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

  • Identify expected physical, cognitive and psychosocial stages of development
  • Identify expected body image changes associated with client developmental age (e.g., aging, pregnancy)
  • Identify family structures and roles of family members (e.g., nuclear, blended, adoptive)
  • Compare client development to expected age/developmental stage and report any deviations
  • Assess impact of change on family system (e.g., one-parent family, divorce, ill family member)
  • Recognize cultural and religious influences that may impact family functioning
  • Assist client to cope with life transitions (e.g., attachment to newborn, parenting, puberty, retirement)
  • Modify approaches to care in accordance with client developmental stage (use age appropriate explanations of procedures and treatments)
  • Provide education to client/staff members about expected age-related changes and age-specific growth and development (e.g., developmental stages)
  • Evaluate client's achievement of expected developmental level (e.g., developmental milestones)
  • Evaluate impact of expected body image changes on client and family

This section will provide you with the expected stages of growth and development for all age groups and how to modify and adjust approaches to care as based on these stages.

The age groups along the lifespan and their age parameters are:

  • The neonate which is the first four weeks of life
  • The infant who is from four weeks old to one year old
  • The toddler who is from one to three years of age
  • The preschool child who is from three to five years of age
  • The school age child who is from six to twelve years of age
  • The adolescent which ranges from thirteen to seventeen years of age
  • The young adult who is from eighteen to twenty five years of age
  • The adult which is defined as from twenty six to sixty five years of age and, lastly,
  • The older adult who is over sixty five years of age

Identifying Expected Physical, Cognitive and Psychosocial Stages of Development

Age and developmental stages are assessed to determine if the client is at the expected level of growth and development, to plan care that is age and developmentally appropriate and to modify care as based on the age related characteristics and needs of our clients. These assessments include the physical, cognitive and psychosocial stages of growth and development.

Cognitive Development: Jean Piaget

Jean Piaget's levels of cognitive development from birth until 12 years of age are used for the assessment of children up to this age, after which the cognitive development of the child is complete.

In the correct sequential order, Jean Piaget's levels of cognitive development include:

  • Sensorimotor thought: Infancy to About 2 Years of Age

The sensorimotor thought level has 6 sub stages; this level includes the development of the infant's and young child's ability to manipulate concrete objects.

  • Preoperational and symbolic functioning: From 2 to 7 Years of Age

Language and vocabulary progressively develop.

  • Concrete operations: 7 to 11 Years of Age

Between these ages, the child is able to use logic and reasoning; they have also developed their ability to solve concrete problems.

  • Formal operations: 12 Years of Age

Under normal circumstances, the child at 12 years of age should have developed the ability to solve abstract problems and to use complex thinking, logic and reasoning.

Psychosocial Development: Erik Erikson

Erik Erickson proposed 8 major stages of psychosocial development and expected tasks along the life span from infancy to old age. People, including our own clients, who are able to resolve their age related tasks are successfully able to progress to the next task; however, psychosocial development can become arrested when a person is not able to achieve their age related developmental task.

Nurses must incorporate these developmental tasks and challenges into the plan of care and they must also modify the plan of care according to these age related tasks.

Eric Erikson's stages, developmental tasks and signs of their lack of resolution are listed below.

  • Age Group: Infant

Task: Trust

Failures to Resolve the Task: Mistrust and a failure to thrive

  • Age Group: Toddler

Task: Autonomy, self-control and will power

Failures to Resolve the Task: Shame, doubt and a poor tolerance of frustration

  • Age Group: Preschool

Task: Initiative, a sense of purpose, self-confidence, and self direction

Failures to Resolve the Task: The fear of punishment and guilt

  • Age Group: School Age Child

Task: Industry, competence and self-confidence

Failures to Resolve the Task: Feelings of inferiority and fears that one cannot meet the expectations of others

  • Age Group: Adolescent

Task: Identity formation and a sense of self as an individual

Failures to Resolve the Task: Role confusion, lowered self-esteem and a poor self concept

  • Age Group: Young Adult

Task: Intimacy, love and affection

Failures to Resolve the Task: Isolation and the avoidance of relationships including intimate relationships

  • Age Group: Middle Aged Adult

Task: Generativity, productivity, and genuine concern for others

Failures to Resolve the Task: Stagnation, self-absorption and a lack of concern about others

  • Age Group: Older Adults

Task: Ego integrity, wisdom and the ability to participate in life with a sense of satisfaction

Failures to Resolve the Task: Despair and feelings that life is without any meaning and without any sense of satisfaction

Psychosexual Development: Sigmund Freud

Sigmund Freud, often referred to as the father of psychotherapy, developed the concepts of id, ego and superego, the psychological defense mechanisms such as sublimation and suppression, as well as the 5 stages of psychosexual growth and development.

