Principles of Growth and Development Life is a dynamic, changing process. Human life proceeds in stages from infancy to adulthood to senescence. Humans spend one-third oftheir lives in preparation for the latter two-thirds. An extended stage ofimmaturity follows as the human passes through intancy, childhood and adolescence, before achieving the capacity for independent function. Although defined as separate physicological processes, they cannot be separated in nature; cells increase in size and number as they differentiate. All human beings share the same mechanisms of growth and development and proceed through the same stages of life. The rate ofmaturation and the final outcome are widely variable because of the expensive and diverse influences on each individual. Growth may be defined as a physiological process by which the organism assimilates ortransforms essential, nonliving nutrients into living protoplasm. Growth involves the incorporation of new materials. Development is defined as a physiological process by which the individual progresses from an undifferentiated state to a highly organized and functional capacity. Development implies an increase in skill and in complexity of function. As growth is measured in pounds and inches, development is measured in abilities. Patterns of Growth and Development: The genetic code determines the rate of the growth and development of the various body parts, which occur in synchrony with overall growth and development. For example, at birth the lower limbs ofthe infant are less well developed than the upper limbs. The ratio of lower
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The stages of bone growth occur at regular intervals that vary little
between individuals. This relative uniformity permits the use of bone age
measurement as a reliable index of maturation.
Skull Growth
The skull is large at birth because of the relatively large size of the
brain. After birth, the skull continues to grow in order to accommodate
the very rapid further growth of the brain. In the first two years of life, the
skull’s capacity grows from 400ml to 950ml and its circumference
increases from about 33cm to 47cm.
At birth, the bones that comprise the cranial vault are separated bygaps filled with fibrous connective tissue; the gaps allows the bones to
slide over each other to some extent as the neonate passes through the
mother’s narrow birth canal.
As ossification of the fibrous connective tissue proceeds, the
individual bones come into contact with each other along a series of
fibrous joints known as sutures. It is at the sutures that skull growth takes place. Skull growth will continue until after puberty, accommodating the
growing brain. After skull growth stops, the sutures will be obliterated by
their ossification and fusing together .
ASSESSMENT OF GROWTH AND DEVELOPMENT
All measurements should be made in a room with adequate
lighting, comfortable temperature, and a firm, level floor. Childrenshould wear only minimal light-weight clothing or none at all.Shoes should not be worn.
Length:
During the first two years of life, the child's length must bemeasured while the child is in the recumbent position.
Arecumbent-length measuring table is required to obtain a obtain a
measurement (see Figure 3-5). Two persons are needed, one tohold the infant's head in contact with the headboard, and one to
bring the movable footboard firmly against the child's heels. Toposition the feet so that the soles are directed vertically against thefootboard, gentle traction may be applied to the legs. Recumbentmeasurement should be recorded to the nearest 0.1 cm.
The child should face forward, with heels together, back as straightas possible, and with heels, buttocks, and the upper part of theback touching the wall. The measurement should be recorded tothe nearest 0.1 cm.
Weight:
The child should be weighed while wearing a minimal amount of clothing, if any. Infants should be weighed on an infant scale
having a capacity of approximately 15kg. the accuracy of thescales should be checked and adjusted approximately three timesa month, and each time the scales are moved. The infant shouldbe placed centrally on the scale and the older child should standcentrally on the platform.
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Head circumference
Head circumference is measured until the child is 2 years old. Itshould be measured with a flexible narrow-width tape. Tle tapeshould be placed on the infant's head so as to obtain the maximalfrontal-occipital circumference. The head circumference should berecorded to the nearest 0.1cm.
The pattern of the growth of the cranium is very different from theof the body; its groth is nearly completed by 6 years of age, sogrowth evaluation is most relevant in infancy and early childhood.
The method for interpretation of head circumference on the growthgrid is identical to that for interpretation of height and weight. Ameasurement outside the normal range does not absolutelyindicate cranial abnormality; rather, it is the rate of growth thatmust be evaluated.
Bone Age
Another clinical tool that assists the clinician in evaluating thechild's progress toward maturity is bone age assessment.
Age can be helpful in interpreting the atypical chil's growth.
The progress of bone growth can be recorded by x-ray. Theappearance of the centers of ossification can be noted becausetheir calcium content makes them radiopaque. The sequence of bong growth is similar in every person.
That individual variations caused by genetic differences mayaccount for atypical maturation, that cannot be reconciled with anorm.
The clinical purpose of bonge age assessment is to identify thelevel of skeletal maturation. This information assists the examiner in making adecision concerning the child with abnormal growth byallowing a comparison with norms for the same chronological age.
Growth Grids
The national center for health statistics (NCHS) has developed agrowth grid that is commonly used in clinical practice. It is basedon a distance curve. The distance curve shows the height, weight,and head circumference of a child at various age.
The standards for each age are derived from measurements of alarge number of children of the specific age. An average (mean)and a rang (fifth through ninety-fifth percentiles) for each height,
weight, and head circumference have been determined for eachage. Ideally, every child's growth should be evaluated in relation tonorms established for children of the same sex, ethnic group, andsocioeconomic status.
