A Story of Makele N332 Nursing Care for Children
Introduction Makele (M) is six years old, just completed Kindergarten and rated 94% in standardized testing for their age and grade. This kid is taller than other six-year-olds, has brown curly hair, big brown eyes that are equal, round and responsive to light with good skin tone; their body movement is strong and balanced and appear well-adjusted emotionally and healthy. M’s bones are still ossifying and has a growth chart at home demarking his growth over the past 6 years. M has one new “best” friend from school and one new friend from the neighborhood. M plays non-stop after school with the neighborhood friend. M enjoys hitting a t-ball, playing team sports, hiking with the family and their dog, watching familiar movies over and over, having family read books, playing board games and riding a play horse around the house. M lives with his single mother, single maternal grandmother, from here onward known as “K”, who both work full-time; M’s maternal grandfather died five months ago after living in the home with them. M spends most weekday afternoons with his 13-year-old step-brother and 11-year-old stepsister at their paternal grandmother’s house until mother returns from work. M’s paternal grandmother, known from here-on-in as “P” has a permissive parenting style allowing aimless roaming throughout the neighborhood accompanying a second six-year-old. The kids eat fast food, drink sodas, play video games and watch cable television or movies for hours upon hours in the evenings and weekends at grandmother P’s house. M’s mother has a democratic parenting style enforcing rules and boundaries about emotions, nutrition, screen time, safety, hygiene. M’s grandmother K has a dictatorial parenting style. Grandmother K does not allow loud noises from M, does not allow for more than two hours of screen time per day, K’s food is home cooked and only served at the table during meal times, outdoor playtime is supervised, safety and consistent bedtimes are strictly enforced.
Growth and Development Makele is six years old, is 50 inches tall (97th percentile), 50 pounds (50th percentile) and just completed Kindergarten. He is expected to grow 2 inches (5cm) and gain 4-6lbs (1.8-2.7kg) during this school-age of development (Ward, 2014 p.8). My kiddo has lost his two front teeth and is expected to lose more in the next year. M has received the diphtheria, tetanus toxoids and pertussis (DTaP), inactivated poliovirus, measles, mumps, rubella (MMR) and varicella vaccinations. M is on-par for the observed stage of growth and development for a 6-to-12 year-old. M can follow simple directions to pick up items and place them in a defined location; M is able to complete a larger number of tasks on his own and better able to manage emotional responses (Ward, 2014).
Fine and Gross Motor Skills M has demonstrated a series of fine motor skills with the following tasks: throwing a ball overhead, catching a medium to large ball barehanded, skipping, jumping, strumming a six-string guitar, dancing, swinging a plastic sword, keeping rhythm on a traditional LusiĂŠno hand drum, running fast, hopscotching, and sketching freehand very well.
Motor Skills (cont) A growing understanding about colors, shapes, up, down, across, into and over is best demonstrated in the favorite video game Minecraft. M has yet to ride a bike without training wheels, cannot cut food simultaneously with a fork and knife, cannot catch a baseball in a gloved hand or cast a fishing pole, but can connect the seatbelt in the car’s booster seat. M has a lot of energy from morning until evening and is learning to exhaust that growing vocabulary. Most of M’s sentences begin with “guess what.” Our kiddo’s eye-hand coordination has developed as evidenced by the force and consistency he can hit a baseball from a tee and accomplish a solid base hit; M contacts the ball more often than other six-year-olds on the t-ball team. M practices using plastic chopsticks and favors drawing to coloring pre-drawn images. M struggles to zip a jacket or button a shirt but can administer an asthma inhaler with a spacer and a minute pause in between each inhale.
Erik Erikson’s Psychosocial Development According to Erikson’s theory of psychosocial development, our six-year-old is in the beginning phase of industry vs. inferiority in which he will begin engaging in tasks that will be carried through to completion. M reveals this transition in the growing dissatisfaction with make believe and the desire to learn all the character’s names of Pokemon, Star Wars, and Yoshi the words to Disney movie theme songs and reading words to his favorite bedtime stories. Additionally, his peer group is becoming increasingly important to him than playing with his siblings or staying in the house with family members.
