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NURS 207: Promoting Pediatric Wellness in the Family & Community. Allan J. V. Cresencia, MSN, CPN, RN Samson Yigezu, PhD, RN Christine Limann, BS, CPN, RN West Coast University - Los Angeles. Theories of Development. Personality Development Freud - Psychosexual Erickson - Psychosocial

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Nurs 207 promoting pediatric wellness in the family community

NURS 207: Promoting Pediatric Wellness in the Family & Community

Allan J. V. Cresencia, MSN, CPN, RN

Samson Yigezu, PhD, RN

Christine Limann, BS, CPN, RN

West Coast University - Los Angeles

Theories of development

Theories of Development

  • Personality Development

    • Freud- Psychosexual

    • Erickson - Psychosocial

  • Mental Development

    • Piaget- Cognitive

    • Kohlberg - Moral

Erikson stages of psychosocial development

EriksonStages of Psychosocial Development

2. Toddler: 18 Months to 3 Years

Ego Development Outcome: Autonomy vs. Shame

Basic Strengths: Self-control, Courage, and Will

1. Infancy: Birth to 18 Months

Ego Development Outcome: Trust vs. Mistrust

Basic strength: Drive and Hope

3. Preschooler: 3 to 5 Years

Ego Development Outcome: Initiative vs. Guilt

Basic Strength: Purpose

Erikson stages of psychosocial development1

4. School Age: 6 to 12 Years

Ego Development Outcome: Industry vs. Inferiority

Basic Strengths: Method and Competence

Erikson Stages of Psychosocial Development

5. Adolescence: 12 to 18 Years

Ego Development Outcome: Identity vs. Role Confusion

Basic Strengths: Devotion and Fidelity

Theories of development1

Piaget – Mental

Sensorimotor – birth to 2 years

Preoperational – 2 to 7 years

Concrete operations – 7 to 11 years

Formal operations – 11 to 15 years

Kohlberg – Moral

Preconventional level – good/bad or right/wrong

Conventional level – approval by being “nice”

Postconventional, autonomous, or principled level – formal operations

Theories of Development

Piaget stages of cognitive development

Piaget Stages of Cognitive Development

Sensorimotor period Years 0-2

  • In this stage, infants construct an understanding of the world by coordinating sensory experiences (such as seeing and hearing) with physical, motoric actions.

  • Infants gain knowledge of the world from the physical actions they perform on it.

  • An infant progresses from reflexive, instinctual action at birth to the beginning of symbolic thought toward the end of the stage.

  • Object permanence is key word.

Infant stimulation

Infant Stimulation

  • Newborn prefers human face for stimulation

  • Visual benefit of black-and-white objects for stimulation

  • Stimulation of human voice

  • Importance of tactile stimulation

Focus on visual objects

Focus on Visual Objects

Fine motor development

Fine Motor Development

  • Grasps object, age 2 to 3 months

  • Transfers object between hands, age

    7 months

  • Pincer grasp, age 10 months

  • Removes objects from container, age

    11 months

  • Builds tower of two blocks, age 12 months

Crude pincer grasp

Crude Pincer Grasp

Neat pincer grasp

Neat Pincer Grasp

Gross motor development

Gross Motor Development

  • Head control

  • Rolls over, age 5 to 6 months

  • Sits alone, age 7 months

  • Moves from prone to sitting position, age

    10 months

Head control

Head Control



  • Cephalocaudal direction of development

  • Crawling, age 6 to 7 months

  • Creeping, age 9 months

  • Walk with assist, age 11 months

  • Walk alone, age 12 months

Psychosocial development

Psychosocial Development

  • Erikson’s phase I: developing a sense of trust

  • Trust vs. mistrust

  • Importance of caregiver-child relationship

  • “Delayed gratification”

  • Importance of consistency of care

Finding hidden object

Finding Hidden Object

Development of body image

Development of Body Image

  • Concept of object permanence

  • By end of first year, recognize that they are distinct from parents

Viewing own image

Viewing Own Image

Development of sexual identity

Development of Sexual Identity

  • Hormonal influences

  • Infant

  • Parental influences on development of sexuality

Social development

Social Development

  • Attachment

  • Reactive attachment disorder (RAD)

