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Nutrition and Child Development

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Tami Bland

on 30 August 2016

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Transcript of Nutrition and Child Development

Nutrition and Child Development
Tami Bland, DNP, CPNP
Infant
Supplement breastfed infants with Vit D
Top recommendation: breastfeed exclusively for 6 months and continue breastfeeding for full 12 months.
Not clinically significant whether fruits or veggies first.
No honey before 1 year!
Brush those teeth!!!
Wean between 6 and 12 months
1 month = eats 2-3 oz, every 2-3 hours
2-4 months = eats 3-4 oz every 3-4 hours
4-6 months = eats 4-5 oz, 4 times/day, begins rice cereal
6-8 months = eats 6-8 oz, 4 times daily, adds vegetables/fruits;
begin weaning to cup; may begin juices
8-10 months = eats 6 oz, 4 times daily, adds meats/finger foods
10-12 months = eats 6-8 oz, 4 times daily, eats soft table foods
feeds self with cup and spoon
Fluid Requirements: Newborn 140-160 mL/kg/day
Infant 100 mL/kg/day for first 10 kg
50 mL/kg/day for next 10 kg
Calorie Requirements: Newborn 105-108 kcal/kg/day
Infant 1-6 months 108 kcal/kg/day
6-12 months 98 kcal/kg/day
Breastmilk and standard formula has 20 kcal/oz
A young couple comes to your clinic for their prenatal visit and you are discussing infant feeding. The mother states that she is concerned that human breast milk may not provide all the nutrients that the baby needs. According to the American Academy of Pediatrics, if her baby is exclusively breast fed, when should the child begin receiving oral vitamin D supplementation?
Never
Within the first month of life
2 months
4 months
6 months
AAP recommends breastfed & formula fed <33 oz/day receive Vit D supplement.
Toddlerhood
A time of physiologic anorexia
Eat only at table or in high chair!
Small portions! (about 1 Tbsp/year)
Limit juice!!!
16 to 24 oz of low-fat milk.
3 meals + 2 snacks
Self-feeding.
Social meals.
Preschooler
Picky eating begins. Food choices establish life-long patterns. Education & guidance important.
Limit juice!!
Limit fast food
Include in meal preparation
Don't overfeed with large servings!
School Age
metabolic needs change through growth spurts
Nutritional teaching key!
family meals important
milk often neglected
Monitor closely for overweight and obesity
Need 2000-3000 calories per day (depending on activity level) due to rapid growth
Adolescent
Barriers to healthy eating
availability of "junk food"
lack of parental involvement
media messages
calcium very important, especially for girls
often using supplements for sports
Higher calorie/kg intake
Preterm Infant
Problems with feeding:
poor suck
uncoordinated suck
too small stomach
poor intestinal absorption
renal immaturity
complicated by any other medical problems
Breast is Best!! (but may need fortification)
Nurses have very important role in teaching parent how to feed their baby.
Fluoride for all babies with teeth getting formula made without tap water or fed breast milk.
Ounce for ounce, this age has the highest metabolic rate and intake requirements of all ages.
Cereal at 4 months (Fe content important)
6 lb newborn
424 ml/day
424 ml = 283 kcal
Within the first month of life
GROWTH MEASUREMENT
Anthropomorphic measurements include weight, length, and head circumference (up until age 2). Standing height begins
once child can stand.
Chest circumference
important in neonatal
assessment.
BMI calculations begin at 2 year
Appropriateness of value is age dependent

>85%: overweight

>95%: obese

>99%: severely obese
A single measurement of growth in a child is of limited use.
Growth over time, GROWTH VELOCITY, is
much
more important.

Neurologic System
head circumference is indicative of brain growth
posterior fontanel closes between 2 and 3 months
anterior fontanel usually open to 12-18 months for brain growth (may close by 9 months)
reflexive behavior replaced by purposeful movement
Primative Reflexes
righting (Labyrinthine)
parachute
Protective Reflexes
Moro
root
suck
asymmetric tonic neck
plantar and palmar grasp
step
Babinski (only one that lasts close to 1 year)
Periodic breathing
Increased risk for respiratory infection:
narrow nasal passages
more compliant trachea and chest wall
shorter and narrower bronchi and bronchioles
funnel shaped larynx
larger tongue
fewer alveolie
lack of IgA in upper respiratory tract
heart doubles in size over 1st year
HR 120-140 in newborn, 100 in 1 year old
BP increases from 60/40 to 100/50
peripheral capillaries mature to thermoregulation over first year
Teeth
natal and neonatal teeth may be associated with other anomalies
first primary teeth on average at 6-8 months starting with lower central incisors
average 12-month-old has 4 to 8 teeth
Digestion
decreased saliva for first 3 months
stomach capacity 0.5-1.0 oz at birth
amylase (carbs) and lipase (fats) deficient until about 5 months
immature liver - conjugation of bilirubin and medications immature
Stools
meconium stools for first few days
formula fed - less consistent, more loose, mustard color
newborns 8-10 stools per day
after newborn period many don't stool every day
straining with bowel movement normal
more susceptible to dehydration due to increased extracellular fluid
frequent urination
reduced renal perfusion
and reaches full maturity
by 2 years
newborn acrocyanosis and mottling is normal





