NURSING DIAGNOSIS: Risk for injury related to curiosity, increased mobility, and developmental immaturity
Outcome Identification and Evaluation
Toddler safety will be maintained: Toddler will remain free from injury.
Interventions: Preventing Injury
• Teach and encourage appropriate use of rear- facing car seat until 2 years of age and forward- facing car seat after 2 years of age to decrease risk of toddler injury related to motor vehicles.
• Teach toddlers to stay away from the street and pro- vide constant supervision to prevent pedestrian injury.
• Require bicycle helmet use while riding any wheeled toy to prevent head injury and form habit of helmet use.
• Childproof the home to provide a developmentally safe environment for the curious and increasingly mobile toddler.
• Post poison control center phone number in case of accidental ingestion.
• Never leave a toddler unattended in a tub or pool or near any body of water to prevent drowning.
• Teach parents first-aid measures and child CPR to minimize consequences of injury should it occur.
• Provide close observation and keep side rails up on crib/bed in hospital because toddlers are at par- ticularly high risk for falling or becoming entangled in tubing as they attempt mobility.
NURSING DIAGNOSIS: Imbalanced nutrition, less than body requirements, related to inappropriate nutritional intake to sustain growth needs (excess juice or milk intake, inadequate food variety intake) as evidenced by failure to attain adequate increases in height and weight over time
Outcome Identification and Evaluation
Toddler will consume adequate nutrients while using an appropriate feeding pattern:
Toddler will demonstrate weight gain and increases in height.
Interventions: Promoting Appropriate Nutrition
• Assess current feeding schedule and usual intake, as well as methods used to feed, to determine areas of adequacy versus inadequacy.
• Determine toddler’s ability to drink from cup, finger feed, swallow, and consume tex- tures to determine if additional exposure is needed or if further interventions such as speech or occupational therapy are required.
• Weigh toddler daily on same scale if hospitalized, weekly on same scale if at home, and plot growth patterns weekly or monthly as appropriate on standardized growth charts to determine if growth is improving.
• Wean from bottle by 15 months of age to discourage excess milk or juice intake in toddler who can carry bottle around.
• Limit juice to 4 to 6 ounces per day and milk to 16 to 24 ounces per day to discourage sense of fullness achieved with excess milk or juice intake, thereby increasing appetite for solid foods.
• Provide three nutrient-dense meals and at least two healthy snacks per day to encour- age adequate nutrient consumption.
• Feed toddler on a similar schedule daily, without distractions and with the family:
toddlers respond well to routine and structure and may eat better in the social context of meals, and they become distracted easily (TV should be off).
NURSING CARE PLAN 26.1
C h a p t e r 2 6 Growth and Development of the Toddler 931
Growth and Development Issues in the Toddler
(continued)NURSING DIAGNOSIS: Delayed growth and development related to motor, cognitive, language, or psychosocial concerns as evidenced by delay in meeting expected milestones
Outcome Identification and Evaluation
Development will be enhanced: Toddler will make continued progress toward realization of expected developmental milestones.
Interventions: Enhancing Growth and Development
• Screen for developmental capabilities to determine toddler’s current level of functioning.
• Offer age-appropriate toys, play, and activities (includ- ing gross motor) to encourage further development.
• Perform interventions as prescribed by physical, occupational, or speech therapist: participation in those activities helps to promote function and accomplish acquisition of developmental skills.
• Provide support to families of toddlers with devel- opmental delay (progress in achieving developmen- tal milestones can be slow and ongoing motivation is needed).
• Reinforce positive attributes in the toddler to maintain motivation.
• Model age-appropriate communication skills to illustrate suitable means for parenting the toddler.
NURSING DIAGNOSIS: Risk for disproportionate growth related to excess milk or juice intake, late bottle weaning, and consumption of inappropriate foods or in excess amounts
Outcome Identification and Evaluation
Toddler will grow appropriately and not become overweight or obese: Toddler will achieve weight and height within the 5th to 95th percentiles on standardized growth charts.
