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Developmental Stages and Transitions of Health Promotion

by Diana Shenefield, PhD
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    00:01 Hi! This is Diana Shenefield. And today, we’re going to talk about Developmental Stages and Transitions which is really important on the NCLEX exam, and a lot of times people think that it’s only important for pediatrics, but we’re going to talk a little bit more about the older people as well because they kind of get forgotten.

    00:21 So our overview is, again, this is really important for NCLEX. I know you know from your pediatric class that you dealt a lot with growth and development. And so you’re going to want to review that. So today, we’re going to do a really fast review of growth and development.

    00:35 But again, we’re going to not stop at teenagers. We’re going to go on to the older adult as well. So we have learning outcomes just like we do for every single class, the things that we’re going to want to learn while we’re taking this class. I want you to read through those learning objectives. And if there are any of them at the end of this program that we didn’t meet or that you feel like you need more practice on, that’s where I want you to focus on your study time. So, first of all, we’re going to start off with a question. So a nurse is assessing a 6-month-old infant. What following reflexes should the 6-month-old have? This is one of the questions that NCLEX is probably going to ask you because it’s really important that you know when the primitive reflexes disappear. Is it moro, plantar grasp, stepping, or tonic neck? Again, in your mind, review what those are.

    01:29 And hopefully, you picked plantar grasp because that doesn’t disappear until about the eighth or ninth month. Let’s try another one. So, you have a parent and they’re discussing behavior with you. And a lot of times, we know as nurses, parents want to know what’s normal, what’s not normal. So in NCLEX, it’s important that you know that. So here, we have a three-year-old, and what is normal for the three-year-old? Is it A, saying no often? Is it B, using a limited vocabulary about 500 to 3000 words? Is it C, speaking in 10-word sentences? Or is it D, believing that adults know everything? So think of that three-year-old that you’ve taken care of. Hopefully, you picked C, speaking in 10-word sentences. They can’t put that many words together. So again, if you had trouble with that, you want to go back and review your toddler.

    02:20 So we’re going to start with infants, best place to start. We’re going to think about what's the physical things that are going on with infants. And you’ll see on the screen that we have primitive reflexes, and that’s what we just talked about in that first slide. We also have what is normal for the infant. We know infants change a lot from day 28 until they’re 12 months old. So there're a lot of reviews there.

    02:44 We’re going to talk about fontanel closing. You know by doing infant assessments that the fontanel is really important for neurological and for behavioral. So you want to make sure you know that. And then ability to gain head control, that’s a big deal, and then birth weight should triple. So when that infant comes into the doctor’s office or into the hospital, you need to make sure you know where they fit on that growth development curve. And then, are they making vocal sounds? Can they recognize their own name? Now, we know a 28-day-old isn’t going to, but by the time they get to the near end of infant, 11, 12 months old, they should turn their head when you call their name.

    03:22 And then, stranger anxiety. Stranger anxiety hasn’t started till about six months.

    03:27 So after six months, they should be afraid when a stranger comes around or somebody else wants to hold them. And then we all know Erikson. Erikson is really important. If you had trouble memorizing Erikson, that’s one that you do need to memorize.

    03:40 And we had trust versus mistrust. And later on in this talk, we’re going to talk about how do I know if they’re not meeting that developmental stage. Now, toddlers. It’s really important too that you know the ages. And toddlers are one and two-year-olds. So again, put in your mind those patients that you’ve taken care of, nieces and nephews. Are they walking? And how did they learn to run? Can they ride a tricycle? Now, a one-year-old probably can’t ride a tricycle, but by the time they’re two moving into the three-year-old, they should be riding a tricycle. Can they feed themselves? And what all parents want to know is when will they be potty trained. So cognitively, they should be able to obey simple commands. When you tell them to pick up their toys, they should be able to do that.

    04:24 Now, they’re not going to be able to do a lot of instructions all at one time, but one at a time, they should be able to do. Their speech should be more understandable. Now, by what I mean by more understandable is that you may not understand every single word that they say because they’re going to blabber a lot. But you should be able to start understanding more common words more clear. And then, toddlers are going to want to seek your attention. Have you ever been around the toddler when they’re talking to you and if you’re not right looking at them, they’ll grab your face, and want you to look right at them? They want to know that you’re paying attention to them. And then psychosocial, we’ve got Erikson again, autonomy versus shame and doubt. So we’re going to review that. Also, it’s real important about this time that children start playing.

