DEVELOPMENTAL THEORIES.
CONCEPTION THROUGH ADOLESCENCE
FUNDAMENTAL CONCEPTS OF GROWTH AND DEVELOPMENT
Development occurs continuously through the life span. Adults continue to have transition periods during which growth and development occur.
Growth is the quantitative (measurable) changes in physical size of the body and its parts, such as increases in cells, tissues, structures, and systems. Examples of growth are physical changes in height, weight, bone density, and dental structure. Even though growth is not a steady process through the life cycle, growth patterns can be predicted. Variations in growth, such as rapid increases contrasted with slower rates of physical change, occur with each individual. Rapid growth is most common in the prenatal, infant, and adolescent stages.
Development refers to behavioral changes in functional abilities and skills. Thus, developmental changes are qualitative, that is, not easily measured.
Maturation is the process of becoming fully grown and developed and involves physiological and behavioral aspects of an individual. Maturation depends on biological growth, functional changes, and learning (assimilation of information with a resultant change in behavior). During each developmental stage of the life cycle, certain goals (developmental tasks) must be achieved. These developmental tasks set the stage for future learning and adaption.
The critical period is the time of the most rapid growth or development in a particular stage of the life cycle. During these critical periods, an individual is most vulnerable to stressors of any type. Growth, development, maturation, and learning are interdependent processes. For learning to occur, the individual must be mature enough to grasp the concepts and make required behavioral changes. Cognitive maturation precedes learning. Physical growth is also a prerequisite for many types of learning; for example, a child must have the physical ability to control the anal sphincter before toilet training skills are learned.
Principles of Growth and Development
All persons have individual talents and abilities that contribute to their development as unique entities. There are no absolute rules in predicting the exact rate of development for an individual. However, some general principles relate to the growth and development of all humans (Table 17-1).
The sequence of development is predictable even though the emergence of specific skills varies with each person. For example, not all infants roll over at the same age, but most roll over before they crawl.
Factors Influencing Growth and Development
Multiple factors such as heredity, life experiences, health status, and cultural expectations influence a person’s growth and development. The interaction of these factors greatly influences how an individual responds to everyday situations; the choices a person makes regarding health behaviors are also greatly determined by these factors.
Heredity A complex series of processes transmits genetic information from parents to children. The genetic composition of an individual determines physical characteristics such as skin color, hair texture, facial features, body structure, as well as a predisposition to certain diseases (i.e., Tay-Sachs, sickle cell anemia). Heredity is a genetic blueprint from which an individual grows and develops; it determines to a great extent the rate of physical and mental development.
Life Experiences A person’s experiences can also influence the rate of growth and development. For example, contrast the differences in physical growth rates between a child whose family can afford food, shelter, and health care and a child whose family has little, if any, resources. The child who is poor has a higher risk of experiencing physical and mental lags in growth and development. Another example of the influence of life experiences, is an elderly person who is enjoying retirement, has an adequate income, and an active support system. If this individual had an impairment in any of these variables, psychological development would likely be affected in a negative way.
Health Status Individuals experiencing wellness are progressing normally along the life cycle. However, illness or disability can interfere with the achievement of developmental milestones. Individuals with chronic conditions will often meet developmental milestones but with a time delay.
Cultural Expectations Society expects people to master certain skills in each developmental period. The age at which an individual masters a particular task is determined in part by culture. For example, the time for mastery of toilet training is greatly influenced by cultural norms. The following are examples of how societal expectations can either promote or hinder one’s growth and development:
• A child who grows up in an economically deprived home may receive inadequate food, shelter, emotional nurturing, or intellectual stimulation with resultant impairments in physical, psychosocial, and cognitive development.
• A woman may not be expected to fully use her intellectual abilities, thus she has altered cognitive development.
• A man may be discouraged from showing tenderness and nurturing behaviors; such discouragement results in dysfunctional psychosocial development.
THEORETICAL PERSPECTIVES OF HUMAN DEVELOPMENT
Nurses must have a thorough understanding of human growth and development in order to provide individualized care. Remember that chronological age and developmental age are not synonymous. An overview of the major developmental theories is presented below. These theories are discussed more fully in the specific sections about each developmental period.
Physiological Dimension
Physiological growth (physical size and functioning) of an individual is influenced primarily by interaction of genetic predisposition, the central nervous system (CNS), the endocrine system, and maturation. The role of heredity in human development is complex and not yet fully understood. Genetics is the foundation for achievement of specific tasks. Factors such as the psychosocial environment and health status help individuals live up to their genetic potential.
Psychosocial Dimension
The psychosocial dimension of growth and development consists of subjective feelings and interpersonal relationships. A favorable self-concept (view of one’s self, including body image, self-esteem, and ideal self) is likely the most important key to a person’s success and happiness. Following are characteristics of an individual with a positive self-concept:
• Self-confidence
• Willingness to take risks
• Ability to receive criticism without defensiveness
• Ability to adapt effectively to stressors
• Innovative problem-solving skills
People with a healthy self-concept believe in themselves; as a result, they set goals that can be achieved. The goal achievement reinforces the positive belief about one’s self. Figure 17-1 illustrates this positive cycle of self-fulfilling beliefs and actions.
Intrapsychic Theory
Intrapsychic theory (also called psychodynamic) focuses on an individual’s unconscious processes. Feelings, needs, conflicts, and drives are considered to be motivators of behavior, learning, and development. Sigmund Freud and Erik Erikson are two major intrapsychic theorists. Freud’s theories, developed in the early 1930s, continue to influence current concepts related to human development. A basic belief of the Freudian model is that all behavior has some meaning. According to Freud (1961), to mature, a person must successfully travel through five stages of development (Table 17-2).