Interventions: Promoting Proportionate Growth
• Wean from bottle and discourage use of no-spill sippy cups by 15 months of age (will keep mobile toddler from carrying around and continually drinking from cup or bottle).
• Provide juice (4–6 ounces per day) and milk (16–24 ounces per day) from a cup at meal and snack time to encourage appropriate cup drinking and limit intake of nutrient-poor, high-calorie fluids.
• Provide only nutrient-rich foods without high sugar content for meals and snacks; even if the toddler won’t eat, it is inappropriate to provide high-calorie junk food just so the toddler eats something.
• Ensure adequate physical activity to stimulate development of motor skills and provide appropriate caloric expenditure. This also sets the stage for forming life-long habit of appropriate physical activity.
NURSING CARE PLAN 26.1
(continued)
932 U N I T 9 Health Promotion of the Growing Child and Family
Growth and Development Issues in the Toddler
(continued)NURSING DIAGNOSIS: Interrupted family processes related to issues with toddler development, hospitalization, or situational crisis as evidenced by decreased parental visitation in hospital, parental verbalization of difficulty with current situation, possible crisis related to health of family member other than the toddler
Outcome Identification and Evaluation
Family will demonstrate adequate functioning: Family will display coping and psychosocial adjustment.
Interventions: Enhancing Family Functioning
• Assess the family’s level of stress and ability to cope to determine family’s ability to cope with multiple stressors.
• Engage in family-centered care to provide a holistic approach to care of the toddler and family.
• Encourage the family to verbalize feelings (verbal- ization is one method of decreasing anxiety levels), and acknowledge feelings and emotions.
• Encourage family visitation and provide for sleep- ing arrangements for a parent or caregiver to stay in the hospital with the toddler (contributes to family’s sense of control of situation).
• Involve family members in toddler’s care, giving them a feeling of control and connectedness.
NURSING DIAGNOSIS: Readiness for enhanced parenting related to parental desire for increased skills and success with toddler as evidenced by current healthy relationships and verbalization of desire for improved skills
Outcome Identification and Evaluation
Parent will provide safe and nurturing environment for the toddler.
Interventions: Increasing Parenting Skill Set
• Use family-centered care to provide holistic approach.
• Educate parent about normal toddler development to provide basis for understanding the parenting skills needed in this time period.
• Acknowledge and encourage parent’s verbalization of feelings related to chronic illness of child or difficulty with normal toddler behavior to validate the normalcy of the parent’s feelings.
• Encourage positive parenting with respect to toddlers and their normal development (helps parents develop approaches to toddlers that can be used in place of anger and frustration).
• Acknowledge and admire positive parenting skills already present to contribute to parents’
confidence in their abilities to parent.
• Role model appropriate parenting behaviors related to communicating with and disci- plining the toddler (role modeling actually shows rather than just telling the parent what to do).
NURSING CARE PLAN 26.1
C h a p t e r 2 6 Growth and Development of the Toddler 933
a sense of self (who they are as a person), they may see their toys as an extension of themselves. Learning to share occurs in later toddlerhood. Toddlers also like dramatic play and play that recreates familiar activities in the home. Toddlers like to listen to music of all kinds and will often dance to whatever they hear on the radio.
Toddlers enjoy drums, xylophones, cymbals, and toy pia- nos. Musical instruments made at home are also enjoyed.
Limit setting (and remaining consistent with those limits) helps toddlers master their behavior, develop self-esteem, and become successful participants in the family. Chil- dren then are able to learn about cooperation throughout the predictable flow of daily life. Nurses need to be aware of normal developmental expectations in order to deter- mine whether the toddler is progressing appropriately.
Table 26.4 lists potential signs of developmental delay.
Any toddler with one or more of these concerns should be referred for further developmental evaluation.
