Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.


Three-Year Visit (Preschool)

Betsy Atkinson Joyce

Night terrors, 307.46


Nightmares, 307.47



A. Preschooler can behave one moment and want to please the parent, but can also be unreasonable and resistant to being examined.

B. Pay attention to evidence of tooth cavities, eye alignment, evidence of bruising or other injuries that may indicate neglect, inadequate supervision, or abuse.


A. Needs 1000-1100 calories/day or 100 kcal/kg/day.

B. Three small meals, 2 snacks, 16-24 oz of milk.

C. Seven grains, 3 vegetables, 2 fruits, 2 meats.

D. Eats with a fork or spoon.


A. Toilet trained for daytime, occasional accidents.

B. Regular pattern for bowel movements.


A. Requires 10-12 hours of sleep a night.

B. One nap/day (usually).

C. Arