Pediatric Nursing Notes - Second Year - First Semester

‫‪Notes in Pediatric Nursing‬‬ ‫المعهد الفنى للتمريض‬ ‫الفرقه الثانيه‬ ‫الفصل الدراسى االول‬ ‫‪0202/0202‬‬  Content Unit one: An overview of human growth anddevelopment  Human growth and development  Normal growth and...

‫‪Notes in Pediatric Nursing‬‬ ‫المعهد الفنى للتمريض‬ ‫الفرقه الثانيه‬ ‫الفصل الدراسى االول‬ ‫‪0202/0202‬‬  Content Unit one: An overview of human growth anddevelopment  Human growth and development  Normal growth and development of newborn  Normal growth and development of infant  Normal growth and development of toddler  Normal growth and development of pre-school  Normal growth and development of school  Normal growth and development of adolescent Unit Two: High risk neonates:  Pre-mature ………………………………………………...  Jaundice  RDS  Infant of diabetic mother  NEC Unit Three: Infectious Disorders  Infectious Disorders of neonates Unit Four: E.N.T and Respiratory problems  Upper respiratory system disorders  Lower respiratory system disorders Unit Five: Gastrointestinal Disorders  Gastroenteritis  Typhoid fever Unit Six: Cardio vascular System Disorders  Cardio vascular System Disorders  Rheumatic fever Unit Seven: Urinary System disorders  Acute glomerulonephritis.  Nephrotic syndrome.  Renal failure  Urinary tract infection Unit Eight: Neurologic disorders:  Cerebral palsy  Mental retardation.  Seizures   Down‘s syndrome Unit Nine: Endocrine and metabolic disorders  Diabetes Mellitus (DM)  Congenital hypothyroidism  Hyperthyroidism Unit Ten: Nutritional disorders I-Vitamin and mineral deficiencies:  Rickets  Infantile Tetany  Scurvey. II-Malnutrition diseases:  Marasmus  kwashiorkor Unit Eleven: Malignant neoplasm  Leukemia  Wilm's Tumor  Hodgkin's disease ‫ة هعحىذة‬  Introduction: Growth and development is a continuous process from conception until death. Growth and development of a child is factor, some of these influences can be manipulated to change the outcome, and others cannot. Understanding the influences on physical growth and development can be useful to the nurse in teaching parents how to enhance their child growth and development. Definition of growth: Is a natural increase in physical size of the whole or any part of the body due to increase in number of cells of different organs. It also involves a quantity changes. It can be measured by centimeters inches, pounds or kilogram, assessed by wt, ht, skull circumference, and skin fold thickness. Definition of development: Progressive increase in skills and capacity of function and acquisition of social relations it involves a qualitative changes. It also a continuous process from conception until maturity through whole life. Types of growth and development: Physical growth: Which can be assessed through measurement of head circumference thoracic diameter, weight,and height. Physiological growth: Which can be assessed through measurement of temperature, pulse, respiration and blood pressure Motor development e.g. sitting, standing, running, usage of fine muscles Mental or intellectual development: e.g. problem solving Social development: e.g raising and training a child in the culture ofhis family group Emotional/personality development: Needs for trust and love 1 Principles of growth and development: 1. Growth and development are continuous processes each stage depends upon the proceeding one. 2. Each child has his own growth pattern, which varies within the individual child but within the normal rate. 3. All children go through a normal sequence of growth, but not in the same rate, i.e. individual difference is noticed. 4. Intellectual, neuromuscular, an emotional and social behavioral aspect is difficult to consider on independent from the others. Patterns of growth and development: Patterns referred to as trends or principles are universal and basic to all human beings. Cephalocaudal: Muscular development proceeds from head to feet. E.g. the child motor controls his neck before his leg and feet. Proximodistal (Proximal to distal): Progress from body to extremities (from the midline to peripheral) e.g. the early embryonic development of limbs, hands, followed by fingers and toes. E.g. the child stand, sit, before the usage of fine muscles of hands. Factors influencing growth: 1- pre-natal factors: 1- Hereditary and constitutional make up. 2- Genetic e.g. there is positive correlation between parental height and their off springs e.g. age of the mother and her daughters. 3- Racial and nationality e.g. American race are tall while Chinese are short. E.g. Black girls begin the pubertal growth at a slightly earlier age than white girls. 3- Disease: For mothers e.g. congenital rubella leads to malformed baby, hereditary disorders leads to dwarfism, metabolic disorders leads to Rickets, chronic illness leads to congenital cardiac anomalies and all diseases and acute illness may cause growth retardation. 4- Drugs: For mother 2  Thalidomide limb and cardiac malformation Amphetamine congenital heart Cytotoxic Intrauterine growth retardation, microcephally, cleft palate, cleft lip, deafness, malformed ears. Corticosteroids high dose cleft palate. 5- Nutrition: Sever maternal malnutrition during prenatal period may negatively influence on physical and mental state. Although the fetus is usually able to obtain adequate nutrition for prenatal growth unless the mother‘s nutrition is very poor. II- Post-natal factors A-E xternal factors 1- Environment: A-Geographic location (Climate): There‘s direct correlation between weight and height of the people and the annular temperature of the locality. People in high attitude tend to be lighter in weight and shorter in length, hot climate fasters growth, cold one slows it down. B-Seasonal: Growth in height appears to be faster in spring and summer months, whereas growth in weight proceeds more rapidly during the autumn and winter. C-Oxygen concentration: Children with disorders that produce chronic hypoxia are small as compared with children of the same chorological age. 3  D-Environmental hazards: 1-e.g. physical injuries are the most consequences of environmental dangers as exposure to chemicals, radiation or smoke after 2nd trimester may produce small size infants. 2- Socioeconomic state: Children from upper or middle class families are ensure good growth- affects the height and the accept frontal circumference more than the weight. 3- Trauma: physical localized e.g. poliomyelitis, less growth of limit limb. B-Internal factors: 1- Endocrinal factors (hormonal): there are three hormones as growth hormone, thyroid hormone and androgen hormone which stimulate protein anabolism and produce retention of elements essential for building protoplasm and bony tissue. 2- Gender: sex of the baby has some influence on growth and development. There is little actual difference between girls and boys e.g. boys have strong muscle power tan girls and activity levels especially during adolescence stage. 3- Psychological condition: Maternal deprivation and emotional deprivation may lead to loss of weight due to lack of love and refuse of food. Also the ordinal position of the child in the family. 4- Emotional status of the child. 5- Diseases. 6- Drugs 7- Nutrition 4  Growth monitoring: Assessment of growth is an essential part of the pediatric physical examination. It is not only helping in detection and diagnosis of disorders in childhood but also serves as a useful guide for treatment and follow up of diseases conditions. Importance of growth monitoring 1- Growth monitoring confirms a child‘s healthy growth and development. 2- Identifies variations from typical growth due to poor nutrition, recent or chronic illness or other health problems. 3- Detect early growth flattering and undertake appropriate and corrective actions Currently, there is significant attention on children‘s growth due to the rising incidence of childhood obesity. Growth Monitoring forms the basis of comprehensive child health care. It includes the regular measurement of weight (and sometimes length) of the child. Weighing starts at birth and continues until the child is five years old. Ideally the child weight must be taken once a month until the age of two years and then each three a month until the child is five years old. The nurse enters the baby's weight on growth chart or the Road to Health Chart. The weight is also checked against the age to see if the weight falls within the acceptable range for the child's age. How nurse can assess growth and development: Nurse can assess growth through measurement of head circumference, thoracic diameter, weight and height and observation for closure of the fontanel and teeth eruption. Nurse can assess development through observation of motor, social, mental and emotional development for each stage of development 5  Newborn Stage Learning Objectives: At the end of this lecture the student should be able to:  Identify neonatal period.  Enumerate newborn screening tests.  Explain the vocabulary terms.  Describe the respiratory and cardiovascular changes that occur during the transition to extra- uterine life.  Recognize the major mechanisms of heat loss and produces heat in the newborn.  Explain normal characteristic of newborn.  List basic needs of newborn.  Describe signs determinations of adaptation of the newborn  Apply the nursing process to make nursing diagnosis and plan the care for newborn.  List Problems of neonates Introduction: Neonatal period presents the greatest risk to newborns. In Egypt, about three quarters of all deaths during the first year of life occur during these four weeks. The born of a baby is one of the most important events to a family, after a waiting for nine months of anticipating and preparing he/ she arrives and affect the life of the parents and siblings if present. Both family and newborn need adjustment for the new situation. The newborn‘s adjustment to extra uterine life is a complex process as many physiological changes occur during the first 28 days after birth, and the family adjustment to the new human being will be with them for life long. I- Definitions of neonatal period: Birth through the first 29days of life is generally referred to as the neonatal period. The newborn period includes the time form birth through the first 28 days of life, during this period the newborn adjusts from intrauterine to extra uterine. The neonatal period describe the periods of time immediately after birth and lasting through the first four weeks of life or the first month of extra uterine life. 6 Newborn screening tests: In the first few days after birth, medical professionals will carefully examine your newborn and may perform a number of tests and screenings to assess their health, such as:  Hearing screening. Performed before a baby leaves the hospital or birthing center, a newborn hearing screening tests your baby‘s hearing.  