Nick: an 8 year old boy

Kelly LewisGrowth & Development, Pediatrics

California State University, San MarcosSchool of Nursing

July 1, 2016

Photo from: www.morguefile.com

About Nick

Nick is an 8 year old boy living with Mom, Dad and no

siblings. He will be attending 3rd grade this fall in the

Poway Unified School District. Nick is an easygoing,

good-natured kid. His social network consists of a best

friend at school, friends on his little league baseball

team and friends in the Cub Scouts. He spends time

with his paternal grandparents a few hours each week.

His hobbies include 2 pet rats, legos and riding his bike

or scooter. His friends include his best friend from

school, Jackson, 3 neighborhood friends, friends on his

baseball team and in his Cub Scout troop. His teacher

notes that he is well-liked. Photo: author’s own

School-Age Child 6-12 yearsNick is much leaner than when he was an infant/toddler. He is in the 90th percentile for height (54”) and 50th percentile for weight (58 pounds) for his age. His growth averages 2” and 4 pounds a year. His BMI is in the 14th percentile. He occasionally experiences growing pain in his legs.

He lost his first baby tooth at almost 8 years of age, which typically starts at age 6-7 (“Eruption Charts”, n.d.).

His mom expresses concern over any future back issues Nick could have. She and Nick’s dad both are tall, thin and have chronic back trouble, mild scoliosis (mom) and poor posture.

Nick sleeps 11 hours at night; the normal range for an 8 year old is 9-11 hours (“Changes in Sleep with Age”, n.d.) .

Images from www.cdc.gov

Piaget: Concrete Operational StageNick interacts with other children cooperatively, a typical milestone in this developmental stage. This

behavior compares to a less egocentric, more outward view. He is thoughtful towards others, cognitively

displaying a more logical, complex way of thinking, but still struggles with abstract concepts. For example, he

has begun asking questions about God and heaven. He wants concrete answers and struggles with uncertain

or ambiguous opinions. Self-esteem can start to be affected due to awareness expanding outside of self and

family to the world around (Ball & Bindler, p. 208, 2014). Mom expresses concern about Nick’s self-esteem. He

has recently begun verbalizing “I am so stupid” or “I hate myself”. Socially, from the age of 3 years, Nick has

preferred the company of adults or being alone rather than play with other children. He speaks of his “best

friend”, Jackson. His preferred school playground activity is still swinging, more of associative play social

behavior seen seen in preschool development (Ball & Bindler, p. 101, 2014). Mom states that Nick

occasionally struggles with reading other kids’ cues and his IEP (Individualized Education Program) team

helps him work on social thinking skills. He intuits most nonverbal cues (such as facial expressions, tone) but

attends speech therapy where perspective taking and how his behavior affects others (talking out loud in

class out of turn) is addressed. Nick is also being supported with executive function skills and learning to stay

on task. His mom notes this is a challenge at home as well.

Erikson: Industry (Competence) vs. Inferiority

Nick is experiencing a surge in industry. His reading and writing skills, while needing a little support during

1st grade, have drastically improved in 2nd grade. His parents have noticed from an early age that he seems to

be a late developer, but always makes great strides. He enjoys reading and his skills have improved greatly

over the past year, also representative of this stage. Nick’s IEP program at school helps with fine motor

coordination such as pencil grasping and writing in between the lines. Another favorite hobby is sewing with

his grandma, which helps with fine motor development. He has started playing baseball with a little league. At

the beginning of the season, he was moderately interested, with beginner level catching and hitting skills.

Throughout the season, his interest, focus and determination skyrocketed. Dad states that nearly every

afternoon, “we play catch and practice batting for 30-45 minutes”. Nick is engrossed in developing this new

skill. Gross motor skills are reflective of his developmental stage. He learned to ride a 2 wheel bike at age 5

years and is skilled at riding his scooter. His current fine and gross motor skill development is reflective of

school age children’s developmental milestones (Ball & Bindler, p. 102-104, 2014).

Photo from: www.morguefile.com photo from morguefile.com

Kohlberg’s Preconventional Morality, Stage 2

This level is defined as when one learns that

it is in their interest to behave well and rules

must be followed (Ball & Bindler, p. 83,

2014). Nick’s parents note that Nick is a big

follower of rules and likes to know what is

expected of him. He points out rules to his

parents and others when he believes they are

not being followed.