The rationale for the use of growth grids is that children followpredicatable patterns of growth and development. The individualchild's measurements are interpreted in relation to the expectednorms for other children of the same age, sex, and ethnic group.
Achild whose measurements falls outside the normal range issuspected of having disease, although disease should not beregarded as the definite cause of atypical measurements.
Asingle measurement determines the size of a child, whereasseveral measurements must be made in order to evaluate thechild's growth.
Two important points should be kept in mind in comparing a child's
growth to a standardized grid. First, the curve derived from a largegroup of children naturally obscures the individual patterns of each
child in the original sample population and with be a smooth curvewith no dramatic peaks; many children with show peaks in thecourse of normal growth. Second, height is a more stable indicator then weight. Weight is more influenced by environmental factors
and may fluctuate more than height. Weight is still a reliablemeasurement but may be more difficult to interpret, especially ininfancy (Falkner, 1962).
Developmental Screening
As was said earlier, humans, unlike other animals, do not inherit arepertoire of instinctive behaviours but must learn behavior; theprolonged period of immaturity enables humans to benefit fromtheir experiences for optimal learning. Behavior is divided nito five
areas; gross motor, fine motor, language, personal social, andadaptive behavior.
Gross motor behavior includes the control of the head, trunk, andextremities. Fine motor behavior is the control of the movements of the vingers. The acquisition of motor control reflects the integrity of the child's neurological system.
Language behavior includes the production of single or combinedwords, and the ability to comprehend speech.
Wide variations exist in personalsocial behavior, since it isdependent on the child's interaction with his or her environmentand culture.
Adaptive behavior is significant because it stems from intellectualpotential. Adaptive behavior indicates the child's ability to solveproblems. It includes the use of motor abilities, to execute practicalsolutions and the use of past experience in the solution of new
problems.Developmental screening, like screening of physical growth, is anintegral part of pediatric health care. A development assessment isa clinical estimate of the developmental progress made in eacharea of behavior.
It must be kept in mind that developmental screening tests are notintelligence tests.
Developmental screening is also used to identify mentally retardedchildren.
Another area of significant clinical use of developmental screeningis its use to educate parents about their child's development. Anticipated developmental changes that the child will undergo canbe delineated for parents. This information can assist parents in
adjusting to their continually changing child. It can also assistparents to adjust the child's environment for optimal support andstimulation of his or her development.
Denver Developmental Screening Test
The Denver developmental screening test (DDST) is widely usedin clinical practice and is a typical screening instrument. The axiomunderlying the DDST is the development follows predicatedpatterns common to all, and that the child who does not follow the
expected pattern is more likely that the typical child to havedisease.
The rest consists of 105 tasks selected from existing infant andpreschool scales. The testWas first administered to a large group of infants and children inDenver, Colorado; the sample population of he children waschosen to match the sociocultural and economic status of Denver'soverall population, and is therefore not necessarily representative
of population of other parts of the United states. The ages at which25, 50, 75, and 90 percent of the subjects passed the items werecalculated for the entire sample (Frankenburg and Campbell,1975).Children between 2 weeks and 6 years old are tested on only 20 or so simple tasks by means of a few basic testing materials. Theitems are arranged in order of difficulty and are divided into four major behavioral areas: personal-social, fine motor adaptive,language, and gross motor.The DDST is a useful clinic tool because of its use an age range inestablishing the norms, which allows for a wider variation individualpatterns. Also, the heterogeneity of the original test population,from which the criteria were derived, allows for variations inchildren of different cultural and socioeconomic backgrounds(Frankenburg and Campbell, 1975).
SUMMARY
Humans are born immature. On the path to independent function,
they progress through the predictable stages of infancy, childhood,and adolescence. The physiological processes of growth and
development are responsible for the changes in body size andcomposition and in abilities that the individual undergoes beforeattaining adulthood.Growth and development begin at the cellular level and advance
under the influence of both the individual's genetic potential andenvironmental influences.Hormones influence growth and development by stimulatingprotein synthesis. The degree of influence of the individualhormones varies during the different stage of growth anddevelopment.The assessment of growth and development is an integral part of pediatric health care. However, the examiner must keep in mindthat individual variations caused by genetic and environmental
differences may cause the child to deviate from the norm.
ASSESSMENT AND MANAGEMENTOF THE HEALTHY CHILD
The nurse practitioner exercises professional judgments andaccepts responsibility for the delivery of primary health care. Mutual trustand collaboration among health care providers and families form the
bases for effective delivery of quality care. Incorporated in thisframework of care are the concepts of prevention, health promotion, and
health maintenance. Teaching and counseling are strongly emphasized.
Part one provides information necessary to maintain and promotethe health of the child from birth through adolescence and to assess and tomanage specific common concerns and conditions of the healthy child.