  • Separation anxiety

  • Stranger anxiety

  • Play as major socializing agent

Stranger fear

Stranger Fear

Language development

Language Development

  • Crying is first verbal communication

  • Vocalizations

  • Three to five words with meaning by age

    1 year

Infant s health promotion

Infant’s Health Promotion

  • Promoting Infant Safety

    • Aspirations

    • Falls

    • Car (MVA)

    • Siblings

    • Bathing and Swimming

    • Childproofing

Infant s health promotion1

Nutritional Health

Recommended dietary reference intakes

Introduction of solid foods

Loss of extrusion reflex

Techniques for feeding solid foods

Nutritional Health

Quantities and types of food


Vegetables and fruit

Meat and eggs

Table food

Chart on next slide.

Infant’s Health Promotion

Infant s health promotion2

Nutritional Health

Establishment of healthy eating patterns



Adequate intake with a vegetarian diet

Development in Daily Activities


Diaper-area care

Use of pacifiers

Care of teeth


Sleep patterns


Infant’s Health Promotion

Infant s health promotion3

Infant’s Health Promotion

  • Parental Concerns and Problems

    • Diaper dermatitis – skin condition

    • Miliaria – sebaceous glands

    • Baby-bottle syndrome – dental carries

    • Obesity – no comment!

Baby bottle syndrome dental carries

Baby-bottle syndrome – dental carries

Health problems during infancy

Health Problems During Infancy

Chapter 13

Protein and energy malnutrition

Protein and Energy Malnutrition

  • Kwashiorkor

    Severe protein malnutrition, especially in children after weaning, marked by lethargy, growth retardation, anemia, edema, potbelly,

  • Marasmus

    A progressive wasting of the body, occurring chiefly in young children and associated with insufficient intake or malabsorption of food

Food sensitivity

Food Sensitivity

  • Cow’s milk allergy

  • Lactose intolerance

Feeding difficulties

Feeding Difficulties

  • Regurgitation and “spitting up”

  • Reflux/GERD

  • Colic (paroxysmal abdominal pain)

  • Failure to thrive

    • Organic FTT

    • Nonorganic FTT

The colic carry

The “Colic Carry”

A consistent nurse in nonorganic ftt

A Consistent Nurse in Nonorganic FTT

Skin disorders


Diaper Dermatitis

  • Principal factors in development

  • Therapeutic management

  • Nursing considerations

Seborrheic dermatitis

Seborrheic Dermatitis

  • Chronic, recurrent, inflammatory reaction

    of the skin

    • Scalp: cradle cap

    • Eyelids: blepharitis

    • External ear: otitis externa

  • Cause unknown

  • Nursing considerations

  • Head & Shoulders to wash hair 1-2 times

Atopic dermatitis

Atopic Dermatitis

  • Also called eczema

  • Is a category of dermatologic diseases and not a specific etiology

  • Pruritic

  • Usually associated with allergy

  • Hereditary tendency

Therapeutic management

Atopic Dermatitis-

Therapeutic Management

  • Hydrate the skin

  • Relieve pruritus

  • Reduce inflammation

  • Prevent and control secondary infection

  • Nursing considerations

Disorders of unknown etiology

Disorders of Unknown Etiology

  • Sudden infant death syndrome (SIDS)

  • Apparent life-threatening events (ALTEs)

  • “Back to Sleep” campaign

  • Increased incidence of positional plagiocephaly

Infants at risk for sids

Infants at Risk for SIDS

  • Unknown Etiology

  • Infants with one or more severe Apparent life-threatening events (ALTEs) requiring CPR or vigorous stimulation

  • Preterm infants experiencing apnea at time of discharge from hospital

  • Sibling of two or more SIDS victims

  • History of central hypoventilation

Health promotion of the toddler and family

Health Promotion of the Toddler and Family

Biologic development

Biologic Development

  • Weight gain slows to 4 to 6 pounds per year

  • Birth weight should be quadrupled by

    2½ years of age

  • Height increases about 3 inches per year

  • Growth is “steplike” rather than “linear”