In each stage, there is a task to be mastered; if the task is not achieved, the individual is halted (develops a fixation) at this stage. A fixation is characterized as either inadequate mastery or failure to achieve a developmental task. A fixation in earlier stages inhibits healthy progression through subsequent stages. Erikson (1968) expanded Freud’s concept of developmental stages by theorizing that psychosocial development is a lifelong process that does not end with the cessation of adolescence. Just as physical growth patterns can be predicted, certain psychosocial tasks must be mastered in each developmental stage. Erikson’s model proposes that psychosocial development is a series of conflicts that can have favorable or unfavorable outcomes. These conflicts occur in eight developmental stages of life that are described in Table 17-3.
Havighurst (1972) theorized that there are six developmental stages of life, each with essential tasks to be achieved. Mastery of a task in one developmental stage is essential for mastery of tasks in subsequent stages. When a task in one stage is mastered, it is learned for life, independent of subsequent neurological change (which may occur with disease or injury). Table 17-4 presents Havighurst’s developmental stages with the associated tasks.
Levinson (1978) studied men to determine developmental phases of young and middle adulthood.
As a result of Levinson’s research, five “seasons” or “eras” (phases) were identified (see the accompanying display). The midlife transition, which begins at approximately age 40, includes examining and structuring one’s life to one’s own satisfaction (Edelman & Mandle, 1997).
Interpersonal Theory Harry Stack Sullivan theorized that relationships with others influence how one’s personality develops. Approval and disapproval from significant others shape the formation of one’s personality. To form satisfying relationships with others, an individual must complete six stages of development, which are shown in Table 17-5.
Cognitive Dimension
The cognitive dimension is characterized by the intellectual process of knowing, which includes perception, memory, and judgment, and develops as an individual progresses through the life span. Intelligence is an adaptive process. Individuals use intelligence to adapt by changing the environment to meet their needs and by altering their responses to environmental stressors. The ability to change behavior in response to the demands of an ever-changing environment is characteristic of intelligent beings. Jean Piaget (1963) studied the differences between children’s thinking patterns at different ages and how intelligence is used to solve problems and answer questions. He theorized that children learn to think by playing. Four factors are catalysts to intellectual development: 1. Maturation of the endocrine and nervous systems 2. Action-centered experience that leads to discovery (“learning by doing”) 3. Social interaction with opportunities for receiving feedback
Each phase is characterized by the ways in which the child interprets and uses the environment. Approximate ages are indicated for each phase, but there is great variation among individuals. The individual learns by interacting with the environment through three processes: assimilation, accommoda– tion, and adaptation.
Assimilation is the process of taking iew experiences or information.
Accommodation allows for readjustment of the cognitive structure (mindset) to take in the new information; thus, understanding is increased.
Adaptation refers to the changes that occur as a result of assimilation and accommodation (Murray & Zentner, 1997).
Moral Dimension The moral dimension consists of a person’s value system that helps in differentiating right and wrong.
Moral maturity (the ability to independently decide for oneself what is “right”) is closely related to emotional and cognitive development. Lawrence Kohlberg (1977) estab– lished a framework for understanding how individuals determine a moral code to guide their behavior. Kohlberg’s model states that a person’s ability to make moral judgments and behave in a morally correct manner develops over a period of time. There are six stages of moral development. Each stage is built on the previous stage and becomes the foundation for successive stages. Moral development progresses in relationship to cognitive development. Individuals who are able to think at higher levels have the necessary reasoning skills on which to base moral decisions. Table 17-7 provides an overview of Kohlberg’s stages of moral development.
Kohlberg stated that individuals move through the six stages in a sequential fashion; however, not everyone reaches stages 5 and
Spiritual Dimension The spiritual dimension is characterized by a sense of personal meaning.
Spirituality refers to relationships with one’s self, with others, and with a higher power or divine source. Spirituality does not refer to a specific religious affiliation; rather, it can be defined as the core of a person. Development of spirituality is an ongoing, lifelong process. Fowler’s theory of spiritual development was influenced by the works of Erikson, Piaget, and Kohlberg. Fowler’s theory is composed of a pre-stage and six distinct stages of faith development (Fowler, 1981). Even though individuals will vary in the age at which they experience each stage, the sequence of stages remains the same. Table 17-9 describes Fowler’s theory.
HOLISTIC FRAMEWORK FOR NURSING
Providing care to the whole person is a basic concept of professional nurses. Knowledge of growth and development concepts are essential for nurses because nursing interventions must be appropriate to each client’s developmental stage. Nursing’s holistic perspective recognizes the progression of individual development across the life span. Developmental progress, or lack of progress, in one aspect affects all other dimensions of life. Figure 17-2 shows the holistic nature of individuals.
Growth and development theories are useful to nurses as assessment parameters. Alterations in expected patterns are indicators for early intervention. Listed below are situations in which knowledge of developmental milestones is essential for prompt identification of problems and comprehensive intervention:
• The infant who does not sit, crawl, or walk at expected times
• The adolescent girl who has not experienced menarche at the expected time
• The adult who has failed to develop adequate problem- solving skills
STAGES OF THE LIFE CYCLE For purposes of this discussion, eleven developmental stages are presented: prenatal period, neonate, infant, toddler, preschooler, school-age child, preadolescent, adolescent, young adult, middle adult, and older adult. For each stage, the manifestations of growth and development in the physiological, psychosocial, cognitive, moral, and spiritual dimensions are discussed with the relevant nursing implications.
Prenatal Period
The prenatal period (the developmental stage beginning with conception and ending with birth) is a critical time in a human being’s development and consists of three developmental phases: the germinal, embryonic, and fetal stages.
The germinal stage begins with conception and lasts approximately 10 to 14 days. This stage is characterized by rapid cell division and implantation of the fertilized egg in the uterine wall. In this very early stage, the CNS is already beginning to form.