Promoting Growth and Development Through Play
Play is the major socializing medium for toddlers. Par- ents should limit television viewing and encourage cre- ative and physical play instead. Toddlers typically play alongside another child (parallel play) rather than cooperatively (Fig. 26.7). The short attention span of the toddler will make him or her often change toys and types of play. It is important to provide a variety of safe toys to allow the toddler many different opportunities for exploring the environment. Toddlers do not need expensive toys; in fact, regular household items some- times make the most enjoyable toys. Toddlers are egocen- tric, a normal part of their development (Piaget, 1969). This
makes it difficult for them to share. As they are developing FIGURE 26.7 Parallel play. The toddler usually plays alongside another child rather than cooperatively.
TABLE 26.4 SIGNS OF DEVELOPMENTAL DELAY Age or Time Frame Concern
After independent walking for several months
• Persistent tiptoe walking
• Failure to develop a mature walking pattern By 18 months • Not walking
• Not speaking 15 words
• Does not understand function of common household items
By 2 years • Does not use two-word sentences
• Does not imitate actions
• Does not follow basic instructions
• Cannot push a toy with wheels By 3 years • Difficulty with stairs
• Frequent falling
• Cannot build tower of more than four blocks
• Difficulty manipulating small objects
• Extreme difficulty in separation from parent or caregiver
• Cannot copy a circle
• Does not engage in make-believe play
• Cannot communicate in short phrases
• Does not understand simple instructions
• Little interest in other children
• Unclear speech, persistent drooling
934 U N I T 9 Health Promotion of the Growing Child and Family
to the toddler. The toddler needs time to complete his or her thoughts without being interrupted or rushed because he or she is just starting to be able to make the connections necessary to transfer thoughts and feelings into language.
Parents should not overreact to the child’s use of the word “no.” They can give the toddler opportunities to use the word “no” appropriately by asking silly ques- tions such as, “Can a cat drive a car?” or “Is a banana purple?” When promoting language development, the parent or primary caregiver should teach the toddler appropriate words for body parts and objects and should help the toddler choose appropriate words to label feel- ings and emotions. Toddlers’ receptive language and interpretation of body language and subtle signs far sur- pass their expressive language, especially at a younger age (Feigelman, 2011b; Goldson & Reynolds, 2011).
Parents should avoid discussing scary or serious topics in the presence of the toddler, since the toddler is very adept at reading emotions.
If the parents speak a foreign language in addition to English, both languages should be used in the home.
A few pebbles or coins inside an empty water bottle with the top tightly secured is a great music maker; an empty butter tub with a lid and a pair of wooden spoons makes a nice drum.
Adequate physical activity is necessary for the devel- opment and refinement of movement skills. Toddlers need at least 30 minutes of structured physical activity and anywhere from 1 to several hours of unstructured physical activity per day (National Association for Sport
& Physical Education, 2012). Indoor and outdoor play areas should encourage play activities that use the large muscle groups. The activity must occur within a safe environment. Outdoor play structures should be posi- tioned over surfaces that are soft enough to absorb a fall, such as sand, wood chips, or sawdust (Fig. 26.8). Box 26.1 lists recommended age-appropriate toys.
Promoting Early Learning
The parent–child relationship and the interactions between parent and child form the context for the toddler’s early learning.
Promoting Language Development
Talking and singing to the toddler during routine activi- ties such as feeding and dressing provides an environ- ment that encourages conversation. Frequent, repetitive naming helps the toddler learn appropriate words for objects. The parent or caregiver should be attentive to what the toddler is saying as well as to his or her moods.
Using clarification validates the toddler’s emotions and ideas. Parents should listen to and answer the toddler’s questions. They should sit down quietly with the toddler and gently repeat what the toddler is saying. Encourage- ment and elaboration convey confidence and interest FIGURE 26.8 Toddlers love outdoor physical play, such as climbing on playground equipment. An adult should always supervise toddlers when they are playing outdoors.