Blood tests. A few drops of blood are taken from a prick made in your baby‘s heel. The sample is sent to a state lab to determine if your baby has one of a few rare but serious health conditions.  Oxygen screening. During this painless test, a device called a pulse oximeter is fastened to your baby‘s arm and foot to measure the amount of oxygen in your baby‘s blood. This test helps doctors see if your child has a congenital heart defect. II- Physical characteristics of normal newborn: A-Anthropometrics measurements: 1- Length: The average crown-heel length of a term baby male 50cm and female 49cm. The normal range for both sexes (47.5- 53.5cm) 2- Weight: The average term neonate's weight ranged from (2.700-3.850kg). During the first few days after birth the neonate's tends to lose about 5 to 10% of his/ her birth weight (physiological weight loss). Factors contributing to this physiological weight loss are:  The withdrawal of hormones originally obtained from the mother.  The withholding of water and the loose of feaces and urine. B-Vital signs: 1- Temperature: The neonate's temperature a birth is slightly higher than his mothers. Since the uterus lies deeply insulated within her body, it drops immediately after birth in adjustment to the temperature of the delivery room and rises to normal within about 8 hours. The neonate's hands and feet are colder than the rest of his body since his circulation is poor, this lack of stability is due to immature of the heat regulating system (hypothalamus) and requires that external heat be applied normal range of neonate's temperature (36.1C to 37.2C). 2- Pulse: The normal rate of heart beats of the newborn is around (120-150B/M). The pulse of the newborn in normally irregular owing to immaturity of the cardiac regulatory center in the medulla. When the newborn is startled or cries, his pulse rate not only increase but also becomes more irregular. 3- Respiration: The respiration of the newborn is irregular in depth, rate and rhythm and ranged from (35-50C/M). if there is tachypnea we must observe for 7  manifestation of respiratory distress (working nasal, intercostals and subcostal retraction, grunting). 4- Blood pressure: During the newborn period, the blood pressure tends to be highest immediately after birth and then descends to its lowest level about three hours of age. By four to six days after birth the blood pressure rises and reaches at a level approximately the same as the initial level. Blood pressure is particularly sensitive to the changes in blood volume that occur in the transition to the neonatal circulation. In the full term the average blood pressure is 74/47mmHg. Where crying may cause an elevation of 20mmHg in both systolic and diastolic blood pressure. C-Skin characteristics: The skin of the newborn is red or dark pink. In the black infant a reddish black and in the Mongolian the skin color is a –rose. Good elasticity or turgor is evidence that an neonate's is in good condition. 1- Lanugo hair: Is a slight downy distribution of fine hair over the body, most evident on the shoulders, back extremities, forehead, and temples lanugo tends to disappear during the first weeks of life. N.B.: Lanugo hair begin to appear on the fetus by about 16 weeks of gestation and disappear after 32 weeks. The premature infant has heavier lanugo hair than full term infant. 2- Vernix caseosa: is a cheese like, greasy, yellowish white substance, sometimes liked to cream cheese or cold cream which covers the newborn‘s skin. It consists of secretion from the sebaceous glands and epithelial cells. Its distribution over the body is variable being heavier in the folds of the skin and between the labia. It increases the neonate's immunity and dries spontaneously and rub off with the infant‘s clothes, it decreases in preterm and increase in full term neonate's because it is formed after the 32 weeks of gestational and disappear in 2 to 3 days of life. 8  3- Desquamation (peeling): It occurs during the first 2 to 4 weeks of life, due to shrink or separation of the placenta and the fetus will not nutritional. It occurs in post mature neonate's who delivered after 40 weeks. 4- Milia (while pimples): Present in 40% of neonate's in which tiny white papillae occurs particularly on the nose and chin, owing to obstruction of the sebaceous glands, disappear in a week or two. 4-Mongolian spots: (Blue-back pigmented): At the base of the back and on the buttocks, medically are unimportant and common in neonate's of dark skinned parents, but can also occur in Caucasian neonate's, they usually disappear during the pre-school age without treatment. 9  5- Capillary or macular haemangioma: (stork bites salmon patch), around the eyes and at the nape of the neck, are seen in 30-50% of but those at the nape may persist. 6- Sweat glands: Usually active by the end of second week. D- Head characteristics The head is proportionately large. 1- Size: 1 / 4 the body. 2- Circumference: Measured around the maximum diameter, (fronto-occipital). Normally: At birth average size about 33-37cm, at 1 year about 45cm, and at 12 years about 55cm. 3- Fontanels: The fontanels are opening at the point of union of the skull bones, or meeting of two sutures. These should be palpate to determine whether they are open or closed. There are six fontanels; two of them are clinically important (anterior and posterior fontanel). Anterior fontanel:  Is located between the two partial and frontal bone.  At birth about 3 fingers = 4.5cm.  6 months about 2 fingers = 3cm.  12 months about 1 fingers = 1.5cm.  Complete closure at 12: 18 months. Posterior fontanel  Is located between parital and occipital bone.  Triangular shape.  Complete closure at 2-6 months after birth. 4- Caput-succedaneum: Swelling or edema of the presenting part of skull due to pressure during labor leads to accumulation of fluids and disappear by the 3rd 'day 5- Cephalo-haematoma.'Accumulation of blood between periosteum (membrane covers the surface of bone and fat bone of the skull). 10  - Disappear after few weeks. - The collection of blood does not cross a suture Sine. - The mass is soft; it does not increase on crying. Complications of cephal-haematoma - Increase jaundice due to increase break down of RBCs. - Infection. - Intracranial hemorrhage. Face: No expression on face of newborn. Ears: Soft and flappy, Neck: Short. - In normal neonate, it should be possible to turn the head freely from side to side. Eyes: - The eye is blue or gray at birth, changing to the permanent color in 3 to 6 months. - Eye movements are not coordinated and both eyes momently may turn inward and outward (false squint). - The eyelids may be edematous for about 2 days after birth, until the kidneys eliminate the excess fluid. - Lacrimal fluid is present in the eyes to some degree from birth. Crying however is tearless, or a variable period ranging from several days to a few months after birth, depending on the maturity of lacrimal ducts. Sub-conjunctive hemorrhages: Because the presence of the neonate‘s head during vaginal delivery, the venous return of blood may be impaired and small capillaries may rupture in the sclera of the eye. This condition has no pathological significance and the red areas will disappear in 2-3 weeks. Nose: An unusual amount of nasal discharge should be removed since neonate can breathe only through the nose. Mouth and throat: No salivation is obvious in the mouth; the tongue appears relatively large for the size of the oral cavity. The sucking pads are deposits of fatty 11  tissue in the checks. The salivary glands are immature at birth, and little saliva is manufacturer until the neonate's is about 3 months old. E-Chest: The chest is ball shaped and at birth is approximately the same circumference of the abdomen and about 2cm less than the head circumference. The thorax of the newborn is almost circular; the infant does not use the thoracic cage in breathing as the older children but uses the diaphragm and abdominal muscles instead. The breast may be swollen because of hormonal activity originating from the mother and pale milk fluid (witch's milk) can be expressed. This condition disappears in 2 to 4 weeks without treatment, but the breast in tender and should be touched gently when necessary. F-Abdomen: On inspection, the normal neonate‘s abdomen appears rounded and slightly protruded. The umbilical cord: The connection between the fetus and placenta, it is bluish- white, gelatinous structure at birth. It normally contains two umbilical arteries and one umbilical vein. The presence of these structure should be determined when the cord is cut. If one umbilical artery is evident, the baby should be assessed for the presence of congenital anomalies. III- Adjustment of newborn to extra uterine life: The newborn‘s adjustment t extra uterine life is a complex physiological process. However, the first 24 hours are the most critical. Since during this time respiratory distress and circulatory failure can occur rapidly with little warning. a-Respiratory adjustment: The mechanism of respiration is established before birth. Pre respiratory movement begins in 4th month of gestation. Amniotic fluid may be move in and out of the lung. as a result of this tidal movement, O2 obtained through placental circulation. Process of birth, environmental change also stimulate the respiration. The first breath usually taken within 30 second after birth helps to expand the collapsed lung although full expansion does rot occur for several days. B-C irculatory adjustment: The circulation of the pulmonary system is perfected and short time after birth, oxygenated blood flow through neonate's body is the same manner of adult. 12  As the newborn adapts to extra uterine life, there are five major areas of change in circulatory function: 1- Increased aortic pressure and decreased venous pressure. 2- Increased systemic pressure and decreased pulmonary artery pressure. 3-Closure of the foramen oval by 3rd month. 4-Closure of the ductus arteriosus from several weeks to 4 month. 5-Closure of the ductus vensus. IV- Physiologic status of other systems: Most of the body systems are immature at birth. Each should be observed closely for proper functioning and adjustment to extra-uterine life. a-The thermoregulation and thermogenesis: Temperature regulation is the maintenance of thermal balance of heat loss to the environment at a rate equal to the production of heat. The thermoregulation in the newborn is closely related to the rate of metabolism and oxygen consumption. A central control system (Hypothalamus) a means to adjust heat production and heat loss. Heat production:  The shivering mechanism of heat production is rarely operable in the newborn.  Non-shivering mechanism accomplished primarily by brown- fat and secondarily by increased metabolic activity as in the brain, heart, liver.  Although sweat glands are present in the newborn, they have little thermo function until the fourth week or later of extra-uterine life. Heat loss: Two major routes of heat loss are: 1- From the internal core of the body to the body surface. 