    05:09 And we know toddlers like to play by themselves. They may have other kids playing at the day care, but they usually aren’t playing together. Preschoolers. Preschoolers is one of the fun ages because they are trying to see what’s going on in the whole world. They are into everything. They are going to be more coordinated. You’re going to see them picking up balls and throwing them. They’re going to be able to dress themselves. Now, to the dismay of many parents, they may not pick up clothes that match but they should be able to put on their own clothes. And they should be able now to be able to walk up and down the stairs without any problems. Cognitively, they are aware of limits. They’re starting to learn rules. Where the toddler didn’t so much know the rules, preschoolers are starting to follow rules. They also have a vocabulary way into the thousands. They’re able to draw shapes. These are the kids that want to color. They may not stay in the lines, but they should be able to make a circle. They should be able to make straight lines.

    06:08 They should be able to try to draw a stick figure.

    06:11 And then, this is where it gets a little tricky. They want to copy mom and dad. You’ll see them playing house, playing school, trying to mow the yard. So again, they’re really watching their parents and trying to do what it is that they are doing. And then psychosocially, we got initiative versus guilt according to Erikson.

    06:28 School age, so now they’re off to school. Lot of growths spurts. Boys, especially.

    06:35 You’ll notice parents will say, “I think they grew two inches over the summer.” Lots of growths spurt. They may go periods of time where they don’t grow, and then all of a sudden, they grow a lot, and that’s normal for them. They’re probably skipping and jumping rope. That’s a coordination that preschoolers can’t do, that you can’t do until about the time that you’re in school age. And then riding a bike, they should be able to ride a two-wheel bike. Cognitively, this is when they’re learning to read and right. And a lot of times, we find out that maybe they’re dyslexic or they’re having hearing problems because they’re not reading and writing, or vision problems, when the teacher says that they didn’t seem like they can see the front of the class. So a lot of times, those kinds of things aren’t caught until they get into school age. And then according to Erikson, the industry versus inferiority. And now, we’re starting to see the cooperative play where they’ll play games with other children.

    07:26 Teenagers. Big physical thing is puberty. We all have been through puberty. We all know the struggles. So these kids, we’re watching for normal development and abnormal development.

    07:39 They have a lot of interests in their personal appearance, and they’re very involved in sports, extracurricular activities. You want to watch for the kids that don’t seem to be involved. Cognitively, they really care about what their peers think about them.

    07:54 And so that guides a lot of their behavior. And they are into a lot of risks taking. So there’s a lot of education for the nurses. And by now, they can do abstract thinking. They should be thinking like an adult. They should be able to follow rules and they should be able to think things through without making impulse decisions. And according to Erikson, they’re in the identity versus role confusion. Now, we get to the adult where sometimes it gets left off, especially in pediatrics. But physical peak for an adult is 25 to 35.

    08:28 After that, we know that the body starts to decline. This is usually when they’re getting jobs, they’re getting married, having children, but unfortunately, this is also a time when a lot of people start developing those chronic illnesses. Cognitively, they should be at the adult level. Psychosocially, we have two stages for the adult. We have the 19 to 34-year-olds which are in intimacy versus isolation, and then the 35 to 64-year-olds which are in generativity versus stagnation. Now, we’re at the older, and we’re clear at the other end of the spectrum. So physically, we start to decline. Cognitively, we start to decline. We know that not everybody declines to the extreme that some people do, but just the nature of our bodies, we do start to decline. And according to Erikson, we're at the ego integrity versus despair. So let’s talk a little bit about death.

    09:22 That’s going to show up on the NCLEX too. When do people understand exactly about death? Now, we know adults. They understand death, but kids, when do they understand it? Well, infants and toddlers, they don’t know anything about death. They don’t have any concept of it. They don’t have any concept in themselves or people around them. But they always move on to preschoolers. That’s when they start thinking magically. That’s when they start thinking that maybe if somebody is really sick or a loved one has died that maybe it was their fault. They also believe that the person is just sleeping.

    09:56 So when you’re talking to children at this age, it’s important to understand what they think is going on. School-agers were starting to get to the adult understanding, but again, they are really curious about what’s going on. And sometimes that can be kind of disturbing.

    10:13 They can ask a lot of questions and parents may think maybe they don’t care about the loved one that has died, but it’s just their normal trying to figure out what’s going on with death. Adolescents now have the adult version of death, but a lot of times, they carry a lot of guilt. They think that maybe they caused it, or something that they did, maybe some of their risk taking or those kinds of things. But they pretty much understand what causes death and how death occurs and what happens with death.

    10:42 And then the older adult. Most older adults know that death is part of life. It’s just part of growing older. Most older adults have accepted the fact that their time has come.

