In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills the aging process in order to:

  • Assess client's reactions to expected age-related changes
  • Provide care and education for the newborn less than 1 month old through the infant or toddler client through 2 years
  • Provide care and education for the preschool, school age and adolescent client ages 3 through 17 years
  • Provide care and education for the adult client ages 18 through 64 years
  • Provide care and education for the adult client ages 65 through 85 years and over

Assessing the Client's Reactions to Expected Age Related Changes

From the day of conception throughout the entire life span, humans grow and develop in a rather predictable manner with specific needs from birth to the elderly years. There are also expected age related changes that also occur throughout the life span. These changes can include rather predictable physical changes, predictable developmental changes, psychological, cognitive, and emotional changes, and social changes.

Like all changes, people react to their expected age related changes in different ways. Some of these reactions lead to adaptive and healthy responses by the client and other reactions can be dysfunctional, maladaptive, abnormal and unhealthy. Nurses, therefore, must assess all clients' responses to expected age related changes and plan their care as based on these assessed responses and reactions to their expected age related changes.

For example, a toddler may emotionally react with anger and defiance to their developmentally expected toilet training regimens; a school aged child may react to the normal physiological changes associated with puberty in the expected and normal manner; a young adult may adapt to pregnancy in an adaptive and healthy and other young adults may have dysfunctional, maladaptive, and abnormal responses and reactions to the changed bodily image associated with pregnancy; and the elderly may adapt or not adapt to the physiological, economic and social changes associated with the normal aging process such as decreased physical stamina and social isolation.

Providing Care That Meets the Needs of the Newborn Less than 1 Month Old Through the Infant or Toddler Client Through 2 Years of Age

Neonates

Neonates are assessed according to the five criteria of the APGAR score which are A for appearance, P for pulse, G for grimace and reflexes, A for appearance in terms of skin color, and R for respiratory rate and effort. Each of these criteria is scored from zero to two with a zero as no activity or the poorest possible color, for example.

APGAR scores are done one minute after birth, five minutes after birth and more often when the neonate is not scoring well in terms of their adaptation to extrauterine life after birth. An APGAR score of less than less indicates that the neonate is in severe distress and in need of intensive care and treatment. An APGAR score of four to six indicates that the neonate is in moderate distress. Scores between seven and ten are considered good.

Gestational age, which indicates the neonate's level of morbidity and mortality, is also determined and assessed among neonates. The New Ballard Scale is used for this assessment. This scale measures physical and neuromuscular maturity from negative one to five according to the neonate's arm recoil, posture, heal to ear movement, the scarf sign which is the neonate's crossing of the arms over the chest and square window formation which is the neonate's wrist movement.

The normal physical size of a neonate is 18 to 22 inches in length, 12 to 13 inches for chest circumference and 12.6 to 14.5 inches for the circumference of the head. The normal weight is from

The normal vital signs for the neonate are:

  • Respirations from 30 to 60 per minute
  • The pulse from 100 to 160 beats per minute
  • A systolic blood pressure from 60 to 80 mm Hg
  • A diastolic blood pressure from 40 to 50 mm Hg
  • A bodily temperature from 97.7 to 98.9 degrees

The normal neonatal abdomen is round; bowel sounds should present within a couple of hours after birth, the umbilical cord and site should be free of any signs of infection like redness and pus, and the neonatal abdomen moves up and down with respirations. Neonates and infants are abdominal breathers.

The eyes are bilaterally equal in terms of their size and shape, the red and papillary reflexes are present, and normal smooth eye movement should be apparent. The neonate's ears should be normally placed bilaterally and they should have with firm and well-formed cartilage; the neonate's ability to hear sounds and noise is normally present. Low set ears and unusual eyes can, at times, possibly indicate the presence of Down's syndrome.

The skin of the neonate should be without any signs of blueness, jaundice or cyanosis; the texture should be soft and smooth and with some normal wrinkles; Vernix caseosa, a thick cheesy substance over the skin, fine hair called lanugo, small red spots called milia, telangiectatic nevi, also referred to as stork bites, purple blue Mongolian spots, and port wine stains called nevus flammeus are often seen on the skin. These unusual skin findings are most often temporary and normally occurring, with the exception the port wine stains which can be permanent and distressing to the parents.

