University of Santo tomas College of Nursing

Nursing Elective Topic 3: The Child

III 9 RLE 3 Santos, Harriene Cristie Santos, Ingrid Joyce Santos, Rene Mercedes Santos, Richelle Jane Sarmiento, Lani See, Glaiza Kathrina Sia, Shirleen Nicole Sibal, Maria Margarita Sioson, Nina Angelica Sison, Maria Danica Submitted: December 5, 2011

1.1 Immediate needs of the neonate at home After 40 weeks of waiting the fruit that have been waiting has finally arrived. After days and months of full of anticipation, there are things that you should know in taking of a neonate at home. Promoting Optimum Health During Infancy A. Nutrition The first 6 months Human milk is the most desirable complete diet for the infant during the first 6 months. The healthy term infant receiving breast milk from a wellnourished mother usually requires no specific vitamin and mineral supplements, with the exception of iron by 4 to 6 months of age(when fetal iron stores are depleted). Daily supplements of vitamin D and vitamin B12 may be indicated if the mothers intake of these vitamins is inadequate. (Hockenberry/Wilson, 2007) The Second 6 months During the second half of the first year human milk or formula continues to be the primary source of nutrition. Fluoride supplementation begins depending on the infants intake of fluoride tap water. If breast-feeding is discontinued, a commercial iron-fortified formula should be substituted. Formulas specifically marketed for older infants, or follow formulas and provide excessive protein (American Academy of Pediatrics, 2004). The major change in feeding habit is the addition of solid foods to the infants diet. Physiologically and developmentally, the infant 4 6 months of age is in a transition period. By this time the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergic foods. (Hockenberry/Wilson, 2007) Selection and Preparation of Solid Foods The choice of solid foods to introduce first is variable but should meet the reasons for feeding solids, such as supplying nutrients not found in formula or breast milk. Iron-fortified infant cereal is generally introduced first because of its high iron content (7mg/3 tbsp of prepared dry cereal). Infants cereal may be mixed with formula in a bowl until whole milk is given. If the infant is breast-fed, the cereal is mixed with expressed breast milk or water. After 6 months of age, fruit juices can be mixed with the dry cereal; the vitamin C content of the juice enhances the absorption of iron in the cereal. Because of their benefit as a source of iron, infant cereals shoul be continued until the child is 18th months of age. (Hockenberry/Wilson, 2007) Fruit juice can be offered from a cup for its rich sources of vitamin C and as a substitute for milk for a one feeding a day. Certain juices (e.g., apple, pear, prune, sweet cherry, peach, and grape) are avoided because it contain high amounts of fructose and sorbitol and may cause abdominal pain, diarrhea, or bloating in some children. White grape juice (no more than 5 oz/day is reported to be better absorbed and safe for infants this

age without causing gastrointestinal distress (Calamaro, 2000). The American Academy of pediatrics (2001b) recommends that fruit juice intake not exceed 4 to 6 ounce per day and that juices not be given to infants less than 4 to 6 months old. Because vitamin C is naturally destroyed by heat, juice is not warmed. Juice containers are always kept covered and refrigerated to prevent further vitamin loss. Offer fruit juices from a cup, rather than bottle, to prevent the development of dental caries (Hockenberry/Wilson, 2007). The order of introduction of other foods is arbitrary. A common sequence is strained fruits followed by vegetables and, finally, meats. Some clinicians prefer to add vegetable before fruit. Only one solid is introduced every 5 to 7 days so that a reaction to a particular food can be distinguished. If foods are introduced early, citrus fruits, meats, and eggs are still delayed until after 6 months of age because of their potential to cause allergy. At 6 months foods such as a cracker or zwieback can be offered as finger and teething food. By 8 to 9 months junior foods and nutritious finger foods such as a firmly cooked vegetable, raw pieces of fruit (except grapes), or cheese can be given. By 1 year well-cooked table foods are served.

Feeding During the First Year BIRTH TO 6 MONTHS Breast-feeding This is the most desirable complete diet for first half of year Recommended supplement of oral vitamin D (200 IU per day)

Introduce one food at a time, usually at intervals of 5 to 7 days, to identify food allergies. Never introduce foods by mixing them with the formula in the bottle.

Formula Cereal Iron-fortified commercial formula Introduce commercially prepared is a complete food for the first half iron-fortified infant cereals and of the year. administer daily until 18th months. Rice cereal is usually introduced 6 TO 12 MONTHS first because of its low allergic Breast or Bottle-Fedding potential. After the child is 6 months of age, Discontinue supplemental iron formula requires fluoride once cereal is given. supplements (0.25 mg per day) when the concentration of fluoride Fruit and Vegetable in the drinking water is below 0.3 Applesauce, bananas, and pears ppm) are usually well tolerated. Avoid fruits and vegetable Solid Foods marketed in cans that are not Solid foods may be started by 5 specifically designed for infants to 6 months of age. because of variable and First foods are strained, pureed, sometimes high lead content and or finely mashed. addition of salt, sugar, and Finger foods such as teething preservatives. crackers, raw fruit, orvegetables Offer dilute fruit juice only from a can be introduced by 6 to 7 cup, not a bottle, to reduce the months. development of bottle caries (limit Chopped table food or to no more than 4 ounce daily) commercially prepared junior

foods can be started by 9 to 12 Meat, Fish, and Poultry months Avoid fatty meats (sausage, With the exception of cereal, the wieners). order of introducing foods is Prepare by baking, broiling, variable; a recommended steaming, or pouching. sequence is weekly introduction Include organ meats such as of other foods, beginning with liver, which has a high iron, fruit, then vegetable, and then vitamin A, and vitamin B complex meat. (Some clinicians prefer to content. introduce vegetable first). If soup is given, be sure all Avoid foods that have potential ingredients are familiar to childs for choking: hot dogs, nuts, diet grapes, raw carrots, popcorn, and Avoid commercial meat-vegetable hard candies. combinations because protein is low. Method of introduction Introduce solid when infant is Egg and Cheese hungry. Serve egg yolk hard boiled and Begin spoon feeding by pushing mashed, soft cooked, or poached. food to back of tongue because of Introduce egg white in small infants natural tendency to thrust quantities (1 teaspoon) toward tongue forward. end of first year to detect an Use small spoon with straight allergy. handle; begin with 1 or 2 Use cheese as a substitute for teaspoons of foods; gradually meat and as finger food. increase to about 1 tablespoon per year of age.

