FAMILY NURSING
Health Problems of Newborns and Infants.
Routine Health Screenings.
OBJECTIVES
Growth and Development of the Newborn
1. Identify the adaptive changes that occur
during the transition to extrauterine life.
2. Describe the normal physiological
development of the newborn.
3. Discuss the psychosexual, cognitive, and
psychosocial development of the newborn.
4. Identify and explain aspects of health promotion
and maintenance pertinent to the newborn.
5. Describe family educational needs
regarding health promotion of the newborn.
6. Explain the etiology and treatment of the
high-risk newborn.
7. Discuss the nurse's role in caring for healthy
and high-risk newborns.
Growth and Development of the Infant
1. Discuss physiological growth and
developmental milestones of infants.
2. Discuss the process of infant fine and
gross motor development, including the principles associated with them.
3. Describe infant psychosexual, cognitive,
and psychosocial development.
4. Describe health promotion and maintenance
activities for infants.
5. Discuss caloric and fluid requirements
for infants.
6. Describe play activities of infancy.
7. Discuss educational strategies for
caregivers of infants as related to nutritional needs, growth and development
patterns, stranger and separation anxiety, and safety.
GROWTH, MATURATION, AND DEVELOPMENT
Growth,
maturation, and development are common terms used to describe human
development. An explanation of these terms and of the age ranges associated
with child development is needed before principles, issues, and theories can be
understood. Growth refers to a physiologic increase in size through cell
multiplication or differentiation. This is most obviously seen in weight and
height changes occurring during the first year of life. Maturation refers
to changes that are due to genetic inheritance rather than life experiences,
illness, or injury.
These
changes allow children to function at increasingly higher and more
sophisticated levels as they get older. Development refers to the
physiological, psychosocial, and cognitive changes occurring over one's life
span due to growth, maturation, and learning, and assumes that orderly and
specific situations lead to new activities and behavior patterns (Figure 1).
Figure 1 (A)
Toddlers are developing their gross motor skills. (B) School-aged children
often become involved in physical activities and team sports.
The
five stages and age ranges of human development relating specifically to pediatric
nursing are found in Table 1.
Table 1. Stages,
Related to
Pediatric Nursing
Principles of Growth and Development
At least eight
principles providing a framework for studying human
development are embedded within the issues and theories discussed in the
following pages. Although not all of these principles are proven by research,
they are often observed in children and generally assumed to be true
(Hetherington & Parke, 1993; Murray & Zentner,
2001).
1.
Development is orderly and sequential. This principle suggests that
maturation follows a predictable and universal timetable. For example, children
learn to crawl before they learn to walk, and they learn to walk before they
learn to run. These changes occur rapidly during the first year of life and
slow during middle and late childhood. Even though the onset and length of each
developmental change vary among children, the basic sequence is the same,
allowing comparison to norms.
2.
Development is directional. Skill development proceeds along two
different pathways: cephalocaudal and proximodistal. Cephalocaudal
development proceeds from the head downward. Therefore, areas closest to
the brain or head develop first, followed by the trunk, then legs and feet. For
example, head control is followed by sitting, then crawling, and then walking. Proximodistal development proceeds from the
inside out. Controlled movements closest to the body's center (trunk, arms)
develop before controlled movements distant to the body (fingers). For example,
grasping changes from using the entire hand to just the fingers as infants get
older.
3.
Development is unique for each child. Ever)' child has a unique
timetable for physiological, psychosocial, cognitive, and moral development.
For example, some children can name four colors by the time the y are 3 years
old, whereas others cannot name four colors until they are 4V2 years old. Some
children walk well at 11 months; others do not walk well until they are 14
months old.
4.
Development is interrelated. Physiological,
psychosocial, cognitive, and moral aspects of development affect and are
affected by one another. For example, central nervous system maturation
is necessary for cognitive development. Children cannot be independent in
toileting if they are not aware of the urge to void and cannot independently
remove clothing.
5.
Development becomes increasingly differentiated. This means responses
become more specific and skillful as the child grows. Young infants respond to
stimuli in a generalized way involving the entire body, whereas older children
respond to specific stimuli in a more refined and specialized way. For example,
infants will react with their entire body to pain by crying and withdrawing,
whereas a child is able to localize the pain, can often identify its source,
and may only withdraw the extremity experiencing the pain. An infant will use
the entire hand to grab a toy before developing the fine motor ability
necessary for the pincer grasp.
6.
Development becomes increasingly integrated and complex. This means, as
new skills are gained, more complex tasks are learned. For example, learning to
drink from a cup initially requires eye-hand coordination, then grasping, and
then hand-mouth coordination. Infants' cooing is followed by babbling, before
these sounds are refined into the understandable speech of a child.
7.
Children are competent. They possess qualities and abilities ensuring
their survival and promoting their development. For example, newborns can
cough, sneeze, suck, swallow, digest, breathe, and elicit caretaking responses
from adults. Children make their needs known to caregivers in increasingly
sophisticated ways so that others know if they are cold, hungry, or in pain.
8.
New skills
predominate. This occurs because of the strong drive to practice and
perfect new abilities, especially early in life, when the child is not capable
of coping well with several new skills simultaneously. For example, when
children are learning to walk, talk, or feed themselves with utensils, their
attention and effort is focused on developing that one skill; they do not
usually learn to walk, talk, and feed themselves at the same time.
Issues of Human Development
Theories on growth
and development are often considered from the perspective of seven issues.
These issues help explain how development occurs and what humans are like and
can be applied to theories of human development. These issues answer questions
related to the importance of biology or the environment on development, whether
children are inherently good, bad, or actively involved in their own
development, if development occurs gradually or abruptly, if children are more
similar than different from one another, or if one's personality or way of
interacting with others remains stable throughout life. The issues discussed
include nature versus nurture, continuity versus discontinuity, passivity
versus activity, critical versus sensitive periods, universality versus context
specificity, assumptions about human nature, and behavioral consistency.
Nature versus Nurture
One
of the more important and oldest issues discussed in human development is the
nature/nurture controversy. This debate concerns the influence that biology
(nature) and the environment (nurture) have on an individual. Nature describes
genetically inherited traits such as eye color or body type, or disease such as
cystic fibrosis or hemophilia. This view sees development as predetermined by
genetic factors and not altered by the environment. A person believing in the
principle of nature would suggest that all normal children achieve identical
developmental milestones at a similar time due to maturational forces. If
children differed in achieving these milestones, it would be because of
differences in their genetic makeup. Nurture refers to the influences
that the environment has on development, and includes the influences that
child-rearing methods, culture, learning experiences, and society have on
development. A person believing in the principle of nurture would suggest that
development can take different paths depending on the experiences that an
individual has over a lifetime.