The neonate's fontanels are soft and flat and they should also be without any signs of bulging or fontanel depression. Bulging fontanels can be a sign of increased intracranial pressure and fontanel depression can indicate decreased intracranial pressure and dehydration, respectively. These neonatal fontanels close by the time the infant is 12 to 18 months of age. The sutures and the yet to be developed skull are normally separated and some normal molding of the skull can occur with a vaginal delivery.

The oral palate is a normally closed palate, the mouth has pink oral mucosa, symmetrical lip and tongue movements are present, possible small white oral cysts called Epstein pearls may be on the tongue, and little saliva is seen when the neonate's mouth is assessed. Down's syndrome may be present when the tongue protrudes and a possible tracheoesophageal fistula is present when there is excessive salivation.

Neonates normally pass meconium and produce urine at about twenty four hours after birth. Male testes are in the testicles, the urinary meatus is on the tip of the penis and the scrotum has rugae. The female may have some edema of the labia and a small amount of vaginal blood, both of which are normal for some neonates.

Infants

Some passive immunity from the mother remains, but the infant does not have a fully developed immune system so the infant is at risk for infections.

As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age. Teeth appear, the infant begins to speak with babble, and they start to walk in about one year.

The infant is in the sensorimotor stage according to Jean Piaget's stages of cognitive development and in Erik Erikson's the trust versus mistrust stage of psychosocial development. The infant begins to see self as separate from others; and separation anxiety and the fear of strangers, including nurses, begins. They communicate with noises and sounds and they receive communication with touch and sounds. Age appropriate toys include rattles, large balls and teething toys.

Commonly occurring injuries and accidents among infants include falls, poisoning, drowning and burns. Aspiration and poisonings are great risks for infants because they are in the oral stage of development and they tend to put foreign bodies in the mouth.

Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight.

The Toddler

The normal vital signs for the toddler are a pulse rate from 90 to 140 beats per minute; the normal respiratory rate for the toddler ranges from 20 to 40 breaths per minute, the diastolic blood pressure is typically between 50 and 80 mm Hg and the systolic blood pressure is from 80 to 110 mm Hg. The normal bodily temperature is 98.6 degrees and it remains at the level throughout the remainder of life.

The toddler grows approximately 3 inches per year and the weight becomes four times the child's birth weight. Toilet training is completed during the toddler years and the child walks without holding onto things by about fifteen months of age. They can jump by the time they are 2 1/2 years of age.

Toddlers move from Piaget's sensorimotor to the preoperational stage of cognitive development; the child's vocabulary improves and the toddler can now speak and communicate with brief but meaningful phrases. They understand parental boundaries and discipline.

The toddler is in Erik Erikson's autonomy versus shame and doubt stage of psychosocial development and the toddler begins to form their own gender identity. They are very curious and energetic; they lack impulse control, they have a short attention span, they are concrete rather than abstract thinkers and they also are mystical thinkers. Toddlers also have a low tolerance for pain, frustration and strangers.

Nutritionally, toddlers eat 3 meals per day totaling about 900 to 1,800 calories each day. Some may be finicky eaters and most enjoy finger foods that they can pick up, manipulate and eat. Supplemental iron is needed for the adequate production of red blood cells.

Large and colorful toys that cannot be placed in the mouth, picture books and blocks are some examples of age appropriate toys. Although toddlers play with other children and siblings, this play is parallel play rather than actual interactive play with other children. They parallel play in close proximity to other children but they do not interact with them in the same manner that an older children does.

Toddlers are at risk for downing, falls, aspiration, burns, automobile accidents and suffocation.

Providing Care That Meets the Needs of the Preschool, School Age and Adolescent Client Ages 3 Through 17 Years of Age

The Preschool Child

The normal vital signs are for the preschool child are a pulse rate from 80 to 110 beats per minute; the normal respiratory rate for the preschool child ranges from 20 to 30 breaths per minute, the diastolic blood pressure is typically between 50 and 75 mm Hg and the systolic blood pressure is from 80 to 110 mm Hg. The normal bodily temperature remains at 98.6 degrees and it remains at the level throughout the remainder of life.

Physically, the preschool child gains about 4 to 7 pounds a year and they grow 2 to 3 inches in height each year. Their gross and fine motor skills continue to be developed and enhanced. Preschool children have fears about the dark and mutilation; separation anxiety decreases; and they are able to express their feelings and wishes to others verbally. They can follow brief, simple and concrete directions from others including the parents and health care providers.

