NCLEX-PN Growth and Development — Key Milestones by Age Group

FALLS are the leading cause of injury death and one of the most common causes of injury in adults aged 65 and older. FALL RISK ASSESSMENT is a key PN nursing responsibility. MAJOR FALL RISK FACTORS: (1) POLYPHARMACY — taking multiple medications increases interaction risks; medications contributing to falls include antihypertensives (orthostatic hypotension), diuretics (frequent urination, dizziness), sedatives/hypnotics (benzodiazepines, sleep aids), opioids, antidepressants, antipsychotics, anticonvulsants, and alcohol; (2) HISTORY OF PREVIOUS FALLS — strongest single predictor; (3) GAIT AND BALANCE PROBLEMS — shuffling gait, Parkinson's disease, stroke deficits; (4) MUSCLE WEAKNESS — sarcopenia; (5) IMPAIRED VISION — cataracts, macular degeneration, glaucoma; (6) ENVIRONMENTAL HAZARDS — poor lighting, loose rugs, no grab bars, clutter, slippery surfaces; (7) ORTHOSTATIC HYPOTENSION — check by measuring BP lying, sitting, standing (significant if drops ≥20 mmHg systolic or ≥10 mmHg diastolic); (8) COGNITIVE IMPAIRMENT — dementia increases fall risk; (9) URINARY URGENCY — rushing to bathroom; (10) FOOT PROBLEMS — neuropathy, poor footwear. STANDARDIZED TOOLS: Morse Fall Scale, Hendrich II — used in hospitals and care settings. NURSING INTERVENTIONS: bed in lowest position, call light within reach, non-skid footwear, frequent toileting rounds, adequate lighting, remove environmental hazards, ensure assistive devices are available, medication review, post fall precaution signs, family education.

SHINGLES (herpes zoster) is caused by reactivation of the varicella-zoster virus (VZV) — the same virus that causes chickenpox — which remains dormant in nerve tissue after initial infection. As people age, immunity wanes and VZV can reactivate, causing the painful shingles rash along a dermatome, and potentially postherpetic neuralgia (PHN) — severe, persistent pain lasting months or years. SHINGRIX (RZV — recombinant zoster vaccine): recommended for adults 50 and older; 2-DOSE SERIES, given 2-6 months apart; efficacy: >90% at preventing shingles and PHN; recommended even for: people who previously had shingles (can recur); people who received the older Zostavax vaccine; people who are unsure whether they've had chickenpox. ZOSTAVAX (live attenuated, ZVL): older vaccine; only 51% effective; no longer available in the US; people who received it should still get Shingrix. IMMUNOCOMPROMISED PATIENTS: Shingrix is a non-live vaccine; can be given to many immunocompromised adults but consult provider for specific conditions (guidelines have nuances for immunosuppressed patients). COMMON SIDE EFFECTS of Shingrix: injection site reactions (soreness, redness, swelling), systemic reactions (myalgia, fatigue, headache, fever) — often quite significant and last 2-3 days; clients should be warned so they don't mistake side effects for illness; recommend scheduling injection before a rest day. NURSING ROLE: assess immunization history; provide Shingrix per schedule; educate on side effects and expected response; document administration.

NOCTURNAL ENURESIS (bedwetting) is very common in young children. Expected timeline for toilet training: DAYTIME DRYNESS — most children achieve by ages 2-3; NIGHTTIME DRYNESS — typically not expected until ages 5-6; NORMAL VARIATION — many children are not consistently dry at night until age 6-7; approximately 15-20% of 5-year-olds and 5% of 10-year-olds still have occasional bedwetting. PRIMARY NOCTURNAL ENURESIS refers to children who have NEVER achieved consistent nighttime dryness; this is distinct from secondary enuresis (a child who was dry for 6+ months and then begins wetting again — which warrants evaluation for: UTI, stress, new sibling, school change, sexual abuse, diabetes). EVALUATION IS WARRANTED if: age 5+ with frequent wetting; daytime wetting; painful urination; polydipsia/polyuria (possible diabetes); symptoms of UTI; recurrence after 6 months of dryness. NURSING GUIDANCE: reassure parents that bedwetting is DEVELOPMENTALLY NORMAL at age 4; avoid punishment or shame (worsens problem and disrupts development); avoid restricting ALL fluids but reduce fluids 1-2 hours before bed; encourage voiding before sleep; use waterproof mattress cover; reward for dry nights (positive reinforcement) but do not punish for wet nights; most children outgrow it without intervention; moisture alarms and desmopressin (DDAVP) are options for persistent enuresis at age 7+. PN ROLE: reassure parents; teach developmental expectations; screen for signs that warrant referral.

