Portfolio

In

Care of Mother, Child at Risk or with Problems (Acute and Chronic)

(NCM – 109)

Submitted to:
Donna B. Auza, RN, MAN
Clinical Instructor

Submitted by:
Christie V. Montano
BSN – 2

June 02, 2020

 INTRODUCTION

Nursing care and assessment of children, other than other factors, play
an important role for child’s health and wellness. The nurses and health care
providers are the ones devising a plan and implementation for the delegation
of health promotion, health maintenance and health rehabilitation to achieve
children’s optimum health. It is a collaborative work along with parents, other
health care providers and the community the children are living.

According to the World Health Organization (WHO), children

represent and perpetuate the future. Thus, ensuring their physical, socio-
emotional and language and cognitive development ought to be a priority for
all societies.

Children are particularly vulnerable to malnutrition and infectious

diseases, many of which can be effectively prevented or treated. Also,
children experience dramatic changes in their bodies and minds, beginning
at birth and continuing through adolescence. Because of these anatomic,
physiologic, and developmental changes, it is crucial for the pediatric nurse
to possess specialized knowledge and skills to accurately assess infants,
children, and adolescents during health and illness. Nursing care and
interventions must be individualized based on the child’s unique needs.
Concepts related to health assessment and physical examination of the adult
patient cannot be applied to children;
they are not simply little adults. In order for the health care of children to be
safe, thorough, and developmentally appropriate, the pediatric health care
provider must ensure that child health assessment is based on a thorough
knowledge of pediatric anatomy and physiology, pathophysiology,
pharmacology, and child development. The child’s social situation, the
community in which he or she lives, and the family’s culture are other
important components that should be included. In addition, when working
with children of different ages and developmental levels,
effective, developmentally appropriate communication skills are essential.
Normal growth and development occurs in a predictable sequence but at a
variable rate and pace. Thus, deviations from this pattern may signify an
abnormality, making it essential for the provider to be familiar with normal
developmental milestones and children’s growth patterns, and to
monitor these trends over time.

As a nursing student, knowing and identifying children developmental

stages as well as their needs and abilities aid the student to grow and to
improve therapeutic nursing skills in dealing with children.

The main objective of this compilation is to gather information about

the application of nursing process based on the children developmental stages
in relationship to their development milestones both the normal and children
with unique needs as well. Along with this compilation, is the proper health
assessment for children from infancy through adolescence. Guided by its
objective, at the end of this study the student nurse will be able to;

 Gather relevant topics about the four chapters about nursing

care of a family with toddler, a pre-schooler child, a school –
age child, and an adolescent child.
 Identify the nursing process being applied in the topics per
chapter.
 Identify the different health assessment for children.
 Discover developmental stages and milestones of the children
from being a toddler through adolescence.
 Identify the children growth and developmental patterns.
 Synthesize and summarize each chapter. ( Chapter 30- 34)
 Develop good reading and comprehension skills about the
topics covered.
 Produce a good output about the topics being studied.
 Encourage good reading and study habits.
 Reflect about the findings being discovered in each chapter
AGE SPAN 1 – 3 years old
For Healthy Development of a Toddler

Assessment  Clinic/health center visits

 Careful observation by a nurse
 Asking parents about a toddler’s ability to
carry out activities of daily living.

Nursing Diagnosis o Health – seeking behaviours related to

normal toddler development
o Deficient knowledge related to the best
method of toilet training
o Risk for injury related to impulsiveness of
the toddler
o Interrupted family process related to need
for close supervision of a 2 – year – old
o Readiness for enhanced family coping
related to the parent’s ability to adjust to the
new needs of the child
o Risk for imbalanced nutrition, more than
body requirements related to fast food
choices
o Disturbed sleep pattern related to lack of
bedtime routine.
Outcome Focuses largely on family education and
Identification/Planning anticipatory guidance that urge the parents to
establish a realistic goals and outcomes.

Implementation Health visits provide opportunities to help parents

learn healthier coping techniques as well as a time
to demonstrate effective communication skills so
that parents can improve their interaction with their
child.

Outcome Evaluation a. Parents state that the child maintains a

consistent bedtime routine within the next 2
weeks.
b. Parents state they have childproofed their
home by putting a lock on kitchen
cupboards by next clinic visit.
c. Grandmother states she has modified usual
activities to conserve energy to care for
toddler granddaughter by 1 weeks’ time.
 Nursing Care Planning Based on 2020 National Health Goals

2020 National Health Goals related to TODDLERS

 Increase the use of child automotive restraints in children 3 years of

age and under from a baseline of 72% to 79%
 Eliminate or improve elevated blood lead levels in children from a
target level of 0.9% of children to a target level of 0%
 Increase the percentage of persons 2 years of age and older who
have a dental visit in the past 12 months from a baseline of 44.5 %
to 49%
 Maintain the rate of deaths caused by poisonings from a baseline at
13.1 out of 100,000

Nursing Assessment of a Toddler’s Growth and Development

1. PHYSICAL GROWTH

Weight – gains only about 5 to 6 lbs.

Height – 5 inches (12cm) a year

Head Circumference – 2 cm on 2nd year, Chest circumference – by 2

years old, chest circumference should greater than the hea

Body Mass Index (BMI) – is completed at 24 months

a. Body Contour
- Prominent abdomen, abdominal muscles are not yet strong enough
to support abdominal contents, lordotic, waddle or walk with wide
stance.
b. Body Systems
- Respiration slow slightly, mainly abdominal, heart rate slows from
110 to 90 beats per minute
- Blood pressure increases about 99/64 mmHg
- The brain develops to about 90% of its adult size
- Respiratory system, the lumens of vessels enlarge progressively
- Stomach secretions become more acid; less common GI infections
- Stomach capacity increases, can eat 3 meals a day
- Control of urinary and anal sphincters become possible
- Immune globulin (Ig)G and IgM antibody production mature
DEVELOPMENTAL MILESTONES OF TODDLER

Age Fine Motor Gross Motor Language Play

15mos. Puts small Walks alone 4 – 6 words Can stack

pellets into well; can seat two blocks;
small bottles; self on a chair; enjoys being
scribbles can creep read to; drops
voluntarily with upstairs toys for adult
a pencil or to recover
crayon; holds a (exploring
spoon well but sense of
may still turn it permanence)
upside down on
the way to
mouth

18mos. No longer Can run and 7 – 20 words; Imitates

rotates spoon to jump in place; uses household
bring it to mouth can walk up and jargoning; chores such
downstairs names one as dusting;
holding onto a body part begins
person’s hand on parallel play
railing; typically (playing
places both feet beside, not
on one step with, another
before child)
advancing

24mos. Can open doors Walks upstairs 50 words; Parallel play

by turning alone, still using two – word evident
doorknobs; both feet on the sentences
unscrew lids same step at like;
same time Daddy go
Dog talks

30mos. Makes simple Verbal Spends time

lines or strokes language playing
for crosses with increasing house,
a pencil Can jump down steadily, imitating
from chairs knows full parent’s
names, name actions, play
1 color is active
 2. TEETH

Eight new teeth (the canines

and the first molars) erupt
during second year. All
deciduous teeth are
generally present by 2.5 to 3
years of age

3. LANGUAGE DEVELOPMENT
- The critical time for language development is during this stage
though it varies from child to child. A word that is used frequently
by toddlers and that is a manifestation of their development in
autonomy.
- To learn other words, children need to be exposed to words
through conversations while watching television promotes
learning because of its passiveness.
- Urge parents to encourage language development by naming
objects as they play with their child and answering their questions
in a simple manner is a good way since toddlers have shorter
attention span.
- Imitation is an effective way toddlers can learn so parents should
speak the exact words fluently and accurately.
4. EMOTIONAL DEVELOPMENT
- Children change a great deal in their ability to understand the
world and how they relate to people during toddler days

a. AUTONOMY Sense of autonomy vs. shame or doubt

( Erik Erikson’s Social Development
Theory)
- To develop a sense of autonomy
is parallel to development of
independence. A healthy level
of development of autonomy is
when the parents allow the child
to move, to play and to do tasks
while providing consistently a
sound rules for safety.

b. SOCIALIZATION Toddlers are resistant to sitting when the can

walk well.

15 months – children are still enthusiastic

interacting with people and are willing to
follow wherever they go.
18 months – toddlers imitate the things they
see with their parents so role modelling is
very important at this stage.
2 years up – gender awareness among
toddlers are evident and identification of
specific gender “a boy or a girl.”

c. PLAY BEHAVIOUR - All during the toddler period,

children play beside other
children, not with them.
- Parallel play ( side – by – side
play) is normal
- The toys toddlers enjoy most are
those they can play with
themselves and require action.
 5. COGNITIVE DEVELOPMENT

A child enters the final stages of Piaget’s sensorimotor and the

beginning of the preoperative period at approximately 12 months. Children at
this stage can remember an action and imitate later (deferred imitation). At
the end of this period, the child enters preoperational period where
preoperational thought begin to use assimilation.

Assimilation – is a cognitive process that manages how the child takes in new
information and incorporates it with existing knowledge.
Planning and Implementation for Health Promotion of a Toddler and
Family

a. PROMOTING TODDLER SAFETY

- Unintentional injuries are the major causes of death in infants
through late adolescents such as unintentional ingestion
(poisoning) and auto accidents. Others include motor vehicle
accidents, burns, falls, drowning and playground injuries.

Some of preventive measures include:

 Lead Screening – the CDC has set its goal to eliminate elevated blood
lead levels in children. Elevated lead levels are caused by eating,
chewing or sucking on objects that are covered with lead – based
paint.
 Car seats – toddlers should use a car seat with a five – point restraint
while riding in an automobile until they reach 2 years of age.
UNINTENTIONAL INJURY PREVENTION MEASURES FOR
TODDLERS

Potential Unintended Prevention Measure

Injury
- Maintain your child in a car seat.
1. MOTOR - Do not allow the child to play
VEHICLES outside unsupervised.
- Supervise toddlers with pedalling
toys.
- Keep house windows closed or keep
2. FALLS secure screen in place.
- Place gates at top and bottom of
stairs and supervise playgrounds.
- Raise crib rails, make sure they are
locked and do not allow the child to
walk with sharp objects in hand or
mouth.
- Examine toys for small parts.
3. ASPIRATION - Do not feed toddler with popcorn or
nuts; caution child not to eat while
running and do not leave the toddler
with a balloon alone.
- Do not leave toddler alone in a
4. DROWNING bathtub or near water. Fence pools;
insist toddler wear safety floats and
vest.
- Never present medication as candy
5. POISONING and never take medication in front of
the child.
- Place all medication and poisons in
unreachable locked cabinets.
- Know the names of houseplants.
- Be certain small batteries or magnets
out of reach.
- Inspect toys to be lead – free and
post emergency telephone numbers.
 - Do not allow toddler to approach
6. ANIMAL BITES strange dogs.

- Cook on the back burners of stove.

7. BURNS - Keep screen in front of fireplace or
heater.
- Monitor toddlers carefully when
they’re near I candles and do not
leave them near hot- water faucets.
- Do not leave coffee/ teas pots on a
table and never drink hot beverages
when they are on your lap sitting.
- Keep electric wires and cords out of
toddler’s reach.
- Know the whereabouts of toddlers at
8. GENERAL all times.
- Be aware of the frequency of injuries
increases when the family is under
stress.
- Be aware of some children are more
active, curious, and impulsive.

 Promoting Nutritional Health in Toddlers

- Allowing self – feeding is a major way to both strengthen
independence in a toddler and improve the amount of food
consumed. Toddlers usually prefer to eat same type of food over
and over because of the sense of security it offers.
 Toddler Nutrition Requirement
- Toddler’s daily food consumption may vary greatly and energy
needs are generally met when sufficient food is supplied in a
positive environment.

 Sedentary children ages 1 to

3 years should consume
1,000kcal daily.
 Calories are best supplied by
a variety of foods into three
meals a day.
 Protein and carbohydrate
Vegetarian Diet
needs are often easily met
- Is adequate for during this period; diets high
toddlers if parents in sugar should be avoided.
are well informed  Fats should not generally be
about needed restricted to toddlers 2 years
vitamins and old below while above 2
minerals. year old toddlers should be
- Is easily designed cut to 30%.
for a toddler who  Trans fats should be kept to
also prefers finger a minimum.
foods.  Adequate calcium and
phosphorus intake is
important for bone
mineralization.
Promoting Toddler Development in Daily Activities

- Learning how to promote autonomy yet maintain a safe, healthful

environment should be a major goal for the family.
a. DRESSING – by the end b. SLEEP – the amount of sleep
of toddler period, most of needs to be gradually decreases
them can put on their own as they grow older. Napping in
socks and underpants. the afternoon is good while
Appreciating them more toddlers sleep by themselves
like saying “You did a when they are tired. Toddlers
good job! Sneakers are love bedtime routine; bathing,
ideal toddler shoe because pajamas, storytelling , tooth
the soles are hard enough brushing, being tucked into
for rough surfaces and bed, having a drink of water,
arch support is limited. choosing a toy to sleep with,
and turning out the lights.

b. BATHING – bath time

should depend on the
parent’s and the child’s d. DENTAL CARE – to help
wishes and schedule. They prevent dental caries from
enjoy bath time and frequent snacking, parents
parents should make an should offer fruit or protein
effort to it more fun. foods. A child shouldn’t be put
Parents shouldn’t add to bed with a bottle of milk or
bubble bath to the water juice. Urge parents to schedule
because its use is for first dental visit and
associated with maintain positive attitude about
vulvovaginitis and the visit.
possibly UTI to girls.
Promoting Healthy Family Functioning

Help parents to understand their responses in the attempt of achieving

independence with to their toddler. That is crucial to a healthy development
of their child. At bedtime, naptime, or anytime they are tired, toddlers need to
be picked – up or carried to feel that they are loved and secured.

Parental Concerns Associated with Toddler Period

Parental concerns of the toddler period usually arise because of a

conflict over autonomy.

1. TOILET TRAINING
- Toilet training is an individualized task for each child. It depends
on the child’s readiness to do so and not for a scheduled time.
- Before children can begin toilet training, they must have reached 3
important developmental levels.
 They must have control of the rectal and urethral
sphincter, usually achieved by the time they walk
well.
 They must have a cognitive understanding of what
it means to hold urine and stools until they can
release them at a certain place and time.
 They must have a desire to delay immediate
gratification for a more socially accepted action.
- Before they can complete toilet training, they must be able to give
up an immediate pleasure – relieving themselves whenever they
have the urge – to gain other pleasure later on – improved physical
comfort and another step in growing up. Toddlers live by a
pleasure principle.
2. RITUALISTIC BEHAVIOUR
- Toddlers enjoy ritualistic patterns. They spend a great deal of
time everyday investigating new ways to do things and then trying
activities they have never been doing before. They will use only
“their” spoon at mealtime or only “their “blanket at bedtime.
3. NEGATIVISM
- Toddlers typically go through a period of extreme negativism
wherein, they don’t want to do anything their parents want them to
do or their reply to every request is a very definite “no”. This
indicates toddlers have learned that they are separate individuals
with separate needs. Parents should not force their child, instead
ask them and give them choices. Once they are helped to practice
this approach it would be very helpful to lessen negativism.