B. Sleep and Activity Sleep patterns vary among infants, with active infants typically sleeping less than placid children, Generally, by 3 to 4 months of age most infants have developed a nocturnl pattern of sleep that last from 9 to 11 hours. The total daily sleep is approximately 15 hours. The number of naps per day varies, but infants may take one or two naps by the end of the first year. Breast-feed infants usually sleep for shorter periods, with more frequent waking, especially during the night, than do bottle-fed infants (Quillin and Gleen, 2004); average total sleep for 4-week-old infant in this study was 14 hours. C. Hygiene a. Dental Health Once the primary teeth erupt, cleaning should begin. Wiping with damp cloth initially cleans the teeth and gums; toothbrushing is too harsh for the tender gingiva. Oral hygiene can be made pleasant by singing or talking to the infant. There are no clear guidelines regarding when toothbrushing should begin; however, it is recommended that the infant have an oral health examination by 6 months of age from a qualified pediatric health practitioner (Hockenberry/Wilson, 2007). b. Bath

Keep all bath items ready (soap, wash cloths, cotton, towels and change of clothes). The room or bathroom should warm, with windows closed. Always test the water first. Remember to fill cold water first in the tub, then add hot water till the temperature is right, to avoid accidental use of very hot water. Hold the baby firmly at all times supporting her / his neck properly. Wash the babys face carefully with minimum of soap, using swabs or a washcloth to clean the eyes. Avoid getting water in the ears. Dry the areas of creases and skin folds groin, armpits, back of knees, neck, etc. Take the baby wrapped in a blanket away from the bathing area before o powdering / dressing up. Do not apply kajal in the eyes or oil to the nose and ears.

c. Care for Special Areas i. Nails Trimming can be done with nail scissors (available in a child care store). It is best done immediately after a bath, when nails are soft. If your baby is a sound sleeper you may do it during the sleep. If not, occasionally you may draw blood because the infant is restless most mothers do so at sometime. Applying pressure stops bleeding and needs no further care. ii. Penis / Vulva During the 1st week you may see an excessive discharge or even bleeding from the genitalia of an infant girl. This is normal and due to the hormones passed from the mother to the child. The vulva and vagina needs no special cares, except that while washing, the movement should be from the front to the back. iii. Penis The uncircumcised penis needs no special care. Do not try and retract the foreskin, as it is generally adherent to the glans. Activity. During the 1st few weeks, a cheesy white substance may be seen at the tip of the penis, which is a collection of the dead cells from the glans and is normal. The circumcised penis needs special care only till the wound heals. Plain soap and water cleaning is ideal for cleaning the penis. iv. Ears No special cleaning is needed. Do not put cotton swabs, etc. to clean the ear. Do not put oil in your babys ears. v. Nose It is self-cleaning. If there is excessive mucus, just wipe off the mucus. Do not use cotton swabs, tissues, fingernails to remove mucus as the delicate membrane of the nose may start bleeding. d. Keeping Clean

Even if you do not bath the infant daily, there is no problem as long as you keep the baby clean by taking care of the following things: Wipe infants bottom from front to back with a wet wipe or wet cotton swab, then wash with water, every time the infant has a bowel movement. At least twice a day, wash the infants bottom with soap and water after a bowel movement. Make sure all the soap is rinsed off. Brush or comb infants head daily to remove scaling dry skin and keep the neonates hair tidy. i. Diapers and Nappies The infant will pass urine and stools many times a day, more so in the first week. Do not worry, most infants settle down to a routine after the first few weeks. In particular, you may notice that every time the infant feeds she may wet or soil himself/herself. This is due to an inbuilt mechanism called the gastro-colic reflex. This will also settle with time, but remember to check the infant nappy after every feeding. You need to decide on what is the type of underclothing you will provide the infant. Nappies or cloth diapers are re-usable, and eco-friendly. More importantly, until the infant grows a little older, preferably a month old, neonate tender skin may not tolerate disposable diapers. This is often seen that disposable diapers which have perfume, makes some infants break out in a rash Cloth diapers should be washed in warm or hot water using detergent. Addition of an antiseptic, which also acts as a bleaching agent may be advisable. This is more important if you do not wash the diaper immediately. The diaper should be rinsed well to remove all traces of the detergent. Once a week, a fabric softener may be used to keep the diapers soft. ii. Changing a diaper/nappy A wet or dirty diaper makes infants skin sore or red, and can lead to rash. Frequent changing should be done as necessary, particularly before and after the infant sleeps. While cleaning the infants bottom, wash the diaper area from front to back (never the other way) to avoid infection. If the infant has a rash, let the bottom dry after each diaper change. Keep infants diaper off for some time to allow ventilation. A zinc-oxide cream can be used on your babys clean, dry bottom to prevent and treat rash. Talcum powder is better avoided as it can worsen a rash, and may act as an irritant. Crying A newborn baby has no other means to express himself/herself other than crying. The infant may cry for different reasons, and may cry loudly or softly. Listen to the infant, hold him/her and dont get hassled yourself. The various causes for crying include: Hunger your baby may want a feed. Wet or Dirty diaper your baby needs changing. Temperature your baby may be hot or cold.

Gas or colic the baby's tummy may be hurting. Try to burp him/her or change position. Attention your baby may just want you to talk to him/her, play with him/her or hold him/her. Noise or crowds your baby may want a little peace and quiet too! Most importantly, dont get nervous if your baby seems to be crying a lot. He/she will settle down soon. If you are tired or need a break, ask your spouse or other family member to take over for a while until your feel better.

Carrying Infants Babies have big head in relation to their bodies, and their necks are not strong enough to support the head for the first few months. Hence special care is required when carrying them. ***Remember a few things to do: Support his/her neck and head well whenever you lift your baby. Wrapping or swaddling the baby before carrying often helps. Do not change position suddenly or toss him/her in the air. Do not let children handle your baby unless an adult is there to supervise or help. A startle response of throwing out his/her arms and legs is not unusual when trying to pick up your baby. Being gentle yet firm is the key to making your baby comfortable.

