Chapter 20: Developmental Stages

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Welcome to the Deep Dive.

Today we're really getting into it, taking a comprehensive look at child and adolescent development.

That's right.

And also, communication and healthcare, safety guidelines.

And the really important topic of end -of -life care.

Yeah, we're pulling everything from Chapter 20 of the Saunders Comprehensive Review for the NCLE -XPN exam, the seventh edition.

So for you, the listener, think of this as us extracting the absolute must -knows, the core concepts, assessments, procedures,

safety stuff.

Priority actions, key terms.

We want to give you that solid foundation from the chapter, but you know, without making your head spin.

Exactly.

So the plan is to move through the life span.

We'll start with hospitalized infants, then toddlers, preschoolers.

School -age kids and adolescents.

We'll look at their specific anxieties, their fears, that feeling of losing control in the hospital.

And importantly, what nurses can actually do, the interventions.

Then we'll shift gears a bit.

We'll talk about communication, how to actually talk to kids at these different ages.

Good one.

And car seats got to cover that.

Definitely.

And then a deeper dive into developmental characteristics, right?

From infancy through middle adulthood.

We'll also touch on gender dysphoria and end -of -life care towards the end, and we'll flag those key medical terms as we go.

Sounds like a plan.

Okay, let's jump in.

Hospitalized infants, it must be just so overwhelming for them.

What are the main things causing distress?

Well, you hit it.

Overwhelming is a good word.

Number one is probably separation anxiety.

Even though they don't understand parent, like an older kid, that absence of the main caregiver is huge.

Right.

It's their whole world.

Exactly.

And they definitely react to pain and injury, though it's more of an immediate, this feels bad thing, not a conceptual fear yet.

And the loss of control.

Total loss of control.

Their routines, their environment, all gone.

It's completely disorienting.

So what can nurses do, practically speaking?

It's all about providing comfort and security.

Lots of physical contact, cuddling, gentle touch, super important,

talking softly, calmly,

offering chances to suck.

Like with a pacifier, the NPO, that's a big comfort mechanism.

Oral stimulation.

Right.

And age -appropriate stimulation.

Think high contrast colors, different textures, things to engage them positively.

Okay.

Moving up to toddlers, say one to three years old.

I feel like separation anxiety gets like dialed up to 11 here.

Why is that?

You're spot on.

It is often much more intense.

Part of it is they're getting object permanence.

They know mom and dad exist even when they're not there.

Okay.

That makes it harder.

It does.

And their understanding of relationships is growing.

So the separation feels bigger.

It often shows up in phases.

Rape protests.

Crying, resisting.

Yeah.

Then despair, sadness, withdrawal.

And the one we worry about most is detachment.

They might seem okay adjusted.

But they're not.

They've kind of emotionally walled off.

It's a coping mechanism, but it can be harder to reconnect later if it goes on too long.

Thankfully, most days aren't that long.

That sounds tough for everyone involved.

What else are toddlers dealing with in the hospital?

Well, still the fear of injury and pain.

But now it's colored by past experiences, maybe previous shots or procedures.

And being away from parents makes that fear worse.

Because parents are their safety net.

Exactly.

And again, that profound loss of control.

Eating, potty time, playing bedtime.

It's all disrupted.

And this often leads to regression.

Going backwards a bit.

Like wanting a bottle again or more accidents.

Precisely.

Going back to earlier behaviors.

It's really common.

So how do we support them?

What are the key nursing interventions?

Choices.

Whenever possible, give them small choices.

Do you want the red cup or the blue cup?

It gives them a tiny bit of control.

Nice.

Keep a positive attitude.

Let them protest.

Let them express that anger or sadness.

Encourage talk about their parents.

And the regression.

Accept it.

Don't shame them or make fun.

Bring in comfort objects from home.

That special blanket.

A favorite stuffed animal.

Huge help.

Familiarity, yeah.

Let them move around as much as is safe.

Be ready for tantrums.

Have a safe space.

Use pain reduction techniques that work for toddlers.

And try, try, try.

Try to keep some routines similar to home.

Okay, that makes sense.