2- From the external surface to the environment through convection, radiation, evaporation and conduction. B-Gastrointestinal system:  Full maturity of the gastrointestinal tract is achieved by 36 to 38 weeks of gestation with the presence of enzymatic activity and ability to transport nutrients. 13   By birth, the neonate has experienced swallowing, gastric empting and intestinal propulsion.  The newborn‘s stomach capacity is 50 to 60ml.  It empties intermittently, starting within a few minutes of the beginning of a feeding and ending between two and four hours after feeding.  The cardiac sphincter is immature as in nervous control of the stomach. So some regurgitation may be noted in the neonatal period.  Continuous vomiting or regurgitation should be observed closely.  Meconium: normal term newborn pass meconium, within 12 to 48 hours of birth.  Meconium is formed in utero from the amniotic fluid and its constituents together with intestinal secretions and shed mucosal cells.  It is recognized by its thick, tarry, dark green appearance. E-Urogential systems: The bladder contains urine at birth and may empty immediately or after several hours. However, urination may be delayed because of the immaturity of the kidneys. Total volume of urine per 24 hours is about 200-300ml. By the end of the first week. The bladder volume is 15ml. So there is about 20 voiding per day. The urine is colorless, odorless, and has a specific gravity about 1020. The most common causes of failure to void in neonates is dehydration. Male genitalia: The tests have usually descended into the scrotum by the eight months of intrauterine life but in some cases it may remain in the abdomen or the inguinal canal. This condition is known as undescended testes. Female genitalia: The female genitalia is slightly swollen owing to hormone activity. The labia majora are undeveloped and exposed labia minora appear large. Blood may occasionally be observed on the diaper of female infant, this pseudo menstruation is related to the withdrawal of maternal hormones. F-Muscular skeletal system: At birth the skeletal system contains larger amounts of cartilage than of ossified bone. The muscular system is almost completely formed at birth. The skeletal is flexible and the joints are elastic to ensure a safe passage through the birth canal and the movement of the neonate is random and uncoordinated. The back is normally straight and flat hen the baby is lying prone. The lumber and sacral curves develop later, when the infant sits up and begins to stand. 14 G-Neurological system: -The nervous system is strikingly immature. -The bodily functions and responses to external stimuli are carried on chiefly by the midbrain and reflexes of the spinal cord. If a reflex is impaired or absent, possibly the CNS has injury. 15  Reflexes of the newborn infants: Description Presence and duration * protective reflexes Startle (Moro) Sudden stimulus causes arms to fly out ad up. At birth, fades at about 2 months of Tremble and slowly relax. age Tonic neck Postural ‗fencing‖ response: head, arm, and leg At birth fades at about 2-3 month of lum to one side, slowly relax. Activated as a result of turning the head to one side. As the head is turned, the arm and leg on the same side will extend, while the opposite limbs bend age. Grasping neonate grasps any object put in the hands A birth, fades at about 2 months of firmly enough to hold body weight, relaxes age Eye blinking Eyelids close and open when stimulated by At birth, lifelong touch Crying Sudden pain, cold, hunger cause air to through At birth, lifelong vocal cords Feeding reflexes Sucking Lips sucker, tongue rolls, inward pull or At birth 6-8months of age (as a reflex sucking caused by hunger, lip simulation movement) Rooting Touch of check or lips causes head to run At birth, 6 months. toward touch Swallowing Throat muscles close trachea, open esophagus A birth, lifelong when food is in mouth Gag At stimulation of uvula. Esophagus open, reverse peristalsis occurs Contraction of the oropharynx to prevent entry of objects other than food for swallowing. 16  Description Presence and duration Breathing reflexes Respiratory Chest and abdominal muscle contraction At birth, lifelong motion and relaxation produce inspiration and expiration Sneeze Violent reverse flow of air form nose and At birth, lifelong throat Cough Violin reverse flow of air from throat and 1 year, lifelong Lunges Conditioned Learned responses to various stimuli such 2 months may begin and Reflexes as to stop crying mother comes end throughout life. Sensory system: 1- Touch: Highly developed sense in newborn, it is usually strong through ears, tongue, cheek, lips and forehead. 2- Vision: Color of eye blue or gray. Eye movements are not coordinated, so false squint may be seen. 3- Hearing: Highly developed since fetal life. 4- Taste: it is more developed than vision. 5- Smell: There is a wide difference among infants. The newborn is able to smell breast milk and search for it. Note: Sensation of touch, pressure, temperature and pain are present soon after birth and at the end of ten days; the infant reacts violently to continuous irritation. The newborn infant sleeps about 16-18 hours/day with little nap during day time (circadian sleep). V- Basic needs of normal newborn: 1- Maintaining a clear airway. 2- Achieving and maintaining adequate respiratory exchange. 3-Warmth. 4- Protection from infection. 5- Love and security (attachment). 6-Nutritional needs. 17 XI. Application of nursing process for the care of normal newborn: The two broad goals of nursing care during this period are to promote the physical wellbeing of the newborn and to promote the establishment of a well- functioning family unit. The first goal is met by providing comprehensive care to the newborn while he/she is in the nursery, the second goal is met by teaching parents how to care for their new baby and by supporting their parenting efforts, so they fell confident and competent. Assessment: Assessment of the newborn is a continuous process used to evaluate the development and adjustment to extrauterine life. Immediate assessment: it includes the initial Apgar scoring system for physical condition, and is based on five signs (heart rate, respiratory effort, muscle tone, reflex irritability and color). Evaluation method for apgar scoring: Aspect of infant 0 1 2 observed Heart rate Absent Less than 100/m More than 100/m Respiratory rate No Weak cry and Good strong cry and regular breathing shallow breathing breathing Muscle tone Flaccid Some flexion of Well flexed extremities Response to Non Some motion, Cry stimulation of grimace feet Color Blue Body pink, Completely pink pale extremities blue Nursing intervention: 1- Maintenance of a clear air way and initiation of respiration: At birth the highest priority need of the newborn is to achieve and maintain adequate respiratory exchange under normal circumstances. The neonate must initiate and maintain adequate respiratory exchange under normal circumstances. The neonate must initiate and maintain inspiration and expiration of sufficient depth and regularity to replace the terminated placental source of oxygen and carbon dioxide exchange. Suction of newborn‘s nose and mouth even before birth and after the cord is 18 clamped, wiping the mouth with a finger covered with a piece of gauze. Then rubber bulb syringe or electric suction may be used to remove mucous which may obstruct respiratory tract. Avoid deep suction through stomach to avoid vagal stimuli that leads to Brady cardia. 2- Maintain a neutral thermal environment The thermal balance is maintained by regulation of heat loss and heat production. The environment plays a major role in heat loss through evaporation, conduction, convection and radiation. Pre-heating the delivery room is important for maintaining the baby‘s temperature. In the immediate post delivery period because of the amniotic fluid covering the body, the most important mechanism of heat loss is evaporation. So that, simply drying a baby after delivery significantly reduced heat loss and wrapping the baby reduced post delivery heat loss by more than 60%. -Placing the newborn on his/her mother to utilize her body heat. -The nurse should implements measures to prevent neonatal heat loss as using heat shields, keeping the infant dry ad covered, avoid air drafts and cool surfaces and cold instruments. -Skin to skin contact is more effective (mother baby bonding). -Breast-feeding contact to be more effective than use of radiant heater. 3- Applying precautions and promote safety: Newborns are highly susceptible to infection they have not developed any defenses against disease. Therefore particular attention to hygiene is essential when the infant is handled. However, this principle applies to nurses, physicians, parents or any one handling a newborn. Clamping the infant‘s cord and inspect the cord to be sure that it is clamped or tied and observe any bleeding. The umbilical stump is an excellent medium for bacterial growth, various methods of cord care practiced, swabbing the cord and base with 70% alcohol and a regular basis to promote healing. Prophylactic eye drops for all newborns instilled in their conjunctiva to prevent gonococcal or chalamydial eye infections (ophthalmia neonatorum). Before the nurse administers the prophylaxis medication, the neonate‘s eyes are wiped clean, two drops of chloramphenical instilled in each of the lower conjunctival sac. An injection of a single dose 1mg of vitamin K preparation is given shortly after birth in the delivery room. 19  Weighing the infant and the scale should be covered with a disposable line or paper towel that is discarded after each infant is weighted, and wiped with a germicidal or fungicidal solution and freshly covered before the next infant is put on the scale. Proper identification of the newborn infant in the delivery room is essential and placed on infant‘s wrists or ankles which include the mother‘s full name, admission number, sex of infant, date and time of infant‘s birth. 