Week 4 Lecture

PRESCHOOL CHILD (3-5 YEAR OLD)

Biologic Development
- Physical growth rate slows and stabilizes during preschool years
- Physical proportions change
- Slender but sturdy
- Graceful, agile
- Posture erect (tone in rectus, less barrel)
- Males and females similar in size and proportion

Behavior
Gross motor
By 36 months
- Walking, running, climbing, jumping
By age 4 years
- Skips and hops on one foot
- Catches ball
By age 5 years
- Skips on alternate feet, jumps rope, learns to skate and swim
Fine motor
Placement stage (age 15 months)
Shape stage (by age 3 years)
Design stage
Combine
Aggregate
Pictorial stage (4-5 years)

Psychosocial Development
- Erikson: Initiative vs. Guilt
- Initiative: Stage of energetic learning in which they play, work, and live to the
fullest and feel a real sense of accomplishment and satisfaction in their activities
- Guilt: Overstepping the limits of their ability and inquiry and experience guilt,
anxiety and fear from thoughts that differ from expected behavior
 - Erikson: Initiative vs. Guilt
- Initiative: Stage of energetic learning in which they play, work, and live to the
fullest and feel a real sense of accomplishment and satisfaction in their activities
- Guilt: Overstepping the limits of their ability and inquiry and experience guilt,
anxiety and fear from thoughts that differ from expected behavior
- Superego (conscience) starts near the end of the toddler years and is a major task
for preschoolers
- Learning right or wrong, good from bad is the beginning of learning morality
- Unable to understand why but are aware of appropriate behavior primarily
through punishment or reward and rely on parental principles to develop their
own moral judgement
- Oedipal Stage (Freud)
- Learn sex differences, sexual modesty
- Relate to same sex parents & others of same sex

Cognitive Development
Piaget Preoperational
- Progresses from preconceptual to intuitive
- Preconceptual: age 2-4, intuitive thought: age 4-7
- The shift is from egocentric thought to social awareness and the ability to conside
other points of view
- Able to think and verbalize their mental processes without acting them out but ca
only think of one idea at a time and can't think of all the parts in terms of whole
- Speech continues to remain primarily a vehicle of egocentric communication
- Preschoolers assume that everyone thinks as they do and a brief explanation of
their thinking makes them understood by others. Therefore, it is often necessary
to explore and understand young children's thinking through other nonverbal
approaches. The most effective and enlightening way is play
- All types of play hold therapeutic and communicative value
- Use language without understanding the meaning of words
- May use concepts correctly but only in situations where they have learned them
(eg. Shoe buckle goes on outside)
- Causality resembles logical thought
- Explain a concept as they have heard it described by others
- Time understanding is limited, thus avoid using yesterday, tomorrow. Instead
relate it to an event such as until Christmas or after lunch
- Magical thinking - thoughts are all powerful and they may feel responsible if a bad
thought coincides with a bad occurrence or a wished event (eg sibling death)

Development of Sexuality
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 relate it to an event such as until Christmas or after lunch
- Magical thinking - thoughts are all powerful and they may feel responsible if a bad
thought coincides with a bad occurrence or a wished event (eg sibling death)

Development of Sexuality
- Important to a person's overall sexual identity and beliefs
- Form strong attachments to the opposite sex parents while identifying with the
same sex parent
- "sex typing" process by which an individual develops the behavior, personality,
attitudes, and beliefs appropriate for his or her culture and sex

Social Development
- Have overcome much anxiety associated with fear of strangers and separation
- Relate to unfamiliar people easily and tolerate brief separations from their parent
- Respond well to anticipatory preparation and concrete explanation
- Able to work through their fears and anxieties through play especially if guided
with appropriate play objects

Growth & Development

- Taller & thinner
- Permanent molars
- Better balance, coordination
- Early writing skills, use scissors
- Dress self, brush teeth
- Increased ability to express ideas; vocabulary
- Role play, imitation
- Blurring of reality & make-believe