Now preschoolers, ages three to five, how's their hospital experience different?

Separation anxiety is still there, but it might be less obvious than with toddlers.

Less physical clinging.

Maybe more verbal complaining.

But it can ramp up under stress.

And their fears.

Fear of injury and pain is big, but it's really shaped by their still developing body image.

They can have this intense fear of invasive procedures, thinking it's mutilation.

Mutilation.

Like they think a shot will leave a permanent hole.

Kind of, yeah.

They don't understand body integrity well.

Plus their imaginations are wild, so they can really blow things out of proportion.

And this is where magical thinking comes in.

Exactly.

Magical thinking, believing their thoughts or actions cause the illness.

Like, I was mad at my brother, so now I'm sick.

And they're very egocentric.

See things only from their viewpoint.

Got it.

So how does that egocentrism and their desire for independence affect their sense of control in the hospital?

They love routines, so the hospital chaos disrupts their sense of security.

Loss of control can definitely trigger regression again.

Their egocentric view makes it hard to grasp why things are happening to them.

But they still want to do things themselves.

Oh yeah.

They want to keep doing the self -care things they've mastered.

Like dressing themselves.

Or using the potty.

So what are the key nursing interventions for preschoolers, keeping all that in mind?

Safe and secure environment, number one.

Communication needs to be simple, clear.

Allow them to express anger.

Acknowledge their fears.

Don't dismiss them.

Validate their feelings.

Right.

Accept the regression, but gently guide them back towards age -appropriate stuff when they're ready.

Rooming in helps.

Or that favorite toy.

Mobility and play are crucial.

Keep them busy.

Yeah.

Diversional activities.

Placing them with other kids their age can help, too.

Explain procedures simply, right before they happen.

Avoid intrusive stuff if possible.

And little things, like letting them wear their own underwear, makes a difference.

Good point.

Okay, school -age kids now.

Six to twelve.

They understand a lot more.

How does hospitalization hit them?

Separation anxiety shifts.

It's less about mom and dad being gone, and more about missing school, missing friends.

Worrying friends will forget them.

Social fears become bigger.

Right.

The classic protest -despair detachment cycle is less likely.

Their fears about injury and pain are more concrete now.

They worry about the pain itself, actual bodily harm, the illness, disability, even death.

They understand consequences more?

Yes.

And intrusive procedures, especially anything near the genital area, can be really frightening or embarrassing.

They're more likely to tell you they're in pain, maybe groaning, whining, or just getting really rigid.

And how do they experience loss of control?

Well, they're usually pretty social, independent, active.

So being stuck in bed, feeling dependent.

That's tough.

They often want information.

They ask questions.

Trying to understand.

Yeah.

And they might try to connect their actions to getting sick, sometimes feeling guilty, like maybe I got sick because I didn't wear my coat.

Ah.

So what interventions work best for school -agers?

Rooming in is still good.

Focus on what they can do.

Involve them in their care decisions.

Accept regression, but always encourage independence.

Choices are still key.

Giving them agency.

Exactly.

Let them express feelings.

Talk about their fears openly.

Use body diagrams or simple drawings to explain procedures.

Privacy is huge now.

Definitely.

Avoid intrusive procedures if you can.

Let them wear their own underwear.

Provide age -appropriate activities.

Encourage contact with friends' calls, video chats, whatever works.

Keep those social ties strong.

Crucial.

And address their school needs so they don't feel left behind.

Of course, effective pain relief is essential.

Right.

Finally, adolescence.

Ages 12 through, say, late teens.

Big change is happening.

How does the hospital fit into that?

It's complex.

Separation anxiety is tricky.

They might act like they don't want parents around, but still need them.

The big separation anxiety is usually from their friends.

Missing out, being excluded, that's major.

Peer group is everything.

Totally.

Fear of injury and pain often links directly to body image.

Being different from peers is a huge fear.

They might hide their fear, act tough, and they can be really guarded about anything involving sexual development or exams.

Understandable.

And loss of control.

How does that show up?

Often is anger, withdrawal, maybe being uncooperative.