Today,
most developmentalists believe that both nature and
nurture are important, and that the relative contribution of each depends on
the aspect of development studied. Developmentalists today
are also more concerned about how biological and environmental factors interact
to produce developmental differences and changes, rather than the importance of
one over the other .
Continuity versus Discontinuity
This
issue addresses the nature of change across development. Continuity suggests
that change is orderly and built upon earlier experiences. Development is a
gradual and smooth process without abrupt shifts; the course of development
looks like a smooth growth curve. This issue also suggests early and late
development are connected; aggressive toddlers become aggressive adults,
curious infants become creative adolescents, and shy preschoolers become
introverted adults. Finally, continuity proposes that changes occur
quantitatively, or in degrees. For example, when children grow older, they
become taller, run faster, and learn more about the world around them.
Discontinuity suggests development is a series of discrete steps or
stages that elevate the child to a more advanced or higher level of functioning
with increased age. The course of development looks like a flight of stairs.
There is no connection between early and later development; behavior seen later
in life has replaced behavior seen earlier in life. For example, infants once
comfortable around strangers may come to fear them as they get older; a shy and
introverted preschooler may become an outgoing, extroverted adolescent.
Discontinuity would also argue that adult behavior cannot be predicted by
knowing what the person was like as a child. Finally, discontinuity implies
qualitative change, or changes that make the individual different as growth
occurs, as when a nonverbal infant becomes a toddler using language, or when a prepubertal child becomes a mature adolescent.
Passivity versus Activity
This
issue views the child as either a passive recipient shaped by external
environmental forces, or as internally driven and actively participating in
development. The passive view suggests that child-rearing beliefs, practices,
and behaviors cause children to be either shy or assertive. Children become
delinquent because of their association with an antisocial peer group. Talented
and creative teachers deserve credit for a child's interest in mathematics or
literature. Those disagreeing with this view believe children purposefully,
creatively, and actively seek experiences to control, direct, and shape their
development. Active children also modify caregiver, peer, and teacher behavior
(Figure 2).
Figure 2 Active
children are interested in learning about other children's projects and art
work.
For
example, an inquisitive, friendly child may encourage that same behavior in an
otherwise indifferent or unfriendly peer or adult.
Critical versus Sensitive Period
This
issue concerns the importance of different time periods in development, and
asks if some phases are more important than others in developing particular
abilities, knowledge, or skills. The critical period refers to a limited
time span when a child is biologically prepared to acquire certain behaviors,
but needs the support of a suitably stimulating environment. Indeed, there are
some periods during development when children need to experience certain
sensory and social input if their development is to proceed normally. The first
3 years of life are important for developing language, social, and emotional
responsiveness. If there is little or no opportunity for these experiences
during this time, children may have difficulty learning language, developing
close friendships, or having an intimate emotional relationship later in life.
The
sensitive period, on the other hand, is a time span that is optimal for
certain capacities to emerge when the individual is especially receptive to
environmental influences (Bornstein, 1989). Supporters of this view believe
some behaviors can be modified during early development. For example, infants
reared in an impoverished orphanage grew up without identifiable intellectual
deficits if they were placed in a stimulating and nurturing adoptive home (Skeels, 1966). The fact that early experiences can be
modified suggests humans are malleable and adaptable and, for some areas of
development, there are sensitive rather than critical periods.
Universality
versus Context Specificity
The importance of
culture to development is embedded within this issue. Some theorists believe an
individual's culture has a profound influence on development. Others suggest
there are culture-free laws of development that apply to all children in all
cultures. For example, universality would say humans follow similar
developmental pathways regardless of their culture: language is acquired and
used at 11-14 months of age, cognitive changes preparing children for school or
higher learning occur during 5-7 years of age, and sexual maturity is reached
during the preteen or teenage years. Context specificity on the other
hand, would suggest there are differences in children related to cultural
values, beliefs, and experiences. For example, some societies encourage early
walking by providing opportunities to exercise and practice these new skills,
whereas in other societies carrying or swaddling infants is the norm, thereby
reducing the chance of walking until older.
Assumptions about Human Nature
T
FAMILY NURSING Health Problems of Newborns and Infants. Routine Health Screenings. OBJECTIVES Growth and Development of the Newborn 1. Identify the adaptive changes that occur
during the transition to extrauterine life. 2. Describe the normal physiological
development of the newborn. 3. Discuss the psychosexual, cognitive, and
psychosocial development of the newborn. 4. Identify and explain aspects of health promotion
and maintenance pertinent to the newborn. 5. Describe family educational needs
regarding health promotion of the newborn. 6. Explain the etiology and treatment of the
high-risk newborn. 7. Discuss the nurse's role in caring for healthy
and high-risk newborns. Growth and Development of the Infant 1. Discuss physiological growth and
developmental milestones of infants. 2. Discuss the process of infant fine and
gross motor development, including the principles associated with them. 3. Describe infant psychosexual, cognitive,
and psychosocial development. 4. Describe health promotion and maintenance
activities for infants. 5. Discuss caloric and fluid requirements
for infants. 6. Describe play activities of infancy. 7. Discuss educational strategies for
caregivers of infants as related to nutritional needs, growth and development
patterns, stranger and separation anxiety, and safety. GROWTH, MATURATION, AND DEVELOPMENT Growth,
maturation, and development are common terms used to describe human
development. An explanation of these terms and of the age ranges associated
with child development is needed before principles, issues, and theories can be
understood. Growth refers to a physiologic increase in size through cell
multiplication or differentiation. This is most obviously seen in weight and
height changes occurring during the first year of life. Maturation refers
to changes that are due to genetic inheritance rather than life experiences,
illness, or injury. These
changes allow children to function at increasingly higher and more
sophisticated levels as they get older. Development refers to the
physiological, psychosocial, and cognitive changes occurring over one's life
span due to growth, maturation, and learning, and assumes that orderly and
specific situations lead to new activities and behavior patterns (Figure 1). Figure 1 (A)
Toddlers are developing their gross motor skills. (B) School-aged children
often become involved in physical activities and team sports. The
five stages and age ranges of human development relating specifically to pediatric
nursing are found in Table 1. Table 1. Stages, Related to
Pediatric Nursing Principles of Growth and Development At least eight
principles providing a framework for studying human
development are embedded within the issues and theories discussed in the
following pages. Although not all of these principles are proven by research,
they are often observed in children and generally assumed to be true
(Hetherington & Parke, 1993; Murray & Zentner,
2001). 1.
