Welcome to the bed. We'll go ahead and give you
the story. This is all going to happen super
fast. Welcome to the emergency room. Welcome
back to the deep dive. So you're getting ready
for your pes rotation, you're staring down those
big foundational exams and you know the school
-aged child is a huge piece of that puzzle. It
really is. So today, we're taking all that source
material, your textbooks, those CDC schedules,
the developmental checklists, and we are boiling
it all down. We're going to pull out the most
critical, high -yield info you absolutely need
to know. And this age group, the six to 12 year
old, is, well, it's arguably one of the most
important transitions to understand. We sometimes
call it the era of industry. Or the calm before
the storm. I've heard that one, too. Right. The
calm before the teenage storm. You get the slow,
steady physical growth, which is a nice break
after the toddler years. But at the same time,
their social and cognitive growth is just exploding.
It's accelerated. And that's the core of it for
nursing, isn't it? That transition. whole world
shifts completely they go from being totally
focused on the family to a world that's you know
dominated by their friends by school by teachers
by coaches so if you are listener are looking
for that one single thread that one idea that
connects everything we're about to talk about
today. What is it? It's Erickson's core stage
for this age. Industry versus inferiority. OK.
That is your clinical lens, everything. Play,
safety, how they handle being sick. It all revolves
around this fundamental drive they have for competence,
for mastery. They don't want to be good at things.
They need to be good at things. If you get that,
you get the school -age child. Perfect. So that's
our mission today. We're gonna use that industry
lens to connect all the dots for you. We'll cover
vitals, development, immunizations, play, and
of course, the huge topic of safety. Let's jump
right in with the body itself, the physiology.
Okay, so physiologically, the big theme here
seems to be things slowing down, but also maturing.
That's a great way to put it. Think deceleration
in terms of rates, but maturation in terms of
function. The body is just getting more efficient,
it's refining itself, moving closer and closer
to adult norms. I see that phrase slow, progressive,
physical growth in all the textbooks. So let's
break that down. Which systems are really making
a big leap during this time? Well, the neurologic
system is a fantastic place to start. The brain
itself, it's already about 90 % of its adult
size by age five. So the actual growth of the
brain and the skull slows way down. Right. But
that physical slowdown allows for this incredible
functional development. The wiring is getting
optimized. Myelination of the nerve fiber is
continuing and that's what allows for faster
processing for the complex thinking we'll talk
about with Piaget. So the hardware is basically
in place and now it's all about upgrading the
software and the connection speed. Exactly. Which
leads us to the immune system. This is a huge
high yield point for any nursing student. The
number of sick visits just plummets, doesn't
it? It really does. And here's the clinical fact
you need to remember. The immune system matures
to an adult level right around 10 years old.
10 years old. OK. So think about it. The preschooler
you saw last week was in for their, what, fifth
year infection? Right, it's just a constant cycle.
But by 10, their immune system is fully competent.
They've been exposed to a lot. They've built
up antibodies. So they get far fewer colds, fewer
stomach bugs, fewer infections in general. Which
means if a 10 -year -old is coming in with constant
nagging infections, that's a bit of a red flag
for you. It's not just a kid thing anymore. Precisely.
It warrants a deeper look. And this shift also
means that the leading cause of, well, morbidity
and mortality, it moves away from infectious
disease and moves squarely into the category
of unintentional injuries. Which we will definitely
get to in the safety section. Yep. What about
the musculoskeletal system? They look so much
more coordinated. They're playing sports. But
you're saying there's a hidden vulnerability.
There is. Their coordination and strength are
increasing like crazy. They can run, jump, swim,
all of that. but the internal structure is still
immature. What does that mean specifically? Specifically,
we're talking about the growth plates, the epiphyseal
plates at the ends of their long bones. They're
still open, they're still soft, they're... relatively
weak until they finish puberty. So their muscles
might actually be stronger than their bones at
certain points. That's the risk. The muscle strength
can outpace the bones structural integrity. This
makes them super prone to injuries during sports,
especially fractures right at that growth plate,
which can be a serious problem. So you can't
treat a 10 year old athlete like a mini adult
athlete. You absolutely cannot. The whole safety
approach has to be different. OK, let's translate
this maturation into the hard numbers, the vital
signs. This is so testable. What's the overall
trend? The trend is simple. Heart rate and respiratory
rate go down and blood pressure goes up. The
body is bigger. It's more efficient. It doesn't
have to work as hard at rest. So let's compare
a preschooler versus our school age kid. Let's
start with pulse rate. OK, for a preschooler,
you're looking at a range of, say, 70 to 120
beats per minute. For the school -aged child,
that slows down to about 60 to 110. So a heart
rate of 115, which is totally fine in a four
-year -old, might make you raise an eyebrow in
a nine -year -old. It should, yeah. It's on the
high end of normal. You'd want to watch that.