They might ask for help, then push it away.

That push -pull for independence.

Classic adolescence.

So how do nurses navigate that?

What are the best interventions?

Encourage questions, especially about appearance, future impacts.

Explore their feelings about the hospital, the illness, how it affects relationships.

Let them talk it out.

Yeah.

Let them wear their own clothes, keep up grooming routines, favorite foods if possible.

Privacy is non -negotiable.

Essential.

Body diagrams can still be useful.

Introduce them to other teens on the unit, maybe.

Encourage contact with their friends outside.

Address school needs.

Talk about future plans.

And help them find positive coping strategies.

Okay, we've covered the hospital experience really well.

Let's shift to communication itself.

It's clear that how we talk to kids changes drastically with age.

Absolutely.

And there are some general rules that apply across the board.

Give them time to warm up to you.

Don't just jump right in.

Let them get comfortable.

Right.

Use objects, sometimes a toy, a puppet, to help bridge the gap.

Be honest, always, but in words, they get.

And tailor that language to their developmental stage.

Okay, let's break it down.

Infants, how do we talk to them?

It's almost all non -verbal, isn't it?

Holding, rocking, patting, cuddling.

Touch, that's your language.

Approach slowly.

Use a calm, soft voice.

Respond to their cries.

Definitely.

That's their communication.

Talk or read to them the sound is soothing.

And let them have those security items.

Blanket, pacifier.

Makes sense.

What about toddlers?

They're starting to talk, but it's literal.

Very literal.

So approach cautiously.

Use their words for things if you know them.

Keep it short, concrete terms.

Prepare them right before something happens, not way in advance.

Avoids build -up anxiety?

Right.

Repeat explanations simply.

Use play, demonstrate on a doll first.

Visual aids work well.

Books, puppets.

Let them handle safe equipment.

Explain it simply.

And again, comfort objects.

Preschoolers.

Lots of questions.

Endless whys.

Offer simple choices.

Use simple sentences.

Keep explanations concise.

Allow lots of time for questions.

Answer honestly.

Describe procedures right before.

Still right before?

Yeah.

Their sense of time is still developing.

Play is great for explanations.

Let them practice on a doll.

Let them handle equipment, too.

School -aged kids.

They can handle more complex talk.

They can.

Establish limits.

Reassure them.

Address those fears directly.

Engage them in thinking conversations.

Medical play is still useful.

Helps them process.

For sure.

Photos, books, dolls, videos.

Use visuals.

Clear terms.

But also give them space to compose themselves.

Respect their privacy.

And finally, adolescents.

Independence.

Body image.

Always keep body image in mind.

Encourage independence.

Provide privacy.

You can use photos, books, videos, even reliable websites for explanations.

Meet them where they are.

Right.

Talk about their interests.

Not just the illness.

Avoid being too abstract or overly technical.

And crucially, avoid prying.

Being confrontational or judgmental.

Especially about maybe less desirable behaviors.

That shuts communication down fast.

Builds trust.

Okay.

Excellent points on communication.

Now a quick but vital detour.

Car safety seats.

Absolutely critical.

Bottom line.

Safest place for all kids is the back seat.

Period.

Always the back seat.

Always.

Lock the car doors.

Use child safety locks on rear doors and four -door cars.

And you must follow the manufacturer's guidelines for the specific seat you're using.

They're all different.

Age, weight, height matter.

Exactly.

And guidelines change.

Always check reputable sources like NHTSA or the AAP for the latest recommendations.

Don't rely on old information.

Good reminder.

Okay.

Let's dive into those developmental characteristics.

Starting back with infancy that first year is just incredible growth.

It really is.

Physically, they grow so fast.

Height increases about an inch a month.

For the first six months, they usually triple their birth weight by a year.

Head circumference starts bigger than the chest, then evens out around age one or two.

Those soft spots.

The fontanels.

The posterior fontanel at the back closes early, by about two months.

The anterior fontanel on top takes longer, usually 12 to 18 months.

And teeth.

First ones, usually bottom front, pop through around six to 10 months.

Sleep -wise, they start sleeping longer, stretches at night around three to four months.