Development is orderly and sequential. This principle suggests that
maturation follows a predictable and universal timetable. For example, children
learn to crawl before they learn to walk, and they learn to walk before they
learn to run. These changes occur rapidly during the first year of life and
slow during middle and late childhood. Even though the onset and length of each
developmental change vary among children, the basic sequence is the same,
allowing comparison to norms. 2.
Development is directional. Skill development proceeds along two
different pathways: cephalocaudal and proximodistal. Cephalocaudal
development proceeds from the head downward. Therefore, areas closest to
the brain or head develop first, followed by the trunk, then legs and feet. For
example, head control is followed by sitting, then crawling, and then walking. Proximodistal development proceeds from the
inside out. Controlled movements closest to the body's center (trunk, arms)
develop before controlled movements distant to the body (fingers). For example,
grasping changes from using the entire hand to just the fingers as infants get
older. 3.
Development is unique for each child. Ever)' child has a unique
timetable for physiological, psychosocial, cognitive, and moral development.
For example, some children can name four colors by the time the y are 3 years
old, whereas others cannot name four colors until they are 4V2 years old. Some
children walk well at 11 months; others do not walk well until they are 14
months old. 4.
Development is interrelated. Physiological,
psychosocial, cognitive, and moral aspects of development affect and are
affected by one another. For example, central nervous system maturation
is necessary for cognitive development. Children cannot be independent in
toileting if they are not aware of the urge to void and cannot independently
remove clothing. 5.
Development becomes increasingly differentiated. This means responses
become more specific and skillful as the child grows. Young infants respond to
stimuli in a generalized way involving the entire body, whereas older children
respond to specific stimuli in a more refined and specialized way. For example,
infants will react with their entire body to pain by crying and withdrawing,
whereas a child is able to localize the pain, can often identify its source,
and may only withdraw the extremity experiencing the pain. An infant will use
the entire hand to grab a toy before developing the fine motor ability
necessary for the pincer grasp. 6.
Development becomes increasingly integrated and complex. This means, as
new skills are gained, more complex tasks are learned. For example, learning to
drink from a cup initially requires eye-hand coordination, then grasping, and
then hand-mouth coordination. Infants' cooing is followed by babbling, before
these sounds are refined into the understandable speech of a child. 7.
Children are competent. They possess qualities and abilities ensuring
their survival and promoting their development. For example, newborns can
cough, sneeze, suck, swallow, digest, breathe, and elicit caretaking responses
from adults. Children make their needs known to caregivers in increasingly
sophisticated ways so that others know if they are cold, hungry, or in pain. 8.
New skills
predominate. This occurs because of the strong drive to practice and
perfect new abilities, especially early in life, when the child is not capable
of coping well with several new skills simultaneously. For example, when
children are learning to walk, talk, or feed themselves with utensils, their
attention and effort is focused on developing that one skill; they do not
usually learn to walk, talk, and feed themselves at the same time. Issues of Human Development Theories on growth
and development are often considered from the perspective of seven issues.
These issues help explain how development occurs and what humans are like and
can be applied to theories of human development. These issues answer questions
related to the importance of biology or the environment on development, whether
children are inherently good, bad, or actively involved in their own
development, if development occurs gradually or abruptly, if children are more
similar than different from one another, or if one's personality or way of
interacting with others remains stable throughout life. The issues discussed
include nature versus nurture, continuity versus discontinuity, passivity
versus activity, critical versus sensitive periods, universality versus context
specificity, assumptions about human nature, and behavioral consistency. Nature versus Nurture One
of the more important and oldest issues discussed in human development is the
nature/nurture controversy. This debate concerns the influence that biology
(nature) and the environment (nurture) have on an individual. Nature describes
genetically inherited traits such as eye color or body type, or disease such as
cystic fibrosis or hemophilia. This view sees development as predetermined by
genetic factors and not altered by the environment. A person believing in the
principle of nature would suggest that all normal children achieve identical
developmental milestones at a similar time due to maturational forces. If
children differed in achieving these milestones, it would be because of
differences in their genetic makeup. Nurture refers to the influences
that the environment has on development, and includes the influences that
child-rearing methods, culture, learning experiences, and society have on
development. A person believing in the principle of nurture would suggest that
development can take different paths depending on the experiences that an
individual has over a lifetime. Today,
most developmentalists believe that both nature and
nurture are important, and that the relative contribution of each depends on
the aspect of development studied. Developmentalists today
are also more concerned about how biological and environmental factors interact
to produce developmental differences and changes, rather than the importance of
one over the other . Continuity versus Discontinuity This
issue addresses the nature of change across development. Continuity suggests
that change is orderly and built upon earlier experiences. Development is a
gradual and smooth process without abrupt shifts; the course of development
looks like a smooth growth curve. This issue also suggests early and late
development are connected; aggressive toddlers become aggressive adults,
curious infants become creative adolescents, and shy preschoolers become
introverted adults. Finally, continuity proposes that changes occur
quantitatively, or in degrees. For example, when children grow older, they
become taller, run faster, and learn more about the world around them. Discontinuity suggests development is a series of discrete steps or
stages that elevate the child to a more advanced or higher level of functioning
with increased age. The course of development looks like a flight of stairs.
There is no connection between early and later development; behavior seen later
in life has replaced behavior seen earlier in life. For example, infants once
comfortable around strangers may come to fear them as they get older; a shy and
introverted preschooler may become an outgoing, extroverted adolescent.