thinner skin leads to increased absorption of topical medications and poorer temperature regulation
fetal hemaglobin (HbgF) in large amounts at birth - shorter lifespan then HgbA, so increased risk for anemia in first 2-3 months as HbgF replaced by HgbA
Iron storage only sufficient for about 6 months
Premature infants miss maternal transfer of iron during last 3 months
immunity from mom during the first 3-6 months due to IgG transfer
infant production of IgG about 60% at 1 year
IgM production begins at birth with IgA, IgD, and IgE gradually increasing
Brain 80% of adult size by 3 years
Myelinization complete around 24 months
Heart rate continues to decrease
BP continues to increase
easy to compress capillaries
alveoli increasing but not adult until 7 years
trachea and airways grow
but relatively small
large tonsils and
adenoids
short and straight
Eustachian tubes
stomach increasing in size - 3 meals a day
stool passage decreases in frequency
digestion still not mature
bowel control usually achieved by 3 years
adult bladder and kidney function by 16-24 months
urinary output 1 mL/kg/hour
decreased urinary frequency due to increased bladder capacity
lengthening of bones and strengthening of muscles
pot-bellied look due to weak abdominal muscles
slower velocity of growth compared with infant
growth is in spurts
average of 3-5 pounds and 3 inches per year
generally 1/2 adult height at 2 years
anterior fontanel should be closed by 18 months
head size more proportional at 3 years
1 month = lifts head momentarily when prone;
startle and rooting reflexes predominate
2 months = raises head 45 degrees
3 months = raises head and chest 90 degrees
4 months = rolls prone to supine, steady head control
with no head lag; moro reflex fading
5 months = rolls supine to prone
6 months = sits tripod; rolls in both directions;
most reflexes have disappeared
7 months = sits with no support
8 months = raises to sitting position unsupported
9 months = crawls rapidly
10 months = pulls to stand, cruises furniture
12 months = takes a few independent steps
Gross Motor Milestones
1 month = follows with eyes to
midline only; hands tightly fisted
2 months = places hand in mouth
3 months = reaches dangling object
4 months = bats at objects; reaches for
objects with both hands
5 months = grasps rattle at will
6 months = releases objects in hand to take
another; holds bottle
7 months = transfers objects
8 months = bangs objects together
9 months = gross pincer grasp (rakes)
10 months = fine pincer grasp
12 months = put objects in containers
Fine Motor Milesones
Cephalocaudal
Proximodistal
15 months = feeds self; turn pages in a book; builds a two block tower; points to one or more body parts

18 months = removes shoes; builds a three block tower; spontaneously scribbling

24 months = undress themselves, builds four block tower; copies a straight line
Fine Motor Milestones
12-15 months = walks well; throws ball underhand

18 months = runs; walks upstairs with hand held; pushes or pulls toys

24 months = walks unassisted up and down stairs; kicks ball; throws ball overhand; jumps with two feet off the floor
Gross Motor Milestones
Put the following gross motor milestones in the correct sequence:
A. sits without support
B. head control
C. rolls over
D. when prone, supports weight on forearms
E. pulls to stand


Put the following gross motor milestones in the correct sequence:
1. head control
2. when prone, supports weight on forearms
3. rolls over
4. sits without support
5. pulls to stand
Sight
Newborn: nearsighted, focuses at 8-15" at birth, prefers dark/light contrast
binocular vision by 4 months
full color vision by 7 months
Hearing
newborn hearing is as acute as adult and prefer parent's voice at birth
Smell
can differentiate smells at 1 week
prefers sweet from birth - develops nonsweet taste
Touch
may be most important for newborn
Sensoral Development
Development
Sensorimotor Period (birth to 2 years)
Use of reflexes (birth to 1 month)
sucking, rooting, grasping; use of senses
Primary circular reactions (1 to 4 months)
pleasure gained from a response causes repetition
Secondary circular reactions (4 to 8 months)
beginning of cause and effect
Coordination of secondary schemes ( 8 to 12 months
more
intentional
behavior
object
permanence
stranger
anxiety

Nursing application
toys and murals
for interesting
environment and
distraction
Cognitive - Piaget
Oral Stage
pleasure largely from mouth
greatest attachment is to mother

Nursing application
pacifier for painful procedures or encourage breastfeeding
Psychosexual - Freud
Trust Vs Mistrust
trust is fostered by basic needs being met
fosters optimism