4. DISCIPLINE
- Parents should begin to instil some sense of discipline early in life.
- When disciplining a toddler, parents need to be consistent and
positive reinforcement. Rules are learned best if correct behaviour
is praised rather than wrong behaviour is punished.
- A time – out is a technique to help children learn that actions have
consequences.
5. SEPARATION ANXIETY
- Fear of being separated from parents begins at about 6 months of
age and persists throughout the preschool period.
6. TEMPER TANTRUMS
- Temper tantrums occur as natural consequence of toddler’s
development and it occurs mostly when toddlers are tired just
before bedtime or naptime or during long shopping or visits.
Concerns of the Family with a Toddler who has a Unique Needs

It may be difficult for children with handicaps or disabilities to achieve

a sense of autonomy or independence because they may never be totally
independent. However it is very important for them to build strong sense of
autonomy to see themselves increasingly self – sufficient as they grow up. A
toddler with a long – term illness or physically challenged can be expected to
exhibit normal toddler behaviour such as tantrums and negativism. The nurse
should remind the parents that these behaviours are often an indication of age
and development rather than of illness so that they can respond appropriately.

 AUTISM SPECTRUM DISORDER

- Classic ASD is a complex range of neurodevelopment disorders
characterized by communication difficulties, poor social
interaction, and frequent repetitive and stereotyped movements.
Symptoms begin to appear during infancy so children need to be
screened for autism symptoms by 12 months of age and again at
18 and 24 months of age by observation and parent’s report.
 NUTRITION and the PHYSICALLY CHALLENGED or
CHRONICALLY ILL TODDLER
- Parents should try to provide other, comparable experiences in
independence, such as letting their child choose what toy to take
to bed or what clothing to wear. Allow their toddler do the things
they want and choices they make. Make them feel supported and
loved just like the normal children do.
REFLECTION:

The transition from infancy to early childhood is dramatic when it

comes to their developmental changes. In this span of time, the child begins to
venture out independently from a secure base of trust established during the
first year. The toddler years are characterized by a struggle for autonomy as
the child develops a sense of self – reliance from parents. In addition to that,
insatiable curiosity and boundless energy drive the toddlers to explore the
environment and master new skills. The combination of increased motor
skills, immaturity, and lack of experience places the toddler at risk for
unintentional injury. Thus, parents and caregivers should be alert and cautious
to avoid such unintentional injuries with their toddlers. With toddlers’
egocentric and demanding behaviours often evidenced by temper tantrums
and negativism, have given this age the label of “the terrible twos”. When it
comes with their, physical growth, toddlers’ growth slows during this period
as well as their brain growth slowly than during infancy. Many parents
consider this period as their favourite age as they are enjoying watching their
toddler’s dramatic transformation who are ready to enter the world of peers
and school. The nurse’s role as a health care provider, family counsellor, and
child advocate continues as they advance their age. Well – child check-ups
provide the nurse with the opportunities to anticipatory guidance related to
growth and development, safety, nutrition, and some of the most common age
– related concerns of parents. In this period, the parents and the health care
providers like the nurses and doctors should have collaborative efforts to hone
and shape their toddlers to achieve optimum health and wellness.
AGE SPAN 3 – 5 years old
Assessment  Regular assessment includes obtaining a
health history and performing both a
physical and developmental evaluation.
 Assess child’s weight, height, and body
mass index (BMI).
Nursing Diagnosis o Health – seeking behaviours related to
developmental expectations.
o Risk of injury related to increased
independence outside home.
o Delayed growth and development related to
frequent illness
o Risk for imbalanced nutrition, more than
body requirements, related to fast food
choices
o Risk of poisoning related to maturational
age of the child
o Parental anxiety related to lack of
understanding of childhood development
Outcome Planning and establishing expected outcomes
Identification/Planning for care of children at this age often begin with
establishing a schedule for discussing normal
preschool development with parents. It is also
important to plan opportunities for adventurous
activities and interactions with other children.
Implementation Preschool children imitate moods as well as
actions. Therefore, role –playing a mood or attitude
you would like the children to learn. To project an
attitude that a health assessment is an enjoyable
activity, nurse might suggests pre-schoolers
participate by listening to their heart of coloring the
table paper.
Outcome Evaluation a. Child states importance of holding
parent’s hand while crossing the street.
b. Parent states realistic expectations of 3
– year – old child’s motor ability by
next visit.
c. Mother reports she has prepared her 4 –
year – old for new baby by next visit.
Nursing Assessment of a Preschooler’s Growth and Development Growth

PHYSICAL GROWTH
- a definite change in the body contour occurs during preschool
years
Ectomorphic Body Build – slim body build
Endomorphic Body Build – large body build
 Lymphatic tissue begins to increase in size particularly the
tonsils.
 Physiologic splitting of heart sounds may be present on
auscultation.
Pulse rate – decreases 85 beats/min
Blood Pressure – stabilizes 100/60 mmHg

 Bladder is easily palpable.

 Exhibit gena valgus (knock – knees) disappears with increased
skeletal growth at the end of preschool period.

Weight – average weight gain 4.5 lbs.

Height – minimal gain 2 – 3.5 inch
TEETH
- Generally have all 20 of their deciduous teeth by 3 years old.
Preserving these teeth is important because they hold the
position for the permanent teeth as the child’s jaw grows larger.
SUMMARY OF PRESCHOOL GROWTH and DEVELOPMENT

Fine Motor Gross Motor

Age Skills Skills Language Play

3  Undresses Runs and Vocabulary Able to take

self alternates feet of 900 words turns; very
 Stacks tower on stairs; imaginative
of blocks rides tricycle;
 Draws a cross stands one
foot

4  Can do Constantly in Vocabulary Pretending is

simple motion; of 1500 major activity
buttons words
jumps; skips

5  Can draw a Throws Vocabulary Likes games

six – part overhand of 2,100 with number
figure. words or letters
 Can lace
shoes

DEVELOPMENTAL MILESTONES

Each year during the preschool

period marks a major step forward in
gross motor, fine motor, and in
language development. Play
activities change focus dramatically
as the pre-schooler learns new skills
and understands more about the
 world.
1. Language Development

Preschoolers are typically egocentric wherein they define objects

mainly in relationship to themselves. Four and five years old children enjoy
participating in mealtime conversation and can describe an incident from their
day in great detail.

Egocentrism - perceives that one’s thoughts and needs are better more
important than those of others.

2. Emotional Development

During the preschool years, children change a great deal in their ability
to understand their world and how they relate to other people.

 Initiative – the development task for preschool – age child is to

achieve a sense of initiative rather than guilt. To gain sense of
initiative, preschoolers need exposure to a wide variety of experiences
and play materials so they can learn as much about how things work as
possible. Urge the parents to provide play materials that encourage
creativity.
 Imitation – children generally imitate those activities best that they
see their parents performing at home. Therefore, role modelling is
crucial and important.
 Fantasy – toddlers can’t differentiate between fantasy and reality just
yet. Television characters give great impact to them and so parents
should always guide them.
 Oedipus and Electra Complexes
Oedipus complex – refers to strong emotional attachment to a son to his
mother
 Electra complex – refers to strong emotional attachment to a daughter to
her father.
 Gender roles – pre-schoolers begin to be aware of the difference
between sexes and so need to be introduced to both gender roles.
 Socialization – because 3 – years – olds are capable of sharing, they
play with their age much agreeably than do toddlers. Four – years –
olds enjoy play groups and five – years – olds begin to develop “best”
friendships.
3. Cognitive Development
- Cognitive development is still preoperational by the age of 3
according to Piaget. Also, pre-schoolers enter a second phase
called intuitional thought. Intuitive children show a style of
thinking called “centration”, which focuses on the characteristic of
an object or person based on one characteristic. Centration also
means that pre-schoolers can’t make mental substitution and they
feel that they are always right. Children at this period aren’t yet
aware of the property of conservation. This inability has
implications for nursing care because it means they are not able to
comprehend that a procedure performed two separate ways is the
same procedure.

4. Moral and Spiritual Development

- Children of preschool age determine right from wrong based on
their parents’ rules because they have little understanding of the
rationale for these rules or even whether the rules are consistent.
Preschoolers begin to have an elemental concept of spirituality if
they have been provided some form of religious training.
Planning and Implementation for the Health Promotion of a Preschooler
and Family

1. Promoting Preschooler Safety

- Safety issues among pre-schoolers must be widen because starting
4 years of age, children may project an attitude for independence
and the ability to take care of themselves but still need
supervision.

Keeping Children Safe, Strong, and Free

 Cautioning a child to never talk with or accept a ride from a

stranger.
 Teaching a child how to call for help in an emergency (yelling
or running to neighbour’s house or calling 911 if near a phone)
 Describing what police officers look like and explaining that
police can help in an emergency situation.
 Explaining that if children or adults ask them to keep secrets
about anything that has made them uncomfortable, they should
tell their parents or another trusted adult.
 Explaining that bullying behaviour from other children is not to
be tolerated and should be reported so they can receive help
managing it.
Common Safety Measures to Prevent Unintentional Injuries to
Preschoolers

Possible Unintentional Preventive measures

Injury
 Teach safety with tricycles (look before
MOTOR VEHICLES crossing the streets).
 Teach the child to always hold hands with
an adult.
 Teach children to consistency wear helmet
when riding bicycle.
 Always supervise a pre-schooler at a
FALLS playground and remove drawstrings from
hooded clothing.
 Help the child to judge safe distances for
jumping or safe heights for climbing.

DROWNING  Teach swimming lessons.

 Do not allow the child to approach strange
ANIMAL BITES dogs.
 Supervise the child’s play with pets.
 Never present medication as a candy.
POISONING  Never take medication in front of a child.
 Never store food or substance in containers
other than its own.
 Post the telephone number of poison
control center or 911.
 Teach the child that medications are
serious substances not for playing.
  Store matches in closed containers.
BURNS  Do not allow the pre-schooler to ignite a
birthday candles or fireplaces. Fire is not
fun or a treat.
 Teach the pre-schooler that not all people
COMMUNITY are friends.
SAFETY  Define strangers as someone the child does
not know.
 Teach the child to say no to people whose
touching uncomfortably including family
members ( When a child is sexually
maltreated, the offender usually a family
member or a friend)
 Know the whereabouts of the pre-schooler
GENERAL at all times.
 Be aware the frequency of unintentional
injuries increases when parents are under
stress. Special precautions must be taken at
these times.
 Some children are more active, curious,
and impulsive and therefore more
vulnerable to unintentional injuries than
others.
2. Promoting the Nutritional Health of a Pre-schooler
Being certain that pre-schoolers get enough daily exercise helps them
to improve their appetite. A sense of initiative, or learning how to do
things, can be strengthened by allowing the child in the preparation of
simple foods, such as making sandwich or toast.
Preschool Nutritional Requirement
Preschoolers may not eat a great deal of meat because it can be
hard to chew. As long as the child is eating foods from all five - food
groups and meets the criteria for a healthy child such as being alert and
active with height and weight within normal ranges, additional
supplement are probably unnecessary.

Vegetarian Diet
A vegetarian diet is usually colourful and appeals to pre-
schoolers. Vegetables, fruits and grains are also healthy snack foods.
Check to be sure a child is ingesting a variety of calcium sources.
3. Promoting the Development of the Preschooler in Daily Activities
DRESSING – SLEEP – children at this EXERCISE –
most 3 and 4 years stage sleeps when tired. Promoting active
old children dress
Parents should screen – games and reducing
themselves and
they prefer bright out frightening or TV television watching
colors. Anyone watching prior to sleep. can be steps toward
who understands
helping children
pre-schoolers
appreciates that the develop motor skills
experience as well as prevent
children gain in
childhood obesity.
being able to select
their own clothing
is worth more than
a perfect
appearance by
adult standards

HYGIENE – CARE OF TEETH

Children this age – If independent
are not paragons of tooth brushing was
neatness and may delayed, it should be
not clean their started sooner. Teeth
hands thoroughly. grinding (bruxism)
Making bathing may begin at this age.
and washing A first visit to a
attractive and dentist should be
enjoyable for arranged no later than
them. Mild and 2 years old for
non-irritant soaps evaluation of tooth
should be used. formation.
 4. Promoting Healthy Family Functioning
Parents’ role of pre-schoolers is respecting their children’s
creativity and delighting them through encouraging imaginative games
and play.
DISCIPLINE
A major parental responsibility is to guide a child through his
struggles without discouraging the child’s right to have an opinion. A
“time – out” is a useful technique for parents to correct behaviour
throughout the preschool years.
5. Parental Concerns Associated with the Preschool Period

Common Health Problems of the Preschooler

The mortality of children during the preschool years is low and

becoming lower every year as more infectious diseases are preventable. Even
though the number of major illnesses is few, minor illnesses such as common
colds and ear infections, is high.
 Common Fears of the Preschooler

a. FEAR of the DARK – the tendency to fear of the dark is an example

of a fear heightened by a child’s vivid imagination. Children may be
reluctant to go to bed or go back to sleep unless a light is turned on or
a parent sits by.
b. FEAR of MUTILATION – fear of mutilation is also a significant
during the preschool age, as revealed by the intense reaction of a
preschooler to even a simple injury such as falling and scraping a knee
or having a needle inserted for an immunization.
c. FEAR of SEPARATION and ABANDONMENT – fear of
separation is yet another major concern for pre-schoolers and their
sense of time is still so distorted that they can’t be comforted by
assurance. Their sense of distance is also limited. Children whose chief
fear is that they will be abandoned or kidnapped. Caution parents to be
sensitive to such fears. A hospital admission or going to a new school
often brings a child’s fear of separation. Help the parents prepare with
these experiences.
BEHAVIOUR VARIATIONS

- A combination of a keen imagination and immature reasoning

results in a number of other common behaviour variations in pre-
schoolers.
a. Telling Tall - Stretching stories to make them
Tales seem more interesting and
phenomenal. Caution them not
to encourage this kind of story –
telling but instead help the child
separate fact from fiction.
b. Imaginary - Many pre-schoolers have an
Friends imaginary friend who plays with
them.
c. Difficulty - Around 3 years of age, children
Sharing begin to understand some things
are theirs, some belong to others,
and some can be belong to both.
Parents may need to help a child
learn property rights as part of
learning to share.
d. Regression - Help parents understand that
regression is normal at this
stage. Removing stress is the
best way to help a child
discontinue this behaviour.
e. Sibling Rivalry - Jealousy of a brother or a sister
may first become evident during
preschool period. To help pre-
 schoolers feel secure and to
promote self – esteem during
this time, reminding them that
there are things they can do that
a younger sibling is not allowed
to do and supplying them with a
private drawer or box for their
things.

f. Preparing for a - Introduction of a new sibling is a

New Sibling major happening that parents
need to take special steps to be
certain that their pre-schooler is
prepared. Help parents not to
underestimate the significance of
a bed to a preschool child.
Encourage women to maintain
contact with their preschool
during short stay in the hospital
giving birth. A new baby makes
significant difference in child’s
life.
SEX EDUCATION

- During the preschool age, children become acutely aware of the

difference between boys and girls and it’s a normal progression in
development. It is very important that parents do not convey that
genital parts are never to be talked about so that they leave an
open line of communication for sexual questions.

CHOOSING A PRESCHOOL OR CHILD CARE CENTER

- A school or child care experience is helpful for pre-schoolers

because peer pressure seems to have a positive effect on social
development. Children who have learned to be comfortable in a
preschool approach school comfortably and ready to learn. Be
sure parents should investigate the school carefully before
enrolling their child. Schools are sometime vectors for
communicable or infectious diseases so vaccination the child is
very important.