Clothing Just like adults dress according to the weather, babies also need to be dressed suitably. However a general guideline is that clothing should be soft, not tight, and should not have prickly or poky attachment (like stiff laces or sharp buttons). See to that appropriate under-clothing is used (nappies or diapers). Check the nappy frequently. In warm weather, look out for heat rashes. A red, raised rash may appear if the infant is too warm. While going to the sun, use a bonnet or a sun-umbrella to keep his/her head covered. Remember that babies have a delicate skin, so it is best to avoid over-exposure to the elements like sun, wind or rain. In cool or cold weather it is better to have more layers of clothes than a single thick garment. Woolen clothing like sweater, bonnet or booties should be made of soft wool and preferably worn over cotton under-garments. A light woolen blanket can be used as a swaddling cloth.

Play As the infsnt is growing up, he/she will stay awake for longer periods. Each neonate has his/her own personality, even so soon after birth. By a few weeks of age, you will get an idea as to what he/she wants to do. Newborn babies recognize the mother by smell, voice and appearance, although proper fixation of gaze on an object or person may not be obvious till a month or more from birth. Your baby may want to look at moving objects like a hanging toy on the crib, or pictures. Some find music enjoyable while some like mirrors. Temperature

If the infant is not looking or acting normal, looks down or sick you may need to check his/her temperature. If he/she is sweating first of all check that you have not over-clothed him/her. You may need to check the temperature if the infant is: Having persistent diarrhea or vomiting. Is unusually fretful or fussy. Feels hot. Has a dry mouth or flushed skin. Has a rash. Is not feeding. Breaths differently (noisy, fast or irregular). A special rectal thermometer may be used for this purpose but your doctor/nurse will instruct you how to use this. Never put a thermometer in babys mouth at this age. Normal body temperature is about 37 C (36.1 C to 37.8 C). A temperature higher than 37.8 C (100 F) should be reported to your doctor.

1.2 Common Behavioral Problems of an Infant Behavior Problems in Infants During early infancy, common issues include crying and night waking. During the second half of infancy, additional issues include separation anxiety, repetitive movements, fears, and clinging behaviors. A. Crying and fussy periods The majority of healthy babies experience daily periods of crying for which there is no explanation. By 6 weeks, the duration of daily crying peaks to 3 hours. B. Repetitive movements Neonates often display rhythmic mouthing and sucking, reflex smiling, and myoclonic twitches. Ninety percent of healthy babies display thumb and finger sucking, lip sucking and biting or toe sucking. C. Fears and clinging behaviors Stranger and separation anxieties emerge as the infant begins to distinguish the familiar from strangers. Separation anxiety is a developmental stage during which the child experiences anxiety when separated from the primary caregiver (usually the mother). 1.3 Role of the nurse in the care of a healthy/Ill infant. Healthy Infant Nursing care of infants begins immediately after birth and progresses as a baby grows. Infants are not just small adults; they are patients with their own set of complex health issues. Nurses who work with infants have training to understand the exclusive illnesses and identifiable issues that are particular to young babies. (Brannagan, 2010)

General Care One of the main duties for a neonatal nurse is the general care of the infant. Babies, even tiny ones or those with physical ailments, need regular changes, feedings and cuddles. Customarily, the NICU will assign each baby "care times" throughout the day and night, usually about 3 or 4 hours apart from each other. At each care time, the nurse will change the baby's diaper, take his temperature, and feed him breast milk or formula. If a baby is receiving any medications, these may also be administered during these times. If the parents of an infant are able to visit regularly, a neonatal nurse will teach them how to perform these basic cares. With time, nurses will help parents to feel equipped in all aspects of meeting their little one's needs and will continue to serve as a basic support system during the hospitalization. Special Needs Sometimes babies are too fragile or small to eat directly from breast or bottle. When this is the case, they are fed either intravenously, or through a gavage tube, which is a small tube that goes from the nose or mouth into the stomach. Nurses will carefully place the correct amount of formula or dietary supplementation if a baby is not yet eating, into either of these methods of nutrition, and monitors the baby for any positive or negative changes in the infant. The duties for a neonatal nurse also include inserting and changing IVs, administering blood transfusions when necessary, and drawing blood for various testing. Nurses are able to perform many other procedures as well, and it fully depends upon each hospital's individual protocol, as well as the nurse's experience level and staff rating. Technical Duties for a Neonatal Nurse Regardless of their other responsibilities, all neonatal nurses do a fair bit of charting on each of their patients. This may be on a paper sheet, or more commonly every year, completed electronically via a special hospital computer system. The details logged into the online chart allow doctors, other nurses, and anyone else within the baby's medical care team to view a baby's updated health records. A nurse may also be responsible for emailing the neonatologist (NICU doctor) or calling the parents with specific requests or information. While a neonatal nurse's priorities are found in caring for the child assigned to them, they often also spend a large portion of their shift charting and getting messages out to those who need to receive them. Emotional Support A neonatal nurse often gets to know the families of infants very well, especially if they happen to have a primary baby they take care of. A primary nurse will care for the same infant for the duration of his hospital stay, whenever he/she is on shift. This works well, as the nurses become very familiar with their babies and can in turn provide them with the best care possible.

In building relationships with these families, they can often provide emotional support and comfort during scary times. If a baby has to go through surgery or is exceptionally ill, nurses are great for reassuring the parents and providing as concrete of answers as they are permitted to. Neonatal nurses are often the unsung heroes to families and able to give the earliest of lives a fighting chance. Their daily duties add up to countless miracles and a rewarding career at the same time. (Warta) A. Nutritional Disturbances When an infant presents with a certain vitamin deficiency, the nurse should teach the family about foods and what vitamins they are rich in. Because one of the best assurances of nutritional adequacy is eating variety of foods, families need guidelines for selecting foods that provide essential nutrients without exceeding energy requirements. (Hockenberry/Wilson, 2007) B. Protein-Energy Malnutrition The nurse should meet the essential needs, including adequate and appropriate food intake for protection from infection, skin care and protection, improve sanitary facilities and assess for the source of malnutrition. (Hockenberry/Wilson, 2007) C. Food Sensitivity Teach family to change or avoid giving the infant substances that may trigger his allergies. Encourage family to read ingredient labels carefully before giving it to the infant. (Hockenberry/Wilson, 2007) D. Feeding Difficulties Most feeding problems are easily corrected with reassurance, guidance and demonstration. (Hockenberry/Wilson, 2007) 2.1 Behavioral problems of Toddler A. Tantrums What Are Temper Tantrums? Temper tantrums are a common behavior problem in preschool children who may express their anger by lying on the floor, kicking, screaming, and occasionally holding their breath. Tantrums are natural, especially in children who are not yet able to use words to express their frustrations. It usually occurs at ages 2 to 3 when children are forming a sense of self. The toddler is old enough to have a sense of "me" and "my wants" but is too young to know how to satisfy the want. Tantrums are the result of high energy and low ability to use words to get needs or wants met. It typically peaks between ages 2 and 3, and start to decline by 4. They usually run their