The embryonic stage (the first 2 to 8 weeks after fertilization of an egg by a sperm) is characterized by rapid cellular differentiation, growth, and development of the body systems. This critical period is when the embryo is most vulnerable to noxious stimuli, which may lead to a spontaneous abortion (miscarriage) (Murray & Zentner, 1997).
The fetal stage (the intrauterine developmental period from 8 weeks to birth) is characterized by rapid growth and differentiation of body systems and parts. Table 17-10 provides an overview of fetal development.
Nursing Implications The pregnant womaeeds to have physical examinations and screenings during the entire pregnancy. Early prenatal care is essential for a positive pregnancy outcome. Learning that one is pregnant is accompanied by several emotions: happiness, fear, sadness, excitement, and anxiety. Emotions lead to alterations in biochemicals; therefore, the mother’s emotional state can bring about biochemical changes in the fetus. By teaching pregnant women how to relax, the nurse can promote a supportive environment for the developing embryo and fetus.
Wellness Promotion The uterus is the primary environment affecting prenatal growth and development. Ideally, this environment nurtures positive growth of the embryo and fetus. An ample supply of nutrients must be provided by the gestating woman. Women who consume insufficient amounts of protein during pregnancy have a high rate of giving birth to premature and low birth weight infants. Such infants are at risk for developmental alterations. When teaching the pregnant woman about nutrition, the nurse must emphasize that vitamin supplements are not to be substituted for adequate intake of food. Other nursing interventions that promote prenatal health include:
• Screening (blood pressure measurement, urine sugar analysis)
• Teaching (nutritional guidelines)
• Counseling (e.g., guidance about bonding with the child and incorporating a child into a family unit)
• Promoting the use of complementary/alternative modalities to reduce stress
• Working with economically disadvantaged clients to obtain prenatal care
Safety Considerations The fetus is especially vulnerable to substances consumed by the mother. In addition to providing the fetus with wholesome nutrients, maternal blood can also transport toxins. Cigarettes contain several toxic substances, such as nicotine, that cross the placental barrier and interfere with the transport of oxygen to the fetus. Such toxins often result in increased risk of premature birth, retarded growth, learning difficulties, and fetal death. Use of alcohol during pregnancy can result in fetal alcohol syndrome (FAS), a condition in which fetal development is impaired and is manifested in the infant by characteristic physical attributes and intellectual problems. Typically, FAS infants are small, have facial abnormalities (such as thin upper lips and short, upturned noses), and may have some degree of brain damage. Alcohol consumption is most dangerous during the first 3 months of pregnancy when the embryo’s brain and other vital organs are developing. The effects of alcohol on the fetus are permanent. FAS is considered to be the leading cause of mental retardation among infants, and the incidence continues to increase (Wong, 1998). In addition to nicotine and alcohol, there are many other teratogenic substances.
A teratogenic substance is any substance that can cross the placental barrier and impair normal growth and development. Client education consists of teaching pregnant women to check labels of all medicines for information about potential effects on the fetus. The Food and Drug Administration requires that all manufactured drugs list their potential for causing birth defects. The use of illegal drugs by pregnant women presents a very serious threat to the unborn. Substance abuse prevention programs can be effective in preventing or reducing this risk.
Neonate The neonatal period (the first 28 days of life following birth) is a time of major adjustment to extrauterine life. The energies of the neonate (newborn) are focused on achieving equilibrium through stabilization of major body systems. Table 17-11 describes neonatal development.
The neonate’s activities, which are reflexive iature, consist primarily of sucking, crying, eliminating, and sleeping (Figure 17-3).
The neonate blinks in response to bright lights and demonstrates the startle reflex in response to loud noises. Neonatal reflexes play a major role in the ability to survive. Table 17-12 lists the reflexive activities of the neonate.
During the first month of life, the neonate progresses developmentally from a mass of reflexes to behavior that is more goal directed (purposeful). In addition to the major physiological adjustments necessitated by extrauterine life, the neonate also undergoes psychological adaptation. The major psychological task of neonates is to adjust to the parental figures. Bonding, the formation of attachment between parent and child, begins at birth when the neonate and parent make initial eye contact. The quality of parent-neonate bonding lays the foundation for trust that is necessary for the development of future interpersonal relationships. Figure 17-4 shows bonding betweeeonate and parent.
Nursing Implications A complete and thorough assessment of the neonate, which is performed immediately after delivery, includes evaluation of the neonate’s reflexes. In addition to focusing on the reflexes, the assessment also evaluates respiratory and cardiac functioning. Table 17-13 shows the Apgar assessment tool that is performed by the nurse at 1 minute and again at 5 minutes after birth. skin integrity be maintained. Parents must be taught the importance of skin cleanliness.
Diaper rash is a common skin problem for newborns and infants because of the ammonia from urine in wet diapers. The ammonia burns and irritates the skin, resulting in localized irritation, blisters, or fissures. In addition to prompt changing of wet diapers, bathing and use of protective creams are useful in preventing skin breakdown. See chapter 31 for a complete discussion of safety considerations and infections control practices.
Infant Infancy (the developmental stage from the first month to the first year of life) is a time of continued adaptation. During this stage, the infant experiences rapid physiologic growth and psychosocial development (Figure 17-5).
Table 17-14 provides an overview of infant development in the physical, motor, psychosocial, cognitive, moral, and spiritual dimensions.