Jean Piaget’s Cognitive Development Theory M is in the preconceptual phase of intuitive thought. The kid is learning about right and wrong and acceptable behaviors from watching and listening to the caregivers. M recently stated the phrases: “don’t ask me one more time or the answer will be no” which echoes mother’s tone, “oh my god” which echoes uncle’s tone and “I don’t have to go to school” which echoes 13-year-old stepbrother’s tone. M is learning vocabulary and storytelling by hearing books ready by mother and grandmother K, learns shapes and numbers by playing video games with these symbols. This kiddo likes to match letters with the sound of pictures which demonstrates Piaget’s preoperational phase of symbolic representation. Additionally, M practices brushing and flossing teeth, tying shoes, rinsing the dishes, watering the plants, walking the dog on a leash, sweeping the patio, and using the remote control by watching and copying mother’s actions first. Piaget’s psychosocial development: M is mastering the concept of conversation by using words and inflection; he uses an app to create videos for his father and uncle in which he uses letters to type words, vocal synthesizer to change the tone of his voice and is learning how to generate a more interesting conversation. Makele says whatever, whenever, however and interrupts other’s conversations several times a day. M possesses a vivid imagination involving elaborate narratives circling around M as the hero, the winner, or ultimate survivor which reflects the egocentrism of pre-operational phase and demonstrates how learning is through osmosis, mimicking the storylines of favorite multimedia characters. M no longer prefers parallel play as described by Piaget’s preoperational stage, but rather prefers competitive and cooperative play such as board games, baseball, basketball, and football which Piaget’s describes as the concrete operations phase (Perry, et al. 2014). M still participates in magical thinking through his creative storytelling; M is not fully relating to the sequence of events and time-related words which demonstrates a preschooler’s phase of growth and development (ATI, 2016).
Kohlberg and Orem Lawrence Kohlberg’s Moral Development M has not yet embraced the point of view of others, but rather accepts the world as a set of pre-established principles and rules. For example, our kid learned from mother and grandmother not to joke about or use terms about killing, dying, and death. M is adopting their concept of death as serious and contemplative. M demonstrates an understanding for the rules but does not an understanding for why they are. Most requests are automatically responded with, “why?” This pause for clarity or understanding seem to be the early hints of a logical pattern of thought and eventual transformation in moral reasoning that adolescents will deliver (Perry et al, 2014). Dorothea Orem’s self-concept theory Respect: Makele shows respect to the housecat, the house dog, grandma K’s horse, mother, classmates, siblings and friends. He does so by using a gentle touch, not raising their voice, and by practicing awareness of physical boundaries. M cannot resist interrupting a conversation and speaks when the thoughts arise and has not learned the art of listening and responding. Grandmother K finds these behaviors disrespectful. Family: Makele is missing the support of a father in his life, however, he is supported by a blending of nuclear and extended family. His interactions are warm and friendly. He seems to like his family and enjoy spending time with them. Friends: Makele has a limited number of friends and spends as much or more time with family members than with friends. However, ever since Kindergarten entered their world the concept of friendships and their warm connection has been a magnet to our young kiddo. As he develops more complex play abilities, so too do his circle of playmates. School habits: Makele enjoys school very much. He is currently enrolled in a summer interim session with emphasis on developing fine and gross motor skills. He struggles to focus on subject matter that is not easily understood like math and reading. Mother has interactive books that incorporate his favorite movie characters with letters and learning math skills making learning more fun.
Nutrition Status The United States Department of Agriculture (USDA) recommend children consume a variety of foods and beverages to “build healthy eating styles;” this variety consists of blending whole fruits with an assortment of vegetables, incorporating whole grains, proteins, dairy products, and oils (Variety, 2018). The benefits of the dairy group include consumption of calcium, phosphorus and Vitamin D which are essential for growing and maintaining bone health for our growing six-year-old. Dairy products also include potassium which is important for keeping a healthy blood pressure. M drinks milk, eats cheese, consumes eggs and fresh fruit for breakfast at mom and grandmother K’s house, but eats pizza, burgers, Taco Bell’s bean and cheese burritos and Pepsis for diner at grandmother P’s house in the evening. Grandmother P has a pantry full of pre-packaged chips, marshmallows, chocolate bars, snacks with high-density preservatives, fats and sugars; the freezer is stocked full of frozen pizza, popsicles, waffles, burritos and pre-packaged meals for grazing and eating on-the-go. On the other hand, grandmother K has fresh cut fruits, water bottles, an outdoor garden of tomatoes and strawberries, home cooked meals with allotted time for seated meals together.