4- Promotion of adequate hydration and nutrition: Breast feeding is the superior way to introduce a newborn to the world and breast milk is the best food to ensure that a baby survive and thrives. Breast feeding should begin shortly after birth in the delivery room, during this time, the infant is often placed skin – to – skin with the mother enhancing the boding process. Nursing on demand seems to work best for most infants. The nursing should be limited to 5minutes on each breast. The time may be increased gradually until the infant nurses 10 to 15 minutes on the first breast to empty it and as the infant desires on the second. Breast feed infants do not need other fluids not even water in very hot climates. One of the most important things a mother needs to learn to do before she will be a successful breast feeder is relax, and the mother must wash her hands and breast before each feeding then start feeding with a comfortable position. After feeding, the infant needs burping to help expel the swallowed air and put on the right side. 5- Fostering and promoting parents-newborn attachment: Attachment is abound of affection between two individuals that endures over time. Parent attachment may be promoted by maternal newborn skin to skin contact immediately after birth. Crying is an newborn behavior that believe fosters the bonding process and when the newborn cry start in increases the blood flow to the mother‘s breast indicating a biologic preparation for nursing. The nurse facilitates attachment by providing an opportunity for the mother, father, and newborn to be alone in a quite environment after birth. Involve parents in caring for their baby. It is important for the nurse to involve parents in caring for their baby. 20 6- Parent education and discharge plan: An integral part of the care of the newborn is the care of the parents because of the strength of influence in the usual parent- newborn relationship, as well as to help parents in their ability to meet the needs of their newborn, the nurse must recognize and meet their needs too by serving as a positive role models continually assessing, teaching and re-evaluating parents knowledge and care. The nurse provides emotional support and anticipatory guidance for the parents in the care of their newborn and assess their attitudes and their potential ability to provide an environment which will foster the development of trust in their infant. The goals of parental education include increasing the parent‘s knowledge of newborn development and methods of care, providing parents with more social contacts and role models of a successful parents. Nurses can use their knowledge of theoretic of growth and development as a basis for describing and explaining the neonate's behavior and predicting outcomes of interaction between newborn and mother. The nurse can do much to faster healthy adaptation by being aware of potential stressed or educating family members as to what to expect by providing support and assisting with problem solving to minimize the effect of stresses. The nurse determines the presence of any psychological factors that may affect the family‘s ability to integrate its newest member. The nurse assess the mother understanding and initiate her skills in caring for her newborn, any basic principles or procedures related to newborn care that the mother finds necessary and useful should be part of the nurses teaching plan for the mother during the first month of newborn life. The nurse have to help the mother to increase her competence in caring for newborn. The nurse should discuss with the mother about several problems that may a raise in the neonatal period and mothers should know when to worry and when they should not worry. 21 Problems of neonates: A-Problems that are considered normal:  Mild degree of nasal obstruction and snoring.  Occasional regurgitation or vomiting (once or twice daily).  Inverted sleep rhythm: sleeping during day hours is usually better than during night.  Straining, even during sleep is normal.  Variable bowel movements: the normal average is 1-2 motions per day. However, passage of 5-6 motions per day often following each feed is normal and not diarrhea, on the other hand passage of one motion every 3- 4 days is also normal and not constipation. B-Problems that necessitate medical consultation  Poor or absent sucking.  Appearance of yellow coloration of eyes and skin.  Significant repeated vomiting  Rapid or difficult respiration or fever.  Appearance of whitish sport or patches on the tongue or oral mucosa. C-Weight gain: Normally the newborn doses not gain weight except after the first 7-10days. The normal rate of weight gain is about 200gm /week. 22  NORMAL GROWTH AND DEVELOPMENT OF INFANT (Age 1 month to 1 year) Objectives: At the end of this lecture the student should be able to:  Define infancy period.  Identify physical growth during 1st year of life.  Enumerate motor development during 1st year.  Assess social and mental development during 1st year of life.  Assess emotional development during 1st year of life.  Enumerate needs of infant.  Identify daily care for infant. Introduction: The first year of life is the period of most rapid gain in physical size and most dramatic achievement in development. It is marked by an orderly progression of physical, intellectual and social maturation. Definition of infancy period: Infancy period starts of the end of the first month up to the first year of life. Infant‘s growth and development during this period are characterized by being rapid. Physical growth: Nurse can detect physical growth through measurement of: A-Weight:  The infant gains : o Birth to 4 months > ¾ kg /month o 5 to 8 months > ½ kg /month o 9 to 12 months > ¼ kg/ month  He will double birth weight by 4-5 month and triple it by 12 months of age. B-Length: Length increases about 2.5cm/month during the first 6 months of age, then, slows in the second 6 months. Average length is 65cm at 6 months and 75cm at 12months. C-Head circumference:  It increases about 1.5cm/month during the first 6 months, then ½ cm/month during the second 6 months of age. Average size 43cm at 6 months and 46cm by 12 months.  Posterior fontanel closes by 2 to 6 months of age.  Anterior fontanel closes by 12-18 months of age. 23 D-Chest Circumference: By the end of the first year, it will be equal to head circumference. Physiological Growth: Nurse can detect physiological growth through measurement of vital signs. -Temperature: 36.5-37.5c -Pulse: 110- 150 beat/minute - Respiration: 35 ± 10 c/min -Blood pressure: 80/50 + 20/10 mm/Hg. Dentition:  The nurse can assess growth through observation for teeth eruption.  Eruption of teeth starts by 6 months of age. It is called ―Milky teeth‖ or ―deciduous teeth‖  A normal healthy child first erupts the lower front teeth known as central incisor between 5-6 months, followed by upper incisor at 7 months. The next teeth to erupt are upper lateral incisors in the 9 month followed by lower lateral incisor at 11 month. Lower first two molars erupt at 12 month. Infant will have (10) teeth at the end of one year. By the time a child is 2.5 to 3 years old he/she has 20 teeth. They are called milk teeth, because they are replaced by permanent teeth in middle childhood. N.B.:  Also nurse can assess growth through observation for teeth eruption.  Eruption of teeth starts by 6 months of age. It is called ―Milky teeth‖ or ―deciduous teeth‖ 24  N.B.: infant will have (10) teeth at the end of one year. - Four upper and lower central incisors - Four upper and lower lateral incisors Development of the infant: 1- Motor development: At 2 months Hold head erects in mid-position. Turn from side back. At 3 months, the infant can Hold head erects and steady. Open or close hand loosely. Hold object put in hand At 4 months, the infant can Sit with adequate support. Roll over from front to back. Hold head erect and steady while in sitting position. At 5 months, the infant can Balance head well when sitting. Site with slight support. At 6 months, the infant can Sit alone briefly. Turn completely over (abdomen to abdomen). At 7months, the infant can Sit alone. Hold cup. 25  At 8 months, the infant can Site alone steadily. Drink from cup with assistance. At 9months, the infant can Rise to sitting position alone. Crawl (i.e., pull body while in prone position). At 10months, the infant can Creep well (use hands and legs). Walk but with help. At 11 months, the infant can: Walk holding on furniture. Stand erect with minimal support At 12 months, the infant can: Stand alone for variable length of time Site down from standing position alone Walk in few steps with help or alone 2- Cognitive development Cognitive development according to “Piaget”: -During the sensorimotor stage ―between birth and 18 months‖, intellect develops and the infant gains knowledge of the environment through the senses. 3- Social development: He learns that crying brings attention. The infant smiles in response to smile of others. The infant shows fear of stranger (stranger anxiety). He responds socially to his name. Psychosocial development according to “Erikson”: 1- Erikosn terms the crisis of infancy as ―trust versus mistrust‖. 2- In this stage, developing a sense of trust on caregivers is the central focus of infant. 3- Infant who receive attentive care learns that life is predictable and that their needs will be met promptly, which fosters trust. Also infant develop self- 26  trust. Also infant develop self-trust when his/her care is effective, comfort and consistent. 4- Infant whose needs are consistently unmet or who experience significant delays in having their needs will develop a sense of uncertainty, leading to mistrust of caregivers and the environment also he develop mistrust when he receive inadequate and inconsistent care. Psychosexual development according to “Freud”: -The oral stage of development extends from birth to 18 months. -During this stage, infant learning to deal with anxiety by mouth and tongue. -Infant libidinal pleasure center about the gratification from using his mouth for sucking swallowing, chewing and biting. Emotional development: His emotions are instable, where it is rapidly changes from crying to laughter. His affection for or love family members appears. By 10 months, he expresses several beginning recognizable emotions, such as anger, sadness, pleasure, jealousy, anxiety and affection. Speech Milestones: 2months: response to care givers voice ah‘‘ eh‘‘ uh 3 months: laugh loudly 6 months : vocalize several well-defined syllables 7 months: vocalizes da , ma , ba― 9 months: associates words with persons or objects, says mama/dada 10 months: one word sentences, 12 months: two or more words Infant needs: 1. Love and security 2. Feeding 3. Sucking pleasure 4. Warmth and comfortable 5. Sensory stimulation 27 Daily care of infant: 1. care of eye, nose, ears and mouth 2. Diaper care 3. Carrying the infant 4. Bathing 5. Clothing 6. Exercise 7. Sleep 1- Eyes: Any secretion that have a cumulated in the corners should be washed out with soft subject and clean water starting from inner to outer on one direction and then dry it. 2- Nose and Ears: Nose and Ears can be cleaned externally by using twisted cotton can be moistened in water. Oil should never be used because of the danger of aspiration when cause harm to respiratory tract. 3- Mouth: The mouth should be cleaned after each feeding by clean water 4- Diaper care: frequent change of diaper after each urination and defecation then clean the genitalia and buttocks very gently ad dry it 5- Carrying the infant: Infant head is large in proportion to his body and he is unable to hold erect without support until he is about 3 months old. The shoulder and back must support at first because of weakness. There are different techniques for carrying infant such as: 1- Cradle technique. 