Nursing Implications The nurse caring for an infant must focus on safety, prevention of infection, and teaching parents about incorporating the child into the family. Teaching parents and other caregivers about developmental milestones is essential. Nursing care involves the provision of support, reassurance, and information to the parents. Wellness Promotion Nurses promote infant wellness by teaching growth and development concepts to parents and other caregivers. Knowledge of the type of behavior to expect at certain times during infancy serves as both guidance and reassurance for parents. Three specific areas in which parents need guidance from the nurse in caring for their infants are nutrition, protection from infection, and promotion of sleep. A major factor influencing health maintenance of the infant is the provision of adequate nutrients delivered in a loving, consistent manner. Caregivers should be taught that the nutrients must be germ free and provide the recommended amounts of carbohydrates, protein, calcium, iron, and vitamins. It is recommended that infants be breastfed for the first 6 to 12 months (Murray & Zentner, 1997).
Breastmilk has several benefits over commercially prepared formulas, including:
• Offers immunologic benefits (e.g., contains immunoglobulins, lymphocytes, and other bacteria growth retardants)
• Is more easily digested because of smaller curds than those in cow’s milk and formula
• Enhances absorption of fat and calcium
• Is readily available and economical.
The act of breastfeeding promotes maternal-infant bonding (Wong, 1998). There are some cultural sanctions against breastfeeding and some cultures view bottle-feeding as a status symbol. Normal growth and development can occur without breastfeeding. Special formulas are available for infants who are hypersensitive to protein, who have PKU, and who experience fat malabsorption. Soy-based formulas have been developed for the infant with lactose deficiency or who is allergic to regular formula. Infants who are formula fed generally have greater deposits of subcutaneous fat (Murray & Zentner, 1997). The Nursing Checklist provides teaching strategies for parents of bottle-fed infants. It is important that the nurse provide accurate information about the types of feeding available and support the parents’ decision about the method chosen. Solid foods are usually introduced at 3 to 4 months of age. Rice cereal is the first solid food of choice because it has the fewest allergic responses (Murray & Zentner, 1997). Infants are especially vulnerable to developing infections. Because the immune system is not fully matured, infections pose a great threat. Immunizations are of utmost importance in preventing infections. Nurses should confirm that infants receive all necessary immunizations. Figure 17-6 provides a recommended schedule for childhood immunization.
In the first few hours after birth, encourage the parents to cuddle the newborn. Explain the neonate’s interactive abilities. Encourage mutual eye contact betweeeonate and parents by showing parents how to hold the child facing them. Wellness Promotion Teaching is one of the most important nursing activities that promote neonatal wellness. First-time parents need information about basic newborn needs (to be held,
rocked, and talked to), nutrition, infection control (especially handwashing and hygienic diaper changing practices), care of the umbilicus, and incorporating the newborn into the family unit. Knowledge of growth and development milestones is necessary for parents to provide appropriate neonatal stimulation and have realistic expectations. Other nursing interventions that promote neonatal wellness are listed below:
• Continually assessing the neonate’s physiological status
• Providing a warm environment (neonates breathe more easily when they are warm)
• Monitoring nutritional status. It is normal for neonates to lose weight (up to 10% of birth weight) during the first week of life.
• Providing a clean environment to protect neonates from infection and teaching parents that neonates need a clean environment, not a sterile one
• Conducting screening tests; for example, the blood test for phenylketonuria (PKU), a genetic disorder that, if untreated, can lead to impaired intellectual functioning
• Promoting early parent-neonate interaction
Selection of a feeding method for the neonate is a major decision for parents. Breastfeeding is the most natural option. However, commercially prepared formula is sometimes used due to the neonate’s special needs or parental choice. For a comparison of feeding methods, see the discussion about nutrition for the infant. Safety Considerations Safety is of primary concern when caring for neonates because neonates are totally dependent on others to meet their needs. Accidents are the primary cause of neonatal mortality (Fuller & Schaller-Ayers, 1999). One of the most important neonatal accident prevention methods is to teach parents about the use of infant car seats. Under current federal law, neonates and infants must be secured in an approved infant car seat every time the child travels in a car. In addition to accidents, infections pose a serious health risk to the neonate. Newborns should not be in contact with anyone experiencing an infectious disease. The skin is the body’s major defense against invasion by disease-producing microorganisms; therefore, it is essential that the neonate’s
Parents ofteeed information about normal sleep patterns of infants and how the patterns change with maturation. Activities that promote sleep include:
• Providing a quiet room for the infant
• Scheduling feedings and other care activities during periods of wakefulness instead of drowsy times
• Developing sensitivity to the unique sleep and rest periods established by the infant
• Providing comfort and security measures (e.g., rocking, singing)
• Establishing routine times for sleep
Safety Considerations
The majority of infant injuries and deaths are related to motor vehicle accidents. Therefore, the consistent and proper use of infant car seats is one of the most effective measures parents can take to ensure their infant’s safety. See the Nursing Checklist for guidelines that the nurse can share with parents to prevent infant accidents.
Toddler
The toddler period begins at 12 to 18 months of age, when a child begins to walk alone, and ends at approximately age 3. The family is very important to the toddler in that the family promotes language development and teaches toileting skills. During this stage, the child becomes more independent. Frequently, when attempts to demonstrate autonomy are prevented, the child will have a temper tantrum; thus, this stage is often referred to as “the terrible twos.” Parents must understand that the toddler’s frequent use of the word “no” is an expression of developing autonomy. Nurses can greatly influence the quality of parentchild interaction by teaching parents about developmental concepts. This information helps parents form realistic expectations of the toddler’s behavior. The use
of firm limits set in a consistent manner helps the toddler learn while providing parameters for safe and socially acceptable behavior. Table 17-15 describes the toddler’s growth and development in the physiological, motor, psychosocial, cognitive, moral, and spiritual dimensions.
