NU 352 Preschool and School Age

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1

How old is the Preschool client?

3-5

2

What changes are made in the areas of fine and gross motor development in the preschool client?

Fine motor skills: copying shapes and figures on paper, dressing themselves (not perfect, but trying, getting more independent).

Gross motor skills: At 3 yrs, they should be able to ride a tricycle, can stand on one foot for a few seconds. A 4 yr old can hop on one foot, skip and throw a ball overhead. 5 yr old can jump rope and walk backwards heel to toe.

3

What is Piaget's cognitive developmental stage for the preschool client? What does this entail for the 2-4 year old? The 4-7 year old?

Pre operational Phase: From the 2-7 year old,

The 2-4 year old has preconceptual thought – Can focus on the single aspect of something but don’t see things like cause and effect. They think about things symbolically, recognize symbols.

Artificialism: Everything is made by humans. If it’s windy outside, someone must be blowing very hard, or painted the clouds in the sky.

Animism: Thinking that inanimate objects are alive.

Imminent Justice: Code that determines law and order in which everything is black and white. If a rule is broken, you get punished immediately, no buts or excuses.

The 4-7 year old has intuitive thought – More advanced, still have trouble with cause and effect, but more aware of it. Not completely logical yet. Still a little bit of magical thinking, like to pretend, dress up, but beginning to piece some things together.

Time: Able to understand things that happened in the past and that there is a future. Sense of time is not clear though. Next week could be tomorrow in their mind.

Language: Starts to speak in sentences, like to talk incessantly, stammering and stuttering is normal. They just have so much to say but their coordination isn’t good and it doesn’t come out. Start to learn letters and should be able to identify their colors and shapes.

4

What is Erickson's psychosocial developmental phase for the preschool client? What does this entail for the client's development during this period? What should a nurse teach parents on how to encourage proper psychosocial development during this time?

Initiative vs. Guilt

Want to take control over their environment. Like to accomplish things, like to be challenged. Question they’re asking themselves is “Am I good or Am I bad?”

If a preschooler wanted to do something, the caregiver should encourage them. Let them be as independent as they an be. Don’t say that they’re not old enough or they’re too small, this gives them a sense of guilt, feeling that they’re bad. Encourage them through failures too. “Good try”

5

How should parents handle sleep problems in a preschool client?

Keep a regular bedtime schedule. Might have trouble with night terrors. If they have a nightmare, give them a nightlight, not a lamp. Less stimulation before bed, have a bedtime routine to wind them down before bed.

6

What are some age appropriate activities for the preschool client?

Pretend and dress up, play kitchen with plastic kitchen sets, plastic doctor kits, books, tricycles, balls, simple puzzles, jump rope.

7

What type of play does the preschool client engage in and what does that mean?

Play is parallel. Not totally cooperative. Called associative play. Will play next to each other with things that are similar, but there is still no direct interaction. No turn taking, no rules, no exchange between players. No competition, no cooperative play yet.

8

How would one encourage health promotion in a preschool client?

Health screenings should include vision screening for myopia (they’re going to school, need to read the board, might struggle in school), immunizations.

Nutrition: still picky eaters, at 5 more adventurous. Serve nutritious foods that the whole family would eat. Don’t let them snack.

9

What should a nurse educate the parents of preschool client about injury prevention?

Anticipatory guidance: stranger danger, gun safety in the home especially where guns are more common, bike helmets for bikes, trikes, or four wheelers. Seat belts in car seat, still sit in the back in a frontward facing car seat, sunscreen, water safety, they should be learning to swim, locking medications away to prevent poisoning.

10

What age is the school age client?

6-12

11

What physical development changes will a nurse expect to see in a school age client?

Proportional changes: Legs start to get long and lanky, lose a lot of body fat, feet and hands seem too large for body (ugly duckling stage), muscle mass begins to develop especially during the latter part.

Weight: Gains about 2-3 kilos a year

Height: Grows about 2 inches a year

Prepubescence: The 2 year period before puberty (the latter stages of school age). Girls are ahead of boys, usually start around 9-12. Boys start about 2 years later.