The id is an unconscious mechanism that operates in terms of instant gratification and instant pleasure. Some say that infants are nothing more than a bundle of id. The ego is the person's sense of self that provides the person with the ability to control oneself and one's behaviors. The superego is the person's conscience.

The 5 stages of Sigmund Freud's stages of psychosexual development are:

  • The oral stage
  • The anal stage
  • The phallic stage
  • The latency stage
  • The genital stage

Some of the lesser known theories of growth and development include those of Stella Chess and Alexander Thomas, Roger Gould, Robert Havighurst, and Robert Peck.

The Development of Temperament: Stella Chess and Alexander Thomas

Stella Chess and Alexander Thomas are credited with the development of the 9 temperamental qualities which include:

  1. Activity level
  2. Sensitivity and reactions to external stimuli
  3. Adaptability
  4. Level of Intensity
  5. Distractibility
  6. Approach/Avoidance and Withdrawal
  7. Persistence
  8. Regularity and organization
  9. Mood

Roger Gould

Roger Gould addresses 7 stages of growth and development that begins at age 16 and progresses to the older adult.

These stages include:

  1. Stage 1 - Ages 16 to 18: The adolescent strives to separate from the parents and to develop autonomy.
  1. Stage 2 - Ages 19 to 22: The autonomous young adult has fears and anxiety about having to return to their family unit and parents.
  1. Stage 3 - Ages 23 to 28: This young adult replaces their fears and anxiety about having to return to their family unit and parents with a more secure sense of self and their abilities. Some may also have a spouse and children.
  1. Stage 4 - Ages 29 to 34: At this age, the young adult no longer feels that they have to prove themselves and many have a career, marriage and even children.
  1. Stage 5 - Ages 35 to 43: This period of time is characterized with self reflection and values clarification.
  1. Stage 6 - Ages 44 to 50: The person is well established and stable.
  1. Stage 7 - Ages 51 to 60: This period of time is characterized with concerns about one's state of health and one's own finality.

Robert Havighurst

This theorist developed 6 age groups and the physical, psychological and social tasks associated with each of these 6 age groups.

These age groups and their associated developmental tasks are:

  1. Infancy and Early Childhood: During this period of time the child develops the super ego, or conscience, and they also develop and maintain emotional stability and relationships with the members of their family unit and friends in their community.
  1. Middle Childhood: The child continues their conscience development, and they also enhance their value system, their sense of morality, and their values systems. Physical abilities continue to be developed and refined; and intellectual skills are developed in their school and home environment.
  1. Adolescence: Gender related roles are assumed, a personal ethical code emerges, mature relationships with others are developed, and the adolescent begins to think about their future and desired goals in terms of employment and/or advanced education.
  1. Early Adulthood: Many start a family and relationships within the family and the community are enhanced.
  1. Middle Age: This period of time is typically characterized with stability and the empty nest syndrome as well as major developmental changes like menopause and aging.
  1. Later Maturity: During later maturity, the person adjusts to retirement, aging and the loss of loved ones including spouses and friends.

Robert Peck

Robert Peck's theory focuses on aging and the aging process. Robert Peck's theory has 3 developmental tasks that somewhat parallel those of Eric Erikson's phase of integrity versus despair in the later years.

Robert Peck's three developmental tasks associated with aging and the aging process include:

  1. Ego Differentiation versus Work Role Preoccupation: The older adult adjusts to retirement and enjoys leisure activities that they were unable to partake in while they were gainfully employed.
  1. Ego Transcendence versus Ego Preoccupation: The individual accepts their own mortality without fear.
  1. Body Transcendence versus Body Preoccupation: The aging person maintains a sense of wellbeing, happiness and satisfaction despite the physical declines associated with the aging process.

Identifying Expected Body Image Changes Associated with the Client's Developmental Age

As with all other nursing care, nurses must be able to identify and report client deviations from what is expected in terms of their growth and development and they must also be able to modify care and their approaches to care as based on these deviations.

Nurses also determine the impact of expected body image changes on the client in terms of how the patient's perceptions are interfering with the patient's quality of life and the continued performance of their activities of daily living. Again, all maladaptation and/or poor coping skills must be determined, documented and reported so that the patient's plan of care can be changed to meet these needs.

The major expected bodily changes and bodily image changes are those that occur with puberty, menopause, pregnancy and the aging process.