Discontinuity would also argue that adult behavior cannot be predicted by
knowing what the person was like as a child. Finally, discontinuity implies
qualitative change, or changes that make the individual different as growth
occurs, as when a nonverbal infant becomes a toddler using language, or when a prepubertal child becomes a mature adolescent. Passivity versus Activity This
issue views the child as either a passive recipient shaped by external
environmental forces, or as internally driven and actively participating in
development. The passive view suggests that child-rearing beliefs, practices,
and behaviors cause children to be either shy or assertive. Children become
delinquent because of their association with an antisocial peer group. Talented
and creative teachers deserve credit for a child's interest in mathematics or
literature. Those disagreeing with this view believe children purposefully,
creatively, and actively seek experiences to control, direct, and shape their
development. Active children also modify caregiver, peer, and teacher behavior
(Figure 2). Figure 2 Active
children are interested in learning about other children's projects and art
work. For
example, an inquisitive, friendly child may encourage that same behavior in an
otherwise indifferent or unfriendly peer or adult. Critical versus Sensitive Period This
issue concerns the importance of different time periods in development, and
asks if some phases are more important than others in developing particular
abilities, knowledge, or skills. The critical period refers to a limited
time span when a child is biologically prepared to acquire certain behaviors,
but needs the support of a suitably stimulating environment. Indeed, there are
some periods during development when children need to experience certain
sensory and social input if their development is to proceed normally. The first
3 years of life are important for developing language, social, and emotional
responsiveness. If there is little or no opportunity for these experiences
during this time, children may have difficulty learning language, developing
close friendships, or having an intimate emotional relationship later in life. The
sensitive period, on the other hand, is a time span that is optimal for
certain capacities to emerge when the individual is especially receptive to
environmental influences (Bornstein, 1989). Supporters of this view believe
some behaviors can be modified during early development. For example, infants
reared in an impoverished orphanage grew up without identifiable intellectual
deficits if they were placed in a stimulating and nurturing adoptive home (Skeels, 1966). The fact that early experiences can be
modified suggests humans are malleable and adaptable and, for some areas of
development, there are sensitive rather than critical periods. Universality
versus Context Specificity The importance of
culture to development is embedded within this issue. Some theorists believe an
individual's culture has a profound influence on development. Others suggest
there are culture-free laws of development that apply to all children in all
cultures. For example, universality would say humans follow similar
developmental pathways regardless of their culture: language is acquired and
used at 11-14 months of age, cognitive changes preparing children for school or
higher learning occur during 5-7 years of age, and sexual maturity is reached
during the preteen or teenage years. Context specificity on the other
hand, would suggest there are differences in children related to cultural
values, beliefs, and experiences. For example, some societies encourage early
walking by providing opportunities to exercise and practice these new skills,
whereas in other societies carrying or swaddling infants is the norm, thereby
reducing the chance of walking until older. Assumptions about Human Nature The doctrine of original
sin used by Thomas Hobbes (1588-1679) to describe a child's nature,
suggests children are inherently evil and selfish egotists who must be
controlled by society. The doctrine of innate purity, proposed by Jean Jaques Rousseau (1712-1778), suggests children are
inherently good and born without an intuitive sense of what is right and wrong.
The doctrine of tabula rasa, proposed by John Locke (1632-1704),
suggests children are neither good nor evil, but rather enter the world as a blank
slate without inborn tendencies, and are molded through life experiences. These
assumptions are based on 17th and 18th century social philosophers and rarely
addressed directly in theories of human development today. However, emphasis on
positive or negative aspects of a child's character and a particular theorist's
belief reflect an individual's orientation and assumptions about human nature.
For example, if one believes children are inherently caring and helpful, or on
the other hand, innately selfish, child-rearing practices would vary.
Permissive parents may believe children should be allowed to develop without
interference (innate purity), whereas authoritarian parents may take an
approach that would combat and control their child's selfish and aggressive
impulses so they would develop positive behaviors. Behavioral Consistency This issue
addresses whether or not a child's basic behavioral traits change according to
the setting (school, neighborhood, family). Some theorists suggest individual
personality characteristics and predispositions cause children to behave
similarly no matter the setting. Others suggest children's behavior changes
from one setting to another. Those supporting the former view would say a
particular child can always be described as honest, helpful, aggressive, or
independent, no matter the situation. The latter view would argue children's
behavior shifts according to the situation and who/what is present—friend in
need, angry caregiver or teacher, competitive game, or a difficult test. Skinner and Operant Conditioning Operant
conditioning, a term originated by B. F. Skinner (1904-1990), involves
behavioral changes due to either negative (punishment)
or positive (reinforcers) consequences rather than
just the occurrence of a stimuli. If behavior is rewarded, the likelihood of it
reoccurring increases; if behavior is punished, chances are it will not
reoccur. Positive reinforcement includes friendly smiles, praise, or special
treats/privileges; punishment includes criticism, a frown, or withdrawal of
privileges. Skinner discovered behavioral change became more permanent when
consequences were provided intermittently rather than continuously, and
believed the essence of development involved constantly acquiring new behaviors
or habits due to reinforcing or punishing stimuli. He emphasized why behaviors
occur rather than simply describing the behavior seen (Skinner, 1953). Bandura and Social Learning A third kind of
behaviorism is social learning, proposed by Albert Bandura (b. 1925). According
to this view, children learn by imitating and observing others (a model), as
well as by classical and operant conditioning. Social learning theorists also
believe behavior is influenced by the environment and learned through various
experiences. However, they do not believe behavioral change is a mindless
response to stimuli. Rather, they suggest personality, past experiences,
relationships with the model, the situation itself, and cognition also impact
behavioral change (Bandura, 1977). Cognition plays a part because to
successfully imitate behavior, a child must be capable of remembering,
rehearsing, and organizing the behavior seen. Children often will think about
connections between behavior and consequences and will likely be affected more
by what they believe will be the consequences rather than what the consequences
actually are. For example, learning to play a musical instrument is expensive
for families, and demanding and time consuming for children. However, children
and their parents continually tolerate the cost and inconvenience because they
are anticipating rewards once the child learns to play the instrument. Bandura also
believes modeled behavior can be weakened or strengthened depending on whether
it is punished or rewarded. Bandura suggests observational learning (learning
that results from merely watching others), where children acquire a variety of
new behaviors when "models" are merely pursuing their own interests
and not attempting to teach, reward, or punish, is another important method of
learning behaviors. For example, research has shown children who watch
television violence frequently are more aggressive than those children who do
not watch very much television violence (Murray & Zentner,
2001). Finally, Bandura found children tend to model behavior of children and
adults of their same gender more often than not, and males model behavior of
others more often than females do. Application Although
behaviorism has been criticized for denying the inherent capabilities of persons
to willfully respond to environmental situations and its relative elementary
nature, it is useful in health care. Positive behaviors can be reinforced by
encouragement, praise, and other rewards, and behaviors needing to be altered
or removed from a child's repertoire can be extinguished by either ignoring or
punishing. Parents commonly use these concepts when toilet training or teaching
their children cooperation, compromise, helpfulness, and empathy. Some academic
and preschool programs and parents use behavior modification and time-out
activities to modify and change undesirable behavior in children. Operant
conditioning can also help plan new or extinguish undesirable behavior by
providing specific guidelines, determining available reinforcers,
identifying responses acceptable for reinforcement,
and planning how reinforcers will be scheduled so
behavior is repeated. Social learning
theory is also readily applicable to health care. Children often will cooperate
with procedures (blood draws, X rays) if they see
other children or adults they emulate cooperating for the same procedure.