Anticipatory guidance for parents For the 6-year-old, health outcomes are reliant upon their environment being safe, secure, and emotionally friendly and flexible. Six-year-olds child is ready for rules and routines, ready to learn and participate in school and after-school activities. They should have their hearing and vision checked for age-appropriate visual acuity. Additionally, this age group should receive screening for anemia, dyslipidemia, lead, oral and tuberculosis (Bright Futures, 2018). Safety should include seatbelts, playing outdoors, playing in and near water, using sun protection, potential harm caused from other adults, and firearms that might be in the home. M’s mother should be setting the tone for behaviors that will be adhered to inside and outside of the home. In other words, a single set of rules should be encouraged even when mom is not present. M should have consistent rules about use of video games, television, and media use along with nutrition, safety, rest, and playtime (Ward, 2014).
#1 The grieving process of losing his “papa” looks like noncompliant and uncooperative behaviors that are not easily detected or interpreted. M has not learned the words to describe emotions as they relate to a loss. M told a schoolmate about the death but has not developed the language to properly express feelings or understanding of the concept of death. It is recommended to introduce the subject matter in a safe environment by reading children’s books about death and the bereavement process (Arruda-Colli, Weaver, Wiener, 2017).
#2 Makele has a diagnosis of asthma and is particularly sensitive to bug bites. He needs to be aware of outdoor allergens, exercise-induced attacks, sudden changes in the weather and temperature and strong emotions. M has learned and demonstrated how to use his long-acting beta2 agonist medication and has a short-acting beta2 agonist inhaler at home in the case of acute exacerbations. It is recommended that M and his family members continue to work with the Allergist to identify asthmatic triggers, and how to best manage allergens, irritants, and situations that exacerbate symptoms (Childhood Asthma, 2018).
Areas of Concern
#3 M is a very physically-active kid, therefore needs to be aware of safety related with these activities. Wearing a bicycle helmet, learning safety rules around the pool and the ocean, including swim lesson and wearing protective gear while playing baseball are important details to prevent injuries. Furthermore, M needs to learn healthy parameters with strangers and not keeping secrets with adults. More specifically, M lives in a desert climate and poisonous snakes and spiders are commonplace. It is recommended that M be taught how to differentiate dangerous insects from non-poisonous creatures and how best to respond if he, a friend or family member is bitten (ATI, 2016).
#4 Family values are more important to this age group than peer interactions and parents, grandparents and siblings are shaping the standard for behaviors. These interactions are shaping M’s physical and social development; our kiddo is learning conflicting behaviors about nutritional intake and meal time from these actors. It is recommended that a hierarchy be established for M to clarify the roles of authority and trust (Demby, Riggs, Kaminski, 2017). Furthermore, a referral to a nutritionist for the paternal grandmother and step siblings is suggested to discuss the need to reduce carbonated, high fructose beverages, limit snacks with high calories and low nutrition and incorporate more fresh fruit, vegetables and water into their daily lives.
References ATI Nursing. (2016). RN Nursing Care of Children. Assessment Technologies Institute LLC. Arruda-Colli, M.F., Weaver, M.S., Wiener, L. (2017). Communication About Dying, Death, and Bereavement: A Systematic Review of Children’s Literature. Journal of Palliative Medicine, 20(5), 548-559. doi:10.1089/jpm.2016.0494 Bright Futures (2018). Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, 4th edition [Lecture notes]. Retrieved from https://brightfutures.aap.org/_layouts/15/WopiFrame.aspx?sourcedoc=/Bright%20Futures%20Documents/BF_MC_Priorities_Screens.p ptx&action=default Clinical Growth Charts. (2017). Retrieved from https://www.cdc.gov/growthcharts/clinical_charts.htm Childhood Asthma. (2018). Retrieved from https://www.mayoclinic.org/diseases-conditions/childhood-asthma/symptoms-causes/syc-20351507 Demby, K.P., Riggs, S.A., Kaminski, P.L. (2017). Attachment and Family Processes in Children’s Psychological Adjustment in Middle Childhood. Family Process, 56(1), 234-249. doi:10.1111/famp.12145 Nursing Theory. (2018). Retrieved from http://www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2014). Maternal Child Nursing Care (5th edition ed.). St Louis, MS: Elsevier Mosby. Nursing Theory. (2018). Retrieved from http://www.nursing-theory.org/theories-and-models/orem-self-care-deficit-theory.php Variety. (2018). Retrieved from https://www.choosemyplate.gov/variety Ward, S. L. (2014). Pediatric nursing care: best evidenced-based practices. Philadelphia, PA: F.A. Davis Company. Photo references: Original works of art by M