Nursing Implications Nurses who work with toddlers must be sensitive to the fact that children of this age are likely to be anxious and fearful in the presence of strangers. The establishment of rapport with the child will help alleviate this stranger anxiety. Play is an effective tool for building rapport with toddlers. When toddlers are hospitalized (for an extended time or only a day), fear and anxiety can make the experience a negative one. The major stressor resulting from hospitalization is the toddler’s separation from parents. An unfamiliar environment also results in stress for the toddler. Nurses can help reduce stress in the hospitalized toddler by teaching both the child and parents about procedures. Toddlers need to have regular health examinations, and immunizations remain an essential part of health care. Encourage parents to be involved during the examination and immunizations. Parents can alleviate the toddler’s stress by holding the child and talking in a calm manner when in the presence of the health care provider (Figure 17-8).
Some specific nursing approaches to use with toddlers are listed below:
• Explain what is being done in a calm tone of voice.
• Use play to alleviate anxiety (e.g., have the child examine a teddy bear or doll).
• Give short, simple directions.
• After a painful procedure, comfort the child (cuddling, rocking).
• Encourage parents’ active participation in the care.
Wellness Promotion Teaching is done with both toddlers and their parents. Play can be used to establish an effective relationship with the child. Play is a valuable process for toddlers in that it is the primary mechanism for learning and socialization. To facilitate teaching, approach toddlers at eye level and use terminology that they can understand. Respiratory infections are common health threats to the toddler. Parasitic diseases are also fairly common. Teaching parents preventive measures becomes the focus of wellness promotion. Nutritional needs change during the toddler period as the rate of growth slows. The need for calories decreases from the requirements for infants. The required amount of protein is also lower than that of the infant; however, toddlers still need more protein than do older children. The toddler needs fewer fluids than the infant (Wong, 1998). Because most toddlers become selective (“picky”) with the foods they enjoy, it is sometimes difficult to provide increased intake of calcium and iron due to the toddler’s food habits. The toddler should consume an average of 2 to 3 cups of milk a day to ensure adequate calcium intake. The toddler who drinks more than a quart of milk per day is at increased risk of developing anemia because the high milk consumption limits the amount of other nutrients taken in (Wong, 1998). Nurses can play a key role in the toddler’s nutritional counseling. The following points should be shared with parents about dietary practices:
• Avoid using food as a reward because this may encourage overeating.
• Do not serve large helpings because the child may be overwhelmed and refuse to eat.
• Expect sporadic eating patterns (e.g., toddler eats a lot one day and very little the next; enjoys one food for several days then suddenly will not eat it).
• Avoid power struggles related to meals. Trying to force a child to eat is counterproductive to establishing healthy eating habits.
• Establish a mealtime routine and follow it (rituals are comforting to toddlers).
• Provide nutritional snacks to meet dietary requirements.
Safety Considerations Accidents (especially those involving automobiles) are the most frequent cause of disability and death in toddlers (Edelman & Mandle, 1997; Murray & Zentner, 1997). The information on the use of car seats for neonates and infants is applicable to toddlers. Another common type of accident occurring with toddlers involves toys. Parents need to be taught to inspect toys for:
• Age appropriateness
• Sharp objects
• Small parts that can be swallowed
• Flammable or toxic materials (e.g., lead-based paint)
As children gaiew skills, parents should be taught to reassess the safety of toys and of the home environment. Toddlers, with their increased mobility and curiosity, are especially prone to accidental poisonings. Parents should be informed of the need for careful observation of the toddler and child-proofing the home. See Chapter 31 for a complete discussion of preventing poisoning in children.
Preschooler The developmental stage from the ages of 3 to 6 is called the preschool stage. During this stage, physical growth slows and psychosocial and cognitive development are accelerated. Table 17-16 describes preschool development in detail.
During this period of childhood, curiosity becomes pronounced and the child is better able to communicate. When teaching the parents, let them know that the child’s frequent use of the word “why” is necessary for normal cognitive and psychosocial development. The child’s world begins to expand outside the immediate home environment. Play is the mechanism used by the preschooler to learn about and develop relationships.
Nursing Implications Play is a tool that can be used by nurses with preschoolers to help reduce fear and anxiety. Through the use of play, preschoolers learn about the environment, incorporate socially defined expectations for behavior, and reduce tension (Figure 17-9).
Wellness Promotion When working with a preschooler, it is important for the nurse to communicate at the child’s level of comprehension without talking down to the child. Include the child in activities and decisions as much as possible. The preschool years are the optimum time for the child to begin showing interest in health. The astute nurse capitalizes on this by making health education fun to promote the development of lifelong health-promoting lifestyles. A major wellness intervention for preschoolers is immunization. Teach parents about and encourage them to adhere to the recommended schedules. Each state in the
Safety Considerations Accidents are the leading cause of death in young children. Eagerness to explore the environment and cognitive immaturity lead to the preschooler’s risk for accidents. Children in this stage often act impulsively and cannot be expected to remember and follow all safety rules. Parents must understand the importance of teaching young children the meaning of “no” to prevent accidents. Common accidents that involve preschoolers are automobile accidents, burns, falls, drowning, animal bites, and ingestion of poisonous substances. It is important for the nurse to emphasize education about protection from potential hazards. The safety practices that are developed by the preschooler will tend to be lifelong. Adults can best teach preschoolers about accident prevention through role modeling. For example, parents who buckle their seatbelts every time they get into a car are not only protecting themselves but are also teaching their children an important accident preventive measure.
School-Age Child During the school-age period (developmental stage from the ages of 6 to 12 years), physical changes occur in a slow, even, continuous pace. Table 17-17 gives an overview of growth and development of the school-age child.