Nursing application:
hold often, especially after painful procedures
encourage parents to room-in
Psychosocial - Erickson
Infant Language
Expressive
Receptive
Birth-2 months
3-6 months
sounds elicit startle reflex
turns and looks for sounds
prefers human voice
crying
comfort sound with feeding
coos
vocalizes to familiar voice
vocalizes during play & pleasure
squeals
laughs aloud
less crying
vowel and consonant sounds
watches speaking mouth
shifts gaze between sounds
understands own name
uses sound to get attention
7-9 months
10-12 months
increases vowels and consonants
uses 2 syllable sounds (dada)
talks along with others
associates words with activity
responds to simple commands
("no no")
understands familiar words
means "mama" and "dada"
repeats sounds made by others
makes intentional gestures
learns 3-5 words
recognizes family member names
recognizes objects by name
understands simple commands
("bye bye")
Play is solitary

1 month = watch caregivers face
2 months = mobiles or cradle gyms
3 months = small blocks or small rattles
4 months = playpen for rolling over
5 months = objects to handle (plastic rings,
blocks, squeeze toys, rattles)
6 months = bathtub toys, teething rings
7 months = transfer toys (blocks, rattles,
plastic keys)
8 months = textured cloth books
9 months = room to crawl
10 months = peek-a-boo games
11 months = cruising along tables, furniture
12 months = dropping objects into
containers
Infant
Cause is really unknown but result is severe, uncontrollable crying.
Paraoxysmal abdominal pain (?)
Rule of 3: Cries intensely for >3 hours, >3 days/week, >3 weeks/month
Worsens in the late afternoon and early evening
Lift their head, draw their legs up to their tummy, become red in the face, and pass gas
Peak incidence is 6 weeks of age and generally resolve by 3-4 months
Potential causes
Feeding too rapidly, swallowing large amounts of air
Neurologic overload - avoid overstimulation
The 5 S's of calming a baby
Swaddle - Cuddle cure
Side position
Swing
Shhhh sound
Suck
Colic
Sudden and unexplained death of an apparently healthy infant aged one month to one year
Peak incidence between 2-4 months of age
Reduce the risk
Back to sleep
No co-bedding
Firm mattress with fitted sheet
No pillows or toys in the bed
Keep crib away from heat vent and set temperature between 68 and 75 degrees
Sudden Infant Death Syndrome - SIDS
Falls -Mobility increases in first year of life, progressing from squirming movements to crawling, rolling and standing
Burns - Infant is dependent on caretakers for environmental control
Increased mobility - Objects are explored by touching and placing in mouth
Motor vehicle accidents - Infant is dependent on caretakers for placement in car
Drowning - Infant cannot swim and is unable to lift head
Poisoning - Infant is dependent on caretakers to keep harmful substances out of reach
Choking/suffocation/strangulation - Infant has minimal head control and can get head into crib slats but cannot remove it
Safety
very rapid growth requires close monitoring for signs of abnormality
newborns lose up to 10% body weight
birthweight regained by 10-14 days
birthweight doubled by 6 months, tripled by 12 months
length increases by 1 inch per month for first 6 months, 1/2 inch for next 6 months
head circumference 1 cm > chest at birth
rapid head growth over first year -
monitored at each visit
Development
Sensorimotor (birth to 24 months)
Tertiary circular reactions
(12 to 18 months)
curiosity, experimentation,
exploration
Mental combinations (18 to 24 months)
object permanence fully developed
language allows more complex thought
Preoperational (2 to 7 years)
words are symbols
poor logic
Preconceptual stage (2 to 4 years)
egocentrism

Nursing application
name objects and give simple explanations
ensure safe environment
Cognitive - Piaget
Anal Stage (1 to 3 years)
control over body secretions is prime force in behavior

Nursing application
ask about toilet
training being
sensitive to
cultural
implications
have potty
chairs available
but do not
begin during
hospitalization or illness
Psychosexual - Freud
Autonomy Vs Shame and Doubt (1 to 3 years)
independence shown through controlling body excretions, saying no, directing motor activity
constant criticism creates shame and doubt in their abilities
important to recognize feelings and needs of others