Nurses can help parents realize that their appearance and behavior is often
imitated by their children, and determine who might be significant role models
for their children to emulate. Finally, nurses need to demonstrate nurturing
approaches or discipline methods so parents learn effective parenting
practices. GROWTH AND DEVELOPMENT OF THE NEWBORN The
neonatal or newborn period is defined as the first 28 days, or 4 weeks, of
life. This chapter will present the normal changes that occur during the
transition to extrauterine life and the normal physiological,
psychosexual, cognitive, and psychosocial development that occurs during the
newborn period as well as information related to the high-risk newborn. Nursing
care of the normal and high-risk newborn will also be presented. EXTRAUTERINE TRANSITION Fetal
circulation is different from neonatal circulation due to structural
differences that include the (1) placenta, (2) umbilical arteries and veins,
(3) ductus venosus, (4)
foramen ovale, and (5) ductus
arteriosus. The placenta provides oxygen and
nutrients for the fetus, and removes carbon dioxide and other waste products.
The umbilical cord connects the fetus to the placenta, and contains two
arteries and one vein. Blood from the placenta flows through
the umbilical vein to the abdominal wall of the fetus. The umbilical
vein then divides into two branches. A small portion of the blood flows through
one branch and to the liver, sinusoids, and hepatic vein before entering the
inferior vena cava. Sixty percent of the blood flows through the ductus venosus (a shunt in the
fetus that carries oxygenated blood from the umbilical veins) and directly
enters the inferior vena cava (Moller & Dwan,
1992a). The blood then enters the right atrium. Most blood will bypass the
fetal lungs via the foramen ovale (an opening
between the right and left atria) and enter the left atrium. From the left
atrium, the blood enters the left ventricle and is pumped into the aorta to the
hypogastric arteries. The small amount of blood that
does pass from the right atrium to the right ventricle will pass into the
pulmonary artery. From the pulmonary artery, a small amount will go to the
nonfunctional lungs into the pulmonary vein, left atrium, left ventricle, and
to the aorta. The remainder of the blood will pass through the ductus arteriosus (channel
between the main pulmonary artery and the aorta) to the aorta. The hypogastric arteries lead to the iliac arteries, which give
rise to the umbilical arteries, which then return the blood to the placenta.
Figure 7-1 represents fetal blood flow. The
transition to extrauterine life begins with the loss of
the umbilical cord and the initiation of respirations. With the initiation
of respirations, the PaO2 levels are increased, and several changes
occur. Decreased pulmonary vascular resistance results in increased pulmonary
blood flow, causing an increase in the pressure of the left atrium, a
decrease in pressure of the right atrium, and closure of the foramen ovale. The foramen ovale closes
shortly after birth and then undergoes fusion of the tissue margins during
early childhood. Increased PaC>2 levels also lead
to an increase in systemic vascular resistance, a decrease in systemic venous
return, cessation of umbilical venous return, and closure of the ductus venosus. The closure of
the ductus venosus occurs
gradually over a period of about 2 weeks. Since systemic resistance is greater
than pulmonary resistance, a left-to-right shunt occurs within the heart,
resulting in closure of the ductus arteriosus (usually within 24 hours of birth) and gradual
obliteration over the next month (Moller & Dwan,
1992b). Figure 7-2 represents transition to extrauterine
life. The
average period of transition is 6—12 hours, but may be shorter or longer
depending on the neonate's ability to adjust to the stresses of labor,
delivery, and a new environment (Kelly, 1994). Therefore, during this
transition period, the neonate needs to be closely observed for any
difficulties so that appropriate interventions can be offered. PHYSIOLOGICAL DEVELOPMENT General Appearance Most
people visualize a newborn as the baby seen in advertisements (Figure 7-3);
however, the actual appearance may be a surprise to caregivers. The newborn's
head, which is one-quarter of the total body size, may appear out of proportion
to the body and be misshapen due to the labor and delivery process (molding;
Figure 7-4). A caput succedaneum may be present as well, especially
after a long labor. A caput is the swelling of the soft tissues of the scalp.
The swelling may extend across the suture lines, is evident within 24 hours
after birth, and usually resolves within a few days. The collection of blood
between the skull bone and the periosteum as a result
of the rupture of blood vessels secondary to head trauma from the birth
process may result in a cephalhematoma. A
cephalhematoma develops 24-48 hours after birth and
does not cross the suture lines (Figure 7-5). A
cephalhematoma may take 2—3 weeks to resolve.
Reassurance to the caregivers is needed that many of these
characteristics will change over the future weeks and months and that the
newborn will then begin to take on the appearance of a "normal" baby.
Eyelids may be puffy and eye color indistinguishable. In addition, the newborn
has a large, round abdomen with an umbilical area that may protrude for several
weeks until the cord stump falls off. The caregiver should be instructed on
appropriate umbilical cord care. The
extremities may appear short in comparison to the body, but hands should be
able to touch the upper thighs when extended. The legs may appear to be bowed
and the newborn typically remains in a position with the extremities flexed.
The skin is delicate, often mottled, or acrocyanosis
may be present. Acrocyanosis is the bluish
discoloration of the hands and feet caused by the instability of the peripheral
circulation system. Many
caregivers are afraid to touch the baby's head or "soft spot" due to
the fear of causing damage. The soft spots, or fontanels, occur at
junctions or suture lines of the skull bones, allowing for adaptation to the
pelvis shape during delivery and growth of the brain over the coming year
(Figure 7-6). The posterior fontanel typically closes by 3 months of age, while
the anterior fontanel closes around 8-18 months of age. Caregivers need
reassurance that many of these characteristics will change during these time
periods and the newborn will then begin to take on the appearance of a
"normal" baby. Head Inspection Shape
and Symmetry With
the child sitting upright either in the caregiver's arms or on the examination
table, observe the symmetry of the frontal, parietal, and occipital
prominences. Normally, the shape of a child's head is symmetrical without
depressions or protrusions. The anterior fontanel may pulsate with every heart beat. The infant of Asian descent generally has a
flattened occiput, more so than infants of other races. A flattened occipital
bone with resultant hair loss over the same area is abnormal and is usually
caused by the infant being in the supine position for prolonged periods of
time. Head
Control Head
control is assessed when the infant is in a sitting position. With the head
unsupported, observe the infant's ability to hold the head erect. At 4 months
of age, most infants are able to hold the head erect and in midline. To
evaluate for head lag, pull the infant by the hands from a supine to a sitting
position. Again by 4 months of age, the head should stay in line with the body
when being pulled forward. Documented prematurity, hydrocephalus, and illnesses
causing developmental delays are possible causes of head lag. Significant head
lag after 6 months of age may indicate brain injury and should be further
investigated. Newborn head lag Palpation Fontanel Place
the child in an upright position. Using the second or third
finger pad, palpate the anterior fontanel at the junction of the sagittal,
coronal, and frontal sutures. Palpate the posterior fontanel at the
junction of the sagittal and lambdoidal sutures.