And respirations, do they drop as much? They
also slow down a bit, usually hovering in the
20 or 25. breast -per -minute range, but the
really critical change here, and exam writers
love this detail, is the way they breathe. It
becomes diaphragmatic. abdominal breathing. They're
moving away from that chest wall, accessory muscle
breathing you see in younger kids. It's just
another sign of a more mature, more efficient
respiratory system. So if you see a calm 10 -year
-old with retractions or using their neck muscles
to breathe, that's a significant sign of distress.
A very significant sign. They shouldn't need
to work that hard. Now, the one that goes the
other way is blood pressure. Right. It starts
to climb. It does. It moves toward adult norms,
which reflects their bigger body mass and increased
can you give us a general range to keep in mind?
Well, it is very age and sex dependent, but generally
systolic for boys is around 96 to 106, and for
girls maybe 94 to 105. Diastolic for both is
in that 55 to 62 range. The key takeaway for
a student isn't to memorize every single number,
but to know the trend. Know the trend. On a pediatric
BP chart, this is the age where that line starts
a clear, steady climb upwards. And thank goodness
temperature taking gets easier. Finally. we can
reliably switch to the oral route usually around
age seven, once they can cooperate and hold it
under their tongue safely. The temp itself is
very stable, right around 37 Celsius or 98 .6
Fahrenheit. Okay, before we wrap this section,
that clinical calculation tip for bladder kinacity,
it's so practical. It is, and you'll use it all
the time. The formula is simple. Age in years
plus two equals the capacity in ounces. So a
10 -year -old has about a 12 -ounce bladder capacity.
Exactly. And that's critical for you when you're
assessing urine output, calculating IV fluids,
or figuring out if a child is in urinary retention.
It gives you a baseline for what to expect. That's
incredibly useful. OK. Let's synthesize this
section for everyone studying. All right. So
what nurses watch for? You're watching for any
sudden jump in heart rate or respiratory rate,
remembering their baseline is way slower than
a toddler's. You're also starting to watch for
signs of prepubescence toward the end of this
stage, around 10 or 12. And why is that important
from a nursing perspective? Because their bodies
might start to look more mature, but their brain
is still that of a 10 -year -old. You have to
base your communication and your expectations
on their cognitive age, not their physical appearance.
That's a great point. And what exam writers love
to test? They love the maturation points, the
immune system hitting adult levels around age
10, and they love the vital sign trends heart
rate and respirations down, BP up. They'll give
you a scenario and ask if the vitals are normal
for the age. Okay, and finally, one easy way
to remember this age group. Their body is running
like a more efficient car lower RPMs at idle,
but the frame is still under construction. The
driver, the brain, needs to be extra cautious.
That's a perfect transition. The body's on a
slower, steadier track, which means all that
energy can be focused outward, focused on the
world. And focused on success in that world.
This is where we get to Erickson's industry versus
inferiority. OK, so if the preschooler's job
was initiative, just starting things, the school
-aged child's job is What? It's production. Their
entire developmental drive is to achieve a sense
of personal competence. That's what industry
means. So if they're in the hospital, their self
-esteem, their whole sense of self, is tied to
their ability to... Do stuff. To contribute,
to master things, to achieve. Success for them
is getting a good grade, scoring a goal, even
just completing a chore correctly. So as nurses,
we have to tap into that. We have to give them
opportunities for industry. Give me a concrete
example of that on the pediatric floor. OK, so
instead of just silently measuring their fluid
intake, you give them the chart and a pen. You
say, your job is to be my official hydrator.
I need you to mark this sheet every time you
finish a cup of water. You're giving them a roll.
A job. Exactly. You're making them a partner.