PREPARING A CHILD FOR SCHOOL

- If a child has been led to believe that learning is fun and new
experiences are enjoyable, the child will easily adapt the school’s
environment that she will be spending his formal education.
Parents should know how to motivate their pre-schoolers that
attending school is fun and exciting.
BROKEN FLUENCY (Secondary Stuttering)

- a repetition and prolongation of sounds, syllables, and words.

Remind the parents that it is just normal part of development.

How to Resolve Broken Fluency

o Do not discuss in the child’s presence the he or she has difficulty with
speech.
o Listen with patience rather than interrupt or ask to speak more slowly
or to start over.
o Always talk to the child in, calm and simple way to role model slow
speech.
o Protect space for the child to talk.
o Do not force a child to speak if he doesn’t want.
o Do not reward a child for fluent speech or punish for non - fluent
speech.
o Broken fluency is developmental stage in language formation.

BATHROOM LANGUAGE

- Many pre-schoolers imitate the language spoken in his

environment even those swear words. Parents should be reminded
that children don’t understand what they are talking. Correction
should be unemotional because if it is, a child realizes the value of
such words and may continue using it for the attention it creates.
Concerns of the Family with a Preschooler with Unique Needs

Physically challenged or chronically ill pre-schoolers should attend a

preschool program if at all possible because of the socialization benefit.

Nursing Interventions to Encourage a Sense of Initiative in the Preschooler with

Special Needs

CONSIDERATION NURSING ACTION

a. Nutrition - Serving foods creatively like animal
shapes appeals to the imagination of
children while adding some appetite and
interest in food. Also, respect child’s
food preference.

b. Dressing - Allow pre-schoolers to measure and cut

Changes tape or draw a face on it.
- Allow the child to see the incision site
and explain the steps of dressing
change.
- Provide extra bandages to put on a doll
to project that bandages are not to be
feared.
c. Medicine - Allow the child to choose a “chaser”
such as juice or milk after oral medicine
- Do not suggest site for injection or IV
line.
d. Rest - Provide a light in the room or bring the
child’s bed into the hallway.
- Identify sounds the pre-schooler might
hear in the hospital and explain these.
e. Hygiene - Allow the child to choose bathtub toys
and clothing to wear after the bath
- Allow the child to wash his/her own
hands and face.
- Allow the child to splash in water as
play activity as well as for cleanliness.
f. Pain - Encourage the pre-schooler to express
pain.
- Allow the child to handle a syringe or
suction catheter and give shots to all
doll to alleviate anger of fear.
- Encourage the child to ask for analgesic
if necessary.
g. Stimulation - Guessing games encourage a sense of
initiative.
- Provide manipulative toys, such as
finger paint, soapy water, clay and the
like.
- Allow the pre-schooler to accompany
you to other departments is a way of
teaching more about the hospital.
- Use “Simon Says” games not only for
socialization but also to urge treatments,
such as deep – breathing exercises.
- Encourage use of playroom for
socialization.
- Encourage the child to interact with his
or her family by drawing pictures or
telephoning home.
REFLECTION

Preschoolers comparing it from toddlers are developing the basic life

skills, independence, and knowledge that they will need as they enter their
school years. By the time they enter nursery, their experiences widen and
social interactions among them will become a good learning experience to
relate with others. This time, discipline could be integrated and positive
actions should be praised and reinforced than the negative actions to
strengthen the positive ones. A dramatic increased in language skills in the pre
– school period can promote self – control and increases the preschooler’s
ability to directed and be directed by others. This is also the critical time for
socialization for they need opportunities to play with others to learn
communication and social skills as they develop to achieve a sense of
initiative. When it comes to their cognitive skills, by 3 years up, the brain has
reached 2/3 of its adult size and maturation of the central nervous system
contributes their increased cognitive abilities. Gender identity and body image
are developing that is why the nurse should encourage parents to answer their
queries simply and honestly. In this time, the nurse plays an important role in
helping parents prepare their children for school and assessing the children
readiness for school. Also, they should teach parents the importance of good
oral hygiene, adequate and good nutrition, and enough time for sleep, safety
from any unintentional injuries, play and exercise. With the child’s increasing
assertion of independence, parents are less able to provide the constant
protection they need since they are outside home. Thus, nurses can provide
parents with strategies design to promote safety and suggest parents to provide
a stimulating environment, encouragement and support. Finally, this is the
time where healthcare providers along with the family, the community and the
school work together to maximize preschooler’s environment permissive to
reinforce learning and broad exploration for a positive growth and
development outcomes.
AGE SPAN 6 – 12 years old
Assessment  History and physical examinations are used
to assess growth and development.
 Parents and school personnel may be
involved in a child’s health care as optimal
school functioning has the greatest potential
when a child is healthy physically,
emotionally, and socially.
Nursing Diagnosis o Health – seeking behaviours related to
normal school –age growth and
development
o Readiness for enhanced parenting related to
improved family living conditions
o Anxiety related to slow growth pattern of
child
o Risk for injury related to deficient parental
knowledge about safety precautions fr a
school – age child
Outcome Keep in mind that school – age children tend to
Identification/Planning enjoy small or short term projects rather than long.
Behaviour problems need to be well defined before
outcomes are identified and interventions planned.
Implementation When giving care, keep in mind that children this
age feel more comfortable if they know the “hows”
and “whys” of actions and may not cooperate
unless they are given satisfactory explanation.
Outcome Evaluation a. Parent states that he permits the
child to make his own age – related
decisions.
b. Child identifies books he has read
together with parents in the past two
weeks.
c. Child states he understands the
variations of growth as related to the
growth chart.
d. Child does not sustain injuries from
sports activities.
Growth and Development of a School – Age Child

1. PHYSICAL GROWTH
Weight gain – 3 to 5 lbs.(1.3 to 2.2kg) annually
Height increase – 1 to 2 inches (2.5 to 5 cm)
Brain growth – by 10 years old completed
Pulse rate – decreases to 70 – 80 beats/min
Blood pressure – rises to 112/60 mmHg
 10 years old – fine motor coordination becomes refined; eye globe
reaches its final shape and eruption of permanent teeth and growth of
jaw.
 9 years old – immune globulins IgG and IgA reach adult level and
lymphatic tissues continues to grow until this age.
Sexual Maturation
- Timing of the onset of puberty varies widely between 8 – 14 years
of age.
- This change in the onset of puberty is important because it means ,
for sex education to be effective
Sexual and Physical Concerns
- The school – age period is a time for parents to discuss with
children the physical changes that will occur and the sexual
responsibility these changes dictate.
CHRONOLOGIC DEVELOPMENT OF SECONDARY SEX
CHARACTERS

Age Boys Girls

9 - 11 Prepubertal weight gain Breast; elevation of papilla

occurs with breast bud formation;
areolar diameter enlarges.

11 - 12 Sparse growth of straight, Straight hair along the labia;

downy, slightly pigmented vaginal epithelium becomes
hair at base of penis. cornified.
Scrotum becomes textured; pH of vaginal secretion
growth of penis and testes becomes acidic; slight mucous
begin vaginal discharge is present.
Sebaceous gland secretion Sebaceous gland secretion
increases. increases.
Perspiration increases. Perspiration increases.
Dramatic growth spurt.

12 - 13 Pubic hair present across Pubic hair grows darker;

pubis. spreads over entire pubis.
Penis lengthens. Breasts enlarge, still no
Dramatic linear growth protrusion of nipples.
spurt. Axillary hair present.
Breast enlargement may Menarche occurs.
occur.
SEXUAL and PHYSICAL CONCERNS

a. Concern of Girls Girls are usually conscious of breast

development.
Early preparation for menstruation is an
important preparation for future childbearing
and for girl’s concept as a woman.
Girls need to know that vaginal secretions will
begin to be present and most girls have
menstrual irregularities during the first year.
b. Concern of Boys Hypertrophy of breast tissue (gynecomastia)
can occur in prepubescent on obese boys.
Some boys can also become concerned of their
pubic hair and wondered of not having beard
yet.
As increased seminal fluid begins to be
produced, boys begin to notice ejaculation
during sleep (nocturnal emission)
c. Concern for Studies on the mental health of transgender
Transgender children reported a higher incidence of
psychosocial disorders such as depression and
Children anxiety.
All children are unique individual that should
be treated with respect same respect for
transgender children

TEETH – deciduous teeth are lost

permanent teeth erupt during the school – age
period
SUMMARY OF SCHOOL – AGE DEVELOPMENT

Psychosocial and Cognitive

Age Physical Development Development
A year of constant motion; 1st grader teacher becomes authority
6 skipping is a new skill; first figure; adjustment to all – day school
molars erupt. may be difficult and my lead to nervous
manifestations
Defines words by their use.
Central incisors erupt; A quiet year; striving for perfection
7 difference between sexes leads to this year being called an eraser
becomes apparent in play; year.
spends time in quiet play. Learns conservation.

Coordination definitely “Best friends” develop; whispering and

8 improved; eyesight fully giggling begin.
develops; playing with Can write in cursive as well as print.
friends becomes important. Understand the concept of past, present,
and future
All activities are done with Friend or club age; has secret codes; is
9 friends. all boys or all girls; clubs disband and
reform quickly.
Coordination improves. Ready for camp away from home;
10 collecting age; likes rules, ready for
competitive games.
Active, but awkward and Insecure with members of opposite sex;
11 ungainly. repeats off – color jokes.

Coordination improves. A sense of humor is present; is social

12 and cooperative.
DEVELOPMENTAL MILESTONES

1. Gross Motor Development

- Children have enough coordination to walk a straight line, many
can ride a bicycle, and they learn to skip rope with practice.

2. Fine Motor Development ( involves play)

- Writing begins to look mature and less awkward. A 6 year- old
child can their shoelaces, cut and paste well and draw a person
with good detail. Older children begin to evaluate their teacher’s
ability and maybe the time a child is turned on to reading. During
their 10th year, children become very interested in rule and
fairness while children ages 11 and 12 years enjoy dancing and
playing table games. They are accommodating enough to play
with their younger siblings and typically like to do jobs around the
house or baby - sitting for money.
 3. Language Development

6 years old – talks easily in full

sentences, using language easily
with meaning.
7 years old – can tell the time in
hours but confuse with some
terms like half – past or quarter
to.
9 years old – discovers dirty
jokes and use it with their friends
and uses swear words heard from
adults to express anger.
12 years old – can carry on an
adult conversation, although
stories are limited because of a
lack of experience.

4. Emotional Development

Ideally children enter the school – age period with the ability to trust
others and with the sense of respect for their own worth.

“INDUSTRY versus INFERIORITY”

If children are prevented from

achieving a sense of industry or do
not receive rewards for
accomplishment, they can develop a
feeling of inferiority or become
convinced they can’t do things they
actually can do. If the opposite, they
will develop a sense of industry.
Positive reinforcement strengthens
the actions. Small tasks enjoyed
best and can be finished shortly.
 HOME as a SETTING to LEARN INDUSTRY

Parents of a school – age child

may need to take a step forward in
development along with their child.
Children 8 and 9 years of age being
spend more and more time with their
peers but role modelling is very
important especially when it comes to
developing and learning industry by
assigning them simple and achievable
tasks. Humility always starts at
home.

SCHOOL as a SETTING to LEARN INDUSTRY

Schools are increasingly assuming

responsibility for education about
sex, safety, avoidance of substances
of abuse, and preparation for family
living. Ideally, a child’s teacher will
think of learning as fun and will
encourage a child to plunge into new
experiences.
 STRUCTURED ACTIVITIES

The Girl Scouts, the Boy Scouts, the

Camping and other club and
organizations are respected school –
age activities. Urge parents to
evaluate competitive sports program
well and as well as injuries that might
happen.

PROBLEM SOLVING

An important part of developing a

sense of industry is learning how to
solve problems. Parents and teachers
can help children develop this skill by
encouraging practice.

LEARNING TO LIVE WITH OTHERS

A good time to urge children to learn

compassion and thoughtfulness
toward others is during early years.

SOCIALIZATION

Some children develop faster than

others; every group has some
members who are almost adolescent
and some who are still children,
making social interactions sometimes
difficult.
 5. Cognitive Development

The age from 5 to 11 years is a transitional stage where children undergo a

shift from the preoperational thought. Children can use concrete operational
thought because they learn several new concepts during school age.

a. DECENTERING – the ability to project one’ self into other people’s

situation and see the world from their viewpoint. Enable the child to
feel compassion for others.
b. ACCOMODATION – the ability to adapt thought processes to fit
what is perceived such as understanding that there can be one reason
for other people’s actions.
c. CONSERVATION – the ability to appreciate that a change in shape
does not necessarily mean a change of size.
d. CLASS INCLUSION – the ability to understand that objects can
belong to more than one classification. It is necessary for learning
mathematics and reading and systems that categorize number and
works.

6. MORAL and SPIRITUAL DEVELOPMENT

School – age children begin to mature in terms of moral development
as they enter a stage of preconventional reasoning as early sa 5 years
of age (Kholbergs, 1984). School – age children are rule oriented;
because when they ask for something, because they were good, they
expect to receive what they are asking.
Health Promotion for a School – Age child and Family

COMMON SAFETY MEASURES TO PREVENT UNINTENTIONAL

INJURIES DURINH THE SCHOOL YEARS

Source of Preventive Measures

Unintentional
Injury

Encourage children to use seatbelts and a booster seat

MOTOR if needed; role model seatbelt use.
Teach street – crossing safety; stress that streets are no
VEHICLE place for roughhousing, pushing or shoving
Teach parking lot and school bus safety.
Teach bicycle safety, including wearing a helmet and
BICYCLE not giving “passengers” rides.
Teach to avoid unsafe areas, such as train yards.
COMMUNITY Stress not to go with strangers and teach the child to
say no to anyone who touches them.
Teach children not to arrange a meeting to the people
they meet on the internet.
For older children, teach rules of safer sex.
Teach safety with candles, matches, and campfires.
BURNS Teach safety with beginning cooking skills and for
safety use of cooking utensils including stove and
oven.
Teach safety with sun exposure; use sunblock.
Teach to not climb electric poles.
Educate that roughhousing on fences or climbing on
FALLS roofs is hazardous.
Teach skateboard, scooter, and skating safety.
Teach that wearing appropriate equipment for sports.
SPORTS Stress not to play to a point of exhaustion.
Use trampolines only with adult supervision.
INJURIES
Teach how to swim; dares and roughhousing when
diving or swimming are not appropriate. Stress not to
DROWNING swim beyond limits of capabilities.

Help your child avoid recreational drugs; prescription

DRUGS medicine should only be taken as directed. Teach to
avoid tobacco and alcohol.

Teach firearm safety. Keep firearms in locked cabinets

FIREARMS with bullets separate from gun.