Health Promotion

Nutrition
- Caloric needs: 1200-1400 calories
- Challenges are allergies, food intolerances, "picky eater", junk food, childhood
obesity

Dental Care
- Primary teeth all erupted
- Start brushing own teeth with help & supervision

Body Image
- Recognize desirable vs undesirable appearances
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Dental Care
- Primary teeth all erupted
- Start brushing own teeth with help & supervision

Body Image
- Recognize desirable vs undesirable appearances
- Recognition of differences (skin colour, race, size, etc)
- Aware of the meaning of words such as pretty or ugly and reflect the opinions of
others regarding their appearance
- By 5 they compare themselves to their peers
- Parents should encourage positive principles regarding body image
- Poorly defined body boundaries and little knowledge about body and internal
anatomy
- Intrusive experiences are frightening (injections, surgery) and may believe it is
crucial to use bandaids after an injury
- Development of sexual identity
- Sexual curiosity & exploration
- Sexual modesty, fears of injury
- Role imitation & socialization

Sex Education
Two rules govern answering sensitive questions about topics:
1. Find out what they know and think
2. Be honest. They may not understand or forget correct information but correct
information can be restated until the child absorbs and understands the facts

Preparing for School

- Preschool is particularly beneficial for children who lack a peer-group experience,
such as an only child, and for children from impoverished homeness
- It provides stimulation for language, physical and social development
- It also is an excellent preparation for kindergarten
- Familiarize child with school site
- Provide experiences with other children
- Practice social skills
- Expose child to school materials
- Read books about going to school
- Create a regular routine at home
- Practice buttons & shoe tying
- Help child recognize own name
- Remember: each child approaches new experiences differently
,
 - Read books about going to school
- Create a regular routine at home
- Practice buttons & shoe tying
- Help child recognize own name
- Remember: each child approaches new experiences differently

Aggression
- This is behavior that attempts to hurt a person or destroy property
- Boys exhibit more physical aggression during preschool years whereas girls exhibi
more relational aggression than girls during preschool years
- Complex set of factors include modeling frustration and reinforcement
- Modeling is imitating a significant other's behavior. A child who sees physically
abusive behavior in their parents or other may come to believe that this is
acceptable and therefore may exhibit this behaviors with others
- Another significant source for modeling is media exposure. Numerous studies hav
found a positive correlation between viewing violent programs and developing
aggression
- Reinforcement can also shape aggressive behavior and is closely associated with
modeling "masculine" behavior
- Frustration, by parental disapproval, humiliation, punishment and insults can lead
children to act out against others
- Regarding violent media, parents need to supervise programming especially with
children who have aggressive tendencies
- Additionally, parents who permit aggressive behavior by not interfering,
communicate silent and implicit approval of these acts
- Parents can help children by modeling appropriate behavior and encouraging
children to express themselves verbally
- Children should not be made to feel guilty or ashamed for being angry or
frustrated
- When they recognize these feelings, they are better able to channel them into
constructive, not destructive outlets
- If a child is having a tantrum, the parents can handle them constructively by not
attending to or reinforcing them and by helping children to find control through
appropriate play situations

Sleep
- Average 12 hours of sleep; may still nap
- Bedtime fears, nightmares, sleep terrors
- Bedtime rituals promote sleep - eg. Bathtime, story reading

Play and Exercise

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 - Average 12 hours of sleep; may still nap
- Bedtime fears, nightmares, sleep terrors
- Bedtime rituals promote sleep - eg. Bathtime, story reading

Play and Exercise

- Associative play; children are playing the same game, but they are not working
together or connecting with one another
- Imaginative and imitative play
- Imaginary playmates
- Encourage motor development, communication, socialization, mental
development