BOX 26.1
APPROPRIATE TOYS FOR TODDLERS
• Familiar household items such as plastic bowls and cups of various sizes, large plastic serving utensils, pots and pans, wooden spoons, cardboard boxes and tubes (from paper towel rolls), old magazines, baskets, purses, hats
• Child-size household item toys (kitchen, broom, vac- uum cleaner, lawnmower, telephone, and so on)
• Blocks, cars and trucks, plastic animals, trains, plastic figures (family, community helpers), simple dolls, stuffed animals, balls, doll beds and carriages
• Manipulative toys with knobs, wind-ups, and but- tons that make things happen; putting large pegs or shapes into matching holes; stringing large beads on shoelaces; blocks and containers that stack; jigsaw puzzles with large pieces; toys that can be taken apart and put back together again
• Gross motor toys: play gym, push and pull toys, wagons, tricycle or other ride-on toys, tunnels
• Tape or CD players for music, various musical instruments
• Chalk, large crayons, finger paint, Play-Doh, wash- able markers
• Bucket, plastic shovel, and other containers for sand and water play
• Squeaking, floating, and squirting toys for the bath
Adapted from Schuman, A. T. (2007). The ABCs of toy safety: More than just child’s play. Contemporary Pediatrics, 24(7), 49–57, 64; and Shelov, S. P., & Altmann, T. R. (Eds.). (2009). Caring for your baby and young child: Birth to age 5 (5th ed.). New York: Bantam Books.
C h a p t e r 2 6 Growth and Development of the Toddler 935
Choosing a Preschool
The older toddler may benefit from the structure and socialization provided by attending preschool. Attend- ing preschool will help the toddler become more mature and independent and give the toddler a different source for a sense of accomplishment. At this age, toddlers need supervised play with some direction that fosters their cognitive development. A strict curriculum is not neces- sary in this age group. When choosing a preschool, the parent or caregiver should look for an environment that has the following qualities:
• Goals and an overall philosophy with which the parents agree (promotion of independence and self- confidence through structured and free play)
• Teachers and assistants trained in early childhood de- velopment as well as child cardiopulmonary resuscita- tion (CPR)
• Small class sizes and an adult-to-child ratio with which the parent feels comfortable
• Disciplinary procedures consistent with the parents’
values
• Parents can visit at any time
• School is childproofed inside and out
• Appropriate hygiene procedures, including prohibit- ing sick children from attending
Teach the parents how to ease the toddler’s transition to attending preschool. Encourage parents to talk about going to preschool and visit the school a couple of times.
On the first day, parents should calmly and in a matter-of- fact tone tell the toddler that they will return to pick him or her up. If the toddler expresses separation anxiety, the par- ent should remain calm and follow through with the plan for school attendance. After a few days of attendance, the toddler will be accustomed to the new routine and crying when parting from the parent should be minimal.
Promoting Safety
Safety is of prime concern throughout the toddler period. Curiosity, mobility, and lack of impulse control all
Encouraging Reading
Reading to the toddler every day is one of the best ways to promote language and cognitive development (Fig. 26.9). Toddlers particularly enjoy homemade or purchased books about feelings, family, friends, every- day life, animals and nature, and fun and fantasy. Board books have thick pages that are easier for young toddlers to turn; older toddlers can turn paper pages one at a time. The toddler may also enjoy “reading” the story to the parent. Reach Out and Read, a program designed to promote early literacy, offers tips for reading with young children (see Teaching Guidelines 26.1).
FIGURE 26.9 Reading to a toddler daily is one of the best ways to promote language development and school readiness.
Teaching Guidelines 26.1
TIPS FOR READING WITH YOUNG CHILDREN
• Make reading part of every day: Read at bedtime or on the bus.
• Have fun: Children who love books learn to read.
Books can be part of special time with your child.
• A few minutes is OK: Young children can sit for only a few minutes for a story, but as they grow they will sit longer.
• Talk about the pictures: You do not have to read the book to tell a story.
• Let your child turn the pages: Babies need board books and help to turn pages, but your 3-year-old can do it alone.