12

What is Piaget's cognitive developmental stage for the school age client? What does this entail for cognitive development?

Concrete operational stage: 7-11

Understand more reason, not as egocentric, understand things from others’ points of view.

More accurate understanding of cause and effect children can see things from another’s point of view .

Learn about conservation. Conservation: matter is not changed when its form is altered; sees weight and volume as unchanging. Before, they couldn’t tell that no difference existed between a small glass and large glass with the same volume. Now they recognize that the volume is the same in both glasses.

Understands time (days, seasons).

Classification Skills: best friend, second best friend

13

What is Erickson's psychosocial developmental stage for the school age client? What does this entail for play, relationships, and parental guidance?

New interests and involvement in activities, like to be more physically active, get into sportsq

Play: cooperative – turn-taking, sharing, role playing (playing house), playing board games

Peer groups are important, but as this age girls stick with girls and boys stick with boys

Friendships with same gender peers

Clubs and best friends are popular

Need a lot of praise, otherwise when they fail at things, they’ll feel inferior.

Develop self-confidence, let them try things, praise them even when they fail. Builds self-esteem and self-confidence through success and adding of new skills.

14

What are some age appropriate activities for the school age client?

Competitive and cooperative play

Activities: 6-9y o: simple board games, hopscotch, jump rope, rock collecting, ride bicycles, organized sports

9-12 y o: make crafts, build models, collect things, have hobbies

Solve more complex jigsaw puzzles, board and card games

15

What are the principles of moral development for the school age client?

Kohlberg stage: Conventional development – the older school age child has a sense of justice and fairness

Begin to realize that being good and obeying has benefits other than a direct reward

Conscience is important

Rules must be followed to be good

Other development:

Spiritual: God is a human faced man in a white robe. Very fascinated with heaven and hell. Lots of questions about God, His nature, and His characteristics.

Early school age: God can punish you for being bad and disobeying. They like to pray for concrete things like a bike. More about them, in it for themselves.

16

What are some teaching points for nurses to parents regarding social development of the school age client?

Age appropriate and appropriate acting peer groups are important to gain independence from parents and follow good examples from their peer group when not around parents, appropriate gender role; establishes standards for acceptance and rejection

17

What are some teaching points for nurses to parents regarding immunizations in the school age client?

HPV for boys and girls as early as age 9. Human Papilloma virus that is responsible for genital warts which can lead to a variety of cancers. A series of shots over 3 months and booster when 16. Need to have immunity before you become sexually active.

Not a requirement for schools or programs.

SE: fever, pain at injection site, headache, and fainting is the big one.

Meningococcal vaccine (MCV4)

First dose is around 11-12. Booster when 16. Prevents against meningitis. More common in adolescents and college age students, spread by saliva.

18

What are some guidelines for nutrition in the school age client?

By 12, adult portions with healthy snacks. No more happy meals.

Obesity is a concern. Prevent obesity as a child!

Avoid using food as a reward

Emphasize physical activity

Balanced diet

Teach children to make healthy choices

Avoid frequent fast food

Avoid skipping meals, tend to eat more at next meal, don’t care what you’re eating

19

What are some guidelines for sleep and rest in the school age client?

Highly individualized

Dependent on: age, activity level, and health status

9-11 hours

No Nap for this age

The older the school age child is, the more difficult to get to bed. Bedtime resistance. They don’t want to go to bed, stop what they’re doing and sleep.

20

What are some guidelines for exercise and activity in the school age client?

Larger, stronger muscles, more able to do things

Improved capabilities

Virtually every child is suitable for some sport

Coaches need to understand a child’s limitations

Protective equipment should be used

At puberty, boys become stronger. Girls and boys should no longer play together at this point.

Organized, practice and unstructured play

21

What are some guidelines for dental health in the school age client?

Deciduous teeth fall out around the age of 6.