Maturation of systems

Maturation of Systems

  • Most physiologic systems relatively mature by the end of toddlerhood

  • Upper respiratory infections, otitis media, and tonsillitis are common among toddlers

  • Voluntary control of elimination

    • Sphincter control age 18 to 24 months

Gross and fine motor development

Gross and Fine Motor Development

  • Locomotion

  • Improved coordination between ages 2 and 3

  • Fine motor development

    • Improved manual dexterity ages 12 to 15 months

    • Throw ball by age 18 months

Typical toddling gait

Typical Toddling Gait

Psychosocial development1

Psychosocial Development

  • Erikson: developing autonomy

  • “Autonomy” vs. “shame and doubt”

  • “Negativism”

  • “Ritualization” provides sense of comfort

  • Id, ego, superego/conscience

Promoting optimum growth and development

Promoting Optimum Growth and Development

  • “The terrible 2s”

  • Ages 12 to 36 months

  • Intense period of exploration

  • Temper tantrums, obstinacy occur frequently

  • Developing independence vs. parental control

Piaget stages of cognitive development1

Piaget Stages of Cognitive Development

Preoperational period (years 2 to 6)

  • Learn spatial relationships

  • Awareness of causal relationships between two events

  • the child learns to use and to represent objects by images, words, and drawings

  • The child is able to form stable concepts as well as mental reasoning and magical beliefs

  • Thinking is still egocentric: The child has difficulty taking the viewpoint of other

Moral development

Moral Development

  • Kohlberg: preconventional or premoral level

  • Punishment and obedience orientation

  • “Time out” is useful at this age

    -1 minutes per year of age

Development of body image1

Development of Body Image

  • Refer to body parts by name

  • Avoid negative labels about physical appearance

  • Recognize sexual differences by age 2

Development of sexuality

Development of Sexuality

  • Exploration of genitalia is common

  • Gender roles understood by toddler

  • Playing “house” or “pirates”

Social development1

Social Development

  • Differentiation of self from mother and from significant others

  • Separation

  • Individualization



  • Increasing level of complexity

  • Increasing ability to understand

Personal social behavior

Personal Social Behavior

  • Toddlers develop skills of independence

  • Skills for independence may result in tyrannical, strong-willed, volatile behaviors

  • Skills include feeding, playing, and dressing and undressing self

Playing dress up

Playing Dress-Up

Transitional objects provide security

Transitional Objects Provide Security

Nurs 207 promoting pediatric wellness in the family community


  • Magnifies physical and psychosocial development

  • Parallel play

  • Imitation

  • Locomotive skills

  • Tactile play

Coping with concerns related to normal growth and development

Coping with Concerns Related to Normal Growth and Development

  • Toilet training

  • Sibling rivalry

  • Temper tantrums

  • Negativism

  • Regressive behavior

Toilet training

Toilet Training

Assessing readiness for toilet training

Assessing Readiness for Toilet Training

  • Voluntary sphincter control

  • Able to stay dry for 2 hours

  • Fine motor skills to remove clothing

  • Willingness to please parents

  • Curiosity about adult’s or sibling’s toilet habits

  • Impatient with wet or soiled diapers

Promoting optimum health during toddlerhood

Promoting Optimum Health During Toddlerhood

  • Nutrition

    • Phenomenon of “physiologic anorexia”