MODERATE ALCOHOL USE — per NIAAA and USDA Dietary Guidelines for Americans: up to 1 standard drink per day for women; up to 2 standard drinks per day for men. A STANDARD DRINK = 14 grams of pure alcohol = 12 oz regular beer (5% ABV); 5 oz wine (12% ABV); 1.5 oz distilled spirits (40% ABV). NOTE: the 2020-2025 Dietary Guidelines note that people who do not drink should not start for any perceived health benefit; even moderate drinking carries cancer risk (particularly breast cancer). BINGE DRINKING: 4+ drinks for women or 5+ drinks for men in about 2 hours, raising blood alcohol to ≥0.08 g/dL. HEAVY DRINKING: more than 4 drinks any day or 14 per week for men; more than 3 any day or 7 per week for women. HEALTH RISKS OF HEAVY DRINKING: liver disease (fatty liver, alcoholic hepatitis, cirrhosis); pancreatitis; certain cancers (mouth, throat, esophagus, liver, colon, breast); cardiomyopathy; hypertension; peripheral neuropathy; Wernicke-Korsakoff syndrome (thiamine deficiency from poor nutrition); sexual dysfunction; depression and anxiety; addiction (alcohol use disorder). ALCOHOL AND PREGNANCY: NO amount of alcohol is known to be safe during pregnancy; alcohol is a teratogen causing Fetal Alcohol Spectrum Disorders (FASD), including fetal alcohol syndrome (FAS) — characterized by facial abnormalities, growth restriction, and neurodevelopmental problems. ALCOHOL AND SLEEP: alcohol may help fall asleep but disrupts REM sleep, resulting in poor sleep quality and daytime fatigue. ALCOHOL AND MEDICATIONS: many drug-alcohol interactions; particularly dangerous with: CNS depressants (benzodiazepines, opioids, sleeping pills), metronidazole, metformin, acetaminophen (hepatotoxicity risk). CAGE QUESTIONNAIRE and AUDIT are brief screening tools for problematic drinking.

PRETERM LABOR is defined as regular uterine contractions resulting in cervical change before 37 weeks gestation. It is a major cause of neonatal morbidity and mortality. WARNING SIGNS of preterm labor (teach clients to report IMMEDIATELY if they experience before 37 weeks): (1) Regular uterine CONTRACTIONS — 4 or more in 1 hour, even if not very painful; (2) PELVIC PRESSURE — feeling that the baby is pushing down; (3) DULL LOW BACKACHE — constant or intermittent, may feel different from usual pregnancy back pain; (4) VAGINAL DISCHARGE — change in amount, color, consistency (watery, mucous, bloody); (5) VAGINAL BLEEDING — any amount is significant; (6) FLUID LEAKING — possible rupture of membranes (call immediately); (7) ABDOMINAL CRAMPING — with or without diarrhea. CONTRAST WITH NORMAL: Braxton-Hicks contractions are irregular, non-progressive, go away with rest and hydration, and do not cause cervical change — normal in the third trimester. RISK FACTORS for preterm birth: prior preterm birth, multiple gestation, cervical incompetence, uterine anomalies, infections (UTI, bacterial vaginosis), placenta previa, abruptio placentae, smoking, substance use, inadequate prenatal care. INTERVENTIONS if preterm labor confirmed: hospitalization; tocolytics (medications to slow or stop contractions: terbutaline, indomethacin, nifedipine); corticosteroids (betamethasone) to promote fetal lung maturity if delivery may occur; magnesium sulfate for fetal neuroprotection at <32 weeks; antibiotics for group B Strep prophylaxis. PN TEACHING: emphasize when to call (don't wait to see if it goes away); early intervention gives the best chance of continuing the pregnancy.

