycle, school bus safety,
•1-2 in /yr CONCERNS
prevention of falls and sports injuries

•10 yo – brain growth complete - problems w/ articulation – disappears 9 yo

- Sex education
•Adult vision - Stealing – 7 yo – importance of money
- Violence/terrorism – education;reassurance
•Abundant tonsillar and adenoid tissue - School anxiety and phobia, bullying, intimidating
•“innocent” heart murmurs -
teachers, something bad happening to parents
Recreational drug and alcohol use
•HR 70 bpm - Obesity
- nocturnal enuresis and encopresis (stool leakage;
•BP 112/60 boys > girls)
•28 permanent teeth REACTION TO ILLNESS AND NURSING INTERVENTIONS

•Pubertal onset •Cause of illness – external forces; aware of significance of

different illnesses
SECONDARY SEX CHARACTERISTICS
Female breast devt •Defense mech: reaction formation
•St 1 (prepubertal) -
-
Death and disability, immobilization - Still need comfort
Unknown events & procedures - Allow to help
•St 2 – breast buds w/ care & treatment
- Loss of ctrl & independence - Give choices
•St 3 – further enlargement of breasts and areola; no - Loss of contact w/ peers - Allow visits
separation of contours - Disruption of school - Talk about interests
- concerns over modesty
•St 4 – breast mound
•St 5 – adult configuration -nutrition – allow choices
- dressing – ask opinions on bulk of dressing and where
Male genitalia devt to apply tape
•St 1 – prepubertal - medicine – teach name and action,
choose form if possible
allow to
- body injury, pain – allow expression of pain, explain
source and cause
- stimulation

ADOLESCENT 13-18 yo
ADOLESCENT
•Girls taller than boys 2-8 in, 15-55 lbs
•Growth stops 16-17 yo
•Boys grow 4-12 in and gain 15-65 lbs
•Growth stops 18-20 yo
•Heart and lung size increase more slowly
•HR 70 bpm
•RR 20 breaths/min
•BP 120/70
ADOLESCENT
•Androgen inc sebaceous gland activity resulting in acne
•Apocrine glands inc activity
•13 yo – 2 molars
nd

•PUBERTY – capable of sexual reproduction

•Secondary sexual characteristics
GROWTH AND DEVELOPMENTAL MILESTONES
13 yo – sports
15 yo - enjoys privacy
- stays in room
16 yo - part time job
- charitable causes
NUTRITION
- faddish diet
- give responsibility for food planning
- increased calories, Ca, protein
DAILY CARE
- dressing and hygiene
- care of teeth
- sleep – need more sleep
- exercise – daily
CONCERNS
- Socialization – falling in love
- Obesity; Diseases – HPN
- Acne
- Body piercing
- Fatigue - emotional fatigue
- Menstrual irregularities
- Sexuality and sexual activity
- Poor posture
- Stalking – educate girls
- Substance abuse
- Suicide
- runaways
- discipline – firm, limit setting
REACTION TO ILLNESS AND NURSING INTERVENTION
Defense mech: Denial and displacement
Main issue – body image – educate and Allow participation
in tx decisions; compassionate understanding
Fears loss of control and independence - Respect privacy
and confidentiality
Fears injury and pain - Provide opportunities for self
expression
Separation from peers and lack of emotional support -
Approach w/ caring and understanding, age compatible
roommate, Phone at bedside
- Nutrition – food preferences
- Dressing – final appearance of dressing, and time for
changing
- Medicine – choice for injection site, teach name and
action
- Rest – time and length of rest periods
- Hygiene – respect modesty, extent of self care
- Pain – allow pain expression, ask for analgesics
- stimulation