Nursing application
allow self-feeding and as much self-care as child is capable of doing
Psychosocial - Erickson
Communication
Expressive
Receptive
12-18 months
18-24 months
24-36 months
starts to combine 2 words
mixes real and jargon words/gestures
uses words more than gestures
familiar objects by name
18-22 word vocabulary
refers to self by name
2 and 3 word phrases
articulation lags behind
270-300 word vocabulary
recognizes names of body parts
identifies pictures of familiar
objects when named
follows 2 consecutive related
directions
understands more complex
sentences
learns concepts such as hot/cold
listens to and identifies sounds
short complete phrases
inverts subject and verbs
answers simple yes/no questions
uses consonants and pronouns
begins to use word endings
900 word vocabulary
Play is parallel
15 month old = stacking boxes or balls that fit inside
each other, wooden puzzles, bath toys
18 month old = pull toys, riding toys, large crayons, play
dough, finger paint
24 month old = imitating adult behaviors (household
items: bowls, pots, purses, hats)
Developmental Concerns
Begin at about 1 year of age
Peak around age 2-3 years
Rules of engagement
Stay calm
Separate child from others
Ignore the child but be sure child is safe
Do not bribe, give in, or reward the behavior
Talk calmly to child
Temper Tantrums
need sphincter control
stays dry for at least 2 hours at a time
has regular bowel movements
able to follow simple instructions
uncomfortable with dirty diapers and wanting them to be changed
asks to use the potty chair
asks to wear regular underwear
RELAX! - punishment and coercion can lead to shame and feelings of inferiority
Toilet Training
Falls - Gross motor skills improve and are able to move chairs to counters and climb up ladders
Poisoning - Gross motor skills enable toddler to get into cabinets
Medicines, cosmetics, and other poisonous substances are easily reached
Burns - Toddler is tall enough to reach stove top
Toddler can walk to fireplace and reach into fire
Drowning
Toddler can walk onto docks or pool decks
Can stand on or climb seats on boat
Can fall into buckets, toilets, and fish tanks and be unable to get top of body out
Motor vehicle accidents
Toddler is unpredictable
Safety
Sensoral Development
Vision: 20/50 to 20/40
Hearing: same as adult
Taste and Smell: continues to develop, but poor discrimination puts toddler at risk for accidental ingestion
Exploration of the world through the senses is the "work" of the toddler
Preterm: <37 weeks gestation
Neonate: <1 month
Infant: 1 month to 1 year
Toddler: 1 to 3 years
Preschool: 3 to 6 years
School-Age: 6 to 12 years
Adolescent: 12 to 18 years
What might this drop in weight indicate?
food source problems at home
abuse
physical diagnosis such as Celiac Disease
mental health issue
Becomes an increasing problem as child ages

Help the child and the family make better choices when at fast food restaurants
fruits rather than fries
salads
non-sugar drinks
Fast Food
Atraumatic Care
use picture books, puppets, to explain procedures
let child practice procedures with doll or teddy bear
allow child to touch equipment
allow them to keep favorite toy at all times
watch for development delays/regressions during prolonged illnesses
Promote effective discipline
spanking is least effective and discouraged by AAP and NAPNAP
positive behavior rewards
Time-out / Time-in
Promoting healthy eating
Teach healthy fast-food alternatives
Food battles are not about food, but power
Never reward or punish with food
Never give "bad" food so that "good" food will be eaten
Limit juices! Promote milk!!
Preschoolers
A time of hand-eye coordination development and muscle coordination
3 years
Walking, running, jumping well established by end of period
Balances on one foot for a second
Jumps off bottom step
Rides tricycle
Alternates feet on steps going up
4 years
Skips and hops on one foot
Alternates feet on steps going down
heel-to-toe walk
catches ball with both arms
5 years
skips and jumps rope
begins to skate and swim
throws and catches ball well
somersaults and swings
bike with training wheels
arms coordinated with legs when running
proficient climber
Gross Motor Skills
3 years
Dresses and undresses self
Draw a face
Tower of 9-10 cubes
4 years
Uses scissors
Stick figure with 2-4 parts
Copies a square
Shows hand preference
5 years
Begins to tie shoes
Does well with pencil
Learning to tie laces
Draws person with at least 6 parts
Copies triangle
Mostly cares for own toileting needs
Fine Motor Skills
Curiosity about body and awareness of difference between girls and boys
Freud's phallic or Oedipal stage
intense attraction and love for the parent of the opposite sex
Begins to take of the behaviors of same-sex caregiver
Exploration of sexual differences (playing "doctor" or "nurse" with peers)
3 years
Knows name and age
Sentences of 3-4 words
Telegraphic speech
Correct us of plurals and pronouns
Talks to self
900 word vocabulary- can learn 10-20 words/day!
4 years
4-5 word sentences
asks lots of questions!
exaggerated stories
one or more colors
1,500 word vocabulary
5 years
6-8 word sentences and long detailed conversations
Prepositions, past verb tenses, adjectives
4 or more colors
days of week, months, and other time-associated words - can answer why and when questions
follows 3 commands in succession
2,100 word vocabulary
Kohlberg's Preconventional or Premoral Stage
Good and bad dependent upon associated punishment
Development of a conscious
Right and wrong determined by parents' rules
Rewards and punishments for behaviors guide behaviors
Learning to deal with anger and frustration
Unable to apply rules to different situations
Moral Development
Psychosexual Development
Stuttering when excited is normal!
Motor Development
Rest and Sleep
Varies from child to child
Most children need 12 hours day of sleep
May be all 12 at night
May be 10-11 at night and 1-2 hours nap
Bedtime routine very important
Keep schedule steady
Quiet time before bed, limiting TV and other exciting activity
Nursing Implications
Masturbation is normal and healthy part of development
Parents should treat as matter-of-factly as possible
Teach child that nudity and masturbation in public is not acceptable - private activity
No one else should touch private parts except parent and health care providers
The nurse is caring for a hospitalized 4-year-old who insists on having the nurse perform every assessment and intervention on her imaginary friend first. She then agrees to have the assessment or intervention done to herself. The nurse identifies this preschooler's behavior as

