Health Promotion and MaintenanceLesson 3.1
Growth, Development, and Aging Across the Lifespan
From first reflexes to life review. Know what is normal at every age, which theorist explains it, and when to refer.
By the end you can
- Name the Erikson and Piaget stage for any age and use it to shape your care
- Tell expected milestones from the red flags that need a referral
- Separate normal aging from findings that need follow-up
Your case
Family clinic · three generations, back to back
Mia, 9 months, screams and clings to her mother the moment you walk in. "She used to be so friendly," her mother says.
Her brother Leo, 2, said 6 words at 18 months. Now he says none and won't look at you. Their grandmother, 79, was sharp last week. Today she can't tell you the day.
Mia 9 months, clingingLeo 24 months, 0 wordsGrandmother 79, new confusion
Hold that thought
- Does Mia's crying need a referral?
- What do you do about Leo?
- Is the grandmother's confusion just her age?
You will answer all three at the end of the lesson.
Concept 1 · Erikson
Given an age, think Erikson first
Match the age to the stage
Quick check 1 of 4
A 10-year-old proudly shows the nurse a science fair project. Which Erikson stage does this reflect?
School-age children build industry through accomplishment: projects, sports, new skills. Praise the effort. Initiative is the preschool stage of asking why and trying new things.
Concept 2 · Piaget and others
Piaget tells you how to teach
- Sensorimotor
- 0 to 2 years: senses and movement. Object permanence
- Preoperational
- 2 to 7: symbols, egocentrism, magical thinking
- Concrete operational
- 7 to 11: logic about real things. Conservation
- Formal operational
- 12 and up: abstract, hypothetical thinking
Oral (0 to 1), anal (1 to 3, toilet training), phallic (3 to 6), latency (6 to 12), genital (12 and up). Tested less than Erikson.
Preconventional (young children): avoid punishment, earn rewards. Conventional (school-age, adolescents): please others, keep order. Postconventional (adults): universal ethical principles.
The gap between what someone can do alone and what they can do with guidance. Teach in that zone with support: not so easy it bores, not so hard it frustrates. It applies to client teaching at any age.
Concept 3 · Newborn and infant
The first year moves fast
- Reflexes
- Rooting, sucking, Moro, grasp. Babinski is normal until about age 2
- Fontanels
- Posterior closes by 2 to 3 months, anterior by 12 to 18 months
- Weight
- May lose up to 10% at first. Back to birth weight by day 10 to 14
| Age | Motor | Social and language |
|---|---|---|
| 2 months | Lifts head when prone | Social smile, coos |
| 4 months | Holds head steady, bats at objects | Knows caregiver's face and voice |
| 6 months | Rolls both ways, sits with support, raking grasp | Babbles "ba-ba," "da-da" (nonspecific) |
| 9 months | Crawls, pulls to stand, pincer grasp starts | Stranger anxiety. Searches for hidden toys |
Pearl: around 6 months come the first solid foods (iron-fortified cereal) and the lower central incisors.
Concept 4 · 12 months to 2 years
From first steps to "No!"
- 12 months: stands alone, may take first steps, neat pincer grasp, 1 to 3 words
- 15 to 18 months: walks well at 15, runs clumsily at 18, 10 to 20 words at 18
- 2 years: 2-word phrases ("want milk"). Saying "No!" all day is autonomy
- Toilet readiness (18 to 24 months): dry for 2 hours, interested, pulls pants down and up
- Play: infants play alone (solitary), toddlers side by side (parallel)
Work it out
A newborn weighed 3.2 kg at birth. About what should the infant weigh at 12 months?
kg
Worked answer: birth weight triples by the first birthday. 3.2 times 3 = 9.6 kg. Length grows about 50% in the same year.
Normal, not a delay: stranger anxiety (peaks at 8 to 10 months) and separation anxiety in toddlers both show healthy attachment. Their absence would worry you more.
Concept 5 · Motor milestones
Milestones come in order
Put these in the order they appear
Pearl: hands follow the same steady march. Raking grasp at 6 months, pincer grasp starting at 9, neat pincer at 12.