2-Upright technique 3-Football hold *Each of them has its special use. The cradle technique is commonly used in lifting, turning and carrying the infant & breast feeding. Upright technique: is usually in eructation the infant & IM injection. The football hold: is usually in washing the infant‘s head over a basin. 6- Bathing: Safety factors must be kept in mind when bathing the infant must not be left alone even if he is in sitting up position in tub alone even if he is old enough to sit up and hold on the sides of the tubs. 7- Clothing: Infant‘s clothes must be simple and bright color, and loose especially when he start to creep or move around freely. Shoes should be soft until the child walks he should be allowed to go bare foot. 28 8- Exercise: - An infant get exercise in a number of ways he is active at bath time. - The clothes should not restrict his movement. - When he is old enough to turn over he should have toys to encourage activity. 9- Sleep:. - Infant needs more than 15-18 hours a sleep a day in the first few months of life. - At first year old she/he sleeps about 12hours out of 24 hours. He needs one or two naps a day. Red flag in infant development Unable to sit alone by age 9 months Unable to transfer objects from hand to hand by age 1 year Abnormal pincer grip or grasp by age 15 months Unable to walk alone by 18 months Failure to speak recognizable words by 2 years. 29  Normal Growth And Development of Toddler (Age 1 year to 3 years) Definition: It is the period from 1 to 3 years. It is characterized by growth slow considerably. Physical growth: Nurse can assess physical growth for toddler through measurement of (weight, height, head and chest circumference). Weight Average weight gain 1.8 to 2.7kgm / year. Formula for calculates weight: {Age in years x 2+8} Height Height increases about 5 to 12cm/years. Formula for calculates height: {Age in years x 5+80} Head circumference increases only about 2 cm during the 2nd year compared to 12cm during the 1st year. Chest circumference exceeds head circumference. Physiological growth: Heart rate: 90-110 b/m Respiration: 20-30c/m Respiration slow slightly but continue to be mainly abdominal. Blood pressure: 99/64 mm Hg. Teeth: Eight new teeth (the canines & the 1st molars) erupt during the 2nd year. All 20 deciduous teeth are generally present by 2.5 to 3 years of age. Abdomen: It is protruded and toddler appears like `` Pot – bellied`` because of the immature abdomen muscles Bowel and bladder control: Daytime control of bladder and bowel control by 24-30 months Senses:  Binocular vision well development by 15 month of age  Visual acuity of 6\ 6 is achieved during this period 30   Senses of smell, hearing , touch and taste become increasingly well development Motor development: 15 months Gross motor Walks alone well-can creep upstairs Fine motor Builds tower of 2-3 blocks Holds a cup with all fingers & grasped about it. Make line with crayon. 18 months Gross motor Can walk up & down stairs with one hand held can run & jump in place. Fine motor holds cup with both hands Imitates a vertical line Removes simple clothes e.g shoes Transfers objects from hand to hand. 24 months Gross motor walks up stairs alone still using both feet on same step at same time Runs well Fine motor Can open doors by turning doorknobs Holds cup with one hand Imitates circle 30months Gross motor Can jump down from chairs. Takes a few steps on tiptoes Fine motor Makes simple lines. Drink without assistance. Good hand-finger coordination. Language development: 15 months: Says 4 to 6 words (mainly names) 18 months Says 7 to 20 words. 24 month: Says 50 words, 2-word sentences such as me come. 30 months: Verbal language increasing steadily. Knows full names can name I color and holds up fingers to show age. 31 Social development: 15 month; Explores drawers 18 month: Plays in company of other children 24 month; dry by day 36 month; knows full name, age and sex, dry by night Emotional development:  Less fear of strangers ,but he develops separation anxiety (anxiety develop when he is separated from the caregiver , who is usually his mother )  Temper – tantrum as means of anger expression  A afraid from falling , loud voices and stranger places and people Psychosocial development according to “Erikson”:  Erikson terms the psychosocial crisis the child faces between 1 and 3 years as “autonomy versus shame and doubt”. Children who have learned to trust themselves and others during the infant year. When the child constantly enlarges and explores his environment and when allowing for the child to do what he is capable to do in a safe environment he develops sense of autonomy. If he feels that his independent actors are ineffective, he acquires a sense of shame or doubts his self. Psychosexual development according to “Freud”:  The child's self –concept as a girl or a boy is probably completed at about 2.5 to 3 years of age.  The anal stage of development extends from age 8 months to 4 years; during this stage the child transfers his focus and expression of libido (libidinal pleasure) from his mouth to his anal region. Cognitive development according to “Piaget”: The toddler enters the 5th and 6th stages of sensorimotor thought. Piaget referred to stage 5 (between 12 & 18 months) as a tertiary circular reaction stage as ―a little scientist‖ because of the child‘s interest in trying to discover new ways to handle objects or new results different actions can achieve. At the end of the toddler period, children enter a second major period of cognitive development (this stage extends from 2 to 11 years) and divided into 2 periods: o 2 to 7 years (it is called pre-operational stage). 32  o 7 to 11 years (it is called concrete operation).  During the pre-operational stage, the child use language well and has memory „thought”. He is not intellectually capable to understand the relationship among phenomena.  Child centers his attention on one feature of something and unable to see other qualities. Needs of the toddler: 1-Love and security: Love enables the toddler to grow up and reach out for mature goals because he feels secure in his parents or mothers because mothers give them tender, loving care. 2- Graded independence Independence is learned gradually and is given the child only in situations in which he can guard himself from physical and emotional trauma. Fulfillment of needs: The toddler whose parents give him graded independence that brings pleasurable results develops a sense of self-reliance and adequacy of autonomy. It will take him a little longer to learn that there are some things he can able to do without being hurt, but may not do because his parents say ―No‖. The child wants to do many things he is not physically able to do.Regulating the toddler‘s activities is an important part of his training and is a challenge to the most mature and resourceful adult. A gradually expanding area of growth in a safe environment must be provided for him. 3- Elimination control or control of bodily functions: Toilet training should be started when the toddler is physiologically and psychologically ready. He is physiologically ready when he can stand alone; the average healthy, intelligent child usually accomplished bowel control by the end of the (12-18) month. Daytime bladder control may be fairly well established by 2 years of age and night control by 3 or 4 years. 4- Learning language: Between the age of one and three years the child is increasingly able to understand others and to express his feeling and ideas in word. The mothers 33 facial expression, gestures, and tone of voice help the child to understand the meaning of her words. Delayed speech: The normal child begins to speech at about 15 months of age. If he does not speak by the time of 2 years old the cause for delay should be investigated. Intelligence speech: Speech are delayed in children of low intelligence, the size of the vocabulary depends to a great extent upon the child‘s intelligence. Social and cultural environment: Children of poor social environment are delayed in speech development because they often have poor models to imitate. Illness: Children who are ill in an institution for a long time have slower speech delayed than well children because they have fewer contacts with other children and also because their needs are answered before they have to ask for what they want. Poor models: If the child has poor models to imitate in speaking his speech will be incorrect or retarded. Negativism: the child may decide not to talk because he was forced to talk when he was not mature enough to want to imitate his mother‘s words. Deafness: If the child cannot hear what others say, he cannot imitate them and therefore will not speak unless he has had special training. Sex: Boys are usually slower than girls in learning to talk them also have a smaller vocabulary than girls and make more grammatical errors. 5- Promoting Healthy Eating Habits The toddler will exhibit food jags. During a food jag, the toddler may prefer only one particular food for several days, then not want it for weeks. It is important for the parent to continue to offer healthy food choices during a food jag and not allowing the toddler to eat junk food 34 6- Preventing Overweight and Obesity 1- Meals should be eaten in a calm and pleasant environment 2- Parents should serve as role models for appropriate eating habits, but toddlers may also be willing to try more foods if they are exposed to other children who eat those foods 3- Praise the child for trying a new food, and never punish the toddler for refusing to try something new. 4- A new food may need to be offered many times in a row before the toddler chooses to try it. 5- Parents should be sure to include foods the child is familiar with and likes to eat at the same meal Note: 1- In children, the greatest risk factor for the development of overweight or obesity is having a parent with a high body mass index 2- Another factor in development of obesity in young children is juice intake, Since most young children like the sweet taste of juice, they may drink excessive amounts of it. 7-Promoting Healthy Teeth and Gums By 30 months of age, the toddler should have a full set of primary teeth. Parents may not be aware of the importance of preventing cavities in primary teeth since they will eventually be replaced by the permanent teeth. Factors that contribute to the development of dental caries: 1-Poor oral hygiene 2- Prolonged use of a bottle 3- Lack of fluoride intake 4- Delayed or absent professional dental care Note: Cleaning of the toddler's teeth should progress from brushing with simply water to using a very small amount (pea sized) of fluoridated toothpaste. 