• Show your child the cover page: Explain what the story is about.
• Show your child the words: Run your finger along the words as you read them.
• Make the story come alive: Create voices for the story characters and use your body to tell the story.
• Ask questions about the story: What do you think will happen next? What is this?
• Let your child ask questions about the story: Use the story as an opportunity to engage in conversation and to talk about familiar activities and objects.
• Let your child tell the story: Children as young as 3 years old can memorize a story, and many children love an opportunity to express their creativity.
Used with permission from Reach Out and Read. (2011). Reading tips. Retrieved March 7, 2011, from http://www.reachoutandread.org/
FileRepository/ReadingTips.pdf
936 U N I T 9 Health Promotion of the Growing Child and Family
Safety in the Home
Key areas of concern for keeping toddlers safe in the home include avoiding exposure to tobacco smoke, pre- venting injury, and preventing poisoning.
AVOIDING EXPOSURE TO TOBACCO SMOKE
Environmental exposure to tobacco smoke has been asso- ciated with increased risk of respiratory disease and infec- tion, decreased lung function, and increased incidence of middle ear effusion and recurrent otitis media. It may also hinder neurodevelopment and may be associated with behavior problems (World Health Organization, 2011).
Parents should avoid cigarette smoking entirely to best protect their children. Even smoking outside of the home is suboptimal because smoke lingers on parents’ cloth- ing and children who are often carried (such as younger toddlers) face more exposure. Counsel parents to stop smoking (optimal), but if they continue smoking never to smoke inside the home or car with children present.
PREVENTING INJURY
The toddler is able to open drawers and doors, unlock deadbolts, and climb anywhere he or she wants to go.
Toddlers have a limited concept of body boundaries and essentially no fear of danger. Toddlers may fall from any height to which they can climb (e.g., play structures, tables, counters). They may also fall from wheeled toys such as tricycles. As toddlers gain additional height and hand dexterity they are able to reach potentially danger- ous items on the counter or stove, leading to an acciden- tal ingestion, burn, or cut.
To prevent injury in the home, stress the following to parents:
• Never leave a toddler unsupervised out of doors.
• Lock doors to dangerous rooms.
contribute to the incidence of unintentional injury in toddlerhood. Even the most watchful and caring par- ents have toddlers who run into the street, otherwise disappear from parents, and fall down the stairs. Tod- dlers require direct observation and cannot be trusted to be left alone. A childproof environment provides a safe place for the toddler to explore and learn. Motor vehicle accidents, drowning, choking, burns, falls, and poison- ing are the most common injuries suffered by toddlers.
Safety and injury prevention focuses on these categories.
Safety in the Car
The safest place for the toddler to ride is in the back seat of the car. Parents should use the appropriate size and style of car seat for the child’s weight and age as required by the state. At a minimum, toddlers should be in a rear- facing car seat with harness straps and a clip until 2 years of age (American Academy of Pediatrics [AAP], 2012a).
After age 2 years, a forward-facing seat may be used.
A toddler riding in a pickup truck should never ride in the cargo area or truck bed. A full rear seat in the truck is the preferred placement for the toddler car seat. If an appropriate rear seat is unavailable, the air bag should be disarmed and the forward-facing car seat should be secured appropriately in the truck seat. The lower anchor and top tether are additionally required for all forward- facing car seats manufactured since 2002 and are accom- modated by motor vehicles manufactured since that time (Fig. 26.10). In older vehicles or car seats, seat belts are utilized for installation. Drivers should avoid using the cell phone or attempting to intervene with the children while they are driving. Excellent resources about car seat safety appropriate for both parents and professionals can be found on .
Top tether
Bottom tether
Seat belt Bars installed
in vehicle seat
Flexible attachment on child seat Seat belt attachment
FIGURE 26.10 A lower anchor and top tether secure the forward-facing car seat. (Adapted from U.S. Department of Transportation, National Highway Traffic Safety Administration, 2011.)