Assess for bulging, pulsations, and size. Crying will produce a distorted,
full, bulging appearance. The anterior fontanel is soft and flat. Size ranges
from 4 to 6 centimeters at birth. The fontanel gradually closes between 9 and
19 months of age. The posterior fontanel is also soft and flat. The size ranges
from 0.5 to 1.5 centimeters at birth. The posterior fontanel gradually closes
between 1 and 3 months of age. It is normal to feel pulsations related to the
peripheral pulse. If
palpation reveals a bulging, tense fontanel, this is abnormal and indicates
increased intracranial pressure. A sunken, depressed fontanel occurs with
dehydration, A wide anterior fontanel in a child older
than 2V2 years is an abnormal finding. An anterior fontanel that remains open
after 2V2 years of age may indicate disease such as rickets. In rickets, there
is a low level of vitamin D relative to decreased phosphate level. A posterior
fontanel greater than 1.5 cm in diameter is abnormal and occurs with congenital
hypothyroidism. Suture
Lines With
the finger pads, palpate the sagittal suture line, which runs from the anterior
to the posterior portion of the skull in a midline position. Palpate the
coronal suture line, which runs along both sides of the head, starting at the
anterior fontanel. Palpate the lambdoidal suture. The
lambdoidal suture runs along both sides of the head,
starting at the posterior fontanel. Ascertain if these suture lines are open,
united, or overlapping. Grooves or ridges between sections of the skull are normally palpated up
to 6 months of age. Suture lines that overlap or override one another, giving
the head an unusual shape, warrant further investigation. Craniosynostosis
is premature ossification of suture lines, whereby there is early formation and
fusion of skull bones. Craniosynostosis may be caused
by metabolic disorders or may be a secondary consequence of microcephaly.
Figure 14-8 illustrates a superior and lateral view of an infant head. Surface
Characteristics With
the finger pads, palpate the skull in the same manner as the fontanels and
suture lines. Note surface edema and contour of the cranium. Normally, the skin
covering the cranium is flush against the skull and without edema. A
softening of the outer layer of the cranial bones behind and above the ears
combined with a ping-pong ball sensation as the area
is pressed in gently with the fingers is indicative of craniotabes,
an abnormal finding. Craniotabes is associated with
rickets, syphilis, hydrocephaly or hypervitaminosis. Infant Head Structures. Another
abnormal finding in a newborn is a cephalhematoma, or a localized, subcutaneous swelling over one of the
cranial bones. Refer to Chapter 7 for additional information about a cephalhematoma. Another
variation in the newborn that causes the shape of the skull to look markedly
asymmetric is known as caput succedaneum or swelling over the occipitoparietal region of the skull. A newborns head may
also feel asymmetric due to molding of the cranial bones as a result of induced
pressure during delivery. Eyes General
Approach From
infancy through about 8—10 years, you should assess the eyes toward the end of
the assessment, with the exception of testing vision, which should be done
first. Remember that the child's attention span is short, and attentiveness
decreases the longer you evaluate. Young children generally are not cooperative
for eye, ear, and throat assessments. Place the young infant, preschooler, or
school-aged or adolescent child on the examination table. The older infant or
the toddler can be held by the caregiver. Vision Screening General
Approach Several
screening tests are available to evaluate visual acuity in children including
the adult Snellen, Snellen
E, and Allen. The child's age and developmental level determine the measures
used. The adult Snellen chart can be used on children
as young as 6 years, provided they are able to read
the alphabet. The Snellen E chart, which shows the
letter "E" facing in different directions, is used for a child over 3
years of age or any child who cannot read the alphabet. Test eveiy 1-2 years through adolescence. If the child resists
wearing a cover patch over the eye, make a game out of wearing the patch. For
example, the young child could pretend to be a pirate exploring new territory.
Use your imagination to think of a fantasy situation. The Allen test (a series
of seven pictures on different cards) can be used with children as young as 3
years of age (American Academy of Pediatrics Committee on Practice and
Ambulatory Medicine, Section on Opthalmology, 1996). Snellen E Chart Ask
the child to point an arm in the direction the E is pointing. Observe for
squinting. Vision is 20/40 from 2 to approximately 6 years of age, when it
approaches the normal 20/20 acuity. The test is abnormal if results are 20/40
or greater in a child 3 years of age or 20/30 or greater in a child 6 years or
older, or if results are different in each eye. Nearsightedness
or myopia is the result of congenital cataracts, retinal trauma, or a tumor. Allen
Test With
the child's eyes both open, show each card to the child and elicit a name for
each picture. Do not use any pictures with which the child is not familiar.
Place the 2-3-year-old child 15 feet from where you will be standing. Place the
3-4-year-old child 20 feet from you. Ask the caregiver to help cover one of the
child's eyes. Show the pictures one at a time, eliciting a response after each
showing. Show the same pictures in different sequence for the other eye. To
record findings, the denominator is always constant at 30, because a child with
normal vision should see the picture on the card (target) at 30 feet. To
document the numerator, determine the greatest distance at which three of the
pictures are recognized by each eye, for example, right eye = 15/30, left eye
= 20/30. The child should correctly identify three of the cards in three
trials. Two- to three-year-old children should have 15/30 vision. Three- to
four-year-old children should be able to achieve a score of 15/30 to 20/30.
Each eye should have the same score. If the scores for the child's right and
left eyes differ by 5 feet or more or either or both eyes score less than
15/30, refer the child to an ophthalmologist. Strabismus
Screening The
Hirschberg test (corneal light reflex) and the cover-uncover test screen for
strabismus. The latter is the more definitive test. Hirschberg Test Hold
a pen light by the side of your head with one hand so the light is facing
straight ahead. The pen light should be approximately 12 inches from the
child's head. Using your other hand turn the child's head so the light is in the
midline position toward the child's eyes. Make a general observation of the
light reflection relative to both cornea noting symmetry and central location.
The reflected light should be seen symmetrically in the center of both corneas. Esotropia, thought to be congenital, occurs when the light
reflection is displaced to the outer margin of the cornea as the eye deviates
inward. Some theories suggest that neurological factors contribute to its
development. Exotropia occurs when the light
reflection is displaced to the inner margin of the cornea as the eye deviates
outward. This abnormality can result from eye muscle fatigue or can be
congenital. More information on eye abnormalities can be found in Chapter 31. Cover-Uncover
Test This
test is performed on infants greater than 6 months of age through school-age.