course within a year. Most children throw tantrums in a particular place with a particular person. They usually are a public display after the child has been told "no" to something he or she wants to do. The tantrum usually stops when the child gets his or her wish. What happens with the temper tantrum depends on the child's level of energy and the parent's level of patience and parenting skill. What to do about it: Keep your cool and speak softly. Seeing you lose your temper will make it harder for your child to calm down. Avoid physical punishment. It's never a good idea, but it's especially risky at a time when emotions are running high and you're in danger of losing control. Move a child who is physically out-of-control (thrashing, hitting) to a safe place. Pick her up firmly (without dragging or pulling). If you're in a public place, carry her outside or to your car. If that's not practical, hold your child tight to prevent her from hurting herself. (Some toddlers calm down when they're held tightly.) Create a diversion. Some kids can be distracted by a favorite activity. Be a comedian. Use humor (funny faces, silly songs, unexpected behavior like talking into a banana) or reverse psychology ("I don't want to see any smiles. Try hard not to smile now. Oh no do I see a smile?") to coax the sun out of the clouds. Some toddlers, though, take offense when their tantrums are not taken seriously. Ignore the tantrum. If your child gets physical during tantrums, make sure she's safe before you try this approach. Another option: Enforce a time-out. Do not give in to her demands. This only teaches the lesson that tantrums are a means to an end. If you're out in public and she won't calm down, consider ending the outing. How to prevent it: Ward off the "fearsome four": hunger, fatigue, boredom, and overstimulation. To that end, make sure your child is well-rested and wellfed, avoid overscheduling, and bring healthy snacks and a favorite small toy or book when leaving the house. Work with your child's personality. For many toddlers, sticking to a regular routine decreases the risk of tantrums. Others thrive on spontaneity. Cut down on the need to say "no." This includes childproofing your home (so you don't have to constantly cry, "No, don't touch that!") and setting clear limits. Provide some choice whenever possible. Being able to make decisions ("Do you want to eat cereal or yogurt this morning?") helps a toddler feel

more in control. Say "yes," "no," or negotiate a compromise, but don't say "maybe." In toddler translation, "maybe" equals "yes."

B. Negativism What is Negativism: Negativism is a behavior characterized by the tendency to resist direction from others, and the refusal to comply with requests. Negativism appears and wanes at various stages of a child's development. Active negativism, that is, behavior characterized by doing the opposite of what is being asked, is commonly encountered with young children. For example, a parent may ask a toddler to come away from the playground to return home; on hearing these instructions, the toddler demonstrates active negativism by running away. Infant studies have revealed that negativism develops during the first year of life, and resurfaces during toddlerhood and again during adolescence. Negativism is used by adolescents as a way to assert their autonomy from their parents, and to control their own behavior. When negativism does not diminish, it becomes a characteristic of the individual's personality. Negativism is an aspect of one of the essential features of oppositional defiant disorder , characterized by a pattern of behavior that is defiant, negativistic, and hostile toward authority figures. However, for the majority of children who display negativism, the behavior will pass with further development. What to do about it: Make a real effort not to let this behavior get to you. When she shouts "no!" it can be tempting to shout back "yes!" But getting riled up will only fuel her fire (and raise your blood pressure). Stay calm and use reason: Explain that while you understand her feelings, sometimes she simply has to do what you say even if she doesn't want to. Do try to say yes to "no" sometimes. (Yielding power can be just as important as wielding it.) If your toddler says "no" when the stakes are low, consider capitulating to keep the peace and let her have the satisfaction of calling the shots. For example, if you want her to wear the pink socks but she insists on the red, let her have her way. (But don't give in during a tantrum that will only encourage future meltdowns.) How to prevent it: Minimize opportunities for "no." Cut down on her chances to refuse by casting your questions carefully. Instead of asking, "Would you like green beans tonight?" offer a choice: "Do you want green beans or peas?" Let her participate in the decision-making process, and she'll feel more in charge of her dinner and her destiny.

Don't offer choices when they don't exist. Avoid asking your child to weigh in when the issue is non-negotiable. For example, saying "How about if we go to the doctor today?" is likely to spawn a mini-mutiny. In cases when your tot's got no choice, it's best just to tell it like it is ("Today we're going to the doctor"). Use "no" selectively. Many of us don't realize how often we say no: "No playing in the dining room." "No touching the CD player." "No cookies." No wonder most toddlers are such experienced naysayers! If possible, think before you say "no," use it sparingly, or try to avoid it altogether by turning a negative into a positive. For example, say, "You can play in the playroom instead of the dining room" or "You can't have a cookie but you can have a piece of melon."