School – age children should keep adults informed as

GENERAL to where they are and what they are doing; cell phones
can help with this.
Be aware the frequency of unintentional injuries
increases when parents are under stress and therefore
less attentive. Special precautions must be taken at
these times.
Caution that some children are more active, curious,
and impulsive and therefore more vulnerable to
unintentional injuries than others.
PROMOTING NUTRITIONAL HEALTH OF A SCHOOL –AGE
CHILDREN

a. Establishing Healthy Eating b. Fostering Industry and

Patterns – children should be Nutrition – the
encouraged to eat a healthy development of proper
breakfast to ensure the ability to etiquette is important and
concentrate during the school parents can model this
day while they can help in the behaviour. Meals eaten
preparation of nutritious foods. while watching television or
performing another activity
is a risk factor for obesity.

c. Recommended Dietary d. A Vegetarian Diet –

Intakes – meeting the daily vegetarians need to obtain
food allowance with high essential nutrients and the
nutritional value should be consumption of protein and
practised. Both girls and boys calcium is important for
require more iron in prepuberty. muscle, bone and dental
Adequate calcium and fluoride development. Iron may be
intake to ensure good teeth and supplemented especially for
bone growth. girls with heavy menstrual
flow.
PROMOTING DEVELOPMENT OF A SCHOOL – AGE CHILD IN
DAILY ACTIVITIES

DRESS – school – age SLEEP – sleep varies EXERCISE – school –

children can dress
among children. age children need daily
themselves and become
adept in the late years. Children with exercise. Urge them to
This is also the right time television sets, participate in some
to teach them the
electronic games, or form of daily exercise.
importance of caring their
belonging. This time smart phones in their
children have already bedrooms have shorter
definite opinions about
sleep time and likely to
clothing styles.
be obese. Night time
terrors are normal due
to reaction to stress in
the beginning of
school.
CARE OF TEETH –
school –age children
HYGIENE – children 6 should visit a dentist
or 7 years of age still need twice yearly for check-
in regulating bath water up, cleaning and
temperature. Both boy and fluoride treatment to
girls become interested in strengthen and harden
showering as they the tooth enamel or
approach teen years. sealants on secondary
Bathing during teeth. They should be
menstruation period is reminded to brush their
safe for girls. teeth daily.
COMMON HEALTH PROBLEMS OF THE SCHOOL – AGE PERIOD

DENTAL CARIES
Caries (cavities) are progressive, destructive lesions of decalcification of the
tooth enamel and dentin. Dental caries are preventable by proper bushing.
Dental visits are recommended every 6 months.

MALOCCLUSION – is a deviation of tooth position from the normal;

maybe congenital due to a condition such as cleft palate resulting on abnormal
tongue position. Malocclusion may either be crossbite (sideways) or anterior
or posterior.
PROBLEMS ASSOCIATED WITH LANGUAGE DEVELOPMENT
The most common problem of school – age child is articulation with
consonants, speech therapy for this normal developmental stage is not
necessary.
COMMON FEARS and ANXIETIES of a SCHOOL – AGE CHILD
1. Anxiety Related to Beginning School
Adjusting to grade school is a big task for 6 years olds while one of the
biggest tasks of the first year in school is learning to read. Many first
graders are capable of mature action at school but appear less when
they return home. Urge the parents to spend some time with the child
after school.
2. School Refusal or Phobia
It is a fear of attending school and similar to agoraphobia (fear of
going outside) or separation anxiety disorder (SAD)
SEX EDUCATION
It is important that school – age children be educated about pubertal
changes and responsible sexual practices.
Topics to teach and discuss in sex education:
 Reproductive organ functions and physiology of reproduction, so
children understand what menstruation is and why it occurs.
 Secondary sexual characteristics, so children can understand what is
happening in their bodies.
 Male sexual functioning, including why the production of increased
amounts of seminal fluid leads to nocturnal emissions.
 The physiology of pregnancy and the possibility or unintended
pregnancies, which will come with sexual maturity.
 Responsibilities of sexual maturity.
 Reproductive life planning measures and the principles of safer sex if
appropriate to cultural setting.
Lesbian, gay, bisexual, and transgender (LGBT) youth may not obtain
the same level of care due to fear of discrimination. Nurses can take steps to
improve health outcomes for LGBT youth. Urge parents or other health
educators to watch films or read booklets with children to show they are truly
available to answer questions.
VIOLENCE and TERRORISM
Children basically view their world as safe but some incidence like
shooting inside the school put them into great shock.
Common recommendation for parents to help children feel safe;
 Assure children they are safe; even if violence is in their community.
 Observe for signs of stress such as sleep disturbances, fatigue, and lack
of pleasure in activities or beginning substance abuse.
 Do not allow children or adolescents to view footage of traumatic
events over and over because this decreases their ability to feel safe.
 Watch news programs with children so you can explain some events.
 Explain that there are bad people in the world doing bad things.
 Prepare a family disaster plan including emergency supplies and kit.
 BULLYING

School – age children cite for feeling so

unhappy that they try to hurt their classmates or
commit suicide because they were ridiculed or
bullied to the point that they could no longer take such
abuse. Alert parents that internet bullying is one common bullying mode
recently.
Traits commonly associated with school – age bullies;
 Advanced physical size and strength for their age.
 Aggressive temperament (both male and female).
 Parents who are indifferent to the problem or are permissive with an
aggressive child.
 There is the presence of a child who is a “natural victim” (small,
insecure, with low self – esteem)
Suggestions for school personnel to deal with bullies;
 Supervise recreation periods closely.
 Intervene immediately to stop bullying.
 Insist if such behaviour does not stop, both the school and parents will
become involved.
 Advise parents to discuss bullying with their school – age child and
help them understand that it should be reported to allow adults to
intervene.
 Parents should monitor their child’s social media and texting
interactions.
 RECREATIONAL DRUG USE

Illegal drugs such as marijuana,

cocaine, and amphetamines are
now available to children as early
as elementary school because they
are available in so many homes,
alcohol, inhalants, and
prescription drugs have become
commonly abused by this age
group. Parents should suspect
recreational drug use if their child
regularly appears irritable,
inattentive or drowsy. Cigarette
smoking also begins at this stage.
To discourage use of tobacco,
health care professionals and
parents need to be the role model
of excellent non-smoking health
behaviour.
CONCERNS OF THE SCHOOL – AGE CHILD AND FAMILY WITH
UNIQUE NEEDS

1. The Child of Alcoholic Parents

Children who live with alcoholic parents

are at the great risk for having emotional
problems than others because of the
frequent disruption of their lives.
Immediate problems that can occur with
children of alcoholic parents include;
 A feeling of guilt that they are the
cause of parent’s drinking.
 Constant worry that the alcoholic
parent will become sick or die.
 A feeling of shame that prevents
child socialization.
 Decreased ability to trust adults.
 Poor nutrition and low grades.
 Anger and helplessness.

2. The Child with a Long – Term Illness or Physical Cognitive

Challenge

Time lost from school is the biggest

problem that faces children with long
– term illness and this threatens their
academic achievement and peer
relationships. Keeping up with school
and communicating with them help
the child foster socialization. Urge
parents of children to assign them
household chores just like other
children and to allow them participate
peers activities. Also, choose short
term activities that they can be able to
complete independently.
NURSING ACTIONS THAT ENCOURAGE a SENSE OF INDUSTRY
in the PHYSICALLY CHALLENGED or CHRONICALLY ILL
SCHOOL – AGE CHILD

Category Nursing Actions

Allows choices of food when possible and respect food
NUTRITION preference
Provide small food servings that child can finish, which
encourages sense of accomplishment.

Ask for suggestion as to how bulky the child wants the

DRESSING dressing and where to apply tape

Teach the child the name and actions of medicine.

MEDICINE Encourage the child to keep track of medication times
by clock or record.
The child may feel more in control of injections and
intravenous insertions if allowed to choose site.
Allow the child to choose oral medicine forms.

Establish clear rules for rest periods.

REST
Respect the modesty of school – age child.
HYGIENE Allow as much as choice as possible such as own
clothing and timing of self – care.

Encourage the child to express and rate pain.

PAIN Encourage the child to use distraction techniques, such
as counting backwards or imagery.
Explain the source and cause of pain to give the child
sense of mastery.

Encourage school work.

STIMULATION Encourage activities that end in a product.
Encourage paper – pencil games, such as connect the
dots or tic – tac – toe.
Don’t suggest competitive games for children below 10
yrs.
Encourage using the playroom for socialization.
Encourage the child to keep in contact with school
friends by texting or e – mailing.
REFLECTION

During the school – age years, the child becomes increasingly

independent while peers become important as the child starts school and
gradually moves away from the security of home. The school – age child
develops a sense of industry and learn the basic skills needed to function in
the society. Thinking becomes less egocentric as children consider the other
viewpoints different from their own. This period is a time for best friends,
sharing and exploring the outside world. It could be stressful for a child, and
this stress could impede the child’s successful achievement of developmental
tasks. Also, at this stage school – years are characterized by slow and steady
growth with their physical changes occurring gradually and subtly. Sexual
development peaks when the child enters puberty that includes the growth
spurt, development of primary and secondary sexual characteristics, and
maturation of sexual organs. That’s why sex education should be integrated in
school curriculum to explain these changes and the reasons of these changes
for the children to be able to understand and protect themselves. At this stage,
the children coordination improve that paved way the development of sense of
balance and rhythm that allows them to do higher level of play executions like
riding wheeled bicycle, dancing, skipping and participating sports activities.
But because children this age enjoy active play and are full of energy, they
don’t often recognize fatigue so parents should keep them well – nourished
and hydrated. When it comes to cognitive skills, thought processes undergo
dramatic changes as the child moves from intuitive thinking to logical
thinking processes. They gain new knowledge and develop more efficient
problem – solving ability and greater thinking flexibility as their
understanding broadens. Rules are important this time while they are also
become more sensitive to the norms and values of the group. Clubs and
organizations are recommended this time to develop leadership skills. The
nurse should encourage the parents to allow their children discover their
talents and skills while interacting with other children. Safety among school –
age children must also be prioritized. Still, at this stage parents, nurses, the
community and the school should work together to provide a good learning
and permissive environment to their growing children.
AGE SPAN 13 - 20 years old
Assessment  When performing physical examinations on
adolescents, be aware they are very self –
conscious with their bodies.

Nursing Diagnosis o Health – seeking behaviours related to
normal growth and development.
o Low self – esteem related to facial acne.
o Anxiety related to concerns about normal
growth and development.
o Risk for injury related to peer pressure to
use alcohol and drugs.
o Risk for disease related to sexual activity.
o Readiness for enhanced parenting related to
increased knowledge of teenage years.

Outcome When planning care, respect the fact that they have
Identification/Planning the strong desire to exert independence and
establish a contract to reach a mutual
understanding.

Implementation Integrating the adolescents in their plan of care

typically helps them be successful. Evaluate how
an intervention appears from an adolescent’s
standpoint before beginning teaching.

Outcome Evaluation a. Patient states she feels good

about herself even though she is
the shortest girl in her class.
b. Patient states he has not
consumed alcohol in 2 weeks.
c. Parents state they feel more
confident about their ability to
parent an adolescent.
d. Patient states she feels high self
– esteem despite persistent facial
care.
Adolescents invariably feel a sense of pressure throughout this period because
they are mature in some respects but still young in others.

1. PHYSICAL GROWTH
The major milestones of physical development in the adolescent
period are the onset of puberty at 8 – 12 years of age and cessation of
body growth.
Height – most girls are 1 – 2 inch. taller than boys
boys typically grow 4- 12 inch. by the end of adolescence
Pulse rate – decrease 70 beats/min
Respiratory rate – 20 beats/min
Blood Pressure – increases 120/70 by late adolescence

Androgen stimulates sebaceous glands to extreme activity, resulting to acne.

Apocrine sweat glands (axiallae and genital areas) produce strong odor in
response to emotional stimulation.

TEETH – adolescents gain their second molar at about 13 while their 3rd
molars between 18 – 21 years of age.

PUBERTY – is a time which an individual first becomes capable of sexual

reproduction. Girls enter this stage when menstruation starts and boys when
they start producing spermatozoa.
SECONDARY SEX CHANGES - such as body hair configuration and breast
growth are characteristics that distinguish the sexes from each other. It begin
to start in the late school – age period.
SEXUAL MATURATION IN ADOLESCENTS

Age Males Females

Growth spurt continuing; Pubic hair thick and curly,
13 – 15 pubic hair abundant and triangular in distribution; breast
curly; testes, scrotum, and areola and papilla from secondary
penis enlarging further; mound; menstruation is ovulatory
axillary hair present; facial making pregnancy possible
hair fine and downy; voice
changes happen with
annoying frequency
Genitalia adult; scrotum dark Pubic hair curly and abundant; may
15 – 16 and heavily rugated; facial extend onto medial aspects of
and body hair present; sperm thighs; breast tissue appears adult;
production mature nipples protrude; areolas no longer
project as separate ridges from
breasts; may have some degree of
facial acne.
Pubic hair may extend along
16 – 17 medial aspects of thighs; End of skeletal growth.
testes, scrotum, and penis
adult size; may have some
degree of facia acne;
gynecomastia fades

17 – 18 End of skeletal growth

DEVELOPMENTAL MILESTONES

Play or Recreation
Team (or school) loyalty becomes
intense and following a coach’s
instructions becomes mandatory.
Overuse injuries from athletics occur
and most adolescents spend a great
deal of time just talking with peers as
social interactions. Many engage in
charitable endeavours during middle
or late adolescence.

1. EMOTIONAL DEVELOPMENT
The developmental task in early and mid – adolescence is to form a sense
of identity versus role confusion. And in late adolescence, it is to form a
sense of intimacy versus isolation.
o IDENTITY vs. ROLE CONFUSION (early & mid- adolescence)
To form identity is for adolescence to decide who they are and what
kind of person they will be.4
4 Main areas to achieve a sense of IDENTITY
1. Accepting their changed body image.
2. Establishing a value system or what kind of person they want to be.
3. Making a career decision.
4. Becoming emancipated from parents
Role confusion – when they fail to develop identity and find it difficult in
functioning effectively as adults.
a. BODY IMAGE
- Adolescents who were able to develop a strong sense of industry
learned to solve problems and to adjust to the changing body
image that comes with adolescents.
b. SELF – ESTEEM
- Self – esteem may undergo major changes during the adolescent
years. Help parents understand how important it is for adolescents
to have immediate future successes.
c. VALUE SYSTEM
- Adolescents develop their value s throughout their childhood as
they interact with their family. Identifying risk – taking
behaviours and offering guidance and support is important in
promoting the health of the adolescent.
d. SOCIAL COUPLING
- Adolescents begin to explore their sexual preference and tend to
dress and behave similarly to other member of the peer group.
Encourage an open dialogue with them to assist to process their
feelings and establish their own identity.
e. CAREER DECISIONS
- The adolescent may identify an educational and career trajectory
during self – discovery of personal positive attributes. Show
increased interest in learning as they become to see education as
relevant to their future.
f. EMANCIPATION from PARENTS
- Encourage parents to give adolescents more freedom in areas such
as choosing their own clothes or after school activities. Both
parents and adolescents need help to understand that independence
can strengthen more their relationship and self-reliance.
o INTIMACY versus ISOLATION (late adolescence)
Developing a sense of intimacy means a late adolescent is able to form
long – term, meaningful relationships with persons of the opposite as
well as their same sex. Some of them require parents or other adults to
differentiate between sound relationships and those that are based only
on sexual attraction. In this stage, if they develop empathy wherein
they are able to understand the feelings of another, their sense of
intimacy has developed its finest form.

g. SOCIALIZATION
Early teenagers may feel more self – doubt than self –confidence when
they meet another adolescent with whom they would like to begin a
lasting relationship. Adolescents watch adults carefully during this
period. Both male and female adolescents tend to be loud and
boisterous, particularly when someone whose attention they would like
to attract nearby. Idolization of famous people or older adolescents of
this nature fades as adolescents become more interested in forming
reciprocal friendships.
2. COGNITIVE DEVELOPMENT
The formal operation thought begins at 12 or 13 years old and grows
in depth over the adolescent years until 25. This stage involves the
ability to think in abstract terms and use of scientific method to arrive
at conclusion. Problem solving in any situation depends on the ability
to think abstractly.