Identifying Family Structures and Roles of Family Members

Family structures are numerous and becoming more numerous and varied than any other time in the past.

These family structures are discussed below:

  • The Traditional Nuclear Family: This family structure consists of biological children and two marred parents of different genders.
  • The Nuclear Family: This family structure consists of two marred parents of a different gender and children that can be step children, adopted children and/or foster children.
  • The Extended Family: This family structure consists of one or more people with a child who resides with others who are related biologically. For example, the extended family unit can consist of a grandparent or grandparents.
  • The Foster Family: This family structure consists of one or more foster children and one or two parents.
  • The Adoptive Family: The adoptive family is one that has at least one adopted child and one or two parents.
  • The Binuclear Family: The frequency of binuclear families has significantly increased over the last several years as more and more divorced parents are sharing custody. This family structure consists of two parents and at least one child. The parents in legal joint custody arrangements share responsibility for the child or children.
  • The Single Parent Family: This family has one parent and one or more children. These children can be biological children, step children, adopted children and/or foster children.
  • The Childless Family: This family structure consists of two adults with no children whatsoever.
  • The Communal Family: The communal family is one that consists of group of unrelated adults who live in a community with their children and who share responsibility for the children and their care, among other things.
  • The Gay, Lesbian and Transgender Family: This family structure consists of two adults of the same gender who have one or more children.
  • The Blended Reconstituted Family: This family consists of two adults who live in the home with one or more step children from a previous marriage or another type of union.

Roles in the family have also changed over the past decades. In the past roles within the family were gender based; now these roles are not usually based on gender. For example, in the past the mother stayed at home and cared for the children while the father worked as the bread winner of the family. Now things are very different. For example, some males are "stay at home dads" while the female in the family works outside of the home as the bread winner of the family.

Other family roles that are assumed by the adults in the family are disciplinarian, teacher, housekeeper, cook and shopper. Ideally, these roles and responsibilities are equally and equitably shared by the adults within the family unit.

Like leadership styles, parenting styles also differ among members of the family when the family has one or more children. For example, parents can be permissive, democratic, participative, laissez faire and authoritarian.

Comparing Client Development to Expected Age/Developmental Stage and Reporting Any Deviations

As with all other nursing care, nurses must be able to identify and report client deviations from what is expected in terms of their growth and development and they must also be able to modify care and their approaches to care as based on these deviations.

Assessing the Impact of Change on the Family System

Families, like all other open systems within the environment including individual clients, are impacted with changes. Some of these changes are expected and developmentally normal and other changes are unexpected and often disruptive to the homeostasis of the family. For example, a family system can be impacted with the empty nest syndrome which is an expected and developmentally normal change; and the death of a child or a spouse is an unexpected and often disruptive change for members of the family.

Families, therefore, just like individual clients, often need the care and services of the health care team to cope with any disruptive changes. Some major life changes that can significantly affect and impact on the family unit are things like poverty, homelessness, divorce, chronic illnesses and legal concerns.

Families, like individual clients, often need the assistance of the nurse to cope with these changes.

Recognizing Cultural and Religious influences That May Impact Family Functioning

Similar to individual clients, families also have their own beliefs, practices, perspectives, values and views, some of which are present as the result of their culture, while others may be related to their religion and still more may just simply result from the family's personal preferences.

Culture impacts on virtually all aspects of the client-nurse relationship. For example, communication patterns, beliefs about illness, who is the major family decision maker, family dynamics, perspectives about health and health care, space orientation, time orientation, nutritional patterns, beliefs about elders and the elderly, parenting, family size, and even death and death vigils are often driven by the family's culture, as passed on from generation to generation.

Religious influences may also impact on the family and its functioning. Some of the same impacts that culture has, religion also has. Religion may impact on the family's beliefs about illness, nutritional patterns, beliefs about elders and the elderly, parenting, birth control, family size, and even death and death vigils are often driven by the family's religion. For example, in terms of the perideath period, some religious practices include a clergy person like a Catholic priest to perform that religion's Sacrament of the Sick.

Assisting the Client to Cope With Life Transitions

Throughout the life span, there are several significant expected life transitions that require the person to cope and adjust. Some of these expected life transitions include attachment and bonding to the neonate, puberty, pregnancy, care of the newborn, parenting, and retirement.

Nurses and other health care professionals assist clients to adapt to and cope with these normally occurring life transitions and changes. For example, the nurse may also seek out community resources that could be helpful to an elderly, retired person who needs transportation to and from doctor's appointments, a nurse could teach the new mother and their partner about how to bond and attach to the newborn, and the nurse could also conduct newborn care classes for new parents to assist these new person to cope with the challenges associated with the care of a neonate and infant.