1. Problematic: the child is old enough to begin to have a basis in reality.
2. Normal: because the child is hospitalized and out of her routine
3. Normal for this stage of growth and development.
4. Problematic, as it interferes with needed nursing care.
Physical growth slows in favor of cognitive and social skills.
About 2 lbs and 3 inches per year
Slimmer, taller, more posturally erect contour
Establishment of handedness by 5
Physical Growth
and Organ System Maturation
Bladder and bowel control in most children (accidents may occur in stressful situations)
Eustachian tubes still short and straight
Visual acuity reaches 20/20 with intact color vision
All 20 deciduous teeth by 3, permanent teeth may appear by 5
Musculoskeletal maturity continues, still susceptible to injury
Myelination is complete.
Mental operations governed by personal perceptions and linkage to events previously experienced
Egocentrism
Animism
Transductive Reasoning - extrapolates from one situation to another, even if unrelated
Concrete thinking
Magical thinking - allows for the actual and the real. May have imaginary friend. May be difficult to understand difference between lying and make believe.
Concepts of time,space, and causality are primitive
May begin to question parents' values
Piaget's Preoperational Thought
Cognitive Development
Erickson's Initiative
Vs Guilt
Energy and enthusiasm in the "work" of play
Sense of accomplishment and satisfaction in accomplishments
Beginning of development of a conscious - Feelings of guilt for not having behaved appropriately
More sociable, negotiates solutions to conflicts
Likes being a helper and pleasing parents
Temper tantrums and negativism decreases
Active imagination and fantasy
Plays with other children and shares toys
Psychosocial Development
Friends are important
Language Development
Vocabulary Explosion
Temperament
Parents can be helped by understanding how to interpret their child's temperament
Temperament displays itself as early as the first week of life - active babies vs quiet babies, easy to calm (or not)
By 3 years, temperament is a predictor of child's responses
Parents in tune with child's temperament can help with transitions and self-control
Task behavior temperaments are behaviors such as highly attentive and persistent or distractable and active
Safety and Injury
Injury is leading cause of death
Rich fantasy life prevents them from seeing cause and effect of actions
Car: Booster seats required (in TN until the child is 9 years old or 5 feet tall) and always in back seat. Do not leave child alone in car!
No smoke exposure - home or car!
Home safety: Poison prevention, electrical outlets, kitchen safety, guns in home, smoke detector
Water safety: never alone in the bathtub, fences around pools, teach child to swim, teach child water safety rules
Teach stranger safety
Never take anything like candy, ice cream or money
Never talk to strangers
Never take a ride from strangers even if they say you the parent sent them because they are sick
If a stranger asks for directions stay away
Never open the door to a stranger
If a stranger knocks on the door, never tell them you are alone
If the stranger won't go away, tell the child to call 911
Infants
Toddlers
Which should be larger at birth, head or chest circumference?
What is your concern if chest is larger?
Microcephaly!
.
Parental support important
Parent time out
Nutrition
Nutrition affects every aspect of the growing child including physical, cognitive, and psychosocial as well as performance in school.
Meals become more social - If
meals are not treated as family
times, risk of obesity & unhealthy eating increases.
Food jags
Need to ask about their perceptions of weight.
Are they trying to gain or lose weight? Look for eating disorders.
Skipping meals is common.
Controlling high sugar/fat meals is more difficult.
Usually have a decrease in dairy intake.
Help family to plan meals around busy teen schedule.
At the health visit for a 12 year old male, you note that he has entered his pubertal height growth spurt. The boy’s mother asks about what changes her son should be expecting in his body over the next several years. You mention that the most typical sequence of pubertal events in males is which of the following?

1. Peak height velocity, pubarche, penile enlargement, testicular enlargement

2. Peak height velocity, testicular enlargement, penile enlargement, pubarche

3. Testicular enlargement, pubarche, penile enlargement, peak height velocity

4. Testicular enlargement, peak height velocity, penile enlargement, pubarche

5. Pubarche, testicular enlargement, peak height velocity, penile enlargement
Nursing
Implications
treat the teen with respect!!
assist to maintain physical appearance during hospital stay
provide privacy
encourage contact with peers regarding school and activities
explain procedures and involve them in decision making
active listening and avoid giving advice
when interviewing - open ended questions
be open to alternative lifestyles e.g. sexual orientation
Developmental
Concerns
Depression
Signs/symptoms
Weight loss
amenorrhea
pubertal delay
lack of growth
changes in body hair
cold intolerance
fatigue
poor concentration
Poor prognosis
Longer duration
binging and purging
comorbid mental illness
lower body weight at diagnosis
Risk factors
Maternal history
family conflict with poor affective involvement and significant communication difficulties
exposure to significant negative life events
medical condition
Symptoms
Changes in sleeping patterns
change in appetite or weight
intense anxiety, agitation, restlessness or being slowed down
fatigue or loss of memory
decreased concentration, indecisiveness or poorer memory
feelings of hopelessness, worthlessness, self-reproach or excessive or inappropriate guilt
If untreated
Problems at school
running away
substance abuse
low self esteem
eating disorders
reckless behavior
violence
suicide
Red flags of antidepressant use
Very agitated or restless
panic attacks
insomnia
acting aggressive
extremely hyperactive
new or worsened depression
Violence
Risk factors for violence
Access to firearms
Weapon carrying
Alcohol and other drug use
Gang participation
Exposure to violence
Violent discipline
Child abuse
Domestic violence
Media violence
Violence related assessment
How many fights have you been in during the past year?
Have you ever been injured in a fight?
Are you scared of disagreeing with your partner? Has your partner ever criticized or humiliated you in front of others?
Has someone carrying a weapon ever threatened you?
What do you do if someone tries to pick a fight with you?
Suicide
Categories of adolescent suicide victims
50% are teens with a long history of school and behavior problems, fighting, and impulsiveness
20-25% are depressed females
20-25% are anxious, perfectionist, rigid teens who are otherwise model children performing well at school
1-2% are psychotic adolescents