Preschool children should consume about 2,000 calories per day and they are less prone to fluid and electrolyte than toddlers and infants. They often need between meal snacks to satiate their hunger and meet their caloric needs.

Commonly occurring injuries among the members of the age group are poisonings, drowning, burns and automobile accidents

Preschool children begin to interactively play with others and they ask a lot of "why" questions. Dress up, role playing, painting, puzzles and reading simple books with lots of pictures are appropriate age specific activities for the preschool child.

Preschool children are in Piaget's stage of preoperations and they can speak in full sentences. In terms of Erik Erikson's psychosocial developmental stages, the preschool child is in the initiative versus guilt stage. Gender identity is complete and gender related activities increase. Some preschool children can understand simple explanations about the human body and illnesses. At times the use of a simple picture, a puppet and a simple picture book can assist with the child's understanding.

The School Age Child

The normal vital signs for the school age child are a pulse rate from 70 to 100 beats per minute; the normal respiratory rate for the toddler ranges from 20 to 25 breaths per minute, the diastolic blood pressure is typically between 55 and 80 mm Hg and the systolic blood pressure is from 80 to 120 mm Hg.

The school age child's height, weight and muscle mass increase with their growth spurts. These changes require additional calories of about 2,500 calories a day, additional calcium, additional iron and additional vitamins, particularly vitamins B and A.

The school age child now prefers same gender friends and they may begin to question and challenge their parents and other authority figures including their teachers and health care providers. Commonly occurring fears include fears of the unknown, bodily mutilation, fears associated with death, and the fear of failure.

Physically, the school age child gains about 4 to 9 pounds a year and they go through growth spurts. Permanent teeth begin to appear, secondary sex characteristics, puberty and menarche can occur.

Their stage of cognitive development, according to Jean Piaget, is concrete operations and a full command of their native language and vocabulary is almost complete by the age of twelve. Erikson's stage of industry versus inferiority marks the school age years. Peers become increasingly important, morals develop and curiosity about sexuality occurs. Age appropriate activities include sports, board and computer games, and pet care.

Burns, automobile accidents, substance abuse, and drowning are the major accidents and concerns among members of this age group.

Adolescents

The normal vital signs for the adolescent are now the same as for the adult.

Adolescents have high nutritional and caloric needs because of the growth spurt when the skeletal and muscular systems double to its completion. Vitamins, protein, and calcium needs have to be met. Females need iron supplementation because of menstruation. Some teens may develop bulimia and anorexia nervosa, both of which are eating disorders.

Sexual maturity is complete; most teens are attracted to the opposite gender; they are self-conscious, they want their own identity, they want to be accepted by their peer group and they are sometimes unpredictable and rebellious towards authority figures.

Adolescents complete the last of Piaget's stages of formal operations which is formal operations. They are in Erikson's identity versus role confusion stage and they begin to think about and plan their future including their career and advanced education beyond high school.

Common threats, accidents and injuries for this age group are substance abuse, injuries from weapons, burns, auto accidents, sexually transmitted diseases and unwanted pregnancy.

Providing Care That Meets the Needs of the Adult Client Ages 18 through 64 Years

The Young Adult

Normally, young adults form and maintain relationships, some of which are long lasting and permanent. They assume adult roles as a spouse, parent and salary earner with gainful employment. They also accept responsibility for their own beliefs, attitudes, opinions, values and actions.

Significant others include the spouse or partner, the children, friends, in laws, and co-workers. Characteristic stressors for this age group include raising children, finding and maintaining a career, finances and managing their multiple roles.

Physical growth is complete; the young adult remains in the formal operations stage of Piaget, the last stage, and Erikson's intimacy versus isolation phase.

Commonly occurring injuries and events include auto accidents, weapon injuries, substance abuse and sexually transmitted diseases.

Middle Age Adults

The normal stages of the aging begin during middle adult years; muscular strength weakens, sex drive decreases, menopause and the male climacteric occur and male erectile dysfunction may occur. Calcium and vitamin D supplementation are needed to prevent osteoporosis and bone loss that can occur as the result of menopause.

