CARING FOR FAMILIES
Caring for Families
From conception to death, individuals are
constantly changing. Physical growth, psychological development, emotional
maturation, cognitive development, moral development, and spiritual growth occur
throughout life. Progression through each developmental stage influences health
status. A thorough understanding of developmental concepts is essential for
professional quality nursing practice. This chapter discusses the changes
occurring in each stage of the life cycle.
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.
See Chapter 19 for a complete discussion about self-concept. A person with
a positive self-concept is likely to engage in health-promoting activities. For
example, a person who values self is more likely to change unhealthy habits
(such as smoking and sedentary lifestyle) to promote health. There are many
different psychosocial theories that explain the development of self-concept.
This chapter presents the intrapsychic and
interpersonal models of personality development.
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
Piaget
and Inhelder (1969) categorized intellectual
development into four phases: sensorimotor,
preoperational, concrete operations, and formal operations. Table 17-6 provides
a description of each phase.
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.
ssimilation is the process of taking in new
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 woman needs 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 in nature, 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 between neonate 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 between neonate 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 often need 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 gain new 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 can never 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). Men need 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.
Falls pose a major health threat to the elderly. See Chapter 31 for
information related to fall prevention and other specific safety promotion
practices for elderly individuals. See Chapter 18 for information on other
safety measures for the elderly.
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?