3. MORAL AND SPIRITUAL DEVELOPMENT

- Because adolescents enlarge their thought processes to include
formal reasoning, they are now able to respond to the questions
“Why is it wrong to steal from your neighbour?” and other
irrational acts. Almost all adolescents question he existence of
God and any religious practices they have been taught.
Health Promotion for an Adolescent and Family
PROMOTING ADOLESCENT SAFETY
Unintentional Health Teaching Measure
injury
Always use a seatbelt and never use cell phones while
MOTOR driving.
VEHICLES Do not drink alcohol while driving and wear helmet
when driving motorcycles.
Take graduated driver programs seriously.
Always consider all guns loaded and lethal.
FIREARMS Learn safe gun handling before attempting to clean or
hunt.
Learn to swim and follow safe water rules.
DROWNING Taking dares has no place in water safety.
Use protective equipment, such as facemask and pads.
SPORTS Don’t attempt to participate beyond physical limits.
Keep well hydrated by drinking fluid before and after
play.
Careful preparation for sports through training is
essential for safety.
Recognize and set one’s own limit for sports
participation.
PROMOTING NUTRITIONAL HEALTH FOR AN ADOLESCENT

Adolescents experience such rapid growth that they may always feel
hungry but one form of adolescent behaviour is to refuse to eat foods that
parents stress as important. Also, adolescents who are slightly obese because
or prepubertal changes may begin low – calorie or starvation diets duing
adolescence to lose weight.

1. Recommended Dietary Reference Intakes

Adolescent needs an increased

number of calories over that
needed previously to support
rapid body growth. Iron,
calcium, and zinc are most apt to
be deficient. Increased calcium
and vitamin D intake plus
physical exercise are necessary
for rapid skeletal growth. Good
sources of iron are meat and
green vegetables, calcium is
abundant in milk and meat and
milk are also high in zinc.
a. VEGETARIAN DIETS
– adolescents need to
consume large amount of
vegetables to achieve an
adequate intake.

b. GLYCOGEN LOADING
– athlete needs more
carbohydrate or energy
than those who don’t
engage in strenuous
activities. It is a procedure
used to ensure adequate
glycogen store to sustain
energy.
PROMOTING DEVELOPMENT OF AN ADOLESCENT IN DAILY
ACTIVITIES

1. Dress and Hygiene

Adolescents are capable of
total self – care because of
their body awareness.
Remember that when caring
hospitalized adolescents,
providing time for self –care is
important while most
teenagers seem to improve
markedly when allowed
wearing their own clothing.

2. Care of Teeth
Adolescents are generally very
conscientious about tooth
brushing. They should continue
using fluoride toothpaste. Teens
with braces must be more
conscientious in tooth brushing.

3. Sleep
Because protein synthesis occurs
readily during sleep, adolescents
need at least 8 hours of sleep and
when sleep disturbances occur,
there’s no need for them a
medication just yet.
4. Exercise
Adolescent needs exercise
every day both to maintain
muscle tone and to provide an
outlet for tension while
adolescents involve in
structured athletic activities do
receive daily exercise as long
as they don’t overdo it to
avoid muscle strain and
injuries.

5. Sun Exposure
Avoiding excessive exposure
to sunlight must be avoided
by adolescents who are
spending outdoor much so
that they will not develop
skin cancer. Also, advise
them to use sunscreen and
avoid tanning beds. Do this
creatively as possible
because teenagers might not
look its effect such as
melanoma and it will affect
their future well – being.
COMMON HEALTH PROBLEMS OF AN ADOLESCENT

1. Hypertension – adolescents who are obese, eat a diet high in salt, or

who has a family history of hypertension are most susceptible to
developing the condition. Hypertension is present if blood pressure is
above 15th percentile or 127/81 for girls and 131/81 for boys for two
consecutive reading.
2. Poor Posture – this is due to imbalance of growth that arises from the
skeletal system growing a little more rapidly than the muscle attach to
it. Urge adolescents of both sexes to use good posture during these
rapid growth years. Asses and appraise to detect the difference
between simple poor posture and the beginning of spinal dysplasia or
scoliosis.
3. Body Piercing and Tattoos – body piercing and tattoos are a strong
mark of adolescence and a way for them to make a statement of who
they are and that they are different from their parents. Be certain that
they know the symptoms of infection and to report it to healthcare
provider. It is important to caution adolescents that sharing needles for
piercing or tattooing carries the same risk for contacting blood – borne
diseases.
4. Fatigue – fatigue may also be the beginning symptoms of disease.
Always assess their diet, sleep patterns, and activity schedules. Blood
tests may be indicated to rule out anemia and common infection.
5. Menstrual Irregularities – it is a major health concern with girls as
they learn to adjust to their individual body cycles.
6. Acne - is a self – limiting inflammatory disease that involves the
sebaceous gland, which empty into hair shafts and a common skin
disorder of the adolescents.
CONCERNS REGARDING SEXUALITY AND SEXUAL ACTIVITY

Adolescents who engage in sexual risk behaviour can have unintended

health outcomes, including unplanned pregnancies and sexually transmitted
infections (STIs) such as HIV. When discussing sexuality with them, the
nurse should avoid assumptions about gender of the adolescent’s partner,
instead, ask open – ended questions to encourage teens to be more open.
During routine visits, it is important to obtain a complete sexual health history
and offer health related education appropriate to the adolescent’s
individualized history. Also, information on date rape and rape prevention
should be provided as they are a high – risk age group to date rape.

1. STALKING – refers to repetitive,

intrusive, and unwanted actions
such as constant threatening
pursuit directed at individual to
gain individual’s attention and
could be through cyber stalking.
To avoid stalking, adolescents
should be aware of and avoid being
alone. Report stalking to law
enforcement authority.
2. CONCERNS REGARDING
HAZING or BULLYING –
hazing is a form of organized
bullying, refers to demeaning or
humiliating rituals that prospective
members have to undergo to join
sororities, fraternities, gangs or
ports team. To prevent this, urge
parents to be aware of what clubs
or organizations their adolescent
join. Help them make sound
decisions about what type of
hazing and subject at health
assessment.
CONCERNS REGARDING SUBSTANCE USE DISORDER

Substance use disorder – refers to the use of chemicals to improve a mental

state or induce euphoria. Use of drugs is common among adolescents and it
occurs from a desire to feel more confident and mature; it also a form of
rebellion related to childhood adversity or violence.

TYPES of ABUSED SUBSTANCES

1. Prescription and Over – The – Counter Drugs -
2. Alcohol
3. Tobacco
4. Performance – enhancing substance use disorder
5. Marijuana
6. Amphetamines
7. Cocaine
8. Hallucinogens
9. Opiates
SYMPTOMS TO HELP IDENTIFY SUBSTANCE USE DISORDERS

Drugs Symptoms of Use Dangers

Violence, drunken Lung , brain, or liver

GLUE appearance, dreamy or damage, death through
blank expression; glue suffocation or choking;
smears on clothing or anemia
fingers; tubes of glue, paper
bags in possession

Stupor, drowsiness, needle Death from overdose;

HEROIN, marks on body, watery eyes, addiction; liver and
MORPHINE, loss of appetite; bloodstains other infections due to
CODEINE on shirt sleeve, runny nose; unsterile needles
possession of needles,
hypodermic needles, cotton,
tourniquet strings, burnt
bottle caps or spoons,
glassine envelops

Drunken appearance, lack Addiction

COUGH of coordination, confusion,
MEDICINES excessive itching;
possession of empty bottles
of cough medicines

Sleepiness, wandering Psychological

MARIJUANA mind, enlarged pupils, lack dependence
of coordination; discoloured
fingers, strong odor of burnt
leaves, possession of small
seeds in pocket lining,
cigarette papers

Severe hallucinations, Suicidal tendencies,

HALLUCINOGENS feeling of detachment, unpredictable
(LSD,DMT,PCP) incoherent speech, cold behaviour; chronic
hands and feet, laughing exposure may have
and crying, vomiting, strong neurologic effects
body odor; possession of
cube sugar with
discoloration in center.
STIMULANTS Aggressive behaviour, Death from overdose;
Methamphetamine giggling, silliness, rapid hallucination;
Cocaine speech, confused thinking, psychosis
no appetite, extreme fatigue,
black caries, dry mouth,
shakiness, insomnia,
absence of nasal hair,
possession of pills or
capsules of varying colors,
possession of glass pipe

DEPRESSANTS Drowsiness, stupor, Death or

Barbiturates dullness, slurred speech, unconsciousness from
Alcohol drunken appearance, overdose; addiction;
vomiting, odor of alcohol seizures from
on breath; possession of withdrawal
pills or capsules in varying
colors

STEROIDS Aggressive behaviour, Violent actions;

increase in muscle strength possible tumor growth
and mass

ASSESSMENT OF SUBSTANCE USE DISORDER

Increased school absences and a decrease in school achievements is

important note. Diagnosis of hepatitis B, HIV positive, or appearing to receive
no benefit from usual analgesic agents are later indicators of high – risk
behaviours. Adolescents who are no longer chemically dependent should be
evaluated by a history and physical examination, if the circumstances that
initially caused them to become chemically dependent recur, they may return
to a dependency pattern.

SELF – INJURY – includes a range of self – destructive actions from cutting

to suicide. Successful suicide occurs more frequently in males than females.
SUICIDE WARNING SIGNS
 Giving away prized possessions
 Organ donation questions, such as “How do you leave your body to a
medical school?”
 Sudden, unexplained elevation of mood, which may indicate the
individual has reached decision about the suicide and feels relief.
 Injury proneness, carelessness, and death wishes
 Decrease in verbal communication or a statement such as “This is
the last time you will see me”
 Withdrawal from peer activities or previously enjoyed events
 Previous attempt (80% of all completed suicides have been preceded
by a failed attempt)
 Preference for art, music, and literature with themes of death
 Recent increase in interpersonal conflict with significant others
 Running away from home
 Recent experience of a friend or famous person committing suicide
 Inquiring about the hereafter
 Asking for information about suicide prevention and intervention
 Almost any sustained deviation from the normal pattern of behaviour

A thorough family history assessment is helpful because suicide usually

reflects a family interaction or relationship. When caring for a child after a
suicide attempt, ask enough questions on a health history so you can help to
analyse whether an adolescent made a detailed suicide plan. It is not important
not to underestimate adolescent’s determination and capability to end his own
life. Refer them to seek professional help. Because adolescents resort to
suicide to solve their own problem, teach them problem solving skills. The
continuing evaluation should be on going and progressive.
CONCERNS OF THE ADOLESCENT AND FAMILY WITH UNIQUE
NEEDS

Homeless or Runaway Youth

An adolescent between ages 10 and 17 years who has been absent from
home at least overnight without permission of parent or guardian. Stress
factors such as family unemployment, alcoholism, sexual maltreatment,
incest, attempted suicide and poverty are frequent characteristics in their
families. Running away is usually preceded by an argument with parent that’s
often the last straw after a number of long – term disagreement and other
personal concerns. In dealing with these children, try to imagine yourself in
their circumstances to determine whether your health instructions or goals will
be sensible for their lifestyle. Also, remember they are runaways; for some
reasons; their home is intolerable.
A Physically Challenged or Chronically Ill Adolescent
Achieving a sense of identity may be difficult for adolescents who have a
chronic illness or other challenges. Some of the biggest problem encountered
by them is achieving independence as they would like to be. Helping these
adolescents realize that even other normal people might also experiencing
difficulties in life so that they feel less indifferent.

Nutrition and the Chronically Ill Adolescent

Adolescent who are not fully mobile must be cautious of their total
calorie intake because, as growth needs decline at the end of adolescence, they
may become obese. Assess their meal plan as well as eating fast – food
restaurants but it could help them in socialization with peers.
REFLECTION

Physical development, hormonal changes and sexual maturation that

occur during the adolescent stage correspond to Freud’s final stage of
psychosexual development, the genital stage. It usually begins, with the
production of sex hormones and maturation of reproductive system. At this
stage, sexual tension and energy are manifested in the sexual relationship with
others. When it comes to physical growth, it occurs relatively predictable by
both genders. The accelerated growth needs more adequate nutritional intake
while periods of intense growth require increased caloric intake. When it
comes with adolescent cognitive skills, cognitive development influences
every aspect of adolescent psychosocial development wherein cognition
moves from concrete to abstract thinking. They are now capable of many
skills however develop a heightened sensitivity to stress demonstrated by an
exacerbated response. The impact and implication of this for nurses is
especially apparent for health teaching because adolescents think in different
ways than adults. Proper health education should be given to them for them to
independently care for themselves. Mostly, this is the stage of curiosity and
adventure for these teenagers as they want freedom and independence from
their parents. With the freedom driving brings adolescent comes responsibility
but their inexperience and risk – taking behaviours can be a lethal
combination. Relationships with opposite sex are more mature when they
reach the late adolescence period. When it comes to moral and spiritual
development, adolescents’ moral reasoning develops in a sequential manner.
Conformity to please others and to avoid punishment are the main reasons
why they need to follow the norms in the society. However, at this stage also
adolescents are attracted to do against the rule because of some reasons,
rebellion, curiosity, and peer pressure. It’s the nurses’ role to educate the
youth to take care of their health, protect themselves from diseases while
parents should also reinforce it. Allowing them to flourish and grow as
individuals should put into consideration as they start to find themselves and
discover their true identity as well. They seem vulnerable with failures
however; consistent support from family should never falter.
Assessment  Health assessment can be a positive,
educational experience for the child and
family if it’s taken carefully to their
concerns and responses.
 Never rush and be sure children have time
familiarizing themselves with the
environment and equipment.

Nursing Diagnosis o Impaired social interaction related to lack

of self – esteem secondary to disability.
o Readiness for enhanced family coping.

Outcome Health promotion and illness prevention are vital

Identification/Planning parts of outcome identification following a health
assessment. Helping parents plan for their child’s
next developmental stage or keeping them
important safety measures. Remind parents about
future immunizations.

Implementation Health interviewing and physical examination both

require a great deal of skills. To perfect skills and
judgment with children of different ages, take
advantage of every opportunity by practising
interviewing and physical examination techniques
with them.

Outcome Evaluation a. After a health examination,

parents state they are satisfied
with their child’s motor
development.
b. After Snellen test, the child
states she is aware her vision
needs correction.
c. The parent states they will
continue to assess their child’s
growth by weighing the child
weekly.
HEALTH HISTORY: Establishing a Database
The assessment of a young child begins with an interview of the child’s
parent while an adolescent may choose to be interviewed without the parent.
The purpose of a health interview is to gather information that will direct
physical or laboratory examinations to complete a thorough health evaluation

INTERVIEW SETTING

An interview is best conducted in a private room with all parties seated

comfortably. During interview, be certain to call the parents by their names.
This lets them know that their input and opinions about their child is
developing are valued. Maintaining good eye – contact and allowing children
to play as active part as possible in the assessment process are important for
good health interviewing.