    10:52 And so we’ve moved from infant to adult. But again, it’s important to remember what everybody believes that each stage about death. So, we’re going to talk a little bit about physical deviations. What happens when things don’t go as we just said they should go? Things like not rolling as an infant, you need to start looking at physical things.

    11:15 You know, is there a reason why they can’t roll from their back to their front? There should be a red flag for nurses. Not transferring toys from hand to hand.

    11:24 Is that a physical or is it a vision problem? Not walking by 18 months, is that a physical problem or a coordination problem or maybe some neurological is going on. Not tripleing birth weight. We worry a lot about organic reasons and non-organic reasons. Do they have failure to thrive? Are their parents not feeding them? Not speaking, not speaking could be from not being able to hear well, it could be a neurological problem, or maybe it’s an abuse or a neglect kind of problem where nobody is working with the child.

    11:56 Can’t follow simple commands, again, is that a neurological problem where they can’t put the words in the actions together? Bed wetting in the childhood always makes us think of either a problem with their bladder or sexual abuse. So again, if they should have been potty trained way before and they’re still having bed wetting, the nurse needs to have some red flags as to what’s going on there. Absence of puberty by age 18, obviously, that’s going to be a lot of self-esteem kind of problems. But again, is there something hormonal going on? Puberty at age seven the other extreme, again, hormones is a big problem.

    12:35 And then chronic illness, the earlier that you develop a chronic illness, obviously, the harder it’s going to be on that person on their family and on their psychosocial development. Cognitively again, if they can’t follow instructions, if they’re not interested in playing with other children, red flag should go up. Is it a behavioral problem? Do they need psychological care? Or is it an autism that maybe hasn’t gotten picked up before because nobody noticed that they weren’t wanting to play with other kids. Anxiety about school. We see that a lot in school age kids. Do they have stomach aches every morning, headaches, because they’re scared about school? Are they incapable of understanding instructions? And then as we move on to the older adult, dementia is a big problem with the older adults and their cognitive. If an older person starts showing sides of dementia, it’s going to affect the family, it’s going to affect their physical care. So again, as the nurse is doing their assessment picking up on those kinds of things to be able to give them the social help that they need. Psychosocial, now we’re back to Erikson.

    13:45 So what did all of those Erikson things mean and what does the nurse need to look for? Well, mistrust. In infant, it’s so sad when an infant doesn’t trust the people around them, and how do they get to that point? They’re not yet in their needs met.

    13:58 When you have a baby that’s crying and nobody picks it up, a baby that doesn’t get fed, all of a sudden that baby will stop crying. It will stop trusting that anything is going to happen to them. So as a nurse, you may see that child come in with an illness and you may think, “Why doesn’t that baby cry? Why doesn’t that baby look at me when I’m holding or when I’m feeding them? You want to delve into that more to look for that mistrust. Shame and doubt in the toddler. If they’re always told, “No, you can’t do that. No you’re not doing that right. You didn’t put your clothes on right. No, you can’t do that. You can’t play ball that way.” That starts to tell the toddler that they can’t do anything right. And so then all of the sudden, they just sit there. They quit. They don’t do anything. So as a nurse, if I’m trying to give a patient, the toddler a block and say, “Come on, let’s play” and they just lay it down and don’t do anything, I’m going to start really watching and watching that family bonding that’s going on. Guilt in the preschooler, again, kind of goes back to that “You can’t do anything right” kind of thing. "You’re not dressing yourself.

    15:06 Those clothes don’t match. You’re not very good at that Pee Wee baseball." All of those kinds of things start telling the child that no matter what you do, you’re never going to be good enough. And unfortunately, if you go back to a lot of people that are in jails and lots of people that are in trouble with the law and you go back, and you can actually go back to the very early ages on how they were taken care of as children, how their needs were met, the attention that they weren't given. And so, these stages are really, really important. Inferiority, again, school is huge. We've hear a lot about bullying, and that’s where this comes in. If I don’t feel like I’m good enough, if I don’t fit in, it causes a lot of problems. Role confusion, once we get to the teenager, again, teenagers are trying to figure out who they are, where they fit in, what their jobs should be. So if all of those things that they don’t have people to help them or they’re not able to cope with the different decisions, they end up choosing nothing. And unfortunately, these are the kids that we see that are more involved in drugs, or stay at home and just play video games because they don’t see any point.

    16:13 They don’t see a future for themselves. And then isolation in the young adult.