Concept 6 · Preschool (3 to 5)
Preschoolers think magically
- Initiative vs. guilt: asks "why?" nonstop, tries new things. Don't punish curiosity
- Magical thinking: believes thoughts cause events ("I was mad, so Mommy got sick")
- Egocentrism: can't see another person's view. Animism: objects are alive
- Centration: focuses on one feature at a time
- Imaginary friends are normal
Quick check 2 of 4
A 4-year-old whose parent just had surgery says, "My mommy is sick because I was bad." Which concept explains this?
Magical thinking belongs to Piaget's preoperational stage (2 to 7): the child believes their thoughts or actions caused the illness. Reassure them that nothing they did caused it. Concrete operations come later, at 7 to 11.
Concept 7 · Preschool skills
Hop at 4, skip at 5
At what age?
Say the age, then tap to check.
- Rides a tricycle:
- Hops on one foot:
- Skips and ties shoes:
- Copies a circle:
- Copies a square:
- Copies a triangle:
- Language: 3 to 4 word sentences at 3, 1,500 or more words by 5
- Play: associative. Plays with others, but without organized rules
- Therapeutic play works best at this age: dolls and toy medical equipment
Concept 8 · School-age and adolescent
Concrete at 8, abstract at 15
- Industry vs. inferiority: praise effort, not just the result
- Concrete operational: logic about real things. Understands conservation
- Kohlberg, conventional: follows rules for approval. "That's not fair!"
- Growth: steady, about 2 inches a year. Permanent teeth come in
- Play: cooperative, with rules. Team sports, board games, same-sex friends
- Identity vs. role confusion: trying on roles and values is normal
- Formal operational: abstract thought. Imaginary audience: "everyone is watching"
- Personal fable: "it won't happen to me" drives risk-taking
- Puberty: growth spurt, menarche at about 12.5 years. Tanner stages track it
- Risks: car crashes, substances, unprotected sex, self-harm. Peers matter most
- Assess privately: confidential time for sexual health, substance use, and mood
Pearl: explain at their level. Preschool: play with a doll. School-age: simple facts, step by step. Adolescent: the rationale, and a say in decisions.
Concept 9 · Adults (18 to 64)
Relationships first, then legacy
Young adult (18 to 35)
- Intimacy vs. isolation: deep, committed relationships
- Physical peak: muscle, bone density, reproductive capacity
- Teach: contraception, STI prevention, substance and injury prevention
Middle adult (35 to 64)
- Generativity vs. stagnation: guiding the next generation
- Presbyopia (near vision) and presbycusis (high tones)
- Menopause: average age 51
- Sandwich generation: caring for parents and children. Assess caregiver strain
Pearl: questioning life's direction in midlife is normal developmental work. It becomes a concern only with depression or destructive behavior.
Concept 10 · Adult screening
Screen on schedule
Fill in the ages
Colorectal cancer screening starts at age .
Mammograms every 2 years start at age .
Bone density screening for women starts at , earlier with risk factors.
Prostate screening is a shared decision, starting around .
Also screen adults for
- Blood pressure, lipids, and glucose
- Cervical cancer, on schedule
- Depression and substance use
Concept 11 · Older adults (65 and up)
Every system slows a little
Integrity vs. despair: the life review. Meaning brings acceptance of death. Regret brings despair and fear.
Lower cardiac output, stiffer vessels, higher systolic BP. Baroreceptors respond slower, so orthostatic hypotension is common. Slower recovery from exertion.
Less elasticity and vital capacity. A weaker cough raises aspiration and pneumonia risk. Kyphosis can limit chest expansion.
Bone density drops (osteoporosis), muscle mass drops (sarcopenia), joints stiffen, height decreases. Fracture risk climbs.
Slower reaction time, weaker deep tendon reflexes, some short-term memory slips. Less deep sleep, more waking, earlier rising. Dementia is not normal aging.
Less saliva and stomach acid, slower peristalsis (constipation). The liver metabolizes drugs more slowly.