Middle age adults are in Erikson's generativity versus stagnation stage; major stressors include the loss of youth, parenting, and the empty nest syndrome. This group is referred to as the sandwich generation because members of this age group are often squeezed and conflicted with their care of children in addition to the care of their elderly parents.

Heath screenings for this age group includes eye examinations for glaucoma and Dexa screening for osteoporosis.

Providing Care That Meets the Needs of the Adult Client Ages 65 through 85 years and Over

In terms of growth and development, this age group undergoes the normal changes of the aging process including changes in terms of their sensory and neurological changes, cardiovascular changes, musculoskeletal changes, joints and bone changes, renal system changes, hepatic functioning changes, skin and hair changes, respiratory system changes, and fluid and electrolyte changes. All of these normal changes of the aging process were fully discussed below with the section entitled "Changes Associated With the Aging Process".

Adults 65 years of age and older are in the ego integrity versus despair phase according to Erikson. Caloric needs are less than other age groups. Some of the safety hazards affecting the aging population are falls and accidental poisonings.

Some of the theories of aging are the:

Programmed Theories of Aging

Programmed Longevity Theory: This theory states that genetic instability and changes occur such as some genes turning on and off lead to the aging process.

Endocrine Theory: Aging results from hormonal changes and the biological clock's ticking.

Immunological Theory: Aging results from the decline of the person's immune system and the decreased ability of the antibodies to protect us.

Damage and Error Theories of Aging

Wear and Tear Theory: This theory describes aging as a function of the simple wearing out of the tissues and cells as one ages.

Rate of Living Theory: One's longevity is the result of one's rate of oxygen basal metabolism.

Cross Linking Theory: This theory of aging explains that aging results for cell damage and disease from cross linked proteins in the body.

Free Radicals Theory: This theory is based on the belief that free radicals in the body lead to cellular damage and the eventual cessation of organ functioning.

Somatic DNA Damage Theory: Somatic DNA Damage theory is based on the belief that aging and death eventually occur because DNA damage, as continuously occurs in the human cells, continues to the point where they can no longer be repaired and replaced and, as a result, they accumulate in the body.

Changes Associated With the Aging Process

Now, we will review the physiological changes related to the aging process system by system. Generally, all of these changes are decreases, rather than increases, of functioning.

  • Sensory and neurological changes: Sensory and neurological changes include decreased vision, hearing, smell and touch, lowered reaction times and night blindness.
  • Cardiovascular system changes: Cardiac changes include decreases in cardiac output, stroke volume, venous return, and the cardiac output.
  • Musculoskeletal system changes: Musculoskeletal changes include decreased muscular tone and strength, the degeneration of joints and bones as the result of decalcification, and decreased intervertebral disc spaces which lead to some loss of height among the elderly.
  • Renal changes: Renal function among the elderly is also affected with aging. Some of these changes include decreased renal size, decreased renal blood supply, decreased creatinine clearance, decreased glomerular functioning, and decreased tubular functioning.
  • Hepatic function changes: Liver function is also altered as the result of the normal aging process. There is decreased hepatic blood flow and functioning. This change reduces hepatic metabolism and it can increase the concentrations of medications in the patient's body.
  • Integumentary system changes: Integumentary, skin, changes include the loss of skin turgor and elasticity, thinning and increased fragility of the skin, dry skin and hair, the presence of wrinkles, "age spots" and skin tags on the skin, faded and grey hair, thicker ear and nasal hair, thicker nails, and diminished sweat gland activity.
  • Respiratory system: Age related respiratory changes include decreases in lung expansion and air exchanges, dry and more fragile mucous membranes, a diminished cough reflex, and a decrease in the efficiency of the body's natural protective immune system which may place elders at greater risk for respiratory infections than their younger counterparts.
  • Changes in fluid and electrolyte balances: Some fluid and electrolyte alterations associated with the aging process are imbalances secondary to the decreased function of those hormones that regulate fluids and electrolytes, impaired thirst sensation, more diluted urine, and changes in the amount of total body water and intracellular fluids.

Medication dosages are often reduced for the elderly because the changes of the aging process make them at risk for more side effects, adverse drug reactions, and toxicity and over dosages. The distribution of drugs is impaired by decreases in the amount of body water, body fat and serum albumin; drug absorption is decreased with the aged patient's increases in gastric acid pH and decreases in the surface area of the small intestine which absorbs medications and food nutrients.

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