    16:18 This is very evident in our large divorce rate. Adults that can’t commit, they don’t know how to have a relationship, they’re very egocentric, it’s all about them. So as they’re moving on, if they can’t develop relationships, they’re not going to be healthy. And then stagnation. Once you get to be an adult and you’ve had your family, if you don’t feel like you’re going anywhere, if you’re stuck in a dead-end job and you don’t know how to advance yourself, you don’t know how to go back to school, you just kind of feel like you’re stuck, you go to work, maybe you go home and you just sit and watch TV, you’ve got to have a purpose. You’ve got to have a reason for getting up, and that kind of leads to the despair in the older adult. There has to be a reason to get up in the morning. So a lot of times, you go into the hospitals and you see older people that seemed very, very depressed, or feel like, you know, “What’s the difference if I take my medicine or not?” You want to really delve into that and see if they’re struggling with despair. Do they have a purpose? This happens a lot of time to people that have retired, and all of a sudden, their whole reason for getting up is gone. And so helping them get involved in hobbies and volunteer work to give them a new renewal into life. So that’s Erikson. So again, if you haven’t figured out Erikson, you’re going to want to do that before you take the NCLEX exam.

    17:42 So hospitalized patient. Now, you’re the nurse in the hospital. So what does this all mean when these patient shows up in the hospital? So we start with infants. You know, infants need their needs met. Infants need to be held in the hospital or not. And we see that a lot in the hospital if they’ve got IVs and oxygen. Sometimes parents are afraid of holding them.

    18:02 But again, we want to make sure that all their needs are being met and that we have appropriate toys that were keeping those infants safe that parents aren’t propping bottles.

    18:12 We have a lot of teachings to do with the infants.

    18:15 And then moving on to toddlers. Now, we know that they’re starting to walk. So not only at home are we making it safe, but we got to make the hospitals safe as well. We also know that when a nurse walks in, hopefully, the patient is scared because they do have that stranger anxiety. If you have a toddler that’s sitting there that doesn’t care who comes in and out of the house, or out of the room, or out of the treatment room, wherever you are, that is a cause of concern because they should be a little bit afraid of you.

    18:43 But you should be able to win their confidence over by playing with them.

    18:46 Now, we move on to preschoolers. Now, they’d want to know everything that you’re doing.

    18:52 These are the kids that you’re going to want to let them play with your stethoscope.

    18:55 Let them look at the medicine. Play games with them because they want to know, before you do anything to them, what it is, they want to understand. Preschoolers are also really good having stuffed animals and doing things to the stuffed animals so that they know that it’s not going to hurt, or if it is going to hurt. Being honest, but the big reward being the prize box afterward, you can win a lot of points to that way as well. And then school age kids. Need to be very honest with school age kids, and make them start to understand medical procedures, diseases, medicine.

    19:28 And so they may not be able to understand it at an adult level. And so when you’re trying to reason with them, the reason they need to take their medicine, you need to do it at their level. But again, give them the benefit of the doubt and help them to understand.

    19:41 That’s what they want. They want to start having some control.

    19:45 And then teenagers. Their fear is loss of control. So we give them as many choices as we can. We also do a lot of teaching with adolescents. They’re not just little kids, but they’re also not adults. And so trying to help them through, especially they’re working with a chronic problem, maybe diabetes, that’s going to affect the rest of their lives.

    20:06 Helping them figure out where they fit in high school and where they fit in college as far as how am I going to do this. So there’s a lot of teaching, but there’s also a lot of education and helping them figure it out so that they can make and form decisions about themselves.

    20:24 And then adults. Adults in the hospital, a lot of times, we just assume they’re adults.

    20:28 They’ll do whatever they’re told. But again, we’ve got to give them a reason.

    20:31 There’s going to be a reason for doing what they’re doing, and there has to be benefits, and we need to give them all the information. And then the older adults. Now we’re kind of swinging the other way. Maybe they have dementia and they don’t quite understand.

    20:45 Maybe they’re hard of hearing and we need to think about when we’re taking to them to make sure that they understand. Or maybe we’re starting to use technology. Like right now in the hospital, a lot of older adults still don’t do computers and those kinds of things. And so when you walk in with your computer, they get a little bit intimidated. So you need to orient them to that, let them know that you’re still all about them as a person and not all about technology.

    21:10 So, we have a couple of review questions here, and I’m just going to kind of buzz through them because I want you to look through them and I want you to try to figure out what the answers are. You will have lots of practice questions, and hopefully, you have an NCLEX book where you can practice a lot of these questions because the best way to know this information besides studying is to take lots of questions.