C. Ritualism What is ritualism: Ritualism is th need t maintain sameness. Rituals r routines provide repetition whr th outcome m gain comfort nd security. Disrupting th rituals wll mk th outcome experience stress, respond b exerting self-rule, nd frequently regress t dependence nd negativism t cope wth th situation. What to do about it: Let it be. Try not to alter or shortcut the routine. Although this may be quite tempting at times, your toddler is likely to dig in his heels and resist. When circumstances require that you deviate from the routine, try to emphasize the novelty and make it special. Try to warn your toddler ahead of time of impending disruptions. Stay relaxed about food and clothing preferences. Food jags are usually short-lived and will generally not lead to nutritional deficiencies. Power-struggles on the other hand, can lead to indigestion for everyone. Likewise, as long as she is dressed appropriately for the weather, allowing preschooler to wear the same clothing items over and over may offend your sensibilities but wont do any harm 2.2 Accident Prevention for Toddlers A. Burns and scalds Prevention: watch children closely when they are near fires, barbecues, cooktops or any open flame, dont let them play or get near to a source of hot or boiling water. Keep lighters and matches out of reach of children. What to do: Put the burnt area under running cold water as soon as you can and leave it there for at least 20 minutes. This lessens the depth of a burn and therefore its severity. Keep the rest of the childs body warm so they dont get chilled. Dont put anything else

on the burn. Get medical help if the burn is bigger than a 20-cent piece, looks raw or blistered, or is on special areas like the childs face, neck or genitals. B. Choking Prevention: Teach your children to sit quietly while theyre eating. Cut meat into small pieces and for very young children, mash, cook or grate hard foods like carrot or apple. Until theyre 4 years old, keep any games or toys with small parts well out of childrens reach. Supervise them closely because children wants to put anything into their mouth and this can be the cause of choking. What to do: Check first if they can breathe, cough or cry and if so see if they can dislodge the item by coughing. Try simple things first, like clearing the mouth or lying them forward. For small children, tip them upside down and use the help of gravity. If this doesnt work for medical help immediately C. Poisoning Prevention : Have a medicines or poisons cupboard where you can store things out of childrens reach ensure theyre clearly labeled and come with child-resistant caps. What to do: Signs of poisoning can include stomach pains and vomiting, drowsiness, trouble breathing, change of skin colour, blurred vision or even collapse. Dont give the child anything or try to make them vomit. Call for medical help immediately D. Near drowning Prevention: Make sure swimming pools and spas are fenced properly with a self-closing, self-latching gate and always supervise children in the bath. Children can drown in a few centimetres of water, so never leave them alone around a container filled with water, whether its a fish pond or bucket. If youre socializing around water, designate one adult to constantly supervise the children. What to do: If the child is unconscious, unresponsive and not breathing, start resuscitation if you know it. If the child is still unresponsive. Call for help. E. Small things stuck in the nose or ears How to avoid it Keep small things out of reach of little fingers and encourage children to play in an open family area where you can see them. What to do: dont try to get it out yourself. Call a doctor to remove it immediately.. F. Bumps & falls

Prevention: Have a firm set of house rules about how children can play at home. Ban running or silly play indoors and around stairs or windows, and dont let them climb furniture. What to do: Apply ice or a cold pack immediately to any bruise, bump or swelling. If theres severe bleeding, apply pressure with a cloth or bandage and keep the affected area elevated. If the pain seems extreme, or if your child cant move an arm or leg, or put pressure on a leg, there may be a severe strain or even break. G. Things poked in the eye Prevention: Teach the dangers of damaging eyes and never let kids run or play rough with sharp objects. What to do: A finger, fork, even a tree branch, can all cause damage if poked into a childs eye. Keep them calm and check if they can open their eye. If the eye is red, sore or irritated, go to a doctor. A scratch on the cornea can be a bad thing and should be checked, 3.1 Preparing a Preschooler for School: Many children experience anxiety about starting preschool and its mainly because they arent quite sure what it is. Here are things that parents can do in order to prepare their child for school: Playing school is a great way to help your child understand how preschool works and what will go on while he is there. Review basic academics -- colors, shapes, the alphabet and numbers 1-10. Make sure she knows his first and last name. Even the landline number of their house would be good to know. Books are a great way to teach your child about what will be awaiting her. Those simple story books that the parents reads to the before bedtime, is a good start. Choose titles that are about preschool but also touch on separation. Bring your child to the preschool that hell be attending. Letting your child pick out her own backpack and school supplies like crayons will make her feel like a big kid. About a week before the big day, start putting the child to bed at her regular, school bedtime. And wake her up at the time you would when she goes to school.

3.2 Sex Education for Preschoolers: By the age of four, most children are curious about certain sexual issues and

they need clear, honest and brief answers to their questions. Here are some ways in handling preschooler children, who are curious about their sexuality: Teaching the child the proper names for his or her sex organs, perhaps during bath time. Inform the child that masturbation is a normal, but private activity. If the child starts masturbating in public, try to distract him or her. Teach about pregnancy and where babies come from. Explain to him simply how the development of the fetus in the womb develops. Set limits on the childs exposure to nudity with the opposite-sex parent. Show the child that you are comfortable with sexual questions. 3.3 Common Behavioral Problems of Preschoolers A. Sibling Rivalry It is a type of competition or animosity among children, blood-related or not. Siblings generally spend more time together during childhood than they do with parents. The sibling bond is often complicated and is influenced by factors such as parental treatment, birth order, personality, and people and experiences outside the family. According to child psychologist HO Sylvia Rimm, sibling rivalry is particularly intense when children are very close in age and of the same gender, or where one child is intellectually gifted. Handling Early Sibling Rivalry Always remember that the fundamental concern of toddlers and preschoolers in this situation is that they'll be abandoned by their parentsin essence, traded in for a newer and better model. This is a fear that parents need to address repeatedly, even if their children never broach the topic. Sometimes the best ways to reassure a child are symbolic rather than direct. For example: If at all possible, don't have the new baby use the same crib as the older child, especially if the older one has recently transferred to a regular bed. You might try swapping cribs with someone in your birthing class who's in the same situation.) If that's too expensive a change to make and swapping isn't practical, buy different bedclothes for it so that it looks somewhat different. Toddlers often attach a great deal of emotional importance to the blankets that comfort them at night. That's why "security blankets" are such a common transitional object. One way of letting your child know that she won't be replaced is to put her old blankets in her room and tell her that she can keep them for the rest of her life. Put together a scrapbook about your older child and her family. This can have pictures of family members, the child's friends, and souvenirs of special family activities such as vacations and holiday celebrations. This

reassures her about the links between her and her family, and gives her something to hold on toboth literally and figurativelywhile her mother's in the hospital. Get out your older child's baby book. Go over the pictures and talk about what she was like when she was born. Retell happy stories about her birth and her first trip home. Talk about how much she cried and when she slept and ate. This will allow her to revisit those feelings of being special and to prepare for what having a new baby in the house will be like. Try to maintain your family's daily rituals during the pregnancy. Even small things, such as eating family meals at the same time, help children feel more secure because some important aspects of their lives are consistent during this time of dramatic change.