Modifying Approaches to Care in Accordance with the Client's Developmental Stage

As somewhat previously discussed with the "Integrated Process: Communication" and the "Integrated Process: Teaching and Learning", communication and teaching are modified according to the client's age, level of cognition, and developmental stage. Physical care, including medication administration, as will be discussed later in this review, is also modified according to the client's age and developmental status.

Some of these modified approaches to care, communication, explanations, teaching and diversionary activities include:

  • The provision of parent or legal guardian patient education when an infant and the young child is being cared for
  • The provision of safe and nontoxic, large toys for infants and young children to prevent aspiration and a foreign body obstructing the young child's respiratory tract
  • The use of touch and a soft voice to communicate with an infant
  • The use of a graphic pain assessment tool, rather than a numerical pain assessment scale, for young children and elderly adults who have a cognitive impairment
  • Using the vastus lateralis as the muscle of choice for an intramuscular injection among infants

Providing Education to the Client and Staff Members About Expected Age-Related Changes and Age-Specific Growth and Development

Clients and staff members must be knowledgeable and educated about expected age related changes and age specific characteristics and needs. Registered nurses can identify knowledge deficits and assess learning needs among staff members by observing how well and how consistently their nursing care is modified according to their clients' age specific characteristics and needs. Similarly, registered nurses can identify knowledge deficits and assess the learning needs among their clients and family members across the life span in terms of their knowledge about expected age related changes and age specific characteristics and needs.

For example, neonates and infants receive communication with the touch or a coo by an adult and they enjoy colorful things like a mobile; infants and toddlers must not be given any small toys or toys that can disassemble into small parts because they are in the oral stage of development where they place objects in the mouth which places them at risk for aspiration and death; adolescents are rebellious and they want to be with and accepted by their peers. Adults enjoy socialization and activities like different sports and an exercise regimen; and older adults may be in need of activities such as those in an elder day care center and reminiscence therapy.

When a staff or client/family learning need is assessed, the nurse then plans, implements and evaluates the teaching that is given specific to the learners' needs. For example, a middle aged man caring for an elderly parent may have the need to learn about the safety needs of the elderly and new parents may need education related to age appropriate toys and car seats.

Evaluating the Client's Achievement of Expected Developmental Level and Milestones

When nurses assess clients they incorporate their knowledge of developmental levels into this assessment to determine and evaluate whether or not the client is achieving the expected milestones associated with their age. As previously detailed, these assessments include the clients' assessment of their physical growth and development, their psychosocial growth and development, their cognitive growth and development, and their psychosexual growth and development.

Determining the Impact of Expected Body Image Changes on the Client

In addition to the physical aspects of body image changes, there are also social and emotional impacts with these changes. With the support of the health care team, the client should be able to adapt to the changes, alter his or her life style as indicated, discard irrational beliefs and replace these with realistic expectations, maintain social interactions, and enhance the bodily image with things like a breast prosthesis and a wig, for example.

Evaluating the Impact of Expected Body Image Changes on the Client and Family

Body image changes such as those associated with aging, pregnancy, menopause, disfiguring surgery, and others place challenges upon the client and the family in terms of coping and adaptation.

Some of the signs that indicate whether or not the client is coping with altered bodily image include the client's acknowledgment of the changes as well as verbal and nonverbal comments about the change.

Providing Education to the Client and Staff Members About Expected Age-Related Changes and Age-Specific

Growth and Development

Staff members must be educated about the age related changes and the age specific characteristics and needs of clients across the life span so that they can modify the care of their client's accordingly.

Clients should also be educated about the age related changes and the age specific characteristics and needs of different age groups as necessary. For example, a young mother may be taught about her toddler's age appropriate toys and a middle age adult may have a need to learn about depression among the elderly when the parents are not coping with the normal changes of the aging process.

Evaluating the Impact of Expected Body Image Changes on the Client and Family

Nurses also determine and evaluate the impact of expected body image changes on the client and family in terms of how their perceptions and beliefs may be interfering with the patient's quality of life and the continued performance of their activities of daily living. Again, all maladaptation and/or poor coping skills must be determined, documented and reported so that the patient's plan of care can be changed to meet these needs.

Some of the most stressful expected body image changes that may adversely affect the client and family include body image changes such as those associated with pregnancy, menopause, puberty, and aging. These changes may occur with significant reactions and responses in terms of the person's physical, psychological and social wellbeing.

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