Discussion about growth and development

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Chapter 18

Toddler

Biology and Genetics

12-18 months → 3 years of age
Overview of developmental/physical changes
2-4 inches height/year; 4-6 lb weight/year
Continue to measure head circumference
May measure length (recumbent) or height (standing)

Physical Characteristics
by System

Kidneys	Specific gravity similar to adults 500-600 mL urine at 2 years old Begin voluntary control
Gastrointestinal	Functional maturity Needs more frequent meals/snacks Control of internal/external anal sphincters
Respiratory	Lung capacity increases Respiratory rate decreases Smaller upper tract diameter (airway obstruction potential)

Physical Characteristics
by System (Cont.)

EENT	Similar to infant Continued risk for otitis media
Endocrine	Become functional (exception: reproductive)
Circulatory	Blood pressure increases Heart rate decreases More effective thermoregulation
Immunity	Active immunity/immunizations by 18 months Exposure to new/different organisms— begin to build immunity

Physical Characteristics
by System (Cont.)

Teeth	All 20 primary teeth erupt by end of toddlerhood At risk of choking because of immature swallowing pattern
Musculoskeletal	Increased size/strength of muscle fibers Myelination of corticospinal tract sufficient for most movement Voluntary motor movements often with involuntary movement on other side of body Does not show hand dominance

Gordon’s Functional Health Patterns

Health perception–health management pattern
Nutritional-metabolic pattern
Elimination pattern
Activity-exercise pattern
Sleep-rest pattern
Cognitive-perceptual pattern
Self-perception–self-concept pattern
Roles-relationships pattern
Sexuality-reproductive pattern
Coping–stress tolerance pattern
Values-beliefs pattern

Health Perception–
Health Management Pattern

Little understanding of health
Depend on caregivers for health management
Health behaviors (e.g., brushing teeth) part of taught rituals
Identify with behavior modeled by caregivers
Nutrition
Exercise

Nutritional-Metabolic Pattern
Nutrition Principles

Ensure adequate iron intake
Moderate amount of milk (low in Fe)
Prevent dental caries: bedtime bottle only water
Juice overconsumption
Appetite decreased—assess intake over several days
Mealtime
Opportunity to offer healthy, age-appropriate choices
Avoid overattention/punishment re food behavior

Elimination Pattern
Toilet Training

Major parental concern
Emotional/physical readiness—usually 18 months of age or older
Nurse provides anticipatory guidance to parents on:
Developmental readiness of child
Parental attitudes and process of toilet training

Activity-Exercise Pattern

Always busy and exploring
Most waking hours at play
Exploring, imitating, creating rituals
Risk for injury
Parallel play: side-by-side, but independent play
Anticipatory guidance
Appropriate toys, opportunities for learning and social encounters, limit TV time

Sleep-Rest Pattern

Need: 12 hours a day; one to two naps
Schedules are helpful to avoid overfatigue
Rituals help develop a sense of security
Night terrors
Normal, less frequent as child develops
Not fully awake
Instruct parent to speak soothingly, do not try to wake child

Cognitive-Perceptual Pattern

Sensorimotor—preoperational
Egocentrism—world as relates to them
Object permanence
Play imperative—learn by repetition
Hearing—critical for language/speech
Hearing loss assessed at birth, can be tested during toddler, preschool years
Otitis media: leading cause of hearing loss in toddlers

Cognitive-Perceptual Pattern (Cont.)

Vision
Amblyopia—diminished or loss of vision in one eye

Brain favors normal eye

Strabismus—deviation in line of vision

Management focused on making child use eye with reduced vision (lazy eye)

Be alert to “red flags” of vision problems (next slide)
Taste and smell
Begin learning conditioned association between smell/taste; develop food aversions

Red Flags of Vision Problems

Rubs eyes excessively
Shuts one eye, tilts head, sideways gaze
Difficulty with close vision
Blinks, frowns, squints on viewing objects
Holds book close to eyes
Red, encrusted or swollen eyelids
Inflamed or watery eyes
Recurrent styes

Self-Perception–Self-Concept Pattern

Erikson: autonomy vs doubt/shame
Relinquish dependence on others
Need to explore world
Physically
Relationships—“NO” and temper tantrums
Guidance to parents
Safe environment
Promoting autonomy
Preventing and dealing with temper tantrums

Roles-Relationship Pattern

Roles understood as they relate to child
Sibling rivalry: ongoing negotiation of roles and relationships
Imitate others
Prefer others’ possessions
Child abuse—nurse’s role
Need to be aware of potential; s/s abuse
Report when child abuse suspected

Sexuality-Reproductive Pattern

Genital exploratory behavior and masturbation
Normal developmental process
Opportunity to learn about body
Parents reaction is variable
Nurse includes this subject when teaching about toilet training
Recommend using correct anatomical terms

Coping–Stress Tolerance Pattern
Temperament

Individual style of emotional or behavioral response across situations
Foundation for coping
Influenced by environmental characteristics
Influences psychosocial adjustments
Nurse can assist parents in recognizing temperament and developing management strategies

Values-Belief Pattern

Healthy behaviors reflect positive values/beliefs
Toddler’s environment
Teach right/wrong
Contribute to security, belonging, autonomy
Values/beliefs
Interactions with parents
Religious rituals/beliefs
Development facilitated by consistent behavioral expectations, reinforcing acceptable behavior

Environmental Processes: Physical Agents

High risk for accidental injury
Structural hazards
“Baby-proof” the environment
Inspect for hazards in unfamiliar environments
Appropriate supervision
Toys
Inspect toys
Risk of small removable parts, batteries, toxic paint, sharp edges

Environmental Processes: Physical Agents (Cont.)

Sports
Improper storage of guns, heavy equipment
Wear bike helmets
Drowning: highest risk ages 1-3
Can drown in water if covers nose/mouth
Danger: pools, tubs, toilets, pails of water
Burns
Hot liquids, electrical cords, fireplaces
Lower water heater to 120-125°F

Motor Vehicle–Related Injury

One of leading causes of death 1-4 years
Child safety seats
Correct seat for weight of child
Proper installation of safety seat
Rear seat position preferred
Pedestrian accident potential at home
Killed/injured in driveway by backing vehicle

Biological Agents and Poisoning

Biological agents
Potential of bioterrorism: talk about fears, appropriate precautions/response
Poisoning—greatest risk ages 1-2
Toddlers use mouth as way to explore environment
Medications, household products, plants, cigarettes, alcohol, cosmetics
Suspected poisoning—contact Poison Control Center
Lead—teach primary prevention, screening (secondary prevention)

Determinants of Health:
Social Factors and Environment

Day care—HHS four-step approach
Interview potential provider and observe setting
Check references
Make decision based on specific criteria
Get and stay involved
Culture and ethnicity
Toddlers shaped by family values/beliefs
Knowledge, respect, negotiation across cultures needed for high-quality health outcomes

Levels of Policy Making and Health

Legislation
Safety and injury prevention
Abuse and neglect protection
Assistance for handicapped children 0-3 years
Economics
Toddler mortality/morbidity rates increase in poverty
Medicaid, uninsured, SCHIP program

Health Services/Delivery System
Health Care Delivery System

Adequacy of system significantly affects health of toddler
Routine assessment needed
Growth/development
Immunizations
Discussion of developmental concerns
Anticipatory guidance

Provide education focused on the physical and developmental changes for toddler
Teach health-promotion activities to toddlers
Engage in screening activities
Promote routine health examinations and childhood immunization schedule
Educate parents about resources available in the community—many free or low cost

Nursing Application
Nursing Involvement with the Family