    21:33 So the first one, which behavior indicates that an 18-month-old-infant, so we’re taking of toddler, is developing none adaptive reaction to hospitalization? So it’s kind of what we just talked about, A, cries when mom leaves, B, ignores mom when she arrives to the hospital, C, is eating with their fingers instead of spoon and fork, or D, is afraid of the dark? So we’re talking about an 18-month-old. So the big one that stands out to me is B, ignores the mom when she comes back into the room. Big red flag, if they don’t care when mom and dad come back into the room, you need to ask some questions.

    22:13 Second question, you have an eight-month-old infant sitting contently on mom’s lap.

    22:19 You’re going in to start doing your well-baby check. Which of the following should you do first? Again, thinking about an eight-month-old, thinking about the assessment that you need to do. Should you A, measure the head circumference, B, obtain body weight and height, C, auscultate the heart and lung sounds, or D, check pupil response to light? Hopefully, you picked C, auscultate their heart and lung sounds. You want to do that while they’re quiet. Some of these other things doing to them is going to make them cry. And so, you won’t get a good assessment of their heart and lungs. Third question, when obtaining a health history from an older adult, the nurse must take which characteristic of the older adult into consideration? So what we just kind of talked about. A, the older adult responds to pain sensation in the same intensity as a younger patient. So think about all those things you’ve learned about pain. B, auditory acuity is the most common sensory loss in the older adult population and it may hinder the interview. C, the older patient requires a lot of repetition because their IQ declines. D, the older patient’s response time in answering questions is just as quick as that of a young person. So, if you had to pick, what would you pick? Hopefully, you picked B. We know that their hearing isn’t so crisp as it was before. So you need to make sure that they’re understanding what you’re saying to them.

    23:52 Four, in patients 65 years of age and older, how is death commonly viewed? Now, this should be an easy one. A, as a romanticized situation, and I don’t know if that’s ever normal.

    24:06 B, as a time of disassociation. C, as a part of life. Or D, as a time of denial. Hopefully, you picked C, it’s just the part of the time of life. If they are at a time of denial, again, that would be going against Erikson’s despair, so you would want to look into that.

    24:25 What would the nurse expect when exploring a 9-year-old's concept of death? And again, there will probably be depth questions on there, so you want to make sure you know.

    24:34 A, knows that death is a final process. B, regards death as a temporary state of sleep.

    24:41 C, believes death is something that just happens. Or D, thinks death results from being bad.

    24:48 So think back to your nine-year-old in school age, and it’s A. It’s just the final process.

    24:53 They’re starting get into that adult level of thinking.

    24:56 The last question. New parents are concerned about unexpected characteristics of their newborn baby. We know that new parents are kind of on edge. They’re nervous. They want to make sure everything is right. So it’s really important that the nurse knows what’s normal and what’s not normal. Which of the following should cause the nurse to contact the physician? So which one stands out as being not right, A, swollen genitals, and breast. B, high-pitched cry. C, misshapen head. or D, Milia? Now, do you remember what milia is? If you don’t, you want to make sure you go back and look that up, but the answer is B, a high-pitched cry, which usually means a neurological problem.

    25:38 So, we just went through developmental stages. Again, know your Erikson, know your normal growth and development from infant all the way to adult, and you’ll do fine on the test. Good luck.


    About the Lecture

    The lecture Developmental Stages and Transitions of Health Promotion by Diana Shenefield, PhD is from the course Health Promotion & Maintenance. It contains the following chapters:

    • Introduction and Overview
    • Development Milestones
    • Concept of Death
    • Deviation Examples
    • Hospitalized Patient
    • Review Questions

    Included Quiz Questions

    1. Ignores mother when she arrivew to visit
    2. Cries when the mother leaves
    3. Eats using fingers rather than utensils
    4. Is afraid of the the dark
    1. Auscultate heart and lung sounds
    2. Measure the head curcumference
    3. Obtain body weight and height
    4. Check pupil response to light
    1. Auditory acutity is the most common sensory loss in the older adult ppulation and may hinder the interview
    2. The older patient responds to pain sensation with the same intensity as a younger patient
    3. The older patient requires a lot of repetition because the IQ declines with the aging process
    4. An older patient’s response time to answering a question is just as quick as that of a young patient
    1. As a part of life
    2. As a romanticized situation
    3. As a time of denial
    1. Regards death as a temporary state of sleep
    2. Knows that death is a final process
    3. Believes death is something that just happens
    4. Thinks death results from being bad
    1. High pitched cry
    2. Swollen genitals and breast
    3. Misshapen head
    4. Milia

    Author of lecture Developmental Stages and Transitions of Health Promotion

     Diana Shenefield, PhD

    Diana Shenefield, PhD


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