First permanent teeth come in at age 6

Dental problems related to limited or inadequate dental care and trauma

Gingivitis – inflammation of the gums, poor dental hygiene, not flossing

Dental caries

Malocclusion – under or over bite. Rapid growth, jaw might grow faster in the top than bottom. This is when you get braces around 9-13.

Avulsion – Teeth are knocked out due to trauma. If a permanent tooth, find the tooth for it to be put back in. Find it, rinse it off with water or saline, put it back in the hole, and go in the dentist. If not able to put back in the child’s mouth, put in cold milk, the child’s saliva, or the parent’s own mouth.

22

What is important about sex education in the school age client?

Sex play: normal part of development and curiosity

Need formal sex education as a part of typical normal development

Effective communication with parents; not peers. If the parent does not teach the child about sex, they’ll learn about it from friends who don’t know everything and will probably be wrong.

76% of children have had sex before they graduate from high school. Need to know about how to say no, the benefits of being in a monogamous relationship, safe sex, contraception.

23

What are some guidelines for injury prevention in the school age client?

Safety: Firecrackers, guns, four wheelers (ATVs). Don’t get a trampoline. If you do, only one person at a time, put an enclosure around it, don’t put a ladder on it, no somersaults.

Drowning: Teach them to swim, never swim alone.

MVA: Should sit in the back until they weigh 80 pounds and are 4’9’’ tall.

24

What are some principles and common areas of stress in the school age client?

Environmental: Long term stress can lead to depression anxiety and chronic health problems.

Violence is everywhere. In movies, around town, bomb threats in schools.

Academic: Giving 9 and 10 year olds have daily homework, taking tests with real grades.

Family: Parents working, financial troubles

Interpersonal: One problem and stressor one children is the over-sexualization of society. Wearing short shorts, heels. The pressure to look older than you are at age 8 is incredible and it’s real. Pressure to grow up earlier.

25

What are some signs of stress in the school age client?

Stomach aches and headaches

Sleep problems

Bed wetting

Changes in eating habits

Aggressive or defiance

Withdrawal

Regressive behavior

Trouble concentrating

THEY WILL NOT TALK ABOUT IT TO YOU

26

What are the principles and treatment of school phobia in the school age client?

To get out of something they find stressful

Also could be for the reward of staying home or going to grandma’s. Creates attention.

Resist or demonstrate reluctance

School refusal and school avoidance

Physical symptoms: Will complain of a headache, nausea, stomach pain but only the night before or morning of school. But fine on the weekends.

Absence of symptoms on weekends and holidays

Usually due to a school related incident

Severe anxiety

Treatment: based on cause. Some of the children need counseling to get over their anxiety.

27

What are the principles of bullying in the school age client?

Form of aggression

One person or many people exert power over another who is considered weaker

May be physical, social and emotional

Most common in middle school

Attempt to embarrass and harm

Bully may perceive behavior as fun

Can occur in groups

It IS harmful and it is NOT normal

There should be a zero tolerance policy for bullying

Boys are more physical with the bullying.

Girls: relational bullying, excluding people, behind peoples’ backs.

Can lead to long term mental health problems including eating disorders, depression, and suicide

Should be taken very seriously

Awareness programs

28

What is a conversion reaction? What are the important concepts to know?

Also called mass hysteria

Non-intentional stress response to a stressor

More in girls than boys

Sudden onset psychophysiologic disorder

Traced to a precipitating environmental event

Seizures, pain, fainting, paralysis, visual disturbances. s/s can last hours to several months.

http://www.cdispatch.com/news/article.asp?aid=3627

How to prevent?

Education

Stress reduction – distraction

29

Describe some common dishonest behaviors in school age clients?

Lying: especially among young children, they exaggerate. The older child knows exactly what the truth is, but still lies occasionally. Lead by example.

Stealing: Common in the younger child. They’ll take something because they like it. They’ll also give their won things away. Don’t take much responsibility for this until middle school. This is when stealing would become an issue. It might be about the rush or that they’re lacking something in their own life.

Cheating: Especially at games and sports. They like to win.