Lower GFR, so drugs clear more slowly. Smaller bladder: frequency and nocturia. Weaker pelvic floor. Men: BPH. Women: atrophic vaginitis.
Thinner, drier, less elastic, less fat underneath. Bruises and tears easily, heals slowly. Higher pressure injury risk. Gray hair.
Weaker T-cell function. Infection may come without fever. Weaker vaccine response, so some vaccines come in higher doses or boosters.
Drugs last longer: slower kidneys and liver mean lower starting doses, slow increases, and close monitoring. Five or more meds (polypharmacy) multiplies the risk. Check the med list first.
Concept 12 · Normal aging or not
Normal aging is not disease
Expected, or follow up?
Tap a finding, then tap the box it belongs in.
Quick check 3 of 4
A 72-year-old says, "I can't see the newspaper anymore, but the TV across the room is fine." What is the best response?
Losing near vision with distance intact is presbyopia: the lens loses flexibility, usually starting in the 40s. Cataracts blur vision at every distance, and macular degeneration takes central vision.
Concept 13 · Red flags
Missed milestone, refer
Expected
- Walks alone by 15 months
- First words at 12 to 14 months
- "No!" all day at 2
- Imaginary friend at 4
- Rules and fairness at 8
- Questions parents' values at 15
Refer
- No social smile by 3 months
- No babbling, pointing, or response to name by 12 months
- No words by 16 months
- Not walking by 18 months
- No 2-word phrases by 24 months
- Loss of any skill, at any age
Pearl: a 10-month-old who isn't walking is normal. A 20-month-old who isn't walking needs a referral. Know the ages and the deviations jump out.
Concept 14 · Developmental screening
Screen, document, refer. Don't diagnose
- Denver II: birth to 6 years. Gross motor, fine motor, language, personal-social
- ASQ: a questionnaire the parent completes
- M-CHAT: autism screening at 18 and 24 months
- Regression is always a red flag. Refer right away
- Early intervention works best. The brain is most adaptable in the first 3 years
Poor eye contact. Delayed or absent speech. No joint attention: doesn't point to share interest or follow your gaze. Repetitive behavior: hand flapping, rocking, lining up objects, rigid routines. No response to name by 12 months, no pretend play by 18 months. Loss of language or social skills.
Quick check 4 of 4
At a 15-month well-child visit, which finding calls for a developmental referral?
Crawling and pulling to stand are expected by about 9 months, and eye contact from early infancy. Missing all three is a real concern. Two-word phrases aren't due until 24 months, and a few words at 15 months is within normal.
Decide it
One family, three ages
Back to the Riveras · family clinic
Mia is screaming on her mother's lap. Leo is lining up blocks in the corner. Their grandmother keeps asking what day it is.
Mia's mother asks, "Is something wrong with her?" What do you say?
Not needed. Clinging to a parent at 9 months is a milestone, not a delay.
Right. It peaks at 8 to 10 months and shows healthy attachment. Keep Mom close, approach slowly, talk softly.
Separating them only raises her distress. The parent stays.
Leo had 6 words at 18 months. Now none, and no eye contact. What do you do?
Regression is never wait and see. Six months is critical time lost.
Reading helps every child, but regression needs a full evaluation now.
Right. Losing skills at any age is a red flag, and early intervention works best.
The grandmother's daughter asks, "Is this just her age?"
Right. Acute confusion is delirium until proven otherwise. In older adults, a UTI may show up as confusion alone.
Small memory slips are normal. Disorientation that came on over days is not.
Dementia develops slowly. Something this sudden points to an acute, often reversible cause.
How it ends
- Mia warms up on her mother's lap and the exam goes smoothly
- Leo starts early intervention and sees a developmental pediatrician within weeks
- The grandmother has a UTI. With treatment, her confusion clears
Lock it in
Three hooks to carry into the exam
Two more
- Erikson's ladder: Trust, Autonomy, Initiative, Industry, Identity, Intimacy, Generativity, Integrity
- Lost a skill? Refer: regression at any age is a red flag
Rapid fire
Stranger anxiety at 9 months is a sign of healthy attachment.