They crave that responsibility. They need to
feel helpful and competent, especially when so
much else feels out of their control. And the
flip side of that coin is inferiority. How does
that manifest? It's a profound danger. Inferiority
is what happens when the tasks are too hard,
when the goals are too high, and the child just
feels like a failure. They feel inadequate, worthless
even. And school is a huge breeding ground for
that. A huge one. If a child is struggling with
reading or they're not good at sports and they're
constantly reminded of that, that feeling of
being less than can just take over their whole
self -concept. So our job is to help set them
up for success, for small wins. Always. Set achievable
goals. This connects directly to how they think,
right? To PJ's stage. Absolutely. We're now in
the concrete operational stage, usually from
about age 7 to 11. Concrete, that's the key word.
It is. This is the beginning of logical, organized
thought. They can understand processes, they
can follow steps, they can classify things. It
unlocks so much for our health teaching. But
there's a huge limitation that you mentioned
earlier. The huge limitation is that they still
cannot think abstractly. Everything has to be
concrete, tangible, and related to the here and
now. So what's the clinical implication there?
How does that change how you teach? It means
you can't talk about long -term abstract consequences.
Telling an eight -year -old smoking might give
you cancer in 40 years is, you know, meaningless.
It's too far away, too abstract. Right. But if
you tell that same child, if you don't use your
asthma inhaler correctly, you won't be able to
play in the soccer game tomorrow. That's concrete.
That's immediate. And it directly impacts their
drive for industry. Let's hit that classic skill
they master in this stage, conservation. Yes.
Conservation is a huge cognitive leap. It's the
understanding that the amount or volume of something
stays the same even if you change its shape or
appearance. The classic water glass test. A classic
test. You pour water from a short, fat glass
into a tall, skinny glass. A preschooler will
say the tall glass has more water, but the school
-aged child who has mastered conservation knows
it's the same amount. They can mentally reverse
the action. That ability to mentally manipulate
things is the core of it all. It is. And they're
also learning to tell time, they understand reversibility,
and crucially, they become much less egocentric.
They can finally see things from someone else's
perspective. Genuinely see it, yes. Which is
the foundation for empathy, for teamwork, for
following rules in a game. And all of this plays
out in their physical milestones too. It's not
just running and jumping anymore. No, the gross
motor skills get very refined, which is why organized
sports become so popular. But the real expression
of industry is often in their fine motor skills.
How so? Their dexterity improves so much that
they take incredible pride in activities that
require precision. Like what? Like neat handwriting,
building complex Lego models, learning a musical
instrument, drawing detailed pictures. They love
to show you what they've made. So if you notice
a child is really avoiding those kinds of tasks,
that could be a clue. A big one. Which brings
us to a major developmental warning sign we have
to screen for, vision problems. Because if you
can't see well, you can't succeed in school.
You can't achieve industry. Exactly. So you,
as the nurse, need to watch for the signs. eye
rubbing, squinting, headaches after school, holding
a book super close to their face. Any of those
are red flags. Let's do a quick deep dive on
amblyopia, the lazy eye. Yeah. Because that's
such a classic issue for this age. Right. And
it's not just a weak eye. Amblyopia is when the
brain starts to ignore or suppress the visual
input from one eye. Why would it do that? It's
usually because the image from that eye is blurry,
maybe from a refractive error or misaligned,
which is called strabismus. To avoid double vision,
the brain just says, nope, I'm only listening
to the good eye. And if that goes on for too
long? The vision loss in that suppressed eye
can become permanent. The critical window for
visual development is still open. So the intervention
is patching. Patching the strong eye, yes. You
have to force the brain to use the weaker eye
to build up those neural pathways. Which I imagine
a nine -year -old is not a huge fan of. They
hate it. Compliance is the number one challenge.
So again, you leverage industry. You don't just
say, wear this. You say, your job for the next
four hours is to be an eye trainer. By wearing
this patch, you're doing the hard work to make
your eyes stronger so you can see better for
video games. Frame it as a task to be mastered.
Always. OK, let's wrap up development. What's
the bottom line here? All right. What nurses
watch for? You're looking for signs of inferiority.
Is the child withdrawn? Are they always saying,
I can't do it? Are they avoiding school or group
activities? Those are major psychosocial red
flags. And, of course, screen for vision problems
aggressively. And for our students studying for
exams, what exam writers love to test? They love
to test the difference between concrete operations
and industry versus inferiority. They'll give
you a scenario about teaching a child and ask
you to pick the best approach based on their
concrete, non -abstract thinking. And your memory
trick. One easy way to remember this age group.
Their whole world revolves around CIP, they've
mastered conservation, they're driven by industry,
and they're learning perspective taking. Okay,
let's move into clinical prevention. This is
where the rubber meets the road, and we have
to start with the immunization schedule. It feels
like this age group is caught between two big
vaccine pushes. That's a good way to describe
it. They're finishing up the early childhood
series and just about to start the adolescent
series. So there are two key moments to know
for your exams. The first one is right before
they start school, right? Yes, the post preschool
boosters. This is that four to six year old checkup.
It's usually the fifth dose of DTaP, fourth IPV,
and the second doses of MMR and varicella. And
there's a key clinical detail about DTAP if a
child is a little behind schedule. A very important
one. If a child is seven years or older and needs
a tetanus diphtheria pertussis vaccine, you do
not give them DTAP. You switch to Tdap. Why is
that? DTAP has a higher dose of the diphtheria
and pertussis antigens, which can cause more
significant reactions in older kids and adults.
By age seven, Tdap is enough to boost their immunity
without the increased side effect risk. Got it.
Okay, now for the second big moment. The big
11 to 12 year set. The middle school shots. Right.
There are three critical vaccines here. First
is Tdap. This is their one dose adolescent booster.
And the big rationale here is that immunity from
their childhood shots starts to wane. This protects
them and others from things like whooping cough.
And there is a super high yield clinical fact
about Tdap and pregnancy. You see this on exams.
All the time. All the time. The rule is, Tdap
is recommended during every single pregnancy.
Every single one. Yes, usually between 27 and
36 weeks. And it doesn't matter when her last
Tdap was. The reason is to protect the baby.
The mother creates antibodies that cross the
placenta and give the newborn passive immunity
to Pertussis, which can be deadly for them. The
mother is cocooning the baby with her own immunity.
That's a perfect way to think about it. OK, second
vaccine in that set. HPV, the human papillomavirus
vaccine. The goal is to give it before any potential
exposure because it prevents the majority of
cancers caused by HPV. The dosing can be a little
tricky. It can. But the rule is pretty simple.
If you start the series between ages 9 and 14,
it's a two -dose series. If you wait until they're
15 or older, or if they're immunocompromised,
it becomes a three -dose series. Simple enough.
And the third one. Meningococcal vaccine. This
is to protect against bacterial meningitis, which
can be devastatingly fast and fatal. And this
is a two dose series as well, but spread out.
Yes. Dose one is at 11 to 12 years, and the crucial
booster dose is given at age 16. just in time
for them to be heading into more crowded environments
like college dorms. Okay, let's quickly hit the
absolute contraindications, the never ever give
situations. There are a few you have to know
cold. First, a severe allergic reaction, you
know, anaphylaxis, to a previous dose is an absolute
contraindication. Obvious but critical. Right.
Second, and this is specific to DTaP or Tdap,
if a child had encephalopathy, a severe brain
issue, like a coma or prolonged seizures, within
seven days of a previous dose, they should not
get any more pertussis -containing vaccines.
Okay, that's very specific. And third, for the
live vaccines, which are MMR and varicella, they
are absolutely contraindicated in anyone who
is severely immunocompromised or who is pregnant.
Got it. And what if a patient is just way behind
schedule on everything? Do you start over? No,
that's the golden rule. You never need to restart
a series. You just pick up where they left off
and follow the minimum interval guidelines. That's
a huge relief. Yeah. Okay, let's pivot from shots
to play. which for this age group is basically
their work. It's totally their work. It's how
they achieve industry. And play shifts from the
parallel play of toddlers to being primarily
cooperative and competitive. They want games
with rules. They love games with rules. It reflects
their new cognitive ability to handle logic and
sequencing. It's not just about the fun of the
action anymore. It's about the challenge of winning
according to the structure. What are the benefits
of that kind of structured play? Oh, they're
huge. Physically, it's It helps with fitness,
weight management, but psychosocially, this is
where they learn teamwork, leadership, compromise,
negotiation. They learn that to succeed as a
group, everyone has to follow the rules. So what
are some age -appropriate recommendations a nurse
can make? Well, organized sports are fantastic.