30

What are the principles and treatment forms for enuresis (bedwetting) in the school age client?

Bedwetting or nocturnal enuresis

Intentional or involuntary

Diagnosis criteria:

Developmental age of at least 5 years

At least twice a week for 3 months

Pathologic causes must be ruled out first: UTI, diabetes, constipation, sickle cell disease, and neurological disorders.

More common in boys. Typically outgrows by age 8.

May be primary or secondary: Primary is when the child was never toilet trained correctly. Secondary is when the child was trained and starts wetting the bed.

Strong family history

Treatment:

Medications are only a 2nd line treatment bc of the side effects

Restricting or eliminating fluid after dinner

Avoiding sugar and caffeine after 4pm

Waking up at night to void

Motivational therapy: Keep a sticker chart, have rewards and motivations to not wet the bed

Conditioning therapy: Alarms that train your body to respond to bladder sensations

Encourage child’s participation in treatment: Make them responsible. Have them make the new bed for themselves

Do not use diapers, they don’t feel the wetness as well

Treat constipation

Do not be punitive

Medications used to treat Enuresis:

Tricyclic Antidepressants: tofranil. Causes cardiac problems, need an EKG

Anticholinergics: oxybutynin

DDAVP: desmopressin, decreases volume of urine

Give all meds at bedtime! That’s when they’re most effective.

31

What are the principles of juvenile idiopathic arthritis in the school age client?

Used to be juvenile rheumatoid arthritis

Chronic inflammatory disease

Affects joints and other tissues especially the eyes

Starts before age 16

Peak incidence of onset 1-3 years

Girls more than boys

Cause unknown, probably an autoimmune disease.

Most children outgrow it, but they’re left with the damage to their joints and the deformity from the disease.

Can cause significant disability

Group of diseases

Classified based on number of joints infected, other system involvement, symptoms, presence of rheumatoid factor

Disease of exclusion

Arthritis in 1 or more joints for at least 6 weeks

Can develop glaucoma and other eye problems. Need eye exams every 6 months.

They have delayed growth and development, enlarged lymph nodes, fever, stiffness, pain, swelling in the joints.

32

How do we diagnose and treat juvenile idiopathic arthritis?

Diagnostic Tests Include

Xrays of affected limb

ESR

Leukocytosis – elevated WBC

Positive ANA titer

Slit lamp eye exam: uveitis

Treatment

No cure, supportive care includes

Treatment goals: To decrease inflammation and preserve functioning

Medication

Physical and occupational therapy: ROM, activities like swimming for exercise without direct pressure on joints.

Eye exams

Splints, comfort measures like heat, warm baths, warming pads

Dietary management – healthy eating, make sure lots of fiber, increase fluid

Psychological Support – It is disabling in some children. Can by anywhere from mild to severe

Medications Used to Treat JIA:

NSAIDS: take with food, may cause GI irritation and bruising

Methotrexate: monitor CBC and LFTs, teach side effects; teens: cataracts and growth suppression

Corticosteroids: immunosuppressants, monitor for SE

Biologic Agents: interrupt the inflammatory process, for severe disease Embrel: SQ injection. SE: increased infection, avoid live vaccines, increased risk of malignancies, pancytopenia

Other Treatments

OT/PT: preserve function, avoid deformity

Water therapy

Night time Splinting: minimize pain, prevent joint deformity

Heat therapy

33

What are the principles of head lice in the school age client?

A louse can live 48 hours off of the scalp. They only like people not pets.

Itching and skin irritation behind the ears or the nape of the neck indicates them.

Only way to diagnose it to look for the white nits. A translucent nit is an empty shell.

Use gloves and a new tongue depressor with every person you’re examining.

If diagnosed, use OTC meds, repeat them a week later, and comb out as many of the nits as you can.

Lice are getting resistant to some meds that we use today

Wash all linens, clothes, and stuffed animals must be washed. Non-washable items should be put in a plastic bag and left for 14 days. And throw away all combs and brushes used.

Affects all socioeconomic classes.