  • Sleep and activity

  • Dental health

    • Regular dental exams

    • Removal of plaque

    • Fluoride

    • Low-cariogenic diet



Injury prevention

Injury Prevention

  • Motor vehicle injuries: car seat safety

  • Drowning

  • Burns

  • Poisoning

  • Falls

  • Aspiration and suffocation

  • Bodily damage

Forward facing convertible seat

Forward-Facing Convertible Seat

Matches are a potentially deadly hazard

Matches Are a Potentially Deadly Hazard

Plastic caps for electrical sockets

Plastic Caps for Electrical Sockets

Storage of cleaning agents

Storage of Cleaning Agents

Health promotion of the preschooler and family

Health Promotion of the Preschooler and Family

Promoting optimum growth and development1


  • Preschool period

    • 3 to 5 years of age

    • Refining tasks mastered in toddlerhood

Biologic development1

Biologic Development

  • Physical growth rate slows and stabilizes during preschool years

  • Physical proportions change

    • Slender but sturdy

    • Graceful, agile

    • Posture erect

    • Males and females similar in size and proportion

Gross motor behavior

Gross Motor Behavior

  • By 36 months:

    • Walking, running, climbing, jumping

  • By age 4 years:

    • Skips and hops on one foot

    • Catches ball

  • By age 5 years:

    • Skips on alternate feet, jumps rope, learns to skate and swim

4 year old hops on one foot

4-Year-Old Hops on One Foot

Psychosocial development erikson

Psychosocial Development: Erikson

  • Developing a sense of initiative

  • Initiative vs. guilt

  • Development of superego (conscience)


Cognitive development piaget

Cognitive Development: Piaget

  • Preoperational phase—ages 2 to 7

    • Preconceptual phase: ages 2 to 4

    • Intuitive thought: ages 4 to 7



      *Magical thinking

      *Logical thinking

Moral development kohlberg

Moral Development: Kohlberg

  • Preconventional (premoral)

    • Punishment and obedience orientation: ages

      2 to 4

    • Naïve instrumental orientation: ages 4 to 7

Preschoolers enjoy friends

Preschoolers Enjoy Friends

Spiritual development

Spiritual Development

  • Parental influences

  • Concrete representation of spiritual beings

  • Development of conscience related to

    spiritual development

Development of body image2

Development of Body Image

  • Increasing awareness of self and others

  • Poorly defined body boundaries

  • Poor understanding of internal anatomy

Development of sexuality1

Development of Sexuality

  • Sexual identity

  • Sexual beliefs

  • Sex typing

  • Gender behaviors

  • Sexual exploration of children is main health concern

Social development2

Social Development

  • Individuation-separation process

  • Effects of prolonged separation (such as hospitalization)



  • Ages 4 to 5: four- and five-word sentences

  • Age 6: understand all parts of speech; identify opposites

Preschooler dressing himself

Preschooler Dressing Himself

Personal social behavior1

Personal-Social Behavior

  • Self-assertion is a major theme

  • Independent in dressing, eating, toileting by ages 4 to 5

  • Desire to please

  • Internalized values--conscience & morals

  • More secure with new sibling arrival at this age

Nurs 207 promoting pediatric wellness in the family community


  • Associative play

  • Make up rules as they go along

  • Imitation

  • Imaginary playmates

  • Mutual play with parents

Preschoolers enjoy a sense of accomplishment

Preschoolers Enjoy a Sense of Accomplishment

Preschoolers enjoy imaginative and imitative play

Preschoolers Enjoy Imaginative and Imitative Play

Coping with concerns related to normal growth and development1

Coping with Concerns Related to Normal Growth andDevelopment

Preschool and kindergarten experience

Preschool and Kindergarten Experience

  • Learning group cooperation

  • Peer group experiences

  • Readiness for academics

  • Preparing the child

Sex education

Sex Education

  • Find out what the child knows and thinks

  • Be honest with responses

  • Understanding the broader concept of sexuality

  • Resources:

    • Sexuality Information and Education Council of the United States (SIECUS)

    • American Academy of Pediatrics (AAP)