Warning signs
Threatening to hurt or kill oneself
looking for ways to kill oneself
talking or writing about death, dying or suicide
has made plans or preparations for a potentially serious attempt
Sadness, hopelessness, emptiness
lack of energy
insomnia
eating problems
loss of interest in social life and school
boredom
loneliness
irritability
truancy
substance abuse
change in social behavior.
Atypical accident proneness
giving away prized possessions
statements such as ‘my family (or the world) would be better off without me’
Adolescent suicide attempt
Long-standing history of difficulties
Escalation phase
Progressive social isolation
Final stage
Contributing factors/triggers
Stress, loss and conflict
drugs
sexual abuse
history of prior attempts
homosexuality
3rd leading cause of death in teens 15-19
Homicide is the 2nd leading cause of death in 10-24
Smoking
Tobacco is the leading preventable cause of death in the U.S.
19% of high school students report current cigarette use
8% use smokeless tobacco
Teens who smoke are 3x more likely to use alcohol, 8x more likely to use marijuana, and 22x more likely to use cocaine
Smoking is associated with other risky behaviors, including fighting and unprotected sex
Short-term health effects
damage to respiratory system and decreased lung growth
addiction to nicotine
associated risk of other drug use
negative impact on physical fitness
Nicotine is an addictive drug. Do you want to be chained to a cigarette?
There are thousands of chemicals in cigarettes. Many of these chemicals are toxic. Some cause cancer. Why pollute your body with these poisons?
Cigarettes cost a lot of money. Wouldn’t it be better to buy a compact disc, or go to a movie?
Smoking causes yellow teeth, bad skin and wrinkles, smelly clothes, and bad breath. Do you think that’s attractive?
Quitting may not be easy, the average number of quit attempts before successful quitting is 7
Be smart. Don’t let tobacco companies manipulate you.
3 minute tobacco cessation message
Alcohol
Use
Substance Abuse
Sexual Activity
Risk factors
Mood disorders (depression, bipolar disorder)
anxiety disorders
ADHD, conduct disorders
eating disorders (bulemia nervosa)
suicidality
schizophrenia
children of substance abusers
victims of physical, sexual or psychological abuse
Protective factors
Stable family and home environment
high degree of motivation for achievement
strong parent-child bond
consistent parental supervision and discipline
association with peers who hold conventional attitudes
exposure to community wide antidrug messages
Common behaviors
Lying
avoiding friends and family
giving up activities they used to enjoy
getting into trouble with the law
suspension from school or missing school
Reasons for initiating sexual activity
younger teens:
curiosity
a grown up feeling
partner pressure
friends having sex
Older teens
being in love
physical attraction
having a partner who was drunk or high
feeling romantic
Risk factors for sexually transmitted diseases
Young age
Female gender
Previous STD diagnosis
Pubic lice
HPV
Chlamydia
trachomatis
Neisseria
gonorrhoeae
Syphilis
HSV
Chancroid
Trichomonas
vaginalis
Bacterial
vaginosis
HIV
Eating Disorders
Risk factors
Age and gender
weight concerns
personality traits
early puberty
physical and sexual abuse
family history
competitive athletics
Behaviors
Dieting
distorted body image
unusual eating behaviors
increased physical activity
purging behaviors
frequent weighing
poor self esteem
isolation
inflexibility
irritability
No sociodemographic differences in teen users
50% of 12th graders and 16% of 8th graders report being drunk at least once
Reasons teens give
Curiosity
peer conformity
enjoyment
escape
parental encouragement to take first drink to celebrate a special occasion
Risk factors
Genetics
Ethnicity - highest in caucasians
Family and peers
Behavioral risk
Early initiation
Postconventional Level III
Moral
Development
Morals based on peers, family, church and societal morals

Early (11-14 years)
Asks broad unanswerable questions about life
Middle (14-17 years)
Developing own set of morals - evaluates individual morals in relation to peer, family, societal morals
Late (17-20 years)
Internalizes own morals and values
Continues to compare own morals and values to those of society
Evaluates morals of others
Freud's Genital Stage (from puberty on)
Separation from parents is necessary, sometimes resulting in conflict between adolescents and parents