Farm Safety
Causes
- Machinery & vehicles
- Drowning, suffocation
- Recreational vehicles
- Livestock
- Fire
- Farm chemicals
- Noise
Issues
- Lack of supervision
- Allowing children near machinery
- Inappropriate work for age
Most injuries from May-Oct
More males than females
Most were children of the family
1. Provide appropriate supervision
2. Encourage children to get help if problem
3. Fence off dangerous areas
4. Safe play area
5. Identify and eliminate hazards
6. Practice no-riders policy

Child Maltreatment
Types:
- Physical abuse
- Sexual abuse (increase significantly in past decade)
- Neglect (most common)
Child Maltreatment
Types:
- Physical abuse
- Sexual abuse (increase significantly in past decade)
- Neglect (most common)
- Emotional abuse
- Exposure to family violence

Predisposing Factors
- Young parent (not interested in taking care of child)
- Single parent
- Social isolation
- Substance abusers
- Low self-esteem
- Parenting skill knowledge deficit

Extent of Child Abuse

No reliable statistics
- Under-recognized
- Underreported
- Only serious cases get reported/investigated
More girls abused than boys
More abuse committed by males than females

Signs of Maltreatment
Neglect
- Poor hygiene, unsuitable clothing, malnutrition
- Lack of health care
- Absenteeism from school
Physical Abuse
- Bruises, burns, injuries not consistent with history
- New & old fractures in various stages of healing
- Fear of parents
Emotional abuse
- Eating/feeding disorder
- Sleep disorder
- Fearfulness, withdrawal
Sexual abuse
- Bruises, bleeding from genitalia
- Pregnancy at young age
Signs of Maltreatment
Neglect
- Poor hygiene, unsuitable clothing, malnutrition
- Lack of health care
- Absenteeism from school
Physical Abuse
- Bruises, burns, injuries not consistent with history
- New & old fractures in various stages of healing
- Fear of parents
Emotional abuse
- Eating/feeding disorder
- Sleep disorder
- Fearfulness, withdrawal
Sexual abuse
- Bruises, bleeding from genitalia
- Pregnancy at young age
- Sexually provocative behavior in young child
- Running away from home

Nursing Interventions
Prevention
- Risk assessment
Protection of child is priority
- Obligation to report
- Careful documentation
Support to child
- Therapeutic relationship
- Help child adjust to changes
Support to family
- Teaching re: normal child behavior
- Help families identify sources of support

Childhood Communicable Diseases

Infection Control Concepts
Standard Precautions
- Barrier protection from blood and body fluids
- Respiratory hygiene/cough etiquette
- Safe injection practices
- Hand hygiene
Transmission-Based Precautions
Standard Precautions
- Barrier protection from blood and body fluids
- Respiratory hygiene/cough etiquette
- Safe injection practices
- Hand hygiene
Transmission-Based Precautions
- Airborne
- Small particle or evaporated droplets or dust (ex viruses)
- Negative pressure isolation room
- Droplet
- Large-particle droplets (sneeze, cough, speech, cry)
- Negative pressure isolation room not needed
- Contact
- Exercise judgement with gloves, gowns, masks

Endemic
- A disease or condition regularly found among particular people or in a
certain area (ex; common cold)
Epidemic
- A widespread occurrence of an infectious disease in a community at a
particular time (ex; influenza)
Pandemic
- A disease prevalent over a whole country or the world
Immunity
- Natural (born with it) vs. acquired (get it from outside source)
- Active (immunizations or had it) vs. passive (mother to fetus through
placenta)
Herd immunity