TYPES OF QUESTIONS ASKED

1. Closed – Ended Questions – this simplest form of question directly

asks for a fact, such as “Did you take Candy’s temperature? “This is an
effective type of question if a particular point is being sought. The
response is mostly “yes” or “no”.
2. Open – Ended Questions – allows for elaboration such as “What did
you do for Candy?” It is important to ask open –ended questions with
school –age children and adolescents so they are encouraged to fully
describe a problem.
3. Compound Questions – this should be avoided if all possible because
the information they elicit is often inaccurate and must be followed by
clarifying question such as “Did Candy have nausea and vomiting?” It
should be only one condition to be asked.
4. Expansive Questions - are open –ended questions gone wrong
because the question being asked is too vague to answer such as “What
can you tell me about Candy?”, leaves parent wonder where to start.
Instead, how has Candy been since her last visit?”
5. Leading Questions – supply their own answers and so they should
also be avoided such as “Candy has had all her immunizations, hasn’t
she?
CONTENTS OF A HEALTH INTERVIEW
Before shifting to next section of an interview be certain to make a
transition statement during interviewing.
1. Introduction and explanation – introducing formally yourself to
parents and children as well as the topics and subjects to be discussed.
2. Demographic data – refers to data such as a child’s name, address,
gender, social security number, and the name of the person who will
be providing information. Be certain to identify the child’s primary
caregiver or if the parents are divorced or deceased to identify the
child’s custody and has the right to sign a consent for healthcare
treatment.
3. Chief concern – this is the first reason to be asked to the parents for
bringing their child. Record the chief concern in the child’s chart
exactly as it’s stated. An effective way to elicit this information is to
 ask directly, “Why did you bring Candy to the clinic today? How is
Candy feeling today? Or Is Candy ill?
4. History of chief concern – once a parent has voiced a chief concern,
ask him/her to describe at least six aspects of the problem
o DURATION – refers to the length of time a specific symptom
such as vomiting or the parent’s concern about the child’s
symptoms has been present.
o INTENSITY – refers the kind of vomiting (drooling, spitting
or actual vomiting)
o FREQUENCY – refers to how many times a day or hourly
o DESCRIPTION – is the amount ( cupful, mouthful)
o ASSOCIATED SYMPTOMS – might include fever,
abdominal pain, difficulty in eating or sign of respiratory
distress
o ACTION TAKEN – parent’s intervention
5. Health and family profile – includes documentation of the
circumstances in which the child lives. Important information
concerning the family include;
 Is the parent married, single, or divorced? If divorced who has
legal custody?
 What is the family type (nuclear, extended or blended)?
 How many children are in the family?
 What are the family’s living arrangements?
 What are the parent’s occupations?
 If both parents work outside home, how do they manage
childcare?
6. Day history - the child’s current skills, sleep patterns, hygiene
practices, eating habits, and interactions with the family.
 PLAY – play is the work of children and so reveals a great
 deal about a child’s development and over – all well – being.
Important questions to ask about play include:
o Is the child kept in a playpen or given room to run?
o What is the child’s favourite toy?
o Does she play active, chasing games or engage in quiet,
pretending types of activities?
o Is she able to sit and play quietly or does she act as if
driven by a motor?
o Do you (the parent) read to the child?
o Do you (the parent) play with the child or let the child
play alone?
 SLEEP - every child needs adequate rest for healthy growth
and development. Poor sleep patterns can often reveal a
psychosocial or physical health problems. Important questions
include;
o What time does the child go to sleep at night?
o How long does the child sleep at night?
o What time does the child wake up?
o Does the child wake independently or do you need to
wake the child?
o How long does the child nap?(if age appropriate)
o Does the child share a room? With whom? Does the
child share a bed? Is the falling asleep a problem?
o Does child sleepwalk?
o Does the child wet the bed (if the child is toilet train?
 HYGIENE – good hygiene practices promote healthy teeth,
gums and sin; prevents infections, and improve self – esteem.
Poor hygiene may reflect neglect, depression, substance abuse,
or inability of the household to have hot water. Important
 questions regarding hygiene include;
o How much self – care does the child do?
o Can the child shower or bathe independently?
o Does the child brush her teeth? How often? Does
she floss regularly? (respond depends the age)
o Has there been a recent change in hygiene
practices?
 NUTRITION - nutritional assessment is an important portion
of health assessment because it strongly influences health.
Taking a history of a child’s food intake can help determine
whether there are any foods missing in a typical meal plan.
PHYSICAL SIGNS OF ADEQUATE NUTRITION
Assessment Finding
Overall impression Alert, with good energy level; positive mood
Hair Shiny, strong, with good body
Eyes Good eyesight, particularly at night;
conjunctiva moist and not pale
Mouth No cavities in teeth; no swollen or inflamed
gingivae; no cracks or fissures; pink mucous
membranes; tongue pink and nontender
Neck Normal contour of thyroid land
Skin Smooth; normal color and turgor; no
ecchymotic or petechial areas present
Extremities Normal muscle mass and circumference;
normal strength and mobility; normal reflexes;
legs not bowed; no tender joints or edema
Gastrointestinal No diarrhea or constipation present
Fingers and toenails Smooth; pink; not cracked or broken
Height and weight Within normal limits on growth chart & BMI
Blood pressure Normal for age
 7. Past health history, including pregnancy history
Ask whether a child has ever had any serious illnesses and inquire
about the child’s immunization history updates. Information about the
outcomes of past illnesses is as important to obtain information about
the illnesses themselves. The child’s health is affected by their
mother’s health during pregnancy. A history of the pregnancy of the
child being assessed can begin with a question such as “How was your
pregnancy with Candy?” Specific events that are known to occur with
pregnancy that may have had an effect on a fetus;
o Did the mother have any complications such as bleeding, falls,
swelling of hands and feet, high blood pressure, or unusual
weight gain or loss?
o Did she take any medications?
o Were any X – ray films or sonograms taken other than a
routine one to date the pregnancy?
o Did she smoke cigarettes, drink alcohol, or use recreational
drugs while she was pregnant?
o Did the pregnancy end early or late?
Next review the labor and birth by including this questions;
o How long was the labor? Was it spontaneous or induced?
o Were there any complications? Was the birth vaginal or
caesarean?
o Was anesthesia used for birth?
o Was the born vertex or breech?
Then, ask about the health of the child immediately after birth, including;
o Did the baby cry right away/
o Did the infant room in or need care in a special nursery?
o Did the infant need special procedures or equipment?
 o Was there cyanosis or jaundice?
o Was the infant discharged from the birth setting with mother?
o How did the parents feel about having a boy or a girl?
o How did it feel for them to be new parents?
o Was the infant breastfed or formula?
8. Family health history – some diseases are inherited or familial, it is
important to know which ones tend to occur. Ask if any family
members has a condition such as cardiac disease, kidney disease,
congenital anomalies, seizures, diabetes 1 &2, tuberculosis, cancer,
hypertension, a sexually transmitted infection (STI), allergies or
mental health issues or cognitively challenge.
9. Review of systems – is considered the summary of the body
symptoms and covers a lot of ground. Don’t rush because each
question is important and need to be scrutinized for further child’s
health exploration if other symptoms persist.
10. Conclusion – a quick review of the information you have gathered
during the health history will help clarify any misunderstanding or fill
the area forgotten by the patient.

PHYSICAL ASSESSMENT
Physical assessment, along with health interviewing, is one of the most
frequently practiced skills of a nurse. The scope and extent of a pediatric
physical assessment will vary, like health interviewing, depending on the
circumstances of each health contact. Therefore, mastery of physical
examination technique is essential to physical assessment.
REVIEW OF SYSTEMS

Overall health What is the general state of health?

Is the child taking any prescription medications, OTC, home or
folks remedies such as herbal remedies?
Neuropsychiatric Has the child ever has a head injury? Seizures? Attention problems?
Depression? Aggressive behaviour? Is there any suspected
symptoms substance abuse?
Has the child had difficulty with eyes not focusing?
Eye infection? Does parent have any reason to believe the child
Eye does not see well? Does the child wear eyeglasses or contacts?
Ear infections? Drainage from the ears? Tubes in ears? Any
infections from piercing? Reasons to believe the child does not hear
Ears well?
Nose Frequent drainage or cold symptoms? Difficulty breathing?
Nosebleeds?
Mouth Difficulty with teeth or teething? Mouth infections? Has the child
seen a dentist (2 years older) does the child chew tobacco?
Throat Throat infections? Difficulty swallowing?

Neck Masses or swelling? Stiffness? Does the child hold the head
straight?
Chest Is breast development in girls appropriate for age? Any pain in
breasts?
Lungs Breathing problems? Infections? Pneumonia ? Asthma? Does the
child smoke any substance?
Heart Has a healthcare provider ever said there was difficulty of
breathing? What exactly was said?
Gastrointestinal Has there been an eating problem? Frequent nausea? Vomiting?
system Diarrhea? Constipation? Is the child toilet trained? Any difficulty
with this?
Genitourinary Pain or burning on urination? Blood in the urine? Does the child
system have a good urine stream?
10 year old girl, has she started menstruation? Any concerns with
menstruation?
Adolescent male started testicular self – examination?
For adolescent, is the child sexually active? Knows safer sex
practices? Wants more information about contraception? Ever has
sexually transmitted disease? ( ask the child for privacy)
Extremities Painful or swollen joints? Broken bones? Muscle sprains? Is the
parent pleased with the child’s coordination?
Skin Rashes? Lesions such as warts?

Immunizations What immunizations has the child received to date? Are they up to
date?
PURPOSE AND TECHNIQUES

The actual process of a physical examination involves four separate technique;

1. Inspection – examining initially with your eyes or nose being alert to
visual indications or odors that may point to a health problem.
2. Palpation – hands- on examination by touch, either light or deep
3. Percussion – determining the sound you hear by striking the part with
the examining finger and then interpret the sound you hear. Dense
body areas such as bones have a dull, flat sound while those filled with
air, such as lungs are resonant. An organ stretched to even greater
point has a tympanic or extremely hollow ringing sound.
4. Auscultation - a stethoscope examination, listening to sounds that
either discernible to the ear. Always listen for four qualities of sound;
duration, frequency, intensity (loudness), and pitch (high or low)

Equipment, Setting, and Approach

Be certain to provide privacy and that the temperature in examining room

is comfortable. Change paper table covers to avoid possible spread of illness.it
is essential to inform parents or children that it is necessary to touch them
when doing physical examination. Assume that adolescents will cooperate in
placing themselves in whatever position is required to inspect the body.
VARIATIONS FOR AGE AND DEVELOPMENTAL STAGE
1. The Newborn – all newborn receive physical examination
immediately after birth and the first 24 hours of life. Do the
examination under a radiant heat warmer to prevent chilling. Take
axillary or tympanic temperature, assess the heart rate apically, be
certain to obtain femoral pulse to rule out coarctation of the aorta. If
possible examine newborns with parents.
2. The Infant – infants are usually examined most effectively if a parent
holds them during most of the examination. Assess heat and lung
function first, temperature can be taken temporally. Between 7 and 12
months, take extra minute to become well – acquainted with the infant
while they calm according to the tone of your voice. Offering a bottle
of water or pacifier will help when during heart assessment.
3. The Toddler and Preschooler – children at this age may be afraid of
examining equipment, allow them to sit on their parent’s lap. Give
generous praise for cooperation then begin to include blood pressure
taking. Establish a good rapport at the beginning of the examination.
4. The School – Age and Adolescent – some of the children at this age
still unaware of what a physical examination. Explain to them
carefully to ease the fear. Use head to toe procedure and leave the
genitalia last. Be certain to assess height and weight. It is increasingly
important to take blood pressure at this time. School – age children
and adolescent are particularly modest. Respect this by using gowns
and drapes. Include breast exam for adolescent girls while testicular
exam for boys at about 13 years old.
COMPONENTS OF PHYSICAL EXAMINATIONS

1. Vital Sign Assessment – refers to temperature, pulse, respiration,

blood pressure, and whether the child has pain. Temperature is an
important assessment in children because it can reveal a subtle
infection not obvious as the other signs.
2. General Appearance – establishes an overall impression of a child’s
health as well as specific body areas that will need a detailed
assessment.
o Does the child appear well or ill overall?
o Is the child’s height and weight proportional?
o Does the child appear well nourished? Appear underweight or
overweight?
o What is the child’s color? Pale? Yellow (jaundice)? Cyanotic
(blue)?
o Is posture normal?
o What is the child’s hygiene level?
o Is the child dressed appropriately for temperature and climate?
o Are lesions or symptoms of specific illness present?
o Are there any significant body odors?
o Does the child appear relaxed or distressed? Lethargic or
active?
o Is breathing easy or distressed?
If the child appears to have pain, ask the child to rate it on a child –
appropriate pain scale to determine the degree of pain.
3. Mental Status Assessment – begin by assessing the child’s level of
consciousness, orientation, appropriateness of behaviour and mood.
For older than preschool, test recent memory and distant memory.
4. Body Measurements
- Weight
- Height
- Head Circumference
- Chest and Abdominal Circumference

5. SKIN– always assess temperature, color, dryness, texture, turgor an

the presence of any lesions
Skin Findings in Children that Suggests Illness
Finding Indication
Central bluish Cyanotic from decreased respiratory function or from heart
disease; Acrocyanosis (blue hands & feet) is normal in newborns
color for the first 48hours.
White color Edema (accumulated subcutaneous fluid is stretching the skin)

Pale color Anemia or decreased circulation to a body part

Reddened color Local inflammation or increased systemic temperature.

Linear abrasion Scratch marks from local irritation from an insect bite or allergic
reactions
Ecchymoses
Recent injury to skin
(black/blue)
Petechiae
(pinpoint blood Blood dyscrasia (poor clotting ability)
marks)
Yellow color Jaundice from increased bilirubin in subcutaneous tissue;
Carotenemia (excess carotene in skin)
Moistness Excess perspiration from elevated temperature

Localized cold
Decreased circulation to particular body part
temperature
Warm
Local irritation or elevated systemic temperature
temperature
Poor turgor Dehydration

Rash Infectious childhood illness, excessive heat, or allergy

o The Newborn and Infant – newborn may appear ruddy because, as
their layer of subcutaneous fat is thin, the intense redness of their
blood circulation is visible.
o The Toddler, Preschooler, and School – Age Child – many of this
age have minor lesions from mosquito bites or flea bites. Lesions,
scratch marks, or excessive dryness can reveal atopic dermatitis
which is a common childhood disorder.
o Adolescent – at least few acne lesions on the face or back are usually
present. Lesions or rashes caused by allergies to cosmetics and if a
child has piercing or tattoo, assess the site for inflammation. Look
carefully for moles that are very dark, have uneven borders, or have
recently changed shape because these are signs of melanoma or skin
cancer.
6. HEAD– to examine a child’s head, slide a hand over the skull,
assessing for irregular configurations or tenderness. Most children
have a prominent occipital outgrowth. Assess the texture and
cleanliness of the hair. Patches of hair loss (alopecia), suggest a
fungal infection (tinea capitis), a child maltreatment, or a possible
drug reaction (chemotherapy will cause total hair loss not patches.
o The Newborn and Infant – the head usually show molding. A caput
succedaneum or cephalohemotoma from the pressure of birth may be
present. A scalp problem commonly encountered in infants is
seborrhea or cradle cap. You can advised parents that increasing the
frequency of hair washing to once a day and applying baby oil
typically reduce the problem
o The Toddler, Preschooler, and School – Age Children – examine
the hair of children who attend school for nits, head lice and fungal
infections.
o The Adolescent – inspect to see that their scalp and hair are healthy
underneath the styling such as hair iron, dye, pomade and etc. Tight
cornrows and weaves can cause the hair to break resulting in the areas
of baldness.