But so are things like simple board games or
card games, activities that involve collecting
and organizing, like stamps or cards, or building
complex models. Anything that requires skill,
planning, and following a set of rules is Perfect.
So synthesizing this section, what's the takeaway?
All right. What nurses watch for? A lack of interest
in these cooperative or competitive games. A
child who can't seem to follow rules or who avoids
all group activities might be struggling with
social skills, or it could be a sign of low self
-esteem. that inferiority piece again. And what
exam writers love to test. They hammer the 11
to 12 year old vaccine schedule. Tdap, HPV, men
in ACWI, know those. And know the absolute contraindications,
especially the Tdap and pregnancy rule versus
the live vaccines and pregnancy rule. Finally,
one easy way to remember this age group. They
need their THM, Tdap, HPV, men ACWI before they
become teens. And their play is all about learning
the rules, rules, rules. All right. Our final
section. And it is a big one. Safety. We've set
the stage perfectly. They're capable, they're
logical in a concrete way, they're independent.
But their judgment is still immature. Their ability
to think about abstract risk and long -term consequences
just isn't there yet. And that creates a perfect
storm for unintentional injuries. Which you said
earlier is the leading cause of death in this
age group. It is, tragically. So the anticipatory
guidance we provide as nurses here is life -saving.
It's not optional. Let's start with the one that
is on every single exam. Car and pedestrian safety.
And the infamous booster seat rule. Yes. If you
remember one thing from this section, remember
this. A child needs to be in a booster seat until
they are at least four feet nine inches tall.
That's 144 .8 centimeters. Four foot nine. And
this is typically somewhere between eight and
12 years old. So it's not about age, it's about
height. It is 100 % about height. Let's talk
about the physics of why that matters. Please
do. When a child is shorter than four foot nine,
the adult lap belt doesn't sit on their strong
hip bones. It rides up onto their soft abdomen.
In a crash, that belt can cause catastrophic
internal injuries to the organs and the spine.
That's horrifying. It is. The booster seat simply
elevates them so the lap belt stays low on the
hips and the shoulder belt crosses the chest
and shoulder, not their neck or their face. The
belt has to engage the skeleton, not the soft
tissue. And they should always be in the back
seat until what age? Until age 13. No exceptions.
Okay. That is crystal clear. Now, what about
when they're outside the car? Pedestrian safety.
They're walking to a friend's house alone for
the first time. But their brain isn't fully ready
for that task. They can pare it back the rule,
look left, right, then left again. But what they
can't do, especially under age 10, is accurately
judge the speed and distance of an oncoming car.
So they see the car, but they have no real concept
of how fast it's closing in. Exactly. Their concrete
thinking doesn't handle that kind of complex
real -time calculation well. So they need continued
supervision when crossing busy streets. Okay,
let's move to sports and bikes. Again, their
coordination is better, but the risk is still
there. The risk is high because they're attempting
more daring things. So for bicycle safety, two
things are non -negotiable. One, the bike has
to fit. They should be able to sit on the seat
and have the balls of their feet touch the ground.
And two, helmets every single time for any real
sport. Bikes, scooters, skateboards, you name
it, a helmet is mandatory. Plus other padding
for knees and elbows. And this goes back to protecting
those vulnerable growth plates we talked about.
It does. The equipment helps absorb and distribute
the force of a fall, protecting not just their
head, but their entire immature skeletal structure.
OK, let's talk about risks inside the home. Fire
safety. This is a great place to leverage their
concrete thinking. They can learn and practice
a plan. So what do you teach? Every home needs
working smoke detectors, check the batteries
twice a year, and, crucially, you have to create
and physically practice a fire escape plan with
a designated meeting spot outside. They need
to walk through the steps. Yes. And they need
to know the concrete actions. Stop, drop, and
roll. Call 911. And any chores involving heat,
like cooking, still need adult supervision. What
about water safety? They're becoming stronger
swimmers. But supervision is still the number
one rule. Never swim alone. Ever. And they need
to be taught never to dive into water if they
don't know how deep it is. That's a huge risk
for spinal cord injuries. And parents need to
know CPR. OK, and then the big two that require
locking things up? Toxins and firearms. Right.