The school-age child’s world expands greatly. Participation in school activities, team sports, and play contributes to an enlarging social network. As children continue to mature, their play time becomes more structured and less spontaneous. Communication increases and vocabulary expands greatly to accommodate the expression of needs, thoughts, and feelings. As the school-age child’s cognitive abilities expand, creativity is expressed in a variety of unique ways. Involvement in academic, sports, and social activities stimulates the development of creativity and provides outlets for its expression.
Nursing Implications The most common health problems of school-age children are accidents and minor illnesses such as upper respiratory infections. Health promotion teaching is a major role of the nurse caring for school-age children. Wellness Promotion Lifestyles begin to be established during childhood; nurses can intervene to promote the development of healthy lifestyles with children in schools. Schools are an area in which health promotion behaviors can be taught in a cost-effective manner. Nurses can promote wellness in the school-age child by teaching parents to:
• Encourage healthy lifestyles (nonsedentary activities, nutritious meals)
• Have children immunized
• Provide nutritious meals
• Teach children appropriate hygienic measures
• Schedule regular checkups with the primary health care provider
• Schedule dental checkups and encourage daily brushing and flossing
• Establish sleep patterns alternating with periods of activity
• Report any symptoms of illness immediately to the health care provider
• Teach safety precautions
Safety Considerations Many accidents experienced by school-age children occur during play. Injuries related to the use of skates, skateboards, in-line skates, and bicycles are common. Children should be taught safety rules for use of such toys (e.g., use of protective equipment; Figure 17-10).
Parents must frequently remind children of the danger of playing near traffic. Children in this developmental stage must also be taught to use caution with strangers because of the possibility of abductions.
Preadolescent
Preadolescence (developmental stage from the ages of 10 to 12 years) is marked by rapid physiological changes with accompanying psychological and social implications. The child is beginning to experience hormonal changes that will result in the onset of puberty (appear- ance of secondary sex characteristics). Girls generally experience preadolescence at a younger age than boys—approximately age 9 to 10 for girls and age 10 to 11 for boys (Edelman & Mandle, 1997). Table 17-18 provides an overview of preadolescent development.
In girls, breast development begins between the ages of 10 and 11. Further breast development is stimulated by the release of estrogen that occurs during puberty. The pattern of female breast development is described in Table 17-19.
Other aspects of female sexual development are described in Table 17-20.
Approximately 2 years after the appearance of breast buds, menarche (onset of the first menstrual period) occurs. The first menstrual periods are usually irregular, scant, and may or may not be accompanied by ovulation. The average age of menarche in the
• Testicular enlargement
• Penile enlargement
• The scrotum becomes thinner and redder
• Pubic hair growth
Table 17-21 illustrates the physiological changes in boys during sexual development of male genitalia.
Nursing Implications Sensitivity is essential for the nurse working with the preadolescent child. To increase one’s sensitivity, the nurse uses a nonjudgmental approach and attends to the child’s body language. It is imperative that the nurse establish a trusting relationship with the preadolescent in order to encourage the child to ask questions about any health-related concerns.
Wellness Promotion The preadolescent needs information about nutrition, rest and activity, and the physiological changes that are occurring. The child must learn about the growth spurt, sexual changes, and psychosocial changes. By preparing the preadolescent for upcoming changes, the nurse is promoting physical and emotional health.
Safety Considerations The preadolescent is at risk for injury from sports and play activities. Another major health risk posed to many preadolescents is violence both in and away from the home. Education is a major preventive approach to violence; it is the tool for helping break the intergenerational cycle of child abuse. Other topics for promoting preadolescent safety are: substance abuse prevention, sex education, and development of healthy lifestyles.
Adolescent Adolescence (the developmental stage from the ages of 13 to 20 years) begins with the onset of puberty. During adolescence, the individual undergoes the major transition from child to adult. Numerous physiological changes and rapid physical growth occur during this stage. The rapid changes that occur during adolescence are not only physical. Many psychosocial adjustments must be made by the adolescent. Establishing a sense of personal identity uses a great amount of the adolescent’s psychic energy. Questions such as “Who am I?” and “What is really important?” are common for adolescents to consider. See Table 17-18 for an overview of adolescent development. Most adolescents are greatly concerned about their appearance. This emphasis on physical attractiveness sometimes results in eating disorders, such as anorexia nervosa (a self-imposed starvation that results in a 15% loss of body weight). Approximately 1% to 2% of female adolescents are affected by anorexia; the rate in males is much lower—about 5% to 10% of the anorectic population is male (Stuart & Laraia, 1998). Other types of eating disorders common in adolescents are bulimia (episodic binge eating followed by purging) and obesity (weight that is 20% or more above the ideal body weight). The teaching checklist provides essential information about eating disorders to share with clients and families.
Nursing Implications The nurse can support adolescents by providing information about the numerous bodily changes. Adolescents should be encouraged to share their health concerns with parents. However, the nurse must honor the adolescent’s choice to withhold sensitive information from parents. The use of a nonjudgmental attitude is essential to the establishment of rapport when working with adolescents. Adolescents should be treated in a respectful, dignified manner. Avoid using a condescending attitude when communicating with them. The Nursing Checklist discusses approaches that can be used when working with adolescents.
Wellness Promotion The nurse promotes the adolescent’s wellness primarily through teaching. Areas to be emphasized in health education of adolescents include hygiene, nutrition, sex education, developmental changes, and substance abuse prevention. Adolescents need education about the physical changes they are undergoing. Health teaching is often done by school nurses, and the establishment of nurse-managed clinics in schools is one avenue for promoting wellness among adolescents. School-based clinics are rapidly increasing.
Nursing’s Agenda for Health Care Reform (American Nurses Association, 1990) calls for the delivery of primary health care services to individuals in convenient, familiar
places. What better place to teach adolescents about health care than in the schools?