B. Middle child complex Middle Child Syndrome Middle child syndrome refers to the feelings a child in the middle of the birth order have about being unimportant compared to their siblings. Middle children never get the benefit of having the undivided attention of their parents like the oldest does, and the attention they receive is further split once a younger sibling is born. This perceived lack of individual attention can manifest itself in the child and cause personality and behavioral problems. Causes Parents tend to be more attentive with the oldest and youngest, leaving the middle child to fight for individual attention. The middle child is not celebrated for accomplishing milestones because parents aren't as excited, having already experienced these moments with the oldest. Parents also tend to concentrate their attention on the youngest because the younger children need more from them. Symptoms and Behaviors Middle children tend to suffer from low self esteem. They believe that they are not special or unique in anyway. Middle children also grow resentful of the lack of personalized attention and often vocalize these feelings. The resentful feelings often lead to sibling rivalry. Middle children tend to fight for attention and crave the spotlight within the family. The behavior of middle children tends to go between extremes. They may be rebellious at some times and extreme people-pleasers at others. Prevention and Treatment To prevent middle child syndrome, parents need to give middle children enough attention before they see signs of a problem. Even if your

child does begin to show resentment, it is not too late to change their behaviors. Praise each child for the unique qualities and skills that set them apart from their siblings. Dispel sibling rivalry by taking steps to avoid perceived favoritism. Treat each child as an individual and do not make comparisons between children. Lastly, make special time for the middle child. This can be done by asking what they would like for dessert or scheduling a special day where they get to choose the activities you will be doing. C. Masturbation What is masturbation? Masturbation is self-stimulation of the genitals for pleasure and selfcomfort. Children may rub themselves with a hand or other object. Masturbation is more than the normal inspection of the genitals commonly observed in 2-year-olds during baths. During masturbation, a child usually appears dazed, flushed, and preoccupied. A child may masturbate as often as several times each day or just once a week. Masturbation occurs more commonly when a child is sleepy, bored, watching television, or under stress. Why does a child masturbate? Occasional masturbation is a normal behavior of many toddlers and preschoolers. Up to a third of children in this age group discover masturbation while exploring their bodies. Often they continue to masturbate simply because it feels good. Some children masturbate frequently because they are unhappy about something, such as having their pacifier taken away. Others are reacting to punishment or pressure to stop masturbation completely. Masturbation has no medical causes. Irritation in the genital area causes pain or itching; it does not cause masturbation. How long does it last? Once your child discovers masturbation, he or she will seldom stop doing it completely. Your child may not do it as often if any associated power struggles or unhappiness are remedied. By age 5 or 6, most children can learn some discretion and will masturbate only in private. Masturbation becomes almost universal at puberty in response to the normal surges in hormones and sexual drive. Will masturbation cause problems later in life? Masturbation does not cause any physical injury or harm to the body. It is not abnormal or excessive unless it is deliberately done in public places after age 5 or 6. It does not mean your child will be oversexed, promiscuous, or sexually deviant. Only if adults overreact to a child's masturbation and make it seem dirty or wicked will it cause emotional harm, such as guilt and sexual hangups.

How can I help the child? Have realistic goals. It is impossible to eliminate masturbation. Accept the fact that your child has learned about it and enjoys it. The only thing you can control is where he or she does it. A reasonable goal is to permit it in the bedroom and bathroom only. You might say to your child, "It's OK to do that in your bedroom when you're tired." If you completely ignore the masturbation, no matter where it's done, your child will think he or she can do it freely in any setting. Ignore masturbation at naptime and bedtime. Leave your child alone at these times and do not keep checking on him or her. Do not forbid your child from lying on the abdomen and do not ask if his or her hands are between the legs. Distract or discipline the child for masturbation at other times. First try to distract your child with a toy or activity. If this fails, explain to your child: "I know that feels good, and it's okay to do it in your room or the bathroom, but do not do it in the rest of the house or when other people are around." By the time children are 4 or 5 years old, they become sensitive to other people's feelings and understand that they should masturbate only when they are alone. Younger children may have to be sent to their rooms to masturbate. Discuss this approach with the child's day care or preschool staff. Ask your child's caregiver or teacher to respond to your child's masturbation by first trying to distract the child. If this doesn't work, they should catch the child's attention with comments such as, "We need to have you join us now." Masturbation should be tolerated at school only at naptime. Increase physical contact with the child. Some children will masturbate less if they receive extra hugging and cuddling throughout the day. Try to be sure that your child receives at least 1 hour every day of special time together and physical affection from you. Common mistakes. The most common mistake that parents make is to try to eliminate masturbation completely. This leads to a power struggle which the parents inevitably lose. Children should not be physically punished for masturbation, nor yelled at or lectured about it. Do not label masturbation as bad, dirty, evil, or sinful, and do not tie your child's hands or use any kind of restraints. All of these approaches lead only to resistance and possibly later to sexual inhibitions.

3.4 Promoting Optimum Health During the Preschool Years A. Nutrition Requirement for calories per unit of body weight: 90 kcal/kg Average daily intakeof 1800 calories. Fluid requirements: approximately 100ml/kg/day but depend on activity level, climatic conditions, and state of health. Protein requirements increase with age, and the recommended intake for preschoolers is 13 to 19 g/day. For children over the age of 2 yrs: saturated fatty acid consumption should be less than 10% of total caloric intake, and total fat over several days should be no more than 30% and no less than 20% of total caloric intake. Diet must contain adequate nutrients. Daily calcium intake for children 1-3 yrs old is 500 mg. Daily calcium intake for children 4-8 yrs old is 800 mg. Milk and dairy products provide a major source of calcium. High fat milk should be replaced with lower or nonfat milk. In children over 2 yrs old, intake of dietary fiber should equal the childs age plus 5 in grams per day. This is equal to five servings of fruits and vegetables each day. Excessive consumption of fruit juices leads to dental caries and gastrointestinal symptoms. Counsel moderation in fruit juice consumption. Provide suggestions for more appropriate souirces of nutrients such as ascorbic acid, folate, and potassium. Limit the intake of fruit juice to 4-6 oz/day for children ages 1-6 yrs. Emphasize the importance of physical activity. When children reach 4 yrs of age, they seem to enter another period of finicky eating. By 5 yrs, children are more aggreable to trying new foods. A 5 yr old child is usually ready for the social side of eating but the younger child still has difficulty sitting quietly through a long family meal. Quality is much more important than the quantity, which should be stressed during nutritional counseling. Children self-regulate caloric intake. If they eat less at one meal, they compensate at another meal or snack. Advise parents to keep a weekly record of everything the child eats. The need to measure the amount of food is stressed to provide a more accurate estimate of food intake at each meal.