7. THE EYES – observe eyes for symmetry and signs of redness,

frequent blinking, crusting, squinting, or rubbing because these are
signs of conjunctivitis, an infection of the thin conjunctiva covering
the eye globe. Also, observe lids and lashes for redness and
abnormalities to detect a hordeolum or stye. Strabismus refers to
eyes that are not evenly aligned. Esotropia if an eye always turning
in.
o The Newborn and Infant - newborns often have a small, bright –
red spot on the sclera because the pressure of birth ruptured a small
conjunctival blood vessel and will fade 7 to 10 days as the blood is
absorbed. Newborns and infants can easily be tested for a red reflex.
This assessment is important because a congenital cataract can lead to
a loss of central vision.
o The Toddler and Preschooler - most young children are reluctant to
let someone look into their eyes. Explaining them about eye
examinations can relieve their anxieties.
o The School –Age and Adolescent – Many older children wear
contact lenses and others may be nervous about having eye
examination. Observe carefully for pupillary appearance and ability
to constrict in adolescent to rule out drug abuse.

8. THE NOSE – observe the nose for flaring of the nostrils as a sign of
oxygen deprivation. Using otoscope light, observe the mucous
membrane of the nose color – it should be pink; pale suggest allergies
and redness suggests infection. Note and describe any discharge.
Assess the sense of smell by asking them to identify familiar odor
such as chocolate or an orange
o The Newborn and Infant – infants are obligated nose breathers and
they can’t coordinate mouth breathing.
o The Older Children – allergies cause a clear discharge and pale
mucous membranes. Adolescents who sniff cocaine lose nasal hair
and may have excoriation or abscesses in the mucous membranes.

9. EARS - observe ears for proper alignment. In the average child, a

lined drawn from the inner canthus of the eye to the outer canthus and
then to the ear will touch the top of the pinna of the ear. Touch the
pinna and watch for evidence of pain which is also as sign of external
canal infections. Appraise hearing by assessing their response to your
questions.

o The Newborn and Infant – many newborns still amniotic fluid or

vernix caseosa in their ear canal. Be certain to check it and assess for
ear level and normal pinna contour. Assess gross hearing ability
watching infant startle to a sudden sound.
o The Older Child – middle ear infection (otitis media) is a common
childhood illness cause ear to be painful when examined. Explaining
the examination procedure helps to allay a child’s fear of having
instrument pressed into the ear. Inspect that the area surrounding tube
is not inflamed.
10. THE MOUTH – assess the external appearance of the lips for
symmetry and color. Ask the child to smile and frown to evaluate the
mobility of facial muscles. Count the number of teeth and assess their
condition. Ask the child to stick out his tongue and assess for midline
position and no fasciculation (trembling). Inspect the area under the
tongue for lesions. Use a tongue blade to press down and forward on
the back to inspect the uvula in midline. Observe for abnormal
enlargement, palatine redness or drainage of tonsils.

o The Newborn and Infant – many newborns have considerable

mucus in their mouths because they are less able to handle
swallowing due to immature muscle coordination. Assess for white
patches that do not scrape away (thrush) it requires anti – fungal
therapy.
o The Older Child – tonsillar tissue in children reaches its maximum
growth at early school age. Many children with enlarged tonsils snore
at night and wake feeling tired, they should be assessed by an ENT.
For a child with braces, assess carefully for pinpoint ulcers on the
gum line.
11. THE NECK – assess the neck for symmetry (the trachea should be in
the midline; any deviation suggests lung or thyroid pathology).
Observe the outline of the thyroid gland (barely noticeable before
puberty) because it is obscured by the sternocleidomastoid muscle.
Palpate the area in front of the ear which is the location of the parotid
gland for any swelling. Ask the child to move the head through
flexion and extension. Pain in forward flexion is an important sign of
meningitis.

o The Newborn and Infant – with infant, always assess the ability to
control the head by laying the infant supine and pulling the child to a
sitting position. Babies younger than 4 months of age will let their
heads lag backward as they pulled up this way. After 4 months, infant
should bring their head up with no head lag. This is an important
neuromuscular coordination appropriate to their age.
o The Adolescent – be certain to palpate the thyroid gland for both
symmetry and possible notes. Palpate the left half to discern any
irregularities. Many adolescents have a normal increase in size of the
thyroid at puberty and not be accompanied with nodes.
12. THE CHEST – inspect for retractions or indentations of intercostal
spaces or the suprasternal and substernal areas which reflect
respiration difficulty. Assess the proportion of anteroposterior to the
lateral diameter. Children with chronic lung disease develop a broad
chest. An infant with a diaphragmatic hernia may have a chest
enlarge on that side. An infant with atelectasis (collapsed lungs) may
have a chest smaller on the affected side. If a child has an enlarged
heart, the left side of the chest may appear larger.

13. THE BREASTS – the degree of breast assessment depends on the

child’s age and development. As part of a usual breast assessment,
inspect, and palpate the breasts of all children to detect any
abnormalities.
o The Newborn and Infant – both male and female newborns may
have edema from the influence of maternal hormones. A few drops of
clear fluid may be present form the nipples and will fade few days
later. Do not squeeze the nipple to remove the fluid. Document if a
supernumerary nipple is present for baseline data.
o The School – Age Child and Adolescent – do a breast examination
on all girls past puberty. Many preadolescent boys develop
hypertrophy of breast tissue due to increased hormonal influences
(gynecomastia). Inspection of the breast tissue is easiest if the child
sits on the examining able, arms at the side with breast exposed.
Inspect for symmetry, it is not unusual if two breasts have slightly
unequal size. Inspect next for edema, erythema, wrinkling, retraction
or dimpling of the skin because it suggest a tumor may be growing in
deeper layer of the breast. Note any nipple discharge. Palpate into
each axilla, no node should be palpated. It’s good to teach self –
breast examination with the teens.
 14. THE LUNGS – assess the rate of respirations whether is relaxed or
stressed. Assessment related to skin tone can affect finding such as
jaundice in a newborn or cyanosis in a child in respiratory distress.
Palpate over the lung area for vibrations that suggest air is having
difficulty moving through small air passages. Percuss lung tissue.
Normal lung sound is resonant in older children and hyperresonant to
infants and younger children.
Diaphragmatic excursions – is an estimation of lung volume. To
establish this, perform the following steps;
 Ask the child to take a deep breath and hold it
 Percuss downward to locate the bottom of the lungs.
 Ask the child to expire fully and momentarily hold that
position.
 Percuss upward to locate the expired or empty lung position.
Auscultate breath sounds by listening through one full cycle at each
ausculatory site with the diaphragm of a stethoscope over each lung lobe
while the child inhales and exhales. Listen both anteriorly and posteriorly;
compare the left side with the right side for equal findings.
BREATH SOUNDS HEARD ON AUSCULTATION
Sound Characteristic
Vesicular Soft, low – pitched sound, heard over periphery of lungs;
inspiration longer than expiration; Normal.
Bronchovesicular Soft, medium – pitched sound, heard over major bronchi;
inspiration equals expiration; Normal.
Bronchial Loud, high – pitched sound, heard over the trachea; expiration
longer than inspiration. Normal.
Rhonchi A snoring sound made by air moving through mucus in
bronchi. Normal.
Rales (crackles) Crackling or crinkling sounds (like cellophane) are created by
air moving through fluid in alveoli. Abnormal
Wheezing Whistling on expiration made by air being pushed through
narrowed bronchi. Abnormal; seen in children with asthma or
foreign body obstruction.
Stridor Crowing or rooster – like sound made by air being pulled
through a constricted larynx. Abnormal; seen in children with
upper respiratory obstruction.
o The Newborn and Infant – infants can’t breathe in and out on
request. Try to listen to breath sounds early in an examination
because breath sounds are difficult to hear clearly over the sound of
crying.

15. THE HEART – heart assessment begins with asking children if they
have ever notice cardiac symptoms as pain. In the children younger
than 7 years old, the apical point is generally laterally to the nipple
line and at the 4th intercostal space. In children older than 4 years old,
it is at the nipple line or just medial to it at the 5th intercostal space.
This point is termed the point of maximum impulse (PMI). Percuss
the left side of the chest to discern the left side of the heart.
Percussing it from the axilla, normally the sound percuss from
resonant to flat midway. A heart located further to the left than this
suggests enlargement.
 HEART SOUNDS

Four Location of Heart Valves

1. Mitral Valve – heard best at the fourth or fifth intercostal space at
the nipple line
2. Tricuspid Valve – heard best near the base of the sternum 4th or 5th
intercostal space
3. Pulmonary Valve – heard best at the 2nd left intercostal space.
4. Aortic Valve – heard best at the 2nd right intercostal space.
The rhythm of the heart sounds should be regular. Ask a child to take
and hold breath, and the rhythm of the heart sound should remain steady.
Heart Sounds Heard On Auscultation
Sound Cause
S1 Closure of tricuspid and mitral valves with beginning of ventricular
contraction (SYSTOLE)
S2 Closure of pulmonary and aortic valves with beginning of atrial
contraction (DIASTOLE)
S3 Rapid ventricular filling

S4 Abnormal filling of ventricles

All unusual heart sounds need further identification and investigation

as to their cause. The skills of listening to and identifying normal and
abnormal heart sounds require considerable practice.
 Heart murmurs - caused by sound of blood flowing with difficulty or in
an abnormal pathway within the heart (swishing sound)
Thrill – palpable vibrations on the chest wall
Heave – feels like a cut purring which denotes a struggling heart.

o The Newborn, Infant, and Toddler – listen to heart sounds in

young children before the child begins to cry. Allow parents to hold
the child while listening to the heart reduces fear.
o The School – Age and Adolescent – be particularly conscientious
with student athletes; abnormal heart finding could be fatal for them
during athletic events. Refer them to primary health care provider for
further evaluation.

16. ABDOMEN – the abdomen is anatomically divided into 4 quadrants.

Auscultate the abdomen for bowel sounds before palpating it because
palpating may alert bowel actions (peristalsis) and disturb bowel
sounds. Next, listen along the middle of abdomen over the aorta of
irregular sounds. A bruit is a swishing or blowing sound occurring if
there is an outpouching of the aorta. Palpate the abdomen in a
systematic way.
o The Newborn and Infant - kidneys may be located by deep
abdominal palpation in newborns and infants. The optimaltime to
palpate the kidneys of newborn is during the first few hours of life,
before the bowel begins. To palpate the kidneys;
 Place a hand under an infant’s back just below the 12th rib
then press upward.
 Place the other hand on that side of the abdomen just
below the umbilicus.
 Press deeply with your upper hand.
 Locate the kidneys, which can be felt as a firm mass
approximately the size of a walnut, between the hands.

o The Preschooler and the School – Age Child - children’s abdomens

at this age are often ticklish, and children may tend to guard their
abdominal muscles when touched. Distract a child by asking question
about home or school or let the child place his or her hands under
your hand to help relax.
17. GENITORECTAL AREA – in both sexes, the rectum should be
inspected for any protruding haemorrhoidal tissue or fissures.
Fissures may signify chronic constipation, intra – abdominal
pressure, or sexual maltreatment.
a. The Female Genitalia – inspection of the external genitalia and
assessment of femoral nodes are included in every complete
health assessment in girls. A pelvic examination is usually
scheduled at the time the girl becomes sexually active, at 21 years
old, or at the first sign of gynecologic disorder.
b. The Male Genitalia – inspection of the male genitalia consists of
observing;
 The distribution and the Tanner stage of pubic hair, which has
a diamond shape
 The penis, for lesions that might suggest STI
 Appearance and placement of the urethral opening, which
should be slit – like and centered at the penis tip.
 The ability to retract the foreskin. Phimosis exists when
foreskin of a child older than 6 – 12 months is too tight to
retract. Hypospadias means urethral opening is located the
inferior or ventral. Epispadias denotes urethral opening on
the superior or dorsal (upper) surface. Inspect the scrotum for
size and the presence of testes.

18. THE EXTREMITIES – observe the upper extremities for good

color and warmth. Inspect fingernails color, contour and shape
because changes in fingernails can be a sign of overall illness.
Clubbed fingers are sign of cyanosis from heart or respiratory
disease. Iron deficiency anemia may cause extremely concave
 surfaces of fingernails. Count the fingers and check for webbing
between fingers. Check also for palmar creases. Check the wrist,
elbow and shoulder joints for movement and for normal range of
motion. Inspect the lower extremities for color and warmth. Check
the ankle, knee and hip joints. Check for developmental hip dysplasia
in infants by attempting to abduct the hips fully. Ask the older child
to walk and observe for ease of gait, limping or any foot
displacement.

19. THE BACK – inspect the back for symmetry and the spinal column
for any deviation. Inspect the base of the spine for dermal sinus or a
tuff of hair or hemangioma that might reveal spina bifida occulta.
Also, inspect for any dimpling that might denote dermal cyst. A
routine assessment of the school – age beginning at 10 years of age
and through adolescence should include screening for scoliosis.
20. NEUROLOGIC FUNCTION – a full neurologic examination takes
at least 20 minutes to complete. It is important to assess for deep
tendon reflex (triceps, biceps, patellar and Achilles reflexes) to test
for motor and sensory function, balance and coordination. Test for
superficial reflexes; abdominal reflexes in both sexes and a
cremasteric reflex in boys. Presence of reflex indicates integrity of
the 10th thoracic nerve and the first lumbar nerve of a spinal cord.
21. MOTOR and SENSORY FUNCTION – test general facial nerve
function y asking the child to make face. The child’s ability to grasp
with the hands and push against surface with the feet establishes
general motor ability. To test the sensory function, ask children to
close their eyes and identify the location where you touch them.

Grading of Deep Tendon Reflex

Grade Interpretation
4+ Hyperactive; extremely marked reaction; Abnormal
3+ Stronger than average but within normal range
2+ Average response
1+ Less than average response but within normal range
0 No response; abnormal
VISION ASSESSMENT
Assessing vision is an important part of a physical assessment because
good vision is so important to childhood development. Any child with
congenital anomalies, low birth weight, or fetal alcohol syndrome is at risk
for eye abnormalities. During an assessment, if you notice an unreported eye
injury or infection or signs of neglected vision, make a special note.
Vision Screening – routine vision screening can begin as early as 6 to
12 months of age.
COMMON VISION SCREENING INDICATORS &
PROCEDURES
Age Common Test
Newborn General appearance
Ability to follow moving objects to midline; focus steadily on
object at 10 – 12 in.
Infant/toddler General appearance
Ability to follow light past midline
3 – school age General appearance
Random dot E for stereopsis (depth perception)
Allen cards or preschool E chart for visual acuity
Ishihara’s plates for color awareness
School age – adult General appearance
Snellen test for visual acuity

Techniques of Vision Testing

Vision is tested by asking a child to read standardized eye chart. All
children need good orientation to such testing so they can appreciate
that this is not test in the usual sense of the word; otherwise they may
be unusually anxious or try to pass it by cheating. It should be started
in the preschool period, so children with amblyopia can be identified
and corrected.
a. SNELLEN CHART – as soon as children can identify letters of the
alphabet, their vision can be tested by use of Snellen eye chart.

b. THE PRESCHOOL E CHART – between 3 years of age and the

age when the children can read alphabet, the can be tested. This chart
is helpful to test children who are cognitively challenged or those
who do not speak fluent English.
c. ALLEN CARDS – consist of pictures of common objects such as a
horse and a rider, a car, a house, and a birthday cake. The cards are
shown to the child at a 15- ft. distance, and the child is asked to
identify pictures.

d. STYCAR CARDS – for this test, a child is given cards with nine
letters; H, C, O, L, U, T, X, V and A. A child holds up a card that
matches the one you point to on a STYCAR chart.

e. TITMUS VISION TESTER – the same instrument used by many

motor vehicle licensing offices. As a child looks into the eyepieces of
the machine, alphabet letters, or preschool Es are projected onto the
screen for the child identity.
 f. VISION COLOR AWARENESS TESTING - the inability to
discern colors is a sex – linked recessive characteristic that occurs in
males rather than females carry the recessive gene for the disorder.
All male children should be screened once during their early school
years. To test the child for color awareness, ask the child to identify
the colored stripes at the top of Snellen chart or show the child a
series of colored diagrams (Ishihara plates). This is important for
identifying and distinguishing color on a traffic light.

Vision Referrals – always screen children twice before referring them to

their primary care provider. Some children do not perform well on eye test
because they are easily distracted or don’t know their alphabet. After second
screening, the following children generally require vision referral;
 Preschool children 3 – 5 years of age who has 20/50 vision or
less in one or both eyes
 Children 6 years up who have 20/40 vision in on or both eyes
 Any child with two – line difference between eyes, as might be
the beginning of amblyopia
 Any child who states or shows other symptoms of visual
difficulty.
 HEARING ASSESSMENT
A thorough health assessment including hearing evaluation should be
included both history and observation, because good hearing is so important
for the development of age – appropriate skills.
Auditory Screening - routine screening for adequate hearing levels is
usually begun at 3 years of age. Testing requires knowledge of the technique,
use of an audiometer, and a quiet, undistracted setting.
o Newborn and Infant – a newborn’s hearing is assessed through
simple response testing – observing whether an infant stirs or
responds to a sound delivered to the child with commercial sound
device. All infant should be screened at birth. Those most apt to be
born with hearing difficulty are those with;
 A history of childhood hearing impairment in the family
 Perinatal infection, such as cytomegalovirus, rubella,
herpes, toxoplasmosis, or syphilis
 Anatomic malformations involving the head or neck
 Birth weight less than 1,500g
 Hyperbilirubinemia at a level exceeding indication for
exchange transfusion
 Bacterial meningitis, especially when caused by
Haemophilus influenza
 Severe birth asphyxia; infants with an Apgar score of 0 to
3, those who failed to breath spontaneously within 10
minutes of birth, or those with hypotonia persisting to 2
hours of age.
o The Older Child – older children who are at risk for hearing loss are
those who have been exposed to loud noises such as explosion or
loud music, were low birth weight, have congenital anomalies, have a
 repaired cleft palate, or have had repeated ear infections. Children
with ear infection like otitis media or allergies should be tested after
the fluid in their ears clears.

Principles of Audiometric Assessment

1. Frequency – is the number of vibrations a sound creates per
second. Normal speech sounds fall into a narrow range of 500 –
2000 Hz; so to function adequately and speak effectively, a child
must be able to hear in this range.
2. Loudness – decibels are an expression of the intensity or
loudness of a sound (vigor of the vibration); 0dB – softest sound
can be heard; 50 -60 dB – normal conversation; 90dB – inner
damage can occur; 140dB – intense and cause pain. Screening
audiometry is done at 25dB.
3. Hearing loss – if the children can hear all frequencies at 25 dB
level, they passed but if a child fails to hear two or more
frequencies at 25 dB, in either or both ears, the child failed and
should be referred to primary care provider or otologist.
Acoustic Impedence Testing – is based on the principle that sound
entering ear canal meets resistance at the tympanic membrane. Also, it is
performed by audiologist.
 LEVELS of HEARING LOSS
Hearing loss (dB level) Hearing Level Present
Slight < 30 dB Inability to hear whispered words or faint speech
No possible speech challenge present
Possible lack of awareness of hearing difficulty
Achievement in school and home is attained by leaning
forward; speaking loudly
Mild 30 – 50 dB Beginning speech challenge may be present
Difficulty hearing if not facing speaker; some difficulty with
hearing normal conversation
Moderate 55–70 dB Speech challenge present, possibly requiring speech therapy
Difficulty hearing normal conversation
Severe 70 – 90 dB Difficulty hearing any but nearby loud voice
Vowels easier to hear than consonants
Speech therapy required for clear speech
Possible ability to still hear loud sounds such as jets or
whistle of train
Profound >90 dB Almost no sound heard

Conducting Hearing Loss Testing

RINNE TEST WEBER TEST
Strike a 500 – Hz tuning fork and hold Strike 500 – Hz tuning fork and hold
the stem of it against the child’s the stem of it against the top of the
mastoid bone. Ask the child to say child’s head. The child with normal
when the tuning fork’s ringing sound hearing in both ears will hear the sound
can no longer be heard. When the child equally well with both ears. If the child
says it is no longer audible, move the has an air conduction loss in one ear,
fork forward so it is at the auditory the child will hear the sound better in
meatus that ear than in the good ear.
 SPEECH ASSESSMENT
Speech problems are directly related to hearing problems. Infants who
don’t hear will make preliminary babbling sounds but then ill develop
intelligible speech because they can’t hear speech sounds to repeat. Speech
difficulties may also related to;
 Motor development, such as when a child does not have enough
control of tongue and facial muscles to be able to form words
properly
 Cognitive development, such as wen a cognitively challenged child
cannot grasp the concept of speech
 Cultural influences, such as when parents speak two languages,
making it difficult for a child to accurately learn and articulate
either language or if parents spoke “baby talk” for so long that the
child mimicked instead of pronouncing words clearly.
Denver Articulation Screening Examination ( DASE)
DASE is designed to detect significant developmental delays as well as
normal variations in the acquisition of speech sounds.
 DEVELOPMENTAL APPRAISAL
It would be ideal if children demonstrated all the developmental skills they
are capable of every time they are asked to demonstrate. Rarely, however, do
they accomplish this. Infants become hungry, sleepy, or upset during testing
while older children become shy. Therefore, a part of information might be
elicited by history taking.
DEVELOPMENTL HISTORIES
1. Denver II Developmental Screening Test – is the most widely used
tool to assess early childhood development, four categories are rated;
a. Personal – social
b. Fine motor – adaptive
c. Language
d. Gross motor skills

This test is also widely used in the Philippines known as the Metro Manila
Development Screening Test (MMDST). Tailored from the Denver II
Developmental Screening Test. It’s administration, scoring, and prescreening
test.
 INTELLIGENCE
Intelligence can be defined as the ability to think abstractly, to adjust to
new situations and to profit from experience. Although intelligence tests are
not part of routine health appraisals, it is helpful to be familiar with those that
are used for childhood measurements because these findings can help
predicts child’s school and future success.
The IQ is the ration of mental age as measured by an intelligence test to a
chronologic age. To determine the IQ
( mental age ÷ chronologic age) x 100
A child aged 9 years old (chronologic age) who passes all the items on an
intelligence test that an average 9 – year – old child is expected to pass
would be: (9 (mental age) ÷ 9 (chronologic age) X 100 = 100 ( child’s IQ)
Goodenough – Harris Drawing Test – is a quick intelligence
measurement that can be administered without special training to children 3
– 10 years of age. A child is given a pencil and paper and instruct he child to
draw a person. Urge the child to draw carefully and take enough time to do it
well. The child receives 1 point for each of the items listed in a box that are
demonstrated in the drawing. For each 4 points scored, 1 year is added to be
a base age of 3 years to calculate the child’s mental age.
For example – drawn by a 4.5 – year – old; it received 8 points. The
child’s IQ level is therefore;
( 5.0 (mental age) ÷ 4.5 (chronologic age)) x 100 = 111
IMMUNIZATIONS
To verify the children immunization status is considered to be one of the
most important health assessment and promotion measures. Teach the
parents about the importance of having their child immunized and help them
understand that although disease such as measles and mumps are referred as
common childhood illnesses, those are potentially serious and could possibly
lead to complications such as pneumonia and encephalitis.

TYPES of IMMUNIZATIONS
Vaccines are the solution to immunize children in order to provide
artificially acquired active or passive immunity and are prepared in number
of forms. Attenuated vaccines are made from live organisms reduced in
virulence to a point where they will not cause active disease but will ensure a
good antibody response. The antibodies produced against toxin – producing
bacteria such as diphtheria are called antitoxins. Gamma globulin is a
serum obtained from the pooled blood of many people because it combines
the serum of many people and so it probably has antibody protection against
measles
CHILDHOOD IMMUNIZATIONS

1. The Diphtheria, Tetanus, and Pertussis Vaccine (DPT) – vaccines

are supplied in a single vial and given 0.5 ml intramuscularly injection
at upper outer portion of the thigh. It is recommended that children
receive primary series of four immunizations with the vaccine (at 2, 4, 6
and 15 – 18 months of age). A booster is then given between 4 and 6
years old against whooping cough and severe pertussis. Side effects
include drowsiness, fretfulness, low – grade fever, and redness and pain
at the injection site.
2. The Polio Vaccine – inactivated polio vaccine (IPV) contains all the
three strains of poliovirus and is the preferred type for routine
immunization. Given orally 2 – 3 drops orally.
3. The Measles, Mumps, and Rubella Vaccine (MMR) – vaccine is
furnished in one injection and routinely administered between 12 and 15
months of age. A second dose is given by the age of 4 and 6 years then
on 11 -12 years old when not given the second dose. Side effects
include rash and fever
4. The Hepatitis B Vaccine (HBV) – a vaccine for blood – borne hepatitis
B virus, 3 doses, and recommended to all infants because hepatitis B is
associated with liver cancer in later life. HBV immunization is
recommended for population at increased risk for contracting hepatitis
B infection including the healthcare providers, patients receiving
hemodialysis, those who take illicit drugs and sexually active
individuals with multiple sexual partners.
5. The Hepatitis A Vaccine – two doses of hepatitis A vaccine,
administered 6 months apart, are recommended for all children 1 and 2
years of age.
6. The Rotavirus Vaccine – rotaviruses are responsible for the majority of
severe gastrointestinal disease in infants like diarrhea. Given 2, 4, and 6
months of age and no doses should be given after children reach 32
weeks of age.

7. Haemophilus Influenza Type B Vaccine (Hib) – Haemophilus

influenza type B vaccine protects against H. influenza bacteria, a major
cause of meningitis in children. Two – doses or three – doses regimen
with additional booster at 12 months of age. Local reactions include
tenderness at the injection site and reactions such as crying and fever.
8. The Varicella Vaccine – (chickenpox) vaccine is given usually 12 to
18 months and during 4 to 6 years old.
9. The Pneumococcal Pneumonia Vaccine – is recommended for all
children between 2 and 23 months of age. It is recommended for
children and adults who would be prone to a pneumococcal infection
(those with pulmonary or cardiac disease, with spleen and who are
immunosuppressed).
10. The Human Papillomavirus Vaccine (HPV) – human papillomavirus
is associated with the development of cervical cancer in women. It is
recommended that all preteens (males and females) receive 3 injections
beginning at 11 to 12 years of age. The second dose be administered
after first dose and then, third dose will be given 6 months after.
11. The Meningococcal Vaccine - children who have immunologic
deficiencies or have had their spleen removed or those receiving therapy
for blood dyscrasia are prone to develop meningitis caused by
meningococcal bacteria. Administer a single dose at age 11 – 12 years
of age with booster at 16 years of age.
12. The Lyme Disease Vaccine – lyme disease is a serious debilitating
 infection caused by Borrelia burgdorferi and transmitted by a deer tick.
13. The Influenza Vaccine – influenza is caused by A, B, or C
retroviruses. All children – infants 6 months of age through adolescents
should receive a yearly injection of the vaccine.
14. The Anthrax and Smallpox Vaccine – anthrax is potentially fatal
disease caused by gram – positive, spore – forming Bacillus anthracis
and spread through farm animal feces while smallpox is an extremely
infectious disease caused by smallpox virus and transmitted by indirect
and direct contact. Both vaccine (active artificial immunity) and passive
artificial immunity are available should a child be exposed to the virus.
ADMINISTRATION of IMMUNIZATION
CHILDREN with UNIQUE NEEDS – children with chronic illnesses may
be hospitalized and couldn’t able to be immunized at the scheduled time so
the primary care providers should be the one to alter the sequence of their
immunization.

PARENTAL EDUCATION – parents should be fully informed about

immunization and the benefits as well as its side effects so that they will not
worry about it. They should be reminded that there are doses to be completed
and followed for the potency and effectiveness of the vaccine. When giving a
vaccine, record the time, date and dose administered and make sure give a
copy for the follow –up doses.
REFLECTION

In various setting, nurses perform physical assessments of infants and

children like in the hospital, in the clinic, in the school premise or even at
home. The ability to perform physical assessment or examination is
fundamental to nursing care of the child. It allows health care providers in
determination of the child’s health status that provides appropriate health
education and makes judgment about the need for nursing care. Parents and
primary caregivers should be involved as much as possible, and the child
should be encouraged to handle and play with instruments that are safe and
clean, such as stethoscope to put them at ease. Also, throughout examination,
the nurse should be sensitive to the cultural needs and of differences among
children. Establishing rapport between the child’s parent or the child itself
should be of number one consideration to eliminate fear, doubt and gain trust.
The nurse should provide a quiet, private environment for the history and
physical examination for them to get accurate results. Effective
communication and therapeutic skills of the nurses are important. Moreover,
the nurse should obtain and acquire good and appropriate strategies dealing
with infants through adolescents because they vary depending on their
developmental levels. Assessment should be individualized based on the child
needs. Health education should be incorporated like discussing the importance
of immunizations and counselling parents when the have a physically and
cognitively challenged children. Physical assessment is comprehensive so the
nurse should master all the skills by practicing it well while assessing his
techniques on performing physical exams. Lastly, physical assessment is the
most crucial and significant stage in the nursing process for it serves as a
baseline for nursing care plan. It should be comprehensive and accurate.
CONCLUSION

As future nurses, one should be knowledgeable and skillful enough to

carry over the nursing process which deals with infancy through adolescence
period. Care should be individualized depending on the child’s pace and
health needs. Special considerations to those cognitively and physically
challenged children should be at all times be given a specific approach. Non-
judgmental listening encourages open and honest communication because
communication in the pediatric setting is a dynamic process. That’s why from
the very beginning of the assessment the nurse should build a rapport towards
his clients to gain trust and to put them at ease. An effective communication
skill is the key to fabricate a factual and accurate history taking and it is
usually done during the interview. Also, quality communication skills take
time to develop as a practitioner, especially in the pediatric setting where there
are many special considerations. Being knowledgeable about pediatric-
specific communication techniques and developmental stages considerations
paved way to successful communication encounters with children and their
families. The nurse should be aware and recognize family dynamics while
encouraging parent involvement and always including the child in the health
care encounter are essential. Moreover, having an understanding of these basic
elements and regularly using them in practice are keys to
successful communication in the pediatric setting.

All the knowledge and information that I have furnished in the

chapters being covered in this portfolio have given me enlightenment and
ideas on handling my future clients in the pediatric section.
REFERENCE

Pillitteri Adele, S. F. (2018). Maternal & Child Health Nursing 8th Edition. Wolters
Kluwer.