All poisons, chemicals, cleaning supplies need
to be in a locked cabinet. And for firearms,
the teaching has to be incredibly specific and
direct. It's a rule. The firearms and the ammunition
must be stored separately, and both must be in
locked containers. And you teach the child a
very simple concrete rule. If you see a gun,
you do not touch it. You leave the area, you
find an adult immediately. No ambiguity there.
None in. Let's shift to the modern risks. The
screen is their new playground. It is, and it's
where they go to find social connection and a
sense of competence, so we have to manage it.
Parents need to set firm time limits and monitor
the content. And a huge safety tip. Keep computers
and gaming consoles in a common area of the house.
Not in the bedroom. Not in the bedroom where
supervision is impossible. And what are the key
internet safety rules you teach? Never. Ever
share personal information, your full name, your
school, your address. Never agree to meet someone
in person that you've only met online. And teach
them that if a message ever makes them feel weird
or sad or scared, they show an adult right away.
OK, and let's end with the two major psychosocial
risks that just devastated child's sense of industry,
abuse and bullying. These have to be part of
every single nursing assessment. For abuse, you're
looking for injuries that don't match the story
or big behavioral changes like a child who suddenly
starts wetting the bed again or refusing to go
to school. And bullying. It's the ultimate attack
on their competence. It is. Bullying, whether
it's physical or verbal or online, it's designed
to make the victim feel worthless. It is the
direct cause of inferiority for so many kids.
It can lead to anxiety, depression, a total withdrawal
from the world. So how do you screen for it when
they're often too ashamed to talk about it? You
have to ask directly, but gently. How are things
at school? Who do you sit with at lunch? Is anyone
ever mean to you? And you have to screen both
ways. It's important to remember that the child
who is doing the bullying is often also struggling
with feelings of inferiority and is trying to
feel powerful. They need help, too. That brings
us all full circle. OK, let's wrap up this vital
section. What nurses watch for? You're looking
for patterns, frequent injuries, unexplained
behavioral changes, lying, stealing, school refusal.
These are often signs of a deeper stressor, like
bullying or abuse that is crushing their sense
of industry. And what exam writers love to test.
The car safety rules. They will test you on that
4 '9 height requirement and the backseat until
13 rule. And they love scenarios that force you
to connect the child's growing independence with
their growing risk for accidents. And finally,
one easy way to remember this age group's safety
needs. Their confidence is growing, but their
judgment isn't. So safety is about protecting
them from that gap. Think of it as keeping them
safe. screening for bullying, activity matched
to ability, firearm safety, and the elevation
rule for car seats four foot nine. Hashtag tag
outro. So that was our deep dive into the school
-age child. We've really tried to frame this
whole era through that critical lens of industry
versus inferiority because that drive for competence
explains so much of their behavior. Right. We
saw that their bodies are actually slowing down
and becoming more efficient. That means a lower
heart rate, lower respiratory rate, but a climbing
blood pressure. And don't forget that key milestone.
The immune system matures around age 10. And
developmentally, their mind is making huge leaps.
They're in that concrete operational stage, which
means they can think logically, they've mastered
conservation, but they still can't grasp those
big abstract ideas about the future. So remember
those high yield screening areas for your practice.
You absolutely have to screen for vision problems
like amblyopia. You have to assess for psychosocial
issues like bullying. And please hammer home
that four foot nine rule for car safety. And
just as a final clinical pearl, remember how
powerful that drive for industry is. When you
have a school -aged child as a patient, make
them a partner. Give them a job to do no matter
how small. It's not just a distraction. It's
about preserving their fundamental sense of self
-worth while they're sick. And that leads us
to our final thought for you to take with you.
We know this age group can understand rules and
immediate consequences because of their concrete
thinking. As nurses, so often we teach by just
giving orders, you need to do this. But given
their intense desire for industry, for mastery,
for being part of the team, how can we change
that? How can we leverage that new logical brain
to engage them in real shared decision making,
especially with things like managing a chronic
illness, moving beyond just telling them what
to do to building a partnership based on competence?
What new doors does this era of industry really
open for your nursing practice? That's a great
question to think about as you head to the bedside.
Thanks for diving deep with us. See you next
time.