B. Sleep and Activity The average preschooler sleeps approximately 12 hours a night and infrequently takes daytime naps. Waking during the night is common throughout early childhood and may be related to social rather than developmental factors. Motor activity is encouraged. The American Academy of Pediatrics (2001c) encourages free play and a variety of physical activities; however, the academy also supports organized play when it is developmentally appropriate and occurs in a nonthreatening, fun, and safe environment. C. Sleep problems The preschool years are a primetime for sleep disturbances. Preschoolers cope with autonomy, separation, and object permanence. For children who delay going to bed, a recommended approach involves counseling parents about the importance of a consistent bedtime ritual and emphasizing the normalcy of this type of behavior in young children. Attention seeking behavior should be ignored. The child should not be taken into the parents bed or allowed to stay up past a reasonable hour. Other measures may be helpful like: keeping a light on in the room, providing transitional objects such as a favorite toy, or leaving a drink of water by the bed. Helping children slow down before bedtime also contributes to less resistance to going to bed. Establish limited rituals that signal readiness for bed, such as a bath or story. Limit the duration of television viewing. Ensure that television shows and other types of media are not too frightening or overstimulating, and the television should be turned off at least 30 minutes before bedtime. Assessing sleep patterns and educating families about the development of healthy sleep behaviors should be incorporated into every well-child visit. D. Dental Health By the beginning of the preschool period, the eruption of the deciduous (primary) teeth is complete. Dental care is essential to preserve these temporary teeth and to teach good dental habits. They require assistance and supervision with brushing, and parents

should perform flossing. Professional care and routine prophylaxis, especially fluoride supplements, should continue. Routune dental care is recommended every 6-12 months.

E. Injury Prevention Poisoning is still a danger. Cognitive ability may play a role in injury avoidance, especially in girls, who are less daring and risk taking. Parents should be informed that children as young as 4 years old have been shown to engage in risk taking behaviors. Intervention strategies targeted at high risk populations need to be part of safety education. Emphasis is now on protection and education for safety and potential hazards. Parents set a good example by practicing what they preach. Establishing habits at this time, such as wearing bicycle helmets, can create long term safety behaviors. F. Anticipatory GuidanceCare of Families The preschool years present fewer childrearing difficulties than the earlier years, and this stage of development is facilitated by appropriate guidance. Injury prevention also shifts from protection to education. Emotional transition between parent and child occurs. Although children are still attached to their parents and accept all their values and beliefs, they are nearing the period of life when they will question previous teachings and prefer the companionship of peers. Parents may need help in adjusting to this change, particularly if one parent has focused his or her daily activities on home responsibilities. Parents may need to seek activities outside the home, such as community involvement or a career. 4. PARENTING A SCHOOLER A. Common behavioral problems of a Schooler: 1. Underachievement A school-aged child is in the industry versus inferiority stage of Eriksons psychosocial development. Having accomplishments is a part of their developmental task of achieving a sense of industry. According to Hockenberry and Wilson, School-age children are eager to build skills and participate in meaningful and socially useful work. Failure to develop a sense of accomplishment may lead to inferiority.

Underachievement may result from the childs failure to accomplish past developmental tasks or from incapability or less preparation for the tasks associated with achieving a sense of industry. Those children with physical and mental disabilities have less capability of accomplishing their developmental tasks. (Hockenberry, M., Wilson, D., 2007) 2. Attention deficit disorder (ADD) ADD Is the most common behavioral disorder that starts during childhood. An individual with ADD finds it more difficult to focus on something without being distracted. They have greater difficulty in controlling what they are doing or saying and are less able to control how much physical activity is appropriate for a particular situation. In other words, a person with ADD is more impulsive and restless. The three defining symptoms of attention deficit disorder are as follows: (1) Attentional deficits. The child has a short attention span. The child often fails to finish things he or she starts, does not seem to listen, and is easily distracted or disorganized. In more severe instances the child is unable to focus attention on anything, while in less severe cases attention can be focused on things of interest to the child. (2) Impulsivity. The child is often described as acting before thinking, shifting excessively and rapidly from one activity to another, or having difficulty waiting for a turn in games or group activities. (3) Hyperactivity. They may fidget, wiggle, move excessively, and have difficulty keeping still. This excessive activity is not noticeable when the children are playing; however, in the classroom or other quiet settings, the child cannot decrease his or her activity appropriately. Many children with attention deficit hyperactivity disorder frequently show an altered response to socialization. They are often described by their parents as obstinate, impervious, stubborn, or negativistic. With peers, many affected children are domineering or bullying, and thus may prefer to play with younger children. Another characteristic often seen in children with the disorder is emotional lability. Their moods change frequently and easily, sometimes spontaneously, and sometimes reactively. Commonly, difficulties in discipline and inadequacies in schoolwork lead to reproof and criticism. As a consequence, children with the disorder usually also have low self-esteem.