35 Personality traits of the toddler (problems of toddler): A-Negativism: in his desire for independence or autonomy. The child wants to do many things he should not do. From infancy through the toddler period he has heard his parents say ―No‖ to his many efforts at ―Don‘t‖ and a rather stubborn ―I won‘t‖. Each child goes through this sometimes a child appears to be negativistic when he really is not. He may not object to doing what his parents wants, but he does not want to stop what he is doing. Handling negativistic behavior: An adult should not use apposition to overcome apposition in a child. An adult should not give the toddler too many commands or interrupt his activities too frequently. The adult should help the child to participate in what is expected of him by giving physical help. B-Ritualistic behavior: The toddler engages in much ritualistic behavior. He makes rituals of simple tasks because he knows that he can master himself in this way. Ritualistic behavior is most common between the ages of 2 and 4 years. Adults should recognize these rituals in such phases as bathing, eating, and sleeping. C- Slowness in carrying out order: The toddler is gradually learning the difference between right and wrong. He cannot decide which of two actions are taking. Therefore he is likely to carry out both actions. Then the child learns through experience which action he should take, he will be able to make decision more likely and more quickly. D-Temper tantrums: Temper tantrums occur when the child cannot integrate his internal impulses and the demands of reality. He is frustrated and reacts in the only way he knows by violent bodily activity and crying. Handling the child during the tantrums: The child not be given extra attention, but should be observed from self –injury or from something in the physical environment which may be a source of injury to himself. E- Sibling Rivalry The toddler has been accustomed to being the baby and receiving a great deal of attention both at home and with the extended family, toddlers are normally egocentric, bringing a new baby into the home may be quite disruptive. To minimize issues with sibling rivalry (competition or jealousy between siblings: 36 1- Parents should attempt to keep the toddler's routine as close to normal as possible. 2- Spend individual time with the toddler on a daily basis to involve the toddler in the care of the baby. 3- Gives the toddler a sense of importance 4-The toddler will need significant support while holding the baby. F- Regression Some toddlers experience regression during a stressful vent (eg, the birth of a sibling hospitalization). Stress in a toddler's life affects his or her ability to master new tasks. During regression, the toddler may want to go back to an earlier stage. He or she may desire bottle of pacifier forgone long ago, may also disrupt the toilet teaching process may not be achieved near the time a sibling is born. The Nurse's Role in Toddler Growth and Development 1- The nurse must have a good understanding of the changes that occur during the toddler years in order to provide appropriate anticipatory guidance and support to the family 2- When the toddler is hospitalized, growth and development may be altered. The toddler's primary task establishing autonomy 37  Normal growth and development of pre- School child Objectives: At the end of this lecture the student should be able to:  Recognize physical and physiological growth of pre-school child.  Describe pre-school motor, mental and emotional development.  Mention the effect of birth of a sibling.  Differentiate between cognitive, psychosexual and psychosocial development of pre-school child.  Identify needs of pre-school child.  Enumerate problems of pre-school child  Mention care of pre-school child.  Discuss nursery school. Physical growth and development of pre-school child: 1- Measurements A-Weight: -Weight gain averages (2.3kg) per year. -Average 6-year- old (18kg) or double the weight at one year of age. B-Height: -Growth averages (6.25 to 7.5cm) per year. -Average 6-year- old (101cm) tall or double birth length. 2- Vital signs: -Temperature …………36.5- 37C -Pulse rate.................... … 90-110b/min. -Respiratory rate…............. 20 c/m. -Blood pressure…............... 85/ 60mmhg. 3- General characteristics: -The rate of physical growth slows and stabilizes during the preschool years. 38  - A healthy pre-school is slender, graceful and posturally erect. -By the end of pre-school period the child appear to be thin and tall. -Children gain muscular coordination, which enables them to explore the physical environment. Motor development: Fine Motor Skills These skills involve the use of a child's smaller muscles such as his fingers or hands. Fine motor development is evident in these children's increasingly skillful manipulation, such as in drawing and dressing. These skills provide readiness for learning and independence for entry into school. Gross Motor Skills The gross motor skills of a preschool child include being able to go up a staircase with alternate steps-- that is putting one foot on each step as he climbs up, instead of both feet on one step, throw and catch a ball, hop, climb and skip, pedal a bicycle and jump over low obstacles. To perform gross motor skills, a child uses his large muscles At 3 years -Can wash hands. -Can feed himself well. -Build a tower of 9 to 10 blocks. -Can go to toilet. -Begins to use a scissors. -Can ride a tricycle. -Go upstairs. -Stand on one foot for a few seconds. At 4 Years: -Can jump well, goes up and down stairs. 39  -Can brush his teeth, lace his shoes. -Can copy a square. At 5 years -Can use scissors well. -Can dress himself without assistance. -Can wash himself without wetting his cloths. -Can balance on one foot for about 8 second. -Explain the meaning of his picture to others. Mental development (Cognitive development “Piaget”): -The preoperational phase covers the age span from 2 to 7 years and is divided into two stages: pre-conceptual phase, ages 2 to 4 years and the phase of intuitive thought, ages 4 to 7 years. - One main transition during these two phases is the shift from totally egocentric thought to social awareness and the ability to consider other viewpoints. However, egocentric is still evident. - Language continues to develop during the preschool age. Speech remains primarily a vehicle of egocentric communication. Preschoolers increasingly use language without comprehending the meaning of words, particularly concepts of right and left, causality and time. - Children may use the concepts correctly but only in the circumstance in which they have learned them. - Preschoolers explain a concept as they heard it described by others, but understanding is limited. Social development: Preschoolers have overcome much of the anxiety associated with strangers and the fear of separation of earlier years. They relate to unfamiliar people easily and tolerate brief separations from parents, with little or no protest. However, they still need parental security, reassurance, guidance and approval, especially when entering preschool or elementary school. 40 Speech and Language Development - During preschool years, language becomes more sophisticated and complex and the major mode of communication and social interaction. Through language, preschoolers learn to express feelings of frustration or anger without acting them out. - Vocabulary increases dramatically from 300 words at age 2 years to more than 2100 words at the end of 5 years. Language development predicts school readiness and sets the stage for later success in school. - Children from 3 to 4 years of age form sentences of about three to four words and include only the most essential words to convey a meaning. - Three year-old children ask many questions and use pleural, correct pronouns and the past tense of verbs. - They name familiar objects such as animals, parts of the body, relatives and friends. From ages 4 to 5 years, preschoolers use longer sentences of four or five and more parts of speech to convey a message. They can follow simple directional commands, but can carry out only one request at a time. Psychosexual development (Freud): -According to Freud, the phallic stage extends from age 3 to 7 years. During this time the child‘s pleasure centers on the genitalia and masturbation. -During the phallic stage, the child experience what Freud termed the oedipal conflict, marked by jealousy toward the same- sex parent and love of the opposite – sex parent. -The oedipal stage typically resolves in the late pre-school period with a strong identification with the same –sex parent. -As sexual identify develops, pre-school children are keen observers but poor interpreters, they may recognize but not understand sexual activity. -Before answering a child‘s questions about sex, clarify:  What the child is really asking.  What the child already thinks about the specific subject. -Answer questions about sex simply and honestly, providing only the information that the child requests, additional details can come later. 41 Emotional development (psychosocial development according to “Erikson”): - After preschoolers have mastered the tasks of toddler period, they are ready to face the developmental endeavors of the preschool periods. Erikson mentioned that the chief psychosocial task of the preschool period is acquiring a sense of initiative. Children are in a stage of energetic learning. They play, work and feel a real sense of accomplishment and satisfaction in their activities. At this age, the child has normally mastered a sense of autonomy and moves on to master a sense of initiative. -Between ages 3 and 6 years, per-school child faces a psychosocial crisis that Erikson terms ―initiative versus guilt‖. - Conflict arises when children overstep the limits of their ability and inquiry and experience a sense of guilt for not having behaved appropriately. Needs of pre-school child 1- Security and independence: -The child feels love and security hen he has two parents. He needs their love and understanding, when he grows he needs opportunity to assume more responsibility ad independence. 2- Guidance: -The parents besides showing love for him must teach and guide him toward maturity by suggestions not commands helpful the child in forming good relation with other people. -Suggestions of children to be helpful should be provided and reinforced at appropriate time. -Commands are seldom necessary but when given in positive rather than negative form is more effective. 3- Sex information: -Sex education during pre-school years contributes specific knowledge, which the child wants to know. -The child learns that he or she is a boy or a girl. 42 -parents should answer the child directly an honestly, the amount of information given based on the child‘s physiologic and developmental level. 