Box 22 has the typical infant vital signs.

Okay.

And nutrition.

Skills.

Nutrition.

Breast milk is best, or iron -fortified formula.

Exclusively breastfed babies and those drinking less than a liter of fortified formula need vitamin D drops to prevent rickets.

Own health.

Right.

Iron stores run low around four months, so breastfed babies often need iron.

Maybe in fortified cereal.

No cow's milk in the first year.

Fluoride might be needed around six months.

Depends on the water.

In solids.

Start around five, six months.

Pureed stuff.

Introduce one new food at a time.

Wait a few days.

Watch for allergies.

Absolutely no honey before age one risk of botulism.

Serious risk.

Very.

Limit juice?

Offer from a cup.

Only after 12 months, maybe it can cause nursing caries or bottle -mouth decay.

Skills -wise, table 20 to 1 shows that progression, head control, rolling, sitting, crawling, pulling up, maybe first steps.

Play starts solitary, just responding to stimuli, then gets more interactive.

Imitating.

Think rattles, soft toys, mobiles.

And safety is paramount.

Constantly.

Choking hazards, small toys, food, strangulation risks, cords, mobiles.

Cribs safety, climbing out, cover outlets.

Keep chemicals, meds, poisons, plants way out of reach.

And never, ever shake a baby.

Shaking baby syndrome is devastating.

Absolutely critical message.

Okay, on to toddlers.

One, three years.

What stands out?

Slower growth and infancy.

About four to six pounds a year.

They get that typical toddler potbelly look that's lordosis.

Anterior fontanel closes.

First dental visit around age one.

Sleep is usually through the night, plus one nap, phasing out around age three.

Bedtime rituals help.

Box 20 to 3 has their vitals.

Nutrition for toddlers.

Still picky eaters.

Can be.

My plate guidelines apply from age two.

Need milk for calcium phosphorus.

Low fat is okay after two.

Don't restrict overall fat too much.

Need it for brain development.

Focus on iron, calcium, vit D, vit C.

They like to feed themselves small meals, finger foods.

Avoid sweets, empty calories.

Watch aspiration risks, nuts, grapes, hot dogs, popcorn.

And that drop in appetite.

Physiological anorexia.

It's normal.

Growth slows down a bit.

Eat at the table.

Don't use food as reward punishment.

Skills wise, they start walking, then running, hopping, might manage stairs, holding on.

Fine motor improves stacking blocks, scribbling.

Lots of no for independence.

Language explodes short sentences.

Maybe 300 words by age two.

Potty training comes into play.

Yep.

Bowel control usually first, then bladder.

Pretty good daytime control by three.

Might need night diapers till four maybe.

Box 20 to four lists readiness signs.

Play is parallel play alongside others.

Not really with them yet.

Short attention span.

Explore body parts.

Love push pull toys, blocks.

Safety for toddlers.

They're into everything.

Everything.

Constant supervision is key.

Stove safety backburners.

Handles in.

No dangling cords.

Window door locks.

Window guards.

Stair gates.

No upper bunks for sleeping or playing.

Preschoolers.

Three five.

Getting more coordinated.

Definitely.

Better posture.

Fine motor skills refine.

Gross motor hopping.

Skipping.

Running approve.

Better balance.

Can alternate feet on stairs usually.

Many learn to tie shoes around six.

Need about 12 hours sleep.

Security objects.

Night lights.

Still helpful.

Baby teeth.

Deciduous teeth are usually all in.

Still need help brushing flossing.

Box 20 to five for vitals.

Nutrition still similar to toddlers.

Still picky.

Pretty similar.

Might play it again.

Stove can be finicky.

Have food fads.

But by five, eating becomes more social.

Language really takes off vocabulary.

Jumps to maybe 900 words at three.

Over 2000 by five.

Longer sentences.

Clearer speech.

Bowel and bladder control.

Usually daytime control by four.

Both controlled by five typically.

Accidents can happen under stress.

Play becomes cooperative.

Lots of imagination.

Maybe imaginary friends.

Building.

Creating.

Understand sharing better.