CHILD HEALTH ASSESSMENT
The Provision of pediatric primary care requires mastery of theknowledge and skills of data gathering, namely, the history and the
physical examination, as well as the ability.
It is often the key to solving many presenting concerns and inhelping formulate a diagnosis. Mastery in the art of interviewing requiresthe ability to weave observation and communication skills into theaccurate picture of a situation. In addition, it provides an excellent
opportunity to learn about the family and health.Clients and the nurse practitioner come to interviews with their
own agendas of concerns and with their own ideas of possible solutions.A useful question to ask the client is : What do you think I can do for youtoday? It is essential to use open-ended, nonjudgmental questions, toavoid the use of technical language, and to be aware of personal biases.The nurse practitioner must be keenly sensitive to client's real problems.The nurse practitioner might discover that a client presenting with acomplaint of "noisy breathing" is really worried about sudden infantdeath syndrome (SIDA) because the neighbor's infant recently diedsuddenly.
CLIENT – NURSE PRACTITIONER RELATIONSHIPS
The inclusion and active participation of clients in their care areimportant aspects of delivering primary care. Continuity of care by thenurse practitioner establishes a therapeutic relation with the family.
1. Personalize the interactions by introducing yourself to thechild and parent by name and addressing them by their names.
2.Use language that is clearly understood.
3.Consider the situation form the client's perspective.
4.Focus on parental needs as wells as those of the child.
5.Reinforce the ideas of the parents as appropriate and encouragethem to develop their own plans of action.
The history is a longitudinal and cumulative process. The amountand the type of history information obtained depend on the purpose of thevisit and on the concerns of the parents.
Obtaining a complete health history (Table 1-1) on the first visit istime consuming because an initial base of information is collected inaddition to eliciting the present concerns.
Table 1-1
Summary of Health History
1. Identifying information NameAddressPhone number Clinic number
2. Present concerns3. Family profile
Family characteristics
Family historyFamily developmentFamily interactionSupport systemsCulture
4. Child profilePast medical history
Gestation
Birth history Neonatal periodImmunizations and
Laboratory testsInfectious diseases
Operations/hospitalizationsAccidentsAllergies
Current medications
4. Child profile (cont).
Review of systemsHeadSkinEyes, ears, nose, throatDentitionHeart and lungBlood
GastrointestinalGenitourinarySkeletal
Neuromuscular Personality
The child as a personInteraction
Development
LanguageFine motor Gross motor
NutritionSleepEliminationSchoolPast utilization of health Care
Does the child awaken at night? If yes, how often?
Does the child have any nightmares or night terrors?
PHYSICAL EXAMINATION:
A skillful physical examination is done with aminimum of trauma tochild . It done with sensitivity to child behavior ,Activity level , and response , and take advantage of opportunities such ascrying by quickly looking into mouth.
There are four basic techniques : auscultation , palpation , percussion andopservation ( inspection : is the most important one. (
SUMMARY OF PHYSICAL EXAMINATION :
Measerement and vital signs. General condition.
Skin.Head:
Face ,eyes , ears , nose , mouth and throat Neck . Heart.
Abdomen.Genitalia.Skeletal.
Neuromuscular .
Measerement and vital signs. Obtain the following measurement : height , weight , headcircumference , temperature , respiration rate and blood pressure.
Approximal Height and Weight
At birth : Weight (w) in lb = 7 lb 6 oz (7.35 lb. (Form 3 to 12 month : (w) = age (mo) + 11From 1 to 6 year : (w) = (age yr * 5 ) + 17From 6 to 12year : (w) = (age yr * 7 ) + 5At birth : length = 20 in
At one year : length =30 inFrom 2 to 14 years : length = (age yr *2.5 ) + 30.
*The kay to auscultation is to listen to one heartsound at a time:1-aortic valve is best heard sound in the second right intercostals space.2- pulmonic valve is best heard sound in the second left intercostals space
3-tricuspid valve is best heard sound in the fifth right intercostal spacenear the sternum.
4-mitral valve is best heart sound in the fifth left intercostals space near midclavicular line.
5-S1 is louder at the apex.
6-S2 is louder at the base. 7- bell of stethoscope detect low – frequency sound.8-diaphragm of stethoscope detect high– frequency sound.
Percuss for liver edge , tympancy and shifting dullness.Femal genitalia:Inspect external genitia for color , labia (minora, majora.(Inspect vagina and cervix .
Palpate the uterus.Male genitalia:
Inspect external genitia for penis (size , gland , shape. (Urethra ( ulceration , position of meatus ) , scrotum (hydrocele , hernia(Palpate testes , epididymis , and spermatic cord .
Skeletal :Observe gait ( opposing arm and leg swing ,normal heel to toe gait ) . gross deformities , posture ,and symmetry .
Examine spine and back ( body alignment , curvature , rigidity ,tenderness , lesion ) , joints ( rang of motion , tightness , edema ,tenderness , redness ) , hips (abduction , internal rotation ) , knee
( length , symmetry,controur ) , forefoot ( abduction ) , fingers and toes (numbers , space ,