Anxiety and heightened distress over how to act out their inner conflict
Refinement of gross and fine motor skills
Rapid growth spurts can cause a time of decreased coordination
Early (11-14 years)
Limited abstract thought process
Egocentrically thinking
Eager to apply limited abstract process to different situations peer groups
Middle (14-17 years)
Increased ability to think abstractly or in more idealistic terms
Able to solve verbal and mental problems using scientific methods
Thinks he or she is invincible - risky behaviors increase
Likes making independent decisions
Becomes involved/concerned with society, politics
Late (17-20 years)
Abstract thinking is established
Develops critical thinking skills - tests different solutions to problems
Less risky behaviors
Develops realistic goals and career plans
Piaget's Formal Operations
Cognitive
Development
If he is not successful in establishing an individual sense of self, then a confusion or roles develops
Focuses on bodily changes
Experiences frequent mood changes
Importance placed on conformity to peer norms and peer acceptance
Strives to master skills with peer groups
Defining boundaries with parents and authority figures
Early stage of emancipation (wants to separate from parents but desires dependence on them) and moves to full emancipation
Identifies with same-sex peers
Takes more responsibility for own behaviors
Works towards mature sexual identity
Importance of individual friendships emerges
Becomes secure with body image
Develops idealistic career goals
Identity Vs Role Confusion
needs to be able to express himself or herself in any manner, or will develop role confusion
Where am I going?
Who am I?
Body assumes an adult appearance
Boys gain 12-14 lbs and 3-6 inches
Girls gain 8-10 lbs and 25-5 inches
Height gain about 2 inches after menarche
Full bone length is reached in extremities first and moves centrally
Subcutaneous fat decreases in males and increases in females
Sebaceous glands increase in size
Heart almost doubles in size
Adult values of BP reached by end of adolescence
Liver
Pituitary
Gland
Hypothalmus
Growth Hormone
Releasing Factor (GHRF)
Somatostatin (SS)
Growth Hormone (GH)
Insulin-Like Growth Factor (IGF-1)
Negative feedback loop
Growth
Bone, Muscle Mass, and Internal Organ Growth
pulsatile
secretion of GH
Physical Growth and Organ Systems Maturation
Psychosocial Development
Motor Skills
Psychosexual Development
Ask about unwanted sexual activity (they may not use the word rape)
Adolescence
May regress to behaviors of younger child (needing special comfort toys or demanding parental attention)
hospitalization brings a loss of control - try to give as much control as possible back to the child
Remain sensitive to possibility that illness or injury may be due to abuse or neglect (to be covered more later)
Assist parents and child as needed in order to maintain school readiness and promoting learning
encourage reading!
Nursing Implications
A nurse is planning to teach a first-grade child about good hand hygiene. Which method of teaching would be best suited for this age group?