Need space to run and jump.

Love dress up.

Paints.

Cranes.

Swimming.

Puzzles.

Safety concerns for this active group.

They're active and curious.

Plus that magical thinking can lead to risks.

But they can learn simple safety rules.

Reinforce playground safety.

No playing with matches lighters.

Fire drills.

Gun safety is crucial if guns are in the home unloaded, locked up.

Teach full name, address, phone, how to call 911.

School age.

Six twelve.

Becoming more independent.

Yeah.

Physically.

Girls often hit a growth spurt first.

Steady weight gain.

Permanent teeth start coming in around age six, losing baby teeth.

Regular dental care is vital.

Sleep needs around 10 -12 hours.

Box 20 -6 for vitals.

Nutrition.

Still need guidance.

Increased needs for growth activity.

Balanced diet.

My plate.

Healthy snacks.

Might still be picky, but often more willing to try things.

Motor skills refine further, both fine and gross.

More strength.

Endurance.

Gameplay changes again.

Becomes more competitive.

Rules and rituals are important.

Lots of activities.

Drawing.

Collecting.

Board games.

Reading.

Sports.

Computer games.

Team sports.

Clubs like South's become popular.

Safety for school -agers.

More aware, but still risks.

Less fearful in play sometimes, which can be risky.

Imitate real life.

Injuries often from bikes, skateboards, sports, dress, helmet, use, water safety, animal safety, fire safety, gun safety, traffic safety.

Teach 911 and start talking about inappropriate touching strangers.

Okay, adolescence again.

Twelve to late teens.

Huge physical changes.

The biggest is puberty sexual maturation.

Big increase in body mass, sebaceous glands, oil and sweat glands, skin changes, body odor, body hair changes.

Girls.

Height weight gain.

Breast development.

Wider pelvis.

Then monarch.

First period.

Usually 2 .5 years after puberty starts.

Boys.

Height weight.

Muscle gain.

Pantastasis growth.

Voice deepens.

Dental care.

Maybe braces.

Sleep patterns shift.

Want to stay up late.

Sleep in, but still need about 8 hours.

Box 20 to 7 for vitals.

Nutrition challenges with teens.

Body image.

Big time.

Reinforce my plate.

Habits can be erratic.

Lots of snacking.

Often empty calories.

Need lots of calcium, zinc, iron, folic acid, protein for growth.

Body image is a huge influence.

Motor skills are well developed.

More strength endurance.

Then their social world play.

Games.

Athletics.

Competition.

Still big.

Videos.

Movies.

Reading.

Parties.

Hobbies.

Computer.

Internet.

Social media.

Friends and peer groups are paramount.

Safety risks seem high in adolescents.

They are often risk takers.

Urge to experiment.

Be independent.

Dangerous of drugs.

Alcohol.

Smoking.

Caffeine.

Unsafe driving.

Need education on choices.

Seat belts.

Consequences of crashes.

Water safety.

Gun violence.

Games.

Complications of body piercing.

Tattooing.

Sun tanning.

And sensitive issues like acquaintance rape.

Safe sex STIs.

Internet safety.

Strangers.

That covers the younger years comprehensively.

The chapter also briefly mentions early and middle adulthood.

Quick overview.

Sure.

Early adulthood.

Late teens, early 20s to mid late 30s.

Physical growth done by 20.

Often active, but might neglect health maintenance.

Lifestyle habits set stage for later health.

Cognitively.

More rational thinking.

Problem solving.

Psychosocially.

Focus on career.

Relationships.

Maybe starting a family.

Separating from family of origin.

Sexually mature, but risk of STIs.

And middle adulthood.

Mid late 30s to mid 60s.

Physical changes.

More apparent menopause for women.

Period stops.

Climate care for men.

Testosterone declines.

Can't affect self -concept.

Health focus shifts to managing stress, preventing chronic disease.

Cognitively.

Maybe learning new skills.

Career changes.

Psychosocially.

Could be emptiness.

Becoming grandparents.

Striving for generativity.

Contributing to the next generation.

Sexuality might involve renewed intimacy, but also affected by physical changes.