SCHOOL-AGE NUTRITION is foundational to healthy growth, cognitive function, and lifelong dietary patterns. Key principles: BALANCED DIET: use MyPlate as a visual guide — half the plate fruits and vegetables; one quarter whole grains; one quarter lean protein; dairy on the side; BREAKFAST: research consistently links eating breakfast to better concentration, memory, and school performance; children who skip breakfast have more behavioral problems and lower academic achievement; limit added sugars (in breakfast cereals, juices, pastries) and provide protein and whole grains; FRUITS AND VEGETABLES: aim for 5+ servings daily; varied colors provide different micronutrients; WHOLE GRAINS: choose whole wheat bread, oatmeal, brown rice over refined grains; LEAN PROTEIN: chicken, fish, beans, eggs, nuts (school-age children need more protein for growth); DAIRY/CALCIUM: critical for bone development during school years; milk, yogurt, cheese or calcium-fortified alternatives; LIMIT: added sugars (soft drinks, candy, pastries), excessive sodium (processed/fast foods), saturated fats; OBESITY PREVENTION: approximately 20% of school-age children in the US have obesity, associated with type 2 diabetes, cardiovascular risk, joint problems, social issues; promote physical activity alongside nutrition; SPECIAL NEEDS: iron-rich foods for girls who begin menstruation; calcium and vitamin D throughout growth; if vegetarian/vegan family, assess for B12, iron, zinc adequacy. PN TEACHING TIP: involve children in food preparation; avoid labeling foods as 'good' or 'bad' (can create disordered relationships with food); role-model healthy eating.

HUMAN PAPILLOMAVIRUS (HPV) is the most common sexually transmitted infection in the US. Certain HPV strains cause: cervical cancer, vaginal and vulvar cancer, anal cancer, oropharyngeal cancer, penile cancer, and genital warts. HPV VACCINE (Gardasil 9): protects against 9 HPV strains (including types 16 and 18, which cause about 70% of cervical cancers, and types 6 and 11, which cause about 90% of genital warts). RECOMMENDED SCHEDULE: PRETEENS (11-12 years): best timing — before any sexual exposure; 2-DOSE series if started before age 15 (0 and 6-12 months apart); 3-DOSE series if starting at age 15 or older, or if immunocompromised; CATCH-UP: recommended through age 26 for those not vaccinated; shared clinical decision-making for adults 27-45 (less benefit at older ages due to prior exposure). MALES AND FEMALES: both benefit — prevents cancers in males too (anal, penile, oropharyngeal) and reduces transmission. PAP SMEARS: the HPV vaccine does NOT eliminate the need for cervical cancer screening (Pap smear/cervical cytology) — the vaccine doesn't protect against 100% of cancer-causing HPV strains; screening continues as recommended (starting at age 21 for most women, Pap every 3 years, or Pap + HPV co-test every 5 years starting at 30). SAFETY: the HPV vaccine is one of the most studied vaccines; common side effects are injection site reactions and brief fainting (syncope is relatively common with this vaccine — observe for 15 minutes post-injection). PN EDUCATION: address common misconceptions (it does NOT encourage sexual activity, it does NOT affect fertility); emphasize recommended age; document vaccine administration and counsel on side effects.

BLOOD GLUCOSE TARGETS for adults with diabetes are established by the American Diabetes Association (ADA) in annual Standards of Medical Care in Diabetes. For most NON-PREGNANT ADULTS with diabetes: PREPRANDIAL (before meals): 80-130 mg/dL; POSTPRANDIAL (2 hours after the start of a meal): less than 180 mg/dL; A1c: less than 7% for most non-pregnant adults. INDIVIDUALIZED TARGETS: more stringent (lower) for: younger patients with long life expectancy, no significant cardiovascular disease, short duration of diabetes, no hypoglycemia history; less stringent (higher) for: elderly patients, history of severe hypoglycemia, advanced complications, limited life expectancy, extensive comorbidities. HYPOGLYCEMIA (low blood sugar): less than 70 mg/dL; symptomatic: shakiness, diaphoresis, pallor, confusion, palpitations, hunger; TREATMENT: RULE OF 15 — give 15 grams of fast-acting carbohydrates (4 oz juice, 4 oz regular soda, glucose tablets), recheck in 15 minutes; if still below 70, repeat; if unconscious or NPO, glucagon or IV dextrose. HYPERGLYCEMIA symptoms: polyuria, polydipsia, polyphagia, fatigue, blurred vision; acute crises: DKA (type 1, sometimes type 2) and HHS (type 2). SELF-MONITORING: teach clients how to use glucometer; proper technique (clean finger, lancet, test strip); documentation; when to call provider. DISEASE MANAGEMENT: medication adherence (oral agents, insulin), diet (consistent carbohydrate intake with attention to glycemic index), physical activity (lowers blood glucose), stress management (stress hormones raise blood glucose), regular provider follow-up, foot care, annual eye and renal exams.