Immune System
- When bacteria or viruses, invade the body, they attack and multiply. This
invasion is called an infection, and the infection is what causes illness
- The immune system uses several tools to fight infection. Blood contains
white blood cells, for fighting infection
- These white cells consist primarily of macrophages, B-lymphocytes, and
T-lymphocytes
- Macrophages are white blood cells that swallow up and digest viruses or
bacteria, plus dead or dying cells. The macrophages leave behind parts of
the invading bacteria or virus called antigens
- The body identifies antigens as dangerous and stimulates the antibodies
to attack the antigens left behind by the macrophages
 T-lymphocytes
- Macrophages are white blood cells that swallow up and digest viruses or
bacteria, plus dead or dying cells. The macrophages leave behind parts of
the invading bacteria or virus called antigens
- The body identifies antigens as dangerous and stimulates the antibodies
to attack the antigens left behind by the macrophages
- Antibodies are produced by defensive white blood cells called B-
lymphocytes
- T-lymphocytes are another type of defensive white blood cell. They
attack cells in the body that have already been infected
- The body keeps a few T-lymphocytes, called memory cells that go into
action quickly if the body encounters the same antigen again. When the
familiar antigens are detected, B-lymphocytes produce antibodies to
attack them
- The first time the body encounters an antigen, it can take several days to
make and use all the antigen-fighting tools needed to get over the
infection. After the infection, the immune system remembers what is
learned about how to protect the body against that disease

Immunizations
- Vaccines help develop immunity by imitating an infection
- This type of infection, however, does not cause illness, but it does cause
the immune system to produce T-lymphocytes and antibodies
- Sometimes, after getting a vaccine, the imitation infection can cause
minor symptoms, such as fever. Such minor symptoms are normal and
should be expected as the body builds immunity
- Once the imitation infection goes away, the body is left with a supply of
"memory" T-lymphocytes, as well as B-lymphocytes that will remember
how to fight that disease in the future
- It typically takes a few weeks for the body to produce T and B-
lymphocytes after vaccination. Therefore, it is possible that a person who
was infected with a disease just before or just after vaccination could
develop symptoms and get a disease, because the vaccine has not had
enough time to provide protection

Nurse's Role
- Be familiar with the schedule (annually updated)
- Be prepared for adverse reactions
- Be aware of contraindications and precautions
- Ensure parental consent prior to administration
- Provide safe administration
 - Be familiar with the schedule (annually updated)
- Be prepared for adverse reactions
- Be aware of contraindications and precautions
- Ensure parental consent prior to administration
- Provide safe administration
- Provide vaccine information and anticipatory guidance to parents and
caregivers

Communicable Diseases
- Incidence has declined with routine immunization
- Some periodic outbreaks have occurred recently
Incidence has declined with vaccine use
Nurse's role:
- Familiarity with infectious agents
- Recognize potential disease during history and exam
- Institute appropriate preventive and supportive measures (isolation)

The Anti-Vax Movement

Anti-vaccination parents:
- Believe their children are not at risk for disease such as polio, measles
and tetanus
- Believe diseases, such as chicken pox and measles, are not serious
- Worry about the safety of vaccines
- Do not think their personal decision affects others
Research shows that giving facts alone will not change their minds
Health professionals need to advocate for laws and public health measures to
support vaccination

Suspect Communicable Disease?

Obtain careful history:
- Known exposure?
- Community exposure?
- Prodromal symptoms
- Fever
- Rash
- Early clinical
- Immunization
- History of having disease
- History of comorbidity/risk factors
 - Early clinical
- Immunization
- History of having disease
- History of comorbidity/risk factors

Chicken Pox (Varicella)

Agent
- Varicella-zoster virus
Transmission
- Direct contact and respiratory secretions
Clinical manifestations
- Prodromal stage - slight fever, malaise
- Pruritic rash begins a macule -> vesicle then erupts
- Rash is typically centripetal -> extremities, face
- Treatment: supportive
Precautions
- Standard/airborne
- Child is contagious a day before rash appears and until vesicles are
crusted
Prevention
- Secondary skin infection and complication
Complications
- Scarring, encephalitis, pneumonia, shingles in later life
Therapeutic Management
- Antivirals (acyclovir)
- Supportive measures
- IGIV for high-risk children if exposed
Nursing Considerations
- Standard and airborne isolation in hospital
- Keep child in home until vesicles have dried
- Keep child cool
- Prevent scratching