Photo from: www.procareblog.com

NutritionNick’s parents established healthy eating habits for him

as a baby. However, over the past year, Nick’s awareness

of other kids’ eating habits have resulted in changing

preferences towards a less-nutritious diet. His parents

believe in an “everything in moderation” approach so

sweets aren’t off limits. His mom keeps a vegetable

garden and keeps chickens, believing it is important for

kids to see where their food comes from. His mom

wonders if he’s getting enough protein. While he likes

beans, yogurt and cheese, he does not like eggs or most

meat but occasionally eats a burger. He likes salad and

some vegetables.. His favorite fruits are tangerines,

raspberries and pears. A nutritious daily diet for a child of

this age is approximately 1600 calories and consists of 4-

5 ounces of protein, 2-3 cups of dairy, 2 cups of

vegetables, 2 cups of fruits, 5 ounces of grains and 25-

35% of their diet from fat (“Nutrition for Healthy Kids:

Guidelines for a Healthy Diet”, n.d.) .

Photo from: www.morguefile.com

Orem: Respect, Family, Friends and School Habits Respect is a practice that requires ongoing guidance for most kids.

Nick’s family has a democratic/ authoritative household, and respect

runs both ways. They attempt to consistently hear his thoughts and

opinions, although they state “that is easier in theory than reality at

times”. He is respectful towards his teacher and the school faculty.

His family self-care requisites are met. He is an engaged, enthusiastic,

connected member of his family. Nick is an only child and has never

expressed a desire for a sibling. He has a very close relationship with

his paternal grandparents, who are local, and he sees them weekly.

Maternal grandparents are long distance but they enjoy their annual

visits. Nick enjoys playing with his neighborhood friends and has a

“best friend” at school. He attends school daily, occasionally walking

with Mom. A few times a week, he is pulled from his class to attend

speech and occupational therapy as well as a social

learning/resource support class.

Photo from: www.morguefile.com

QSEN

When considering Quality and Safety Education for Nursing (QSEN) competencies, Teamwork and Collaboration are key factors in coordinating care for Nick. Conflict between the interdisciplinary team used to be the norm, benefited no one and can be detrimental to the patient (Lancaster, Kolakowsky-Hayner, Kovacich, & Greer-Williams, 2015). Fortunately, cooperation , collaboration and teamwork are the standard of care today.

Enlisting parents as “primary partners” in their child’s development is key to health promotion (“Eliciting Parental Strengths and Needs”, 2015). The collaboration of family, pediatrician, physical therapist, school teacher, school speech therapist, school occupational therapist and school IEP team results in thorough patient-centered care.

Photo: www.brightfutures.aap.org

Four areas of focus for Nick

1. Nutrition – ensuring adequate protein intakeTeaching intervention: lists of vegetarian protein sources, since Nick seems to dislike many animal proteins: hummus, black beans, greek yogurt, cheeses, pumpkin seeds and soybeans. Since he enjoys salads, almost any of the above can be incorporated into a salad. Reassure parents that it is typical for children at this age to be lean, and that the 14th percentile is considered healthy.

2. Physical development – posture, back strengthReferral intervention: See pediatrician for assessment and referral to physical therapist. Seating modifications in the classroom such as a stool for feet, back support. Mom is interested in pursuing some type of strength training or beneficial kid’s sport, such as gymnastics.

3. Social development Teaching intervention: continue IEP services at school; schedule playdates with friends. Autism spectrum testing was completed and ruled out. In the past 6 months, he has developed more interest in friends.

4. Safety teaching – Nick forgets to look both ways when crossing the street. He is not allowed to cross without permission and/or presence of an adult. Teaching intervention: continue discussing street crossing safety rules with Nick.

REFERENCES

Ball, J., & Bindler, R. M. (2014). Pediatric nursing: Caring for children. Upper Saddle River, NJ: Pearson/Prentice Hall.

Bright Futures. (2015, April 01). Eliciting Parental Strengths and Needs. American Academy of Pediatrics. Retrieved June 17, 2016, from https://brightfutures.aap.org/ Changes in Sleep with Age. (n.d.). Retrieved June 18, 2016, from http://healthysleep.med.harvard.edu/healthy/science/variations/changes-in-sleep-with-age

Eruption Charts. (n.d.). Retrieved June 18, 2016, from http://www.mouthhealthy.org/en/az-topics/e/eruption-charts Nutrition for Healthy Kids: Guideline for a Healthy Diet (n.d.). Retrieved June 18, 2016, from http://www.mayoclinic.org/healthy-lifestyle/childrens-health/in-depth/nutrition-for-kids/art-20049335 Lancaster, G., Kolakowsky-Hayner, S., Kovacich, J., & Greer-Williams, N. (2015). Interdisciplinary Communication and Collaboration Among Physicians, Nurses, and Unlicensed Assistive Personnel. Journal of Nursing Scholarship, 47(3), 275-284. doi:10.1111/jnu.12130