  • Definition: behavior to hurt person or destroy property

  • Frustration

  • Modeling

  • Reinforcement

  • Professional help for parenting



  • Night terrors

  • Animism: ascribing lifelike characteristics to inanimate objects

  • Techniques to overcome fears

Promoting optimum health during the preschool years




  • Nutritional requirement approximately

    90 kcal/kg

  • Fluid requirement approximately 100 ml/kg daily

  • MyPyramid application to preschoolers

  • Concerns about childhood obesity

Choosing healthy foods

Choosing Healthy Foods

Assist in food preparation

Assist in Food Preparation

Sleep and activity

Sleep and Activity

  • Sleep average is 12 hours per night for preschool

  • Sleep problems

  • Sleep rituals help establish routine & consistency

Dental health

Dental Health

  • Eruption of primary teeth is complete in preschoolers

  • Need assistance with toothbrushing

  • Routine prophylaxis including fluoride supplements

Injury prevention1

Injury Prevention

  • Poisoning

  • Drowning

  • Pedestrian motor vehicle injuries

  • Seat belts

  • Bicycle helmets

  • Emphasis on protection and education for safety

Health problems of early childhood

Health Problems of Early Childhood

Infectious disorders

Infectious Disorders

  • Communicable diseases

    • Incidence has declined with increase of immunizations

    • Further decreased with use of antibiotics and antitoxins

Nursing assessment in identification of infection

Nursing Assessment in Identification of Infection

  • Recent exposure to infectious agents

  • Prodromal symptoms

  • Immunization history

  • History of having the disease

Prevent spread of disease

Prevent Spread of Disease

  • Primary prevention of the disease

    • Immunization

  • Control spread of disease to others

    • Reduce risk of cross-transmission of organisms

    • Infection control policies

    • Hand washing

Caution for compromised children

Caution for Compromised Children

  • Children with immunodeficiency

    Receiving steroid therapy

    • Other immunosuppressive therapies

    • Generalized malignancies

    • Immunologic disorder

  • Risk for complications from communicable diseases, especially varicella (chickenpox) and erythema infectiosum (EI)

  • Risk for viremia from varicella zoster virus



  • Agent: varicella zoster virus

  • VZG also causes herpes zoster (shingles)

  • VZIG treatment for children at risk

  • Transmission: direct contact, droplet, and contaminated objects

  • Incubation: 2 to 3 weeks

  • Communicability: 1 day before eruption until all lesions crusted

Erythema infectiosum fifth disease

Erythema Infectiosum (Fifth Disease)

  • Agent: human parvovirus

  • Rash in three stages:

    • “Slapped face” appearance disappears in

      1 to 4 days

    • Maculopapular rash on extremities; lasts 7 days or more

    • Rash subsides but reappears if skin irritated or traumatized by heat, cold, friction, etc.



  • Agent: human herpesvirus type 6

  • Incubation: 5 to 15 days

  • Persistent high fever for 3 to 4 days; otherwise appears well

  • After fever subsides, rash appears

  • Rash first on trunk, then face and extremities

Rubeola measles

Rubeola (Measles)

  • Agent: virus

  • Transmission: secretions, droplets

  • Incubation: 10 to 20 days; communicability from 4 days before to 5 days after appearance of rash

  • Koplik spots appear 2 days before rash



  • Agent: paramyxovirus

  • Transmission: via droplet or direct contact

  • Incubation: 14 to 21 days

  • Fever, headache, malaise, followed by parotitis

  • May cause orchitis and meningoencephalitis

Pertussis whooping cough

Pertussis (Whooping Cough)

  • Agent: Bordetella pertussis

  • Transmission: droplet or direct contact

  • Incubation: 6 to 20 days

  • Cough: short rapid coughs followed by crowing or “whoop” sound

  • Complications: pneumonia (usual cause of death)

Rubella german measles

Rubella (German Measles)

  • Agent: rubella virus

  • Transmission: direct contact or indirect contact with article freshly contaminated with nasopharyngeal secretions, blood, stool, or urine

  • Incubation: 14 to 21 days

  • Complications: rare; greatest danger is teratogenic effect on fetus

Scarlet fever

Scarlet Fever

  • Agent: group A hemolytic streptococci

  • Transmission: droplet or direct contact

  • Incubation: 1 to 7 days

  • Complications: carditis, peritonsillar abscess, glomerulonephritis

Scarlet fever cont

Scarlet Fever (Cont.)