Safety Considerations Unhealthy behaviors contribute to the three major causes of adolescent death: accidents, homicide, and suicide. The following developmental factors increase the adolescent’s risk for accidents:
• Impulsive behavior
• Sense of being invulnerable to accidents (a feeling that “It caever happen to me!”)
• Testing limits
• Rebelling against adult advice
As a result, many adolescents engage in unhealthy behaviors such as smoking, consuming alcohol and other drugs, reckless driving, violence, and unprotected sexual activity.
Many health problems in adolescents are related to sexual behaviors including acquired immunodeficiency syndrome, sexually transmitted diseases (STDs), and unplanned pregnancy.
The effect of teen pregnancy on families and communities is great. Social programs that provide resources for meeting the special needs of pregnant adolescents are decreasing. Many pregnant teens become trapped in a cycle of school failure (or dropout), limited employment opportunities, and poverty. Adolescents who become pregnant experience developmental difficulties in that they must make adult decisions. Infants born to adolescent mothers are likely to experience health-related problems such as prematurity and low birth weight. The pregnant adolescent needs expert prenatal care, a supportive environment, and information. Client teaching must emphasize the prevention of STDs because the pregnancy itself is evidence of high-risk (unprotected) sexual activity. Sexually transmitted diseases present a serious health threat for adolescents. Diseases such as genital herpes virus, human papillomavirus (which causes genital warts), chlamydia, syphilis, and gonorrhea are spread through sexual contact. The human immunodeficiency virus (HIV), which causes AIDS, is also transmitted through unprotected sexual activity. Table 17-22 describes the most common STDs.
Nurses must educate adolescents about methods for preventing the spread of STDs. Preventive education should include the following topics:
• Methods of transmission
• Incubation period
• Clinical manifestations
• Treatment methods
• Consequences of lack of or inadequate treatment
• Notification of sexual partner(s)
Nurses who teach adolescent clients about safe sex practices need to be especially sensitive to cultural influences on sexual activity. Another major health problem during adolescence is the high risk of suicide. Often, suicide is perceived by the adolescent as the only alternative to an overwhelming situation. Low self-esteem, lack of maturity, and impulsive behaviors may increase the risk of suicidal behavior. The rate of suicide is higher among adolescent males than females. When assessing for suicidal potential, the nurse should always directly question the adolescent about any plans for harming or killing self. The accompanying display lists signs indicative of suicide risk in adolescents. When teaching suicide prevention, inform people to immediately contact a health care professional if someone is exhibiting any of the indicators of suicide risk. Many communities have a special telephone suicide-cope line available.
Another significant health problem for many adolescents is substance abuse. Using alcohol or other drugs is a common maladaptive attempt to cope with the stressors of adolescence. The accompanying display lists indicators of substance abuse in adolescents.
Nurses can play a key role in substance abuse prevention with adolescents. A comprehensive substance abuse prevention educational program includes:
• Hazards of drug use
• Misuse of legal substances, such as tobacco and alcohol
• Self-esteem boosting methods
• Assertive communication skills (how to say “no” to peers)
• Adaptive coping mechanisms for dealing with stress
By providing such information, nurses can help adolescents make responsible, informed decisions before experimentation with drugs begins.
Young Adult Physical growth stabilizes during young adulthood (the developmental stage from the ages of 21 to approximately 40 years). The young adult continues to experience physical and emotional changes at a slower rate than adolescents. Table 17-23 describes the development of young adults.
Young adulthood is a time of transition from an adolescent to a person capable of assuming adult responsibilities and making adult decisions. Pregnancy, a time of transition and lifestyle adjustment, is experienced by many young women. Table 17-24 lists a few of the changes commonly experienced by women during pregnancy.
Throughout pregnancy, women experience changes in self-concept and may need reassurance that such changes are normal.
Nursing Implications Usually, young adulthood is the healthiest time in a person’s life. Consequently, concern for health is low among people in this age group and wellness is taken for granted by many young adults. Preventive measures for young adults focus on two primary areas: 1. Avoidance of accident, injury, and violence 2. Development of health-promoting behaviors (e.g., lifestyle modification; Figure 17-11).
The nurse plays an important role in each of these areas of health promotion by teaching and counseling. Other topics that are developmentally appropriate for the nurse to address are vocational counseling and establishing relationships
Wellness Promotion Decision making by young adults affects their health status. Since young adults tend to take excessive risks, they are at greater risk for death from accident, suicide, or homicide (Edelman & Mandle, 1997). For example, driving recklessly, driving while intoxicated, engaging in unprotected sex, and participating in gang activities are examples of the lack of a sense of fear demonstrated by many young adults. Sexually transmitted disease is a leading cause of infection with resultant reproductive dysfunction in young adults. The information presented about STDs in the discussion of safety considerations for adolescents is also applicable to young adults. Nurses should teach women how to perform a monthly breast self-examination (BSE). Meeed to learn how to perform a testicular self-examination (TSE). See Chapter 27 for a complete discussion of the methods involved in performing BSE and TSE.
Safety Considerations Because vehicular accidents are a major cause of health problems for young adults, providing information about driving safety is a must. Another activity that poses a health risk for many young adults is sunbathing. Exposure to direct sunlight with the resultant radiation or use of tanning salons is directly linked to skin cancer. Nurses can be influential in decreasing the occurence of skin cancer through teaching and by role modeling safe behaviors.
Middle Adult Middle adulthood (the developmental stage from the ages of 40 to 65 years) is characterized by productivity and responsibility. For most middle-aged adults, the majority of activity revolves around work and parenting, and success and achievement are measured in terms of career accomplishments and family life. Physiological changes that affect many of the body systems occur during middle adulthood. Table 17-25 lists the major changes experienced by the middleaged person.