4- Learning language: -The pre-school child learns to communicate his feeling and ideas through language in a more precise form than he did as a toddler. -During this period he uses longer and more complex sentences. -This is a period of rapid vocabulary growth. -He also learns by imitating adult and other children. 5- Religious education: -Religious can be understood at this age. He can be taught that ―God‖ is within our lives, that ―God‖ loves him. Problems of pre-school child: 1- Thumb-suckling: -Thumb-suckling may be a sign of dissatisfaction with life and also may be a sign that the child feels unloved, that he is in danger or not good enough. -Adults should provide more love and security for him. 2- Enuresis: -It is defined as ―repeated involuntary voiding of urine after control should be established‖. -The term enuresis alone is commonly used to indicate wetting during the day. -Nocturnal enuresis refers to involuntary voiding during the night. N.B.: Control bladder at night (3.5-5 years) -During the day at (2-2.5 years) -control bowel starts at (1 year), completed at (1.5 year). Etiology: a- Developmental disorder …………delay in the development of the bladder reflex due to -Hereditary factors. -Inadequate toilet training. b- Psychological disturbance................... Emotional stresses or insecurity. c- Environmental factors...................... Such as darkness or coldness. 43 d- Organic factors such as: -Mental retardation. -Congenital anomalies. -Urinary tract infection. -Diseases associated with polyuria as diabetes. Management and nursing care for enuresis: - Proper management of organic causes. - Psychotherapy if the emotional problem is prominent. - Fluid intake may be limited at night. - Let the child pass urine before going to bed. - Drugs as doctor order. 3- Encopresis: -The child continuous to have uncontrolled stool passage beyond the time when bowel control is expected. N.B.; Start bowel control at (1 year). Completely controlled at (1.5 year) Etiology: I- Developmental failure. II- Inhibited –dependent child. III- Disturbed child. Management and nursing care of encopresis: -Regular evacuation of the bowel each day may help reestablishment bowel habits. 4- Selfishness: -No child is born with the ability to share with others. He must first develop a sense of owner ship before he can learn to be generous. -Group play encourages the habit of sharing. 5- Bad language: - Children learn improper words in their vocabulary. In such a situation adults should relax and not be worried or shocked. - The child should not be punished. 44 6- Hurting others: -Small children hurt others and themselves when they play together. -The child who repeated wants to hurt others by biting, scratching and pulling hair is a troubled child; he may be jealous or frustrated. -He needs to fell secure. -He must be identifying with group accepting them and being accepted by them. 7- Masturbation: ―Phallic stage‖ the child‘s pleasure centers on the genitalia and masturbation. -The child‘s feels pleasure sensation when he playing with the genital organs. -Avoid punishment and threats, tract attentions to other play or toys. -The child must be ware salopet. He can give opportunity for happy relations with playmates and sufficient toys to play with it. 8- Destructiveness: ―Boundless energy and endless curiosity‖. -Destructive child is usually an unhappy child, unable to control his feeling of jealousy, helpless, aggressive or anger. -To avoid accidental destruction at home, the parents should remove valuable objects that the child break or damage it. -The child must be providing wide space to play in without danger. -The parents should avoid punishment and help him direct his energy into appropriate activities. 45  NORMAL GROWTH AND DEVELOPMENT OF SCHOOL AGE CHILD (Age 6 to 12 Years) Objectives: At the end of this lecture the student should be able to: -Define school age period. -Discuss physical growth of school age. -Discuss physiological growth of school age -Describe developmental theory according to Freud, Erikson, and Piaget of school age period. -List needs of school age. -Enumerate health problems of school age. -Discuss health teaching to the parents as regards health problems of school age period. Introduction: All culture agrees that, the child entering new phase of life at 6-7 years. It creates new and more complex behavior pattern. Beside that there privacy makes them to take physical care of himself. Definition: The segment of the life span that extends from age 6 years until 2 years. It is a period, which characterized by first eruption of permanent teeth and finished by beginning the puberty. Physical growth:  During the school age, the general growth is slow until puberty.  The child shows progressive lower in growth in height and rapid gain in weight.  In this age boys different little from girls in height in height and weight.  Boys are taller and heavier while girls retain more fatty tissues.  The average gain in weight is about 3kg and 6cm in height/ year.  Weight at 6 years > 22kgm.  Double at 12 years > 44 kgm  Height at 6 years > 117cm.  At 12 years > 150cm Physiological growth *Vital signs:  -Temperature: 37c  -Pulse 95 beats / minute.  -Blood pressure: 100 / 60mmHg. 46  -Respiration 19-20 breath /minute. *Gastrointestinal tract: there are maturation of GIT and the child able to digest any food. *The genitourinary system: The urinary system is functionally mature and the kidneys are better to concentrate the urine. *The circulatory system: The heartbeats are shifts from the fourth to fifth lefts inter costal space at the midclavicular line. A functional murmur characterized by soft heart sound was heard and not significant. *Neurological system: The changes in the neurological system result in improved memory and the ability to conceptualize. In addition to full voluntary control of fine motor function. *The skeletal and muscles development: Muscle ache are common complains at this age. Therefore good posture should be encouraged as the hips should be parallel to both sitting and standing position. *Endocrine system: All endocrine system function is mature except those regulating reproductive functions. *The immunological system: the main function of this system is the elimination of substances that are foreign to the body. So, lymphoid tissues, which are a part of the immunological system, reach to greater amount in school age than adults. *The sense organs: Regarding to the taste & smell, the child is able to identify and discriminate between the common objectives. The central visual acuity is established by 6 years. Physical fitness has declined among school age children. Sedentary habits at this age are associated with increased life time risk of obesity, cardiovascular disease, lower academic achievement and lower self -esteem. Psychosexual development according to “Freud” -The latency period, that extending from age 5 to 12 years represents a stage of relative sexual in differences before puberty and adolescents. - During this period, school child turns his attention and focus from sexuality to tasks of socialization and development of self-esteem is closely linked with a developing sense of industry Motor development: By this age, the child At 6 years:  Throwing a ball and running At 7 years:  Jumping, ride a bicycle. 47 At 8-9 years  Playing musical instrument. At 10 – 12 years: -Help in household, skillful in manual activity and sports Psychosocial Development Erikson termed the psychosocial crisis faced by child aged from 6 to 12 years ―Industry versus inferiority‖. During this period, school child normally has mastered the developmental tasks which are trust, autonomy and initiative and now focuses on mastering industry. Failure to develop a sense of industry result in inferiority (feelings of inadequacy) and child become more isolated Mental development: At 6 years: - Count to 20, define the common object as chair, and obey command an open door. - Know the right arm. At 7 years: -Read clock or watch. -Read clock. At 8 years -Give similarities and differences between two things from memory. -Count back word 20-1 -know months, days, number. At 10 – 12 years: -Write short letter to friends. -Use telephone, read story and books. Vocalization: At 6 years: -Talk in full sentence. At 7 years. -Oriented time, know months, reasons and read clock. At 8-9 years: -Able to understand past, present and future. At 10 –12 years: -Vocabulary depending on his intelligent. 48 Moral development: It divided into 2 stages 1- Stage of constraints: The child views every act as wrong or right, he believes that everyone shares his view. The child thinking is egocentric (sense of self). 2- Stage of cooperation: This occur at 10-12 years, child more flexible and see possibility of more than one point of view. Social development: At 6 years  Share with others, interest in group game.  Has temper tantrum. At 7 years -Child aware family to family roles and responsibility. -Less resistant and stubborn. At 8-9 years: -Like reward system, dramatic. At 10-12 years: -The child moves out the family environment and into the world of peers. Spiritual Development: At 6 years: -The basic tents of religious. -The concept of God as the creator of the world. At 7-8 years -They expect prayers to be answered. At 11 years -Child will seek god help for protection when fearful. Cognitive development according to “Piaget”: Between ages 7 and 11 years, the child is in the stage of concrete operations. Specific characteristics of this stage are the development of principle of conversation and development of various mental classifying. Child can take more responsibilities and ordering activities, transition from egocentric to objective thinking. Needs of school –age: 1- Sleep and rest. 2-Bathing 3-Nutrition 4-Exercise and activity 5-Dental health 6-Education: A-Sex education. B-Religious education 49  Health problems of school age children 1-School problems A. School phobia: All organic cause must be ruled out before school phobia. The most common complaints are abdominal pain, headache, vomiting, and regression. Health education for parents:  Encourage attendance to school result in resolution of the child problem.  The teacher can give special attention to this child.  The teacher must be characterized by sympathy, kindness give the child enthusiasm and leads the child into learning rather than punishing the child. B-Learning difficulties: The learning difficulties are represented in variety of specific learning disabilities in children. The difficulties are in reading, writing, and understanding. o Health education: The children need special attention. 2- Behavioral problems: Children sometimes employ aggressive, negative or disobedient behavior in an attempt to feel important and control others. The forms of aggression are: a- Lying b-stealing c-Cheating 3- Sexual problems: Anxiety from parents toward these points. 