  • Newborns: chlamydia, gonorrhea or herpes simplex virus

  • Infants: may be sign of tear duct obstruction

  • Children: causes are bacterial (most common), viral, allergic, or foreign body

Intestinal parasitic diseases

Intestinal Parasitic Diseases

  • Ascariasis (common roundworm)

  • Hookworm

  • Strongyloidiasis (threadworm)

  • Giardiasis—caused by a protozoon

Ingestion of injurious agents

Ingestion of Injurious Agents

  • Cosmetics and personal care products

  • Cleaning products

  • Plants

  • Foreign bodies, toys, and miscellaneous substances

  • Hydrocarbons (gasoline)

Principles of emergency treatment

Principles of Emergency Treatment

  • Poison control center

    • Call first, before initiating any interventions

  • Assessment

  • Gastric decontamination

    • Induce vomiting, absorb toxin, or perform gastric lavage depending upon agent ingested

  • Prevent recurrence

Heavy metal poisoning

Heavy Metal Poisoning

  • Mercury toxicity (less frequently)

    *Air & water pollutant from coal plants, etc

  • Most common is lead ingestion

    *Most common by peeling lead-based paint

    *Micro particles of lead contaminate bare soil

    *Can be inhaled or ingested

    *Affects renal, hematologic, and neurologic

    systems developing brain and nervous

    are especially vulnerable

Effects of lead on body systems

Effects of Lead on Body Systems

Lead poison diagnosis

Lead Poison Diagnosis

  • Rarely symptomatic

  • Venous blood sample of 10 mcg/dl

  • Screening for lead poisoning at ages

    1 and 2 years

  • Chelation therapy with calcium disodium edetate (EDTA) and succimer (DMSA)

  • Prognosis

Child maltreatment

Child Maltreatment

  • Intentional physical abuse (22%) or neglect (54%)

  • Emotional abuse (4%) or neglect

  • Sexual abuse of children (8%)

Types of neglect

Types of Neglect

  • Physical neglect

    • Deprivation of food, clothing, shelter, supervision, medical care, and education

  • Emotional neglect

    • Lack of affection, attention, and emotional nurturance

  • Emotional abuse—destroy or impair child’s self-esteem

Munchausen s syndrome by proxy

Munchausen’s Syndrome by Proxy

  • Caregiver fabricates signs and symptoms of illness in child (the proxy) to gain attention from medical staff

  • Child may undergo needless and painful procedures and treatments—10% of cases may be fatal to the child

Factors predisposing to physical abuse

Factors Predisposing to Physical Abuse

  • Parental characteristics

  • Social isolation, poor support systems

  • Parental low self-esteem and less adequate maternal functioning

Child characteristics predisposing to physical abuse

Child Characteristics Predisposing to Physical Abuse

  • Compatibility between child’s and parent’s temperament and parent’s ability to deal with behavioral style

  • Removing the child victim from the home may place other siblings at risk for abuse

Environmental characteristics

Environmental Characteristics

  • Chronic stress

  • Divorce, poverty, unemployment, poor housing, substance abuse, frequent relocation, crowded living conditions

  • Child abuse can occur in any socioeconomic population

Sexual abuse

Sexual Abuse

  • Defined as: “the use, persuasion, or coercion of any child to engage in sexually explicit conduct or simulation of such conduct for producing visual depiction of such conduct, or rape, molestation, prostitution, or incest with children”

Characteristics of abusers and victims

Characteristics of Abusers and Victims

  • Typical abuser is a male the victim knows but may be ANYONE

  • All socioeconomic backgrounds

Nursing care of the maltreated child

Nursing Care of theMaltreated Child

  • Identify abusive situations as early as possible

  • History pertaining to the incident

  • Evidence of maltreatment

    • Pattern or combination of indicators that arouse suspicion and further investigation

    • Protect child from further abuse



  • Hockenberry, M. J. (2005). Wong’s Essentials of Pediatric Nursing 8th ed. St. Louis, Missouri: Elsevier Mosby.

  • Jordan, D. N.(2005). Nursing 202 Lecture #1 Power Points. Los Angeles, CA.

  • Pillitteri, A. (2007). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins.

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