The primary developmental task of the middle-aged adult revolves around the conflict of generativity (a sense that one is making a contribution to society) versus stagnation (a sense of nonmeaning in one’s life). When an individual successfully resolves this developmental conflict, acceptance of age-related changes occurs. Achievement of the developmental task is indicated by the following:
• Demonstrating creativity
• Guiding the next generation
• Establishing lasting relationships
• Evaluating goals in terms of achievement The evaluation of goals often leads to a midlife crisis, especially if individuals feel they have accomplished little or not lived up to earlier self-expectations.
Nursing Implications A large proportion of the
Wellness Promotion As health educators, nurses can encourage middle-aged adults to assume more responsibility for their own health (Figure 17-12).
Self-care education topics appropriate for the middle-aged adult include:
• Acceptance of aging
• Nutrition
• Exercise and weight control
• Substance abuse prevention
• Stress management
• Recommendations for health screening (cholesterol screening, prostate examination, mammogram, Papanicolaou [Pap] test).
Safety Considerations Automobile accidents, especially those involving the use of alcohol, are a serious health problem for middle-aged adults. Another significant problem is occupational health hazards such as exposure to environmental toxins. Middle adulthood is also the time when a lifelong accumulation of unhealthy lifestyle practices, such as smoking, sedentary habits, inadequate nutrition, and overuse of alcohol, begins to exert adverse effects. Most middle-aged individuals have increased leisure time. Consequently, there is an increased risk for recreational accidents, such as, boating accidents, sportsrelated injuries, and jogging mishaps.
Older Adult Older adulthood is the developmental stage occurring from age 65 and beyond. Chapter 18 provides an indepth discussion of the elderly adult. Therefore, this section only highlights the concepts of growth and development as they relate to the older adult. Table 17- 26 provides an overview of growth and development in the older adult.
Older adults have several psychosocial tasks to accomplish, such as:
• Developing a sense of satisfaction with the life that one has lived (to find meaning in one’s life)
• Establishing meaningful roles
• Adjusting to infirmities (if any exist)
• Coping with losses and changes
• Preparing for death
Nursing Implications Professional nursing care is important in assisting aging people to develop a sense of well-being (Eliopoulos, 1996). Nurses who work with the elderly must be especially sensitive to their own feelings, attitudes, and beliefs about aging and be aware of the effect of these responses on their care of older clients. When assessing the older adult for health-related needs, the nurse needs to learn about the client’s background, family history, work history, hobbies, and achievements (Figure 17-13). Clients should be encouraged to talk about their life experiences.
When planning care, it is important to build on the client’s lifelong interests. By recognizing each client’s unique experiences and assets, the nurse is more likely to individualize care. When clients express dissatisfaction and regrets about the past, the nurse should listen in a nonjudgmental manner and avoid trying to convince them that things are really better than they remember or perceive. It is important, however, to help clients put disappointments into perspective by balancing them with accomplishments and achievements. Nurses should encourage families to engage in a positive life review with elderly clients. Most nursing interventions for the elderly center around introspection and reflection on their lives. Life review (or reminiscence therapy) promotes a positive self-concept in older people (Stuart & Laraia, 1998).
Wellness Promotion Health promotion activities should be implemented with the elderly to maintain functional independence. Health promotion activities are aimed at maximizing the elder’s abilities and strengths. Specific topics that are developmentally appropriate for older clients are: use of leisure time, increased socialization, engaging in regular physical activity, maintaining a positive mental attitude, and developing and maintaining healthy lifestyles.
K E Y C ONCEPTS
• Growth is the quantitative changes in physical size of the body and its parts.
• Development refers to behavioral changes in functional abilities and skills.
• Maturation is the process of becoming fully grown and developed and involves both physiological and behavioral aspects of an individual.
• During each developmental stage, certain developmental tasks must be achieved for normal development to occur.
• Growth and development of an individual are influenced by a combination of factors, including heredity, life experiences, health status, and cultural expectations.
• According to Freud, certain developmental tasks must be achieved at each developmental stage; failure to achieve or a delay in achieving the developmental task results in a fixation at a previous stage.
• Erikson stated that psychosocial development is a series of conflicts that occur during eight stages of life.
• Sullivan stated that personality development is strongly influenced by interpersonal relationships.
• Piaget’s theory states there are four stages of cognitive development: sensorimotor, preoperational, concrete operations, and formal operations. Each stage is characterized by the ways in which the child interprets and uses the environment.
• Kohlberg’s theory describes six stages of moral development through which individuals determine a moral code to guide their behavior.
• Gilligan states that women’s moral judgment revolves around three issues: a concern with survival, a focus on goodness, and an understanding of others’ need for care.
• Fowler’s theory states that there are six distinct stages of faith development and, even though individuals will vary in the age at which they experience each stage, the sequence of stages remains the same.
• Providing care to the whole person is a basic concept of professional nurses, and knowledge of growth and development concepts guides holistic care of clients.
• The stages of the life cycle are the prenatal, neonate, infant, toddler, preschooler, school-age child, preadolescent, adolescent, young adult, middle adult, and older adult.
• Nurses have important roles in promoting the health and safety of individuals at each stage of the life cycle.
CRITICAL THINKING ACTIVITIES
1. State some ways in which Erikson’s developmental theory relates to nursing.
2. Shaw stated, “Faith is the soul riding at anchor.” What does this mean to you? In what ways do you demonstrate your faith? Observe several nurses. Note their demonstrations of faith.
3. You are assigned to care for a 4-year-old girl. What games and toys would be appropriate for her? Consider her developmental needs when answering.
4. You are a nurse in a clinic setting providing teaching to an adolescent male who has tested positive for chlamydia. What information will you discuss with him?
5. Name five beliefs you have about the elderly. Can you identify the source of these beliefs? How will these beliefs influence your care of elderly clients?