1. Use a special black light solution to show the child how effectively she washed her hands.
2. Demonstrate good hand washing techniques so all children can see and understand.
3. Give the child a handout that includes a step-by-step guide to hand washing with coloring pages.
4. Show the child a video and then ask if the child has any questions afterwords.
Obesity
Developmental Concerns
Bullying
Tobacco and Alcohol
Provide healthy meals and snacks
Schedule and encourage daily exercise
Encourage involvement in sports
Restrict TV and game use
Limit the amount of fast-food intake
Provide education about healthy nutrition
Never use food as a reward
Be a good role model
Discuss physical and social dangers of use
Urge parents to be good role models
Discuss peer influence
Advocate for smoke-free home
Educate on spit tobacco
Bullies:
Have difficulty accepting criticism
Think too highly of themselves
Have the need to be the center of attention
Be more likely to drink alcohol and use drugs excessively
Be at greater risk of being victimized themselves (about 50% of bullies are also victims at some point)
Be at higher risk for mental health problems (such as conduct disorder and ADHD)
Be more likely to be antisocial in adulthood
Be more likely to use violence in relationships
Be more likely to get in trouble with the law
Victims
Higher risk for physical and emotional problems (depression, abdominal pain, headaches)
More school absences
Higher levels of anxiety
Low self-esteem
Loss of control
Child who is easy may adapt to school entry and other experiences smoothly
Slow-to-warm child may be slow to adapt to changes
Difficult or easily distracted child may need help through role-playing, site visits, or slow transitions
Temperament
Kohlberg's Conventional Level
conscience develops an internal set of "rules" that must be followed in order to "be good"
morality is based on avoiding the disapproval of others
accidents are punishment for disobeyig
respect for authority figures and the law
in the later stages, child can evaluate the circumstances surrounding the incident
Moral Development
Car safety
Guns
Burns - more likely to play with fire
Assault - especially if left alone frequently
Bike safety
Skating, skateboarding, scooters
Pedestrian safety
Water safety
Safety
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Z
Sleep
Sleep varies from 8-10 hours
Schedule very important
Irritability or even ADHD symptoms may be sleep deprivation
Sleepwalking and sleep talking
Growth hormone peaks during sleep
Language
Reading efficiency improves language skills
More complex forms i.e. plurals and pronouns
Metalinguistic awareness - ability to think about language and comment on its properties
Can understand double meanings, jokes, & riddles
Understand metaphors
Imitates speech patterns and styles of family members
Learns by manipulating concrete objects
Lacks ability to think abstractly
Learns that certain characteristics of objects remain constant
Understands concepts of time
Engages in serial ordering, addition, subtraction
Classifies or groups objects by their common elements
Understands relationships among objects
Starts collections of items
Can reverse thought process
Piaget's Concrete Operational Stage
Cognitive Development
Can a school-age child understand that 2 different shaped glasses can hold the same volume of water?
Motor Development
Legibly prints letters
Uses knife, fork, and spoon
Rides 2-wheel bike
Masters all skills on the DDST
Improved dexterity
Cuts, pastes, folds paper
Ties shoe laces
Throws overhand
Copies a diamond
Walks a straight line
6-7 Year Olds
Developing eye-hand coordination
More fluid movement
Plays team sports. Body becomes flexible.
Able to use household tools
Writes using cursive
Dresses self completely
Jumps, skips, draws three-dimensional figures
8-9 Year Olds
Eye-hand coordination well developed
Fine motor skills well developed
Gross motor skills may become awkward with growth spurt
Balances on one foot for 15 seconds
Catches a fly ball
Cooks and sews
10-12 Years
Freud's Latency Period
Psychosexual Development
focus is on activities that develop social and cognitive skills
relate more to same-sex parents and friends
Sexual development differences during the onset of puberty can be very difficult.
Embarassment and low self-esteem often accompany this time.
Early onset of puberty often leads to high risk behaviors.
Nursing implication: Assurance is often needed to help the child realize that she is in the "normal" range of development. We can help decrease anxiety and promote a better self-image.
Children develop independence from parents and spend more time with peers of the same gender
Energy is channeled into concrete activities (school, sports, and hobbies) that should bring a sense of accomplishment
if child feels she is not living up to the expectations of caregivers or teachers, or is different than peers, then a sense of inferiority develops
imperative to have a positive relationship with an affirming adult
Erickson's Industry Vs Inferiority
Psychosocial Development
Typical height gain of 2.5" per year and weight gain of 7 lbs per year
Great variance in growth, both in same sex and between girls and boys
Increased physical size does not mean increased maturity (and visa versa) - treat children by their age and not the age they appear to be
Physical Growth and
Organ Systems Maturation
Organ Systems
Head growth slows greatly
Abdominal breathing replaced by diaphragmatic breathing
Frontal sinuses develop
Stomach capacity increases and caloric needs decrease
Bladder capacity is about years + 2 ounces
Prepubescence
the 2 years before the onset of puberty
rapid growth in girls
girls are about 2 years earlier than boys
Adrenal
Gland
Pituitary
Gland
Hypothalmus
Corticotropin-
releasing factor
(CRF)
Adrenocorticotropic
hormone (ACTH)
Cortisol
Negative feedback loop
Androgens
Aldosterone
onset of female breast development

tender nodules of firm tissue centered on areolae (felt before seen)

adipose related growth is soft, homogeneous, and nontender
Thelarche
Adrenarche
onset of androgen-dependent signs of puberty (pubic hair, acne, adult body odor)

females: adrenocortical activity

males: adrenal or gonadal maturation
Menarche
onset of menstruation
Adrenarche
Gonads
Pituitary
Gland
Hypothalmus
Gonadotropin-releasing
hormone (GnRH)
Follicle-stimulating hormone (FSH)
Luteinizing hormone (LH)
Testosterone (testes)
Estrogen & Progesterone (ovaries)
Negative feedback loop
Male pubic development
1 prepubertal, with testicular volumes less than
4 mL, a thick and rugated scrotum, and an
immature penis.
2, coarse, sex steroid-dependent hair has
appeared on the pubis, but it is sparse and
does not typically meet in the midline. The
penis remains immature, but scrotal thinning
and testicular enlargement have begun.
3. characterized by pubic hair meeting at the
midline and the start of penis growth,
predominantly in length.
4, the pubic hair growth is dense and continuous,
but has not reached a full adult pattern. The penis has enlarged in both length and circumference.
5 is that of full adult development.

Normal pubic hair development of the female descriptions are similar to those for male pubic hair growth.
Normal progression of breast development.
1 is the normal prepubertal state.
2,tender “buds” are felt and seen
3. further development of breast tissue well beyond the areolar diameter and incomplete nipple development.
4 is easily recognized by secondary elevation of the areola above the contour of the breast,
5, this areoloar elevation recedes to the plane of the surrounding breast.
Sexual
Development
Growing pains are common
Pubarche
first appearance of pubic hair

School-Aged Child
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