Stand 2 feet in front of the child. Place the child in a seated position on the
examining table or caregiver's lap. Ask the child to focus attention on the pen
light by the side of your head. Place a cover card or your hand over one eye.
Wait until the uncovered eye focuses then remove the occluder
and evaluate the eye just uncovered for focusing movement. The
normal finding is neither eye moves when the occluder
is being removed. Infants younger than 6 months of age display strabismus due
to poor neuromuscular control of eye muscles. It is abnormal for one or both
eyes to move to focus on the penlight during assessment. Assume strabismus is
present. Strabismus after 6 months of age is abnormal and indicates eye muscle
weakness. Inspection Eyelids Sit
at the child's eye level. Observe for symmetrical palpebral fissures (opening
between the margins of the upper and lower eyelids) and position of eyelids in
relation to the iris. Normally, the palpebral fissures of both eyes are
positioned symmetrically. The upper eyelid covers a small portion of the
iris, and the lower lid meets the iris. Epicanthal
folds are normally present in children of Asian descent. An epicanthal
fold is an excess skinfold over the angle of the inner canthus of the eye. It
is abnormal for a portion of the sclera to be seen above the iris as it is in
children with hydro-cephalus. As the forehead becomes
prominent, the eyebrows and eyelids are drawn up, creating a setting sun
appearance of the child's eyes. Children with Down syndrome have a fold of skin
covering the inner canthus and lacrimal caruncle.
During embryonic development, the fold of skin slants in a downward direction
toward the nose. Lacrimal
Apparatus If
lacrimal duct obstruction is suspected, use the index finger to lightly palpate
the lacrimal sacarea while bracing the child's head
with the other hand. Note drainage from the lacrimal duct orifice. The child's
caregiver reports that the child is unable to produce tears, an abnormal
finding. The lacrimal ducts should be open by 3 months of age. Dacryocystitis is an infection of the lacrimal sac caused
by obstruction of the lacrimal duct. It is characterized by tearing and discharge from the eye. Anterior
Segment Structures Sclera The
sclera is observed mainly to determine its color. Normally, the newborn
exhibits a bluish -tinged sclera related to thinness of the fibrous tissue. The
sclera is white in light-skinned children and a slightly darker color in some
dark-skinned children. A yellowish color to the sclera indicates jaundice,
which is due to hemolysis of red blood cells, non-functioning liver cells, or
obstruction of bile in the common or hepatic duct. Iris Using
the light source on the opthalmoscope, observe the
iris for lesions and color. Up to about 6 months of age, the color of the iris
is blue or slate gray in light-skinned infants and brownish in dark-skinned
infants. By 12 months of age, complete transition of iris color has occurred.
Small white Hecks, called Brushfield's
spots, noted around the perimeter of the iris are abnormal. Brushfields
spots are found on the iris of the child with Down syndrome. The spots develop
during embryonic maturation. Pupils The
pupils should be inspected for size, shape, equality, and response to light.
Pupils should be equal in size; however, a small number of individuals (5%)
normally have pupils of different sizes (Jarvis, 1996). To test for pupillary
light reflex, dim the room lights. Position the child according to age. Move
the lighted instrument in from the side and observe the change in the size of
the pupils. The pupils should react equally and accommodate to light. An
abnormality is suspected if one or both pupils are nonreactive. Any central
nervous system insult (e.g., head injury, meningitis, seizures) may cause an
abnormal response. Inspection Red
Reflex Turn
the opthalmoscope to 0 diopters. Stand 10-12 inches
from the client and observe the pupil through the opthalmo-scope's
window. Note the color of the reflex within the eye. In children, the red
reflex appears as a brilliant, uniform red glow. In newborns and infants, the
red reflex will appear lighter. In many darker-skinned individuals, the reflex
will appear darker. Black spots or opacities within the red reflex are abnormal
and may indicate a cataract. Chromosomal disorders, intrauterine infections,
and ocular trauma are possible causes of cataracts in newborns. A yellowish or
white light reflex (cat's eye reflex) is also abnormal and may indicate
retinoblastoma, a malignant glioma located in the
posterior chamber of the eye. Retina Assess
the retinal background for color. Divide the retina into four quadrants and
follow the retinal arteries and veins from the disc to periphery. Note the size
and distribution of retinal arteries and veins. The retinas background is
generally pink but may be lighter in some Caucasians and darker in African
American individuals. There is no difference in normal vasculature among
children and adults. A red to dark-red color is abnormal. Some areas may be
rounded or flame shaped. Hemorrhage is seen in trauma. Bleeding into the optic
nerve sheath is found in children who have been physically shaken. Optic
Disc At
a 15° lateral position to the eye, move in closer to the eye approximately 1
inch from the child. Move the diopter to -5 to 0. Locate a vessel and move medially
(nasal side) to locate the disc. Observe the color of the disc along with
margin definition. The disc is creamy yellow to salmon in color. The disc is
lighter in an infant. It measures about 1.5 mm in diameter and is round in
shape. The margins of the disc are regular and clearly defined. If abnormal,
the margins are blurred. In papilledema, the optic disc margins are abnormal.
The margins are poorly defined (blurred) related to increased intracranial
pressure. Ears Auditory
Testing General
Approach Perform
auditory testing at about 3^ years of age or when the child can follow
directions. Prior to 3 years of age, the following are a few parameters for
evaluating hearing: 1.
Does the child react to a loud noise? 2.
Does the child react to the caregiver's voice by cooing, smiling, or turning
eyes and head toward the voice? 3.
Does the child try to imitate sounds? 4.
Can the child imitate words and sounds? 5.
Can the child follow directions? 6.
Does the child respond to sounds not directed at him or
her? External
Ear Inspection
of Pinna Position Position
the child on the caregiver's lap or examining table. Draw an imaginary line
from the outer canthus to the top of the ear. The top of the ear should be at
or a little above the imaginary line. An abnormal finding occurs when the top
of the ear is below the imaginary line drawn from the outer canthus to the top
of the ear. Kidneys and ears are formed at the same time in embryonic
development. If a child's ears are low set, renal anomalies must be ruled out.