4-Abuse in children: It is one of the most common crime of violence against children, it including physical or sexual abuse. It is important for the parents to teach their children the concept of good touch versus bad touch prior to school age. 5- Nutritional problems: A-Overfeeding (obesity) B-Underfeeding  Informing parents about qualities of foods rather than quantities. 6- Communicable diseases: Ex.: Diphtheria, Typhoid fever, Hepatitis A virus.  The nurse should assess the immunization status of school age and review the times when booster doses are needed. 7- Allergy:  Bronchial asthma, sinusitis, urticaria.  Streptococcus infection and staphylococcus. A-Streptococcus infection as tonsillitis, rheumatic fever 50 B-Staphylococcus infection as nephritis.  The nurse must be assessing the cause, time of induction allergy, and make good referral for these children. 8- Skeletal problems: A-Bone fracture B-Scoliosis. 9- Accidents: A-Motor cars accident B-Drowning. C-Electric shock  Instruct the parents about first aids & methods of prevention these accidents. 10- Bullying : It is defined by unwanted, repeated emotional or physical aggressive behavior that is intentional and mean. It occurs repeatedly over time and within the context of a power imbalance. It is so common in youth relationships and peer groups. Bullying in often occurs in unstructured school settings, such as the playground area during recess. Bullies often look for victims who appear weak and defenseless. 51  Normal Growth And Development of Adolescence (Age 12 to 18 Years) Objectives: At the end of this lecture the student should be able to: -Define the adolescence period. - Define puberty. -List physical changes in the body. -List the factors affecting growth and development of adolescence. - Discuss Cognitive development according to „Piaget - Discuss Psychosocial development according to Erikson - Discuss Psychosexual development according to "Freud -List physical problems of adolescence. -State psychological problems of adolescence. -List needs of adolescents. Definitions of adolescence:  It transitional period from childhood to adulthood. Period of rapid physical growth when secondary sex characteristics appear. It ends when somatic growth is completed and the individual psychologically mature and able to take his place in society as a contributing member.  It is a period of stress, conflict and anxiety.  Age: female: 12-16 years and male: 13-18 years.  The World Health Organisation defines adolecence as any person between the age of 10 and 19. It is between child-hood and adulthood and is closely related to the teen age years. Definition of puberty: It is a period of several years in which rapid physical growth and psychological changes occur, culminating in sexual maturity. The average age of onset of puberty is at 11 for girls and 12 for boys. Physical changes in the body: 1- The head is approximately 1/8 of the body weight. 2- Full set of 32 permanent teeth and wisdom teeth erupt (17-21) ears. 3- Increase the activity of sebaceous glands of the face, back and chest. 4- Gain in weight is proportionately greater than gain in height during early adolescence. 5- Skeletal system grows faster than its supporting muscles. 6- Full maturation of other systems (heart, lung). 52 2- Changes in girls: 1- Increase the transverse diameter of the pelvis. 2- Development of the breasts. 3- Changes in the vaginal secretion. 4- Growth of the pubic and axillary hair. 5- Start to menstruate. 6- Capable of reproduction. 3- Changes in boys: 1- Growth of pubic, axillary, facial and chest hair. 2- Increase the size of genitalia 3- Swelling of the breasts. 4- Voice changes. 5- Production of spermatozoa. 6- Capable of reproduction. Factors affecting growth and development of adolescence: 1-Heredity. 2-Sex. 3- Racial and national characteristics. 4- Environment. 5-Prenatal condition. 6-Socioeconomic status of the family. 7-Nutrition of the family 8-Climate. 9-Illness and injury. 10-Exercises. 11-Position in the family 12-Intelligence. 13-Hormonal balance 14-Emotions. *Cognitive development according to ‘Piaget”: It called ―format operations‖, which commonly occurs from age 11 to 15 years.  In this stage, adolescents develop the ability to process Information, improve in areas of decision making, memory, critical thinking and self-regulatory learning. Adolescence develops the ability to order, the capacity for true formal thought, and the ability to connect separate events and has ability to develop problem solving. This is known as the „Formal Operation Stage of Development. *Psychosocial development according to "Erikson”:  Erikson terms the psychosocial crisis faced by adolescent between age 13 to 18 years identity versus role diffusion or role confusion.  Development of who they are and where they are going becomes a central focus for adolescents.  Adolescents who cannot develop a sense of who they are and what they can become may experience role diffusion and an inability to solve core conflicts. 53  After the youth has developed a sense of identity, he should be able to develop a sense of intimacy with himself and with persons of both sexes. If the adolescents fail to achieve the sense of intimacy, he will develop a state of isolation keeping his relations with others on a cool, rigid formal basis. Psychosexual development according to "Freud":  Adolescents focus on the genitals and engage in masturbation and sexual relations with others. This extends from about 12 to 20 years during this period; adolescents experience conflict between their own needs for sexual satisfaction and society's expectations for control of sexual expression.  Male is more of his genitalia, and much more aware of genital responsiveness. Erections occur almost daily. Spermatogenesis is evident by 13 years of age. Masturbation is a central concern in early adolescence especially in boys. Girls may do it to a lesser extent. Through experience the adolescent learns that sexual excitement and erection of penis or the clitoris can occur as a result of masturbation. *Emotional changes Adolescence is said to be a period of heightened emotionality. Heightened emotionality is a state of more than normal emotional experience. This period is often known as the ―period of storm and stress‖. The word storm and stress suggest anger and turmoil. Causes for heightened emotionality The major causes for heightened emotionality are as follows:  Psychological problems due to physical changes – Sudden spurt in height, appearance of secondary sex characteristics, voice change, appearance of acneon the face. etc. cause much embarrassment to them and they become worried about their physical appearances.  Social expectations- Adolescents are treated neither as a child nor as an adult. The constant pressure to live up to social expectations causes a generalized state of anxiety in them.  Reproductive hormones are active and so there is the presence of sex urge. This may lead to anxiety.  Identity crises- The adolescent is expected to form a realistic self-concept. They have to try out different roles and develop a holistic idea of their future role. Until they find their role they are often confused and anxious 54   Unfavorable family relationships- Conflicts often occur between adults and adolescents due to the generation gap between them. Health problems of adolescence: 1-Pre menstrual syndrome The premenstrual period is the period immediately preceding the menses from 1:3 days and up to 12 days before the period starts. Symptoms: 1-Nervous tension. 2-Depression. 3-Irritability. 4-Anxiety. 5-Leg pain 6-Headaches. 7-Dizziness. 8-Tender abdomen and breast. The impact of premenstrual syndrome upon the individual: 1-Poor achievement in high school. 2-Problems in home. 3-Increase the emotional upsets. Management and nurses’ role 1- 1-Physical examination to detect any abnormality. 2-Explanation (ovulation – menstruation). 3- Reassurance. 4- Diversionary activities and exercises. 5-Reduction of the individual work load. 6-Duretics, tranquilizers can be given to relieve fluid retention and irritability. 7-Ovarian hormone can be given. 2-Dysmenorrhea: Difficult menstruation with painful sensation there are 2 types primary and secondary. 1- Primary: Most common, in which pelvis organs are normal. It is due to muscle spasm of the uterus, sexual conflicts, nervous tension, vascular changes, hormone imbalance, and cervical obstruction, poor posture. Symptoms: 1-Abdominal discomfort 2-Nausea 3-Vomiting 4-Pallor 5-Sweating 6-Syncope Management and nurses’ role: 1- Warm bath 2- Heating pad applied to abdomen, lower back. 3-Exercises 4-Good posture 55  5-Mild analgesic or sedative to decrease discomfort 6-Duretics to relive fluid retention 7-Oral contraceptive may be helpful 9-Rarely surgical interference may be necessary. 1- Secondary: Which is associated with organ pathology e.g pelvic inflammatory disease. Treatment is directed toward the cause. 3- Size of the penis: Since the adolescence is extremely concerned with his physical self, any deviation from what he considers to be normal can be a source of excruciating self- consciousness. Many adolescence boys are concerned too much with the size of penis ―the question: what is normal size? We should inform the adolescent that:  There is a wide variation in size among healthy young males  The size of penis has no relationship with sexual drives or the ability to gives sexual pleasure to the opposite sex during course.  Counseling, exercise and diversion activities. 4- Masturbation: Is normal during adolescence and has a role in the process of physical and emotional development the adolescence that has learned from his parents to feel guilty about masturbating and at the same time has experienced pleasurable release following the act will be in conflict. This conflict may be expressed in physical symptoms such as: severe weakness and fatigue, numerous aches and pain. Nursing intervention:  Based on an identification of the unmet needs is directed toward aiding the young person toward more effective methods of attaining gratification.  Parents should give the young more love, affection and attention.  Engage the young in other activities..  Increased the activity with his peers.  Counseling. 5- Postural defects: The erect posture of the adult is usually attained during adolescence. Causes of poor posture: 1- Physically: The bony structure of the body develops more rapidly than the muscles do, the child may appear clumsy and have poor posture. 56  2- Emotional reaction of the youth who find himself suddenly much taller than his peers. 3- Girls may slump to hide the development breasts. 4- Young people of both sexes may develop a forward thrust and round shoulders from watching T.V. for years. - All these problems should discuss freely with the adult to avoid isolation; shaming and any other problems, as well as avoid threatening. 6- Fatigue: Adolescent frequently complain of being tired. It is due to rapid physical growth, over activity, lack of sleep, faulty nutrition, anemia or emotional problems. Tr