Stress.

Health issues.

Meds.

Later adulthood is chapter 21.

Okay.

The chapter also brings up gender dysphoria.

What are the key takeaways there?

It references the DSM -5 criteria.

Basically a strong feeling of incongruence.

A mismatch between one's experienced gender and the gender assigned at birth.

Including physical sex characteristics.

How does that manifest?

Desire to be rid of one's sex characteristics.

Desire for the other gender's characteristics.

Desire to be or be treated as the other gender.

Feeling like you have the typical reactions of the other gender.

Data collection involves exploring these feelings.

It also mentions post -transition.

Living full -time as desired gender.

Potentially undergoing medical treatments like hormones or surgery.

Got it.

Important topic.

Finally, let's discuss end -of -life care.

Very significant area.

Hugely important.

It's about care and support during death and dying.

Cultural and religious beliefs are critical here.

Chapter 5 covers that more.

Legal and ethical issues are big too.

Patient wishes, organ donation, advanced directives, decisions about withholding treatment or CPR.

And the difference between palliative and hospice care.

Good question.

Palliative care focuses on symptom management and quality of life, not cure.

It can start at any stage, even alongside curative treatment.

Hospice care is for the last phases of incurable disease.

Usually months left.

Focuses purely on comfort, quality of remaining life, supporting client and family.

What are the physiological signs someone is nearing death?

Metabolism slows down.

Sensory changes.

Blurred vision, less taste -smell, left pain -touch sensitivity, loss of blink reflex, staring gaze, hearing is often the last sense to go.

Respirations change.

Rapid slow, shallow regular.

Maybe noisy wet sounds, the death rattle.

Or chainstokes, breathing periods of no breathing, apnea, alternating with deep rapid breaths.

Circulation changes.

Heart rate slows, BP drops.

Extremities get cool, pale, mottled, maybe bluish, cyanotic.

Skin can look waxy near the end.

Urinary output decreases, maybe incontinence.

GI motility slows, constipation, gas, distension, incontinence possible.

Musculoskeletal, gradual loss of movement, trouble speaking, swallowing, loss of gag reflex.

And then death itself.

Cessation of all vital functions.

Respirations usually stop first, then heartbeat.

Brain death is irreversible loss of all brain function.

Mercy and care at the end of life, what are the priorities?

Frequent assessment.

Physical care, box 20 to 8.

Manage pain, effectively don't delay.

Manage shortness of breath, dyspnea, elevate head, O2 maybe, suction, meds.

Skin care check often, prevent breakdown.

Dehydration, oral care, ice chips maybe, lip lubricant, don't force fluids.

Anorexia, nausea, anti -medic, small favorite meals.

And the psychosocial side.

Crucial.

Monitor for anxiety, depression, encourage talking.

Support the family.

Involve them if they wish.

Address spiritual needs.

Provide comfort, privacy.

After death, prepare the body for viewing.

Clean up, close eyes, dentures in, clean gallons, pads, remove tubes,

usually straighten body, pillow under head.

Allow family time.

No rules about medical examiner cases.

Non -natural deaths require preserving evidence.

Box 2010 details general postmortem procedures.

That critical thinking exercise answer seems to hit all the preschooler points we discussed.

Yeah, safe environment, communication, allowing feelings, accepting regression, comfort objects, play, simple explanations.

It pulls it all together.

We have definitely covered a huge amount of critical information today.

From the specific needs of hospitalized kids at every age.

To how we communicate effectively.

Key safety points like car seats and those really vital aspects of end of life care.

Right.

Understanding all this is just fundamental to providing good, holistic nursing care.

We really hope this deep dive into Chapter 20 gave you, the listener, a clear and useful overview.

Hopefully hitting those aha moments without feeling totally buried in details.

So here's something to think about.

Knowing all these distinct fears and needs at each developmental stage.

How could we actually design healthcare spaces and processes differently?

How could we build environments that genuinely reduce distress and give kids and families back some sense of control?

That's something to keep mulling over.

And with that, we've wrapped up our deep dive covering all the key areas of this chapter.