Low-set ears can also occur in Down syndrome. Internal
Ear Inspection A
cooperative child may be allowed to sit for the assessment. A young child may
be held as shown in Figure 14-9A. Restrain the uncooperative young child by
placing him or her supine on a firm surface. Instruct the caregiver or
assistant to hold the child's arms up near the head, embracing the elbow joints
on both sides of either arm. Restrain the infant by having the caregiver hold
the infant's hands down. With
your thumb and forefinger grasping the otoscope, use
the lateral side of the hand to prevent the head from jerking. Your other hand
can also be used to stabilize the child's head. Pull the lower auricle down and
out to straighten the canal. This technique is used in children up to about 3
years of age. Use the adult technique after age 3. Insert the speculum about V4
to Vg inch, depending on the child's age. Suspected otitis media must be
evaluated with a pneumatic bulb attached to the side of the otoscope's
light source. Select a larger speculum to make a tight seal and prevent air
from escaping from the canal. If a light reflex is present, focus on the light
reflection. Gently squeeze the bulb attachment to introduce air into the canal.
Some nurses prefer to gently blow air through the tubing rather than squeezing
air into the canal. Observe the tympanic membrane for movement. The
tympanic membrane is transparent and pearly gray to light pink in color. The
membrane is smooth and continuous. Light from the otoscope
is reflected off the membrane. The tympanic membrane moves when air is
introduced into the canal. Nose Observe
the size and shape of the external nose, which should be symmetric and
positioned in the center of the face. A short and small, large, or flattened
nose may indicate congenital anomalies. Observe the external nose for flaring,
discharge, or odor. Nasal flaring indicates respiratory distress. Purulent
yellow or green discharge accompanies an infection. Clear, watery secretions
may indicate allergic rhinitis, the common cold, or a foreign body. A foul odor
may indicate a foreign body lodged in the nasal cavity. In an infant and young
child, the nasal cavity can be visualized by tilting the head back and pushing
the tip of the nose upward. The nasal mucosa should be firm and pink. Patency
of the nares must be determined at birth because newborns are obligatory nose
breathers. With the infant's mouth closed, block one nostril and then the
other. Observe the respiratory pattern. If total obstruction exists, the infant
will not be able to inspire or expire through the uncompressed nostril. If
obstruction is suspected, an assessment for choanal
atresia should be performed. Information about the assessment can be found in
Chapter 7. In choanal atresia, there is a unilateral
or bilateral bony or membranous septum between the nose and the pharynx. Mouth
and Throat Inspection Lips Observe
if the lip edges meet, which is normal. Cleft lip is seen as a separated area
of lip tissue. It involves the upper lip and sometimes extends into the
nostril. A cleft lip is an obvious finding during a newborn assessment. It
occurs mainly on the left side and is more frequently found in males. A cleft
lip develops during the fifth to sixth week after fertilization. Genetics plays
a small role in etiology. Refer to Chapter 23 for a full discussion of cleft
lip. Buccal
Mucosa If
the child is unable to open the mouth on command, use the edge of a tongue
blade to lift the upper lip and move the lower lip down. The buccal membranes
are pink, moist, and smooth. Thrush, a thick, curdlike
coating on the buccal mucosa or tongue, is abnormal. It can be acquired when a
newborn passes through the vagina during delivery. Teeth Count
the number of teeth present on the gum line. Observe the condition of teeth
surface for caries or chips. Infants cut their first tooth between 5 and 8 months.
By one year of age there are normally eight teeth. Between 5 and 6 years of
age, a child will shed the lower central incisors. About 1 year after deciduous
shedding, the first permanent teeth erupt. A lack of visible teeth coupled with
roentgeno-graphic findings revealing absence of tooth
buds is abnormal. Absence of deciduous teeth beyond 16 months of age signifies
an abnormality most commonly related to genetic causes. It is abnormal for the
teeth to turn brownish black, possibly with indentations along the surfaces of
the teeth. These brownish black spots may be caries (cavities), which can be
caused when a child falls asleep with a bottle in the mouth (Jones, Berg, &
Coody, 1994). Hard/Soft
Palate Observe
the palate for continuity and shape. For infants, you will need to use a tongue
depressor to push the tongue down. Infants usually cry in response to this
action, which allows visualization of the palates. The roof of the mouth is
continuous and has a slight arch. It is abnormal if the roof of the mouth is
not continuous. This anomaly is called cleft palate. Cleft palates vary greatly
in size and extent of malformation. The degree of malformation is classified
into two groups. A midline malformation may involve the uvula or extend through
the soft or hard palates or both. If associated with cleft lip, the
malformation may extend through the palates and into the nasal cavity. Cleft
palates form between the sixth and tenth week of embryonic development, during
fusion of the maxillary and premaxillary processes.
Genetics plays a small role in etiology. Epstein's
pearls in the newborn appear on the hard palate and gum margins and are
abnormal. The pearls are small, white cysts that feel hard when palpated. These
cysts result from fragments of epithelial tissue trapped during palate
formation. Oropharynx Observe
the position and color of the uvula. Observe the color and size of tonsillar tissue in the oropharynx. The tonsils are part of
the lymphatic system and normally are hypertrophied in early childhood.
Beginning at age 10 years, they gradually shrink in size. Tonsillar
size ranges from +1 to +4 (Figure 14-10). Up to the age of 10 years, a tonsil
grade of 2+ is considered normal. Tonsils should not interfere with the act of
breathing. Excessive salivation is an early sign of a tracheoe-sophageal
fistula (TEF). Drooling is accompanied by choking and coughing during the
child's feeding. The esophagus failed to develop as a continuous passage during
embryonic formation. Refer to Chapter 23 for additional information on TEF. Neck
Inspection General
Appearance Observe
the neck in a midline position while the child is sitting upright. Note
shortening or thickness of the neck on both right and left sides. Note any
swelling. Normally, there is a reasonable amount of skin tissue on the sides of
the neck and no swelling. Unilateral or bilateral swelling of the neck below
the angle of the jaw is abnormal. Enlargement of the parotid gland occurs in parotitis or mumps, an inflammation of the parotid gland.
There is pain and tenderness in the affected area. Palpation Thyroid Use
the first two finger pads to palpate the thyroid gland and its lobes. Have the
younger child who is unable to swallow on command take a drink from a bottle.
Upon palpation, note any tenderness, enlargement, or masses. An enlarged
thyroid gland can be indicative of hyperthyroidism. References 1.
Stanhope, M., &
Lancaster, J. (2000). Community and Public Health Nursing (5th Edition) St.
Louis: Mosby. 2.
Stanhope, M., &
Lancaster, J. (2006). Foundations of Nursing in the Community:
Community-Oriented Practice (2nd Edition) St. Louis: Mosby-Elsevier. 3.
Hitchcock, J.E., Schubert,
P.E, & Thomas S.A. (1999) Community Health Nursing: Caring in Action / Delmar. 4.
American Psychological
Association. (1994) Publication Manual of the American Psychological
Association (4th ed.). Washington, DC: Author. 
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