PHARMACOKINETICS IN OLDER ADULTS is altered in multiple ways, creating significant medication management considerations. ABSORPTION: generally less affected; gastric motility may be slowed (delayed peak effect); some medications requiring acidic environment may be affected by reduced gastric acid. DISTRIBUTION: decreased total body water (more concentrated water-soluble drugs); increased body fat proportion (fat-soluble drugs stored longer, extended duration of action); decreased serum albumin (more free drug in circulation for protein-bound medications — higher risk of toxicity). METABOLISM: decreased hepatic blood flow and enzyme activity; slower first-pass metabolism; many drugs metabolized more slowly, requiring lower doses or longer intervals. ELIMINATION: RENAL CLEARANCE is the most clinically significant change — GFR decreases approximately 1 mL/min/year after age 40; drugs cleared renally (e.g., digoxin, metformin, many antibiotics, NSAIDs) accumulate more easily; creatinine clearance (CrCl) must be estimated using Cockcroft-Gault formula using ACTUAL weight and creatinine — note that older adults may have a 'normal' serum creatinine despite low GFR due to reduced muscle mass and creatinine production. POLYPHARMACY: the term for taking 5 or more medications; very common in older adults; increases risk of: drug interactions, adverse effects, nonadherence, falls, cognitive impairment. BEERS CRITERIA: AGS (American Geriatrics Society) list of medications considered potentially inappropriate for older adults: benzodiazepines, first-generation antihistamines (diphenhydramine/Benadryl), anticholinergics, some NSAIDs, muscle relaxants. NURSING MONITORING: watch for toxicity signs of narrow-therapeutic-index drugs (digoxin — bradycardia, nausea, visual changes; warfarin — bleeding; lithium — tremors, GI upset, cognitive changes); monitor renal function; keep medication lists updated; reconcile medications at every visit.

Jean PIAGET's theory describes four stages of cognitive development. The PREOPERATIONAL STAGE (approximately ages 2-7) is characterized by: EGOCENTRISM — the child cannot take another's perspective; believes others see, think, and feel exactly as they do; demonstrated by Piaget's 'three mountains' task; MAGICAL THINKING — animism (attributing life to inanimate objects), belief that thoughts can cause events; SYMBOLIC/LANGUAGE THINKING — beginning to use symbols (words, pictures) to represent objects; dramatic play; LACK OF CONSERVATION — does not understand that quantity stays the same when appearance changes (pouring water from a short, wide glass to a tall, narrow glass — child says the tall glass has 'more' water); CENTRATION — focuses on only one dimension at a time; IRREVERSIBILITY — cannot mentally reverse actions; TRANSDUCTIVE REASONING — reasoning from specific to specific (if A caused B once, A always causes B). Piaget's full stages: SENSORIMOTOR (birth to 2 years) — learns through senses and motor action; object permanence develops; PREOPERATIONAL (2-7 years) — symbolic thought, egocentrism; CONCRETE OPERATIONAL (7-11 years) — logical thinking with concrete materials, conservation, decentration, reversibility; FORMAL OPERATIONAL (12+ years) — abstract, hypothetical reasoning. NURSING APPLICATION: preoperational children may think their illness is punishment for bad thoughts (magical thinking); medical procedures should be explained simply and concretely; allow them to handle equipment when safe; don't assume they understand explanations aimed at adults; they may not report symptoms accurately because of egocentrism; school-age/concrete operational children benefit from logical explanations and hands-on demonstration.