School refusal Sometimes referred to as school avoidance and used to be known as "school phobia." It is when a child persistently avoids or refuses to go to school and is truly distressed with visible anxiety about attending. Often, no

matter how much a parent reasons, the child will not enter the school building. Signs of School Refusal Complain of vague physical ailments such as stomaches, headaches, nausea, fatigue or just "not feeling well." Worry about something happening at school. Feel anxious about what will happen to their parents while they are in school Have learning problems or trouble getting along with their teacher and/or peers Reasons for School Refusal The reasons for school refusal are as varied as the children it effects. However, the National Association of School Psychologists (NASP) outlines some of the more common reasons as being anxiety-related: Separation anxiety: Children with separation anxiety worry about what will happen to their parents when they are apart from them. This is often the reason that younger children refuse to go to school. It can result in temper tantrums before and at drop-off time and sometimes even leads children to run away from school once they arrive. Performance anxiety: Children who refuse school for this reason may be extremely concerned about doing well on tests, having to speak in class and worry about how failing will affect their relationship with peers. Social anxiety: Children with social anxiety have tremendous difficulty in social situations and worry about how to interact with peers and teachers. Generalized anxiety: Children with generalized anxiety are often fearful of the world and tend to worry about things like extreme weather events occurring while they are at school. Childhood depression, bullying and health-related concerns as other reasons for school refusal. In fact, in some cases school refusal begins after a prolonged absence due to a real illness. School Bullying It is defined as aggressive behavior that is intentional. It can be physical (such as pushing or hitting) or verbal (such as hurting someone with insults or malicious gossip). In younger children, bullying can also frequently include exclusion (a child telling another she doesnt want to play with her and urging others to join her in excluding the victim of the bullying behavior, for instance). Bullying in Grade School Bullying among younger kids can take the form of ostracism, as in when a group of kids may agree not to include a classmate in their games. Some other ways younger children bully may include verbal aggression,

such as name-calling or physical aggression such as shoving or hitting. Kids who are targeted by bullies often include those who have a disability or children who are not adept at making friends and have little social support. Obesity is also a significant risk factor for being a victim of bullies. In some instances, a child may become the target of bullying behavior based upon nothing more than a distinguishing characteristic, such as her name. B. Role of the nurse in the care of a healthy/ill schooler Promoting Optimum Health during the School Years: HEALTH BEHAVIORS Children should be able to assume personal responsibility for self-care Health education is a primary component of comprehensive health care NUTRITION Emphasize importance of a balanced diet to parents and children to promote growth School age children develop an eating style that is increasingly independent of parental influence Children acquire a taste for an increasing variety of foods The quality of diet depends to a large extent on their familys pattern of eating With the influence of mass media, it is too easy for children to fill up on empty caloric foods (e.g. junk foods) which do not promote growth Nutrition education should be integrated throughout the school years into the classroom learning. Diet should be with plenty of grain products, vegetables and fruits, low in fat, and cholesterol, moderate in salt and sodium and sugars, and they should have a lifestyle that combines sensible eating with physical activity

SLEEP AND REST The growth rate has slowed; therefore, less energy is expended in growth than was expended during the preceding periods Usually do not require a nap, but they sleep approximately 11 hours (5 years old) and 9.25 hours (12 years old) If they are allowed to remain up later than usual, they are fatigued the following day A firm approach during bed time is usually the most successful Parents can help children by giving them a little advance warning, but children should realize that when the final bedtime is announced, the parents mean it Consistent reassurance and limit setting would resolve the childrens problem of multiple curtain calls before going to sleep (e.g. wanting to drink water,

storytelling, etc) Resolving worries will often reduce nightmares, which is a common sleep problem in school age children PHYSICAL ACTIVITY Exercise is essential for muscle development and tone, refinement of balance and coordination, gaining of strength and endurance, and stimulation of body functions and metabolic processes Children should be provided with opportunities that provide satisfying experiences to meet individual likes and dislikes (e.g. running, jumping, and the like) Most children need little encouragement to engage in physical activities Children with disabilities require special assessment and help in determining activities suitable for them The development of physical fitness is the goal for all children Every child is suited for some type of sport, and authorities do not discourage participation if children are matched to the type of sport appropriate to their abilities All children should have an opportunity to participate Children with mental retardation need not be excluded from sports competition if they are matched evenly against other children of equal abilities and provided with skilled coaching Parents are advised to monitor program selections, view television programs with their children, and discuss program content when the programs are finished Parent and teacher education relating to television, videogames, and the Internet should include recommendations to limit playing time, monitor game selection and content, and increase access to games and information that are educational. DENTAL HEALTH The first permanent teeth erupts at about 6 years of age Permanent dentition is somewhat more advanced in girls than in boys Good dental hygiene and regular attention to dental caries are vital parts of health supervision during this period School nurses should be alert for opportunities to teach correct brushing and flossing techniques, to reinforce avoidance of sticky sweets, and to be alert for problems of malocclusion, toothache and mouth infections Children should be taught to carry out their own dental care with the supervision of parents Ideally, teeth should be brushed after meals, after snacks, and at bedtime The bedtime brushing is important because there is more time overnight for interaction between oral bacteria and un-removed substrate on tooth substance

Children who brush their teeth frequently and become accustomed to the feel of a clean mouth at an early age usually maintain the habit throughout life The best toothbrush is one with soft nylon bristles and an overall length of 21 cm SCHOOL HEALTH A safe and healthful school environment is an essential element of any school program Health education of school age children is directed toward providing knowledge of health and influencing habits, attitudes and conduct in relation to health The school nurse is in the position to promote and evaluate health services throughout the community as they affect children and to collaborate with agencies in planning for health and safety INJURY PREVENTION Nurses are primary advocate for preventive care and guidance Safety education and anticipatory guidelines for parents and school-aged children The most effective means of prevention is education of the child and family regarding the hazards of risk-taking behaviors and improper use of equipment Nurses could provide effective safety education to parents and childrenan can correct misconceptions before injuries occur

References:
Fredrickson, B. L. (2000, March 7). Behavioral Problems in Infants. Retrieved December 2, 2011, from http://www.medical-library.org/journals4a/infant_problem_behaviors.htm Hockenberry, & Wilson. (2007). Wongs Nursing Care of Infants and Children. Phillipines. ELSEVER, INC. Morin, Amanda (2011). School-aged Children. [Online] In Child Parenting Retrieved December 3, 2011 from http://childparenting.about.com/od/schoollearning/a/school-refusal.htm> McGraw-Hill Science & Technology Encyclopedia: Attention deficit hyperactivity disorder [Online] Retrieved December 3, 2011 from http://www.answers.com/topic/attention-deficit-hyperactivity-disorder

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http://www.planababy.com/CARE%20NEWBORN.HTM