Measles (Rubeola)
Agent
- Rubeola virus
- Incubation: 10-20 days
Transmission
- Via cough or sneeze from an infected person
- Patients are contagious 4 days before - 5 days after rash appears
 - Rubeola virus
- Incubation: 10-20 days
Transmission
- Via cough or sneeze from an infected person
- Patients are contagious 4 days before - 5 days after rash appears
Clinical Manifestations
- Prodromal state: fever, malaise -> coryza (runny nose), cough,
conjunctivitis
- "Koplick Spots" on mucosa
- Rash appears on day 3-4 of illness
Precautions
- Airborne if in hospital until day 5 of rash
Complications
- Pneumonia, encephalitis
Therapeutic Management
- Vitamin A supplement
- Fever management
- Eye care
- Cough
- Skin care

Rubella (German Measles)

- Incubation: 14-21 days
Transmission
- 7 days before
- 5 days after rash appears
Clinical Manifestations
- Fever, malaise, headache, sore throat, rash
Complications
- Rare, teratogenic effect on fetus

Pertussis ("Whooping Cough")

Transmission
- Contact, droplet
- During catarrhal stage (excessive discharge or buildup of mucus in the
nose or throat, associated with inflammation of the mucous membrane)
Incubation Period:
- 7-10 days
Clinical Manifestations
- Catarrhal Stage: sneezing, cough, fever
 nose or throat, associated with inflammation of the mucous membrane)
Incubation Period:
- 7-10 days
Clinical Manifestations
- Catarrhal Stage: sneezing, cough, fever
- Paroxysmal Stage: "whooping" and vomiting with cough
Complications
- Pneumonia, atelectasis
- Seizures
Therapeutic Management
- Antibiotic; erythromycin, azithromycin
Nursing Considerations
- Respiratory (contact/droplet) isolation
- Bedrest while febrile
- Offer fluids frequently
- Re-feed after vomiting
- Suction as needed
- Monitor for obstruction

Scarlet Fever
Group A Beta-hemolytic streptococci
Incubation
- 2-5 days
Transmission
- Contact, droplet
Communicability
- During incubation period and clinical illness it is approximately 10 days
during incubation & illness
Clinical manifestations
- High fever, vomiting, headache, chills, malaise, halitosis
- Swollen, sore tongue, mouth
- Extensive rash
Complications
- Throat abscess
- Acute glomerulonephritis
- Rheumatic fever
Treatment
- Full course of penicillin (or erythromycin)
Nursing Management
- Fluids, rest
- Infection control
 - Rheumatic fever
Treatment
- Full course of penicillin (or erythromycin)
Nursing Management
- Fluids, rest
- Infection control
- Encourage full course of treatment with antibiotics

Zoonotic Diseases
- A disease normally occurring in animals that can be transmitted to
humans
- Transmission is animal/insect to human, not human-human (Zika)
- Ex; Lyme disease, Zika virus disease

Lyme Disease
- Tick-borne disease, usually deer tick
- Spirochete
Three stages of disease
1. 3-30 days; localized "bulls-eye" rash
2. 3-10 weeks; early disseminated disease
3. 2-12 months; chronic disseminated stage
Diagnosis
- Based on clinical signs
- ELISA or an IFA test, followed by Western immunoblot (WB) test to
confirm
Treatment
- Antibiotic for 14-21 days
Prevention/Awareness
- Avoid tick-infested areas
- Cover exposed skin areas
- Insect repellant (DEET)
- Regular tick checks, if in risk area
- Safe tick removal

Zika Virus Disease

- Spread by bite from infected Aedes species mosquito & can be sexually
transmitted by infected person
- Outbreaks currently affecting Mexico, Central and South America, and
United States
- Incubation: 2-7 days
- Mild symptoms: fever, rash, joint pain, conjunctivitis