It peaks at 8 to 10 months. Its absence would be more concerning.
A 2-year-old who used to say six words and now says none can be rechecked in 6 months.
Regression means referral now.
Birth weight triples by the first birthday.
And length grows about 50% in the same year.
New confusion in an 80-year-old is a normal part of aging.
Acute confusion is delirium. Look for infection, medications, or dehydration.
Parallel play is typical of school-age children.
Parallel play is the toddler pattern. School-age children play cooperatively, with rules.
NCLEX traps
What the exam will try to trick you with
Normal. Stranger anxiety peaks at 8 to 10 months. Keep the parent close and warm up slowly.
Refer now. Timing varies, but losing a skill is always a red flag.
Not sudden confusion. Delirium has a cause: infection, medications, dehydration, metabolic problems. Find it and treat it.
Never. Be honest: "a quick pinch." A lie breaks trust for every procedure after it.
Normal. Walking alone usually starts at 12 to 15 months. Not walking by 18 months is the red flag.
Cheat card
The whole lesson on one card
Theory
- Any age: think Erikson first
- Piaget: Some People Can Fly
- Preschool magical, school-age concrete
- Teens abstract: assess privately
Infant and toddler
- Birth weight triples by 1
- Stranger anxiety 8 to 10 months: normal
- Walks well at 15 months
- 2-word phrases by 2
Red flags
- No words by 16 months
- Not walking by 18 months
- Any lost skill: refer now
- M-CHAT at 18 and 24 months
Aging
- Presbyopia normal, sudden vision loss not
- Sudden confusion = delirium
- Drugs last longer: start low
- Infection may come without fever
The printable version is in the Cheat Sheets library.
Lesson quiz · 1 of 5
The nurse is preparing a 4-year-old for a blood draw. Which approach is most developmentally appropriate?
A preoperational 4-year-old learns through play, so therapeutic play on a doll is the gold standard. Honest words like "quick pinch" build trust. Saying it won't hurt is a lie the child will remember, and cell biology is far too abstract.
Lesson quiz · 2 of 5
The nurse is teaching a 7-year-old about an upcoming tonsillectomy. Which approach fits this stage best?
A 7-year-old is concrete operational: logical about real events, so simple facts in order work best. Puppet play fits a preschooler, diagrams of the physiology are too abstract, and school-age children want to understand what happens to their own body.
Lesson quiz · 3 of 5
A 48-year-old says, "My kids are grown, my career feels stale, and I don't feel like I'm contributing anything anymore." Which Erikson stage is this?
Feeling that you've stopped contributing is stagnation, the negative side of middle adulthood's generativity stage. Support new outlets such as mentoring or volunteering. Integrity vs. despair is the older adult's life review.
Lesson quiz · 4 of 5
A 70-year-old says, "Looking back, I'm proud of my life. I raised good children, had a meaningful career, and was a good friend." This shows:
Integrity is the positive outcome of the last stage: looking back with satisfaction and accepting death. Generativity is middle adulthood's drive to guide the next generation, and industry belongs to school-age children.
Lesson quiz · 5 of 5
An 84-year-old is starting a new medication cleared by the kidneys. Which principle should guide the nurse?
Lower GFR and slower liver metabolism mean drugs last longer and accumulate faster. Start with a lower dose, increase slowly, and monitor closely. Slower metabolism raises side effect risk, it does not lower it.
Wrap-up
0 / 5
Quiz score
Back to the Riveras · family clinic
Does Mia need a referral? No. Crying and clinging at 9 months is stranger anxiety, a sign of healthy attachment. Keep her on her mother's lap and approach slowly.
What about Leo? Refer him now. Losing words he once had, plus no eye contact, is regression, the clearest red flag. Early intervention works best when it starts early.
Is it just her age? No. Confusion that came on over days is delirium, not aging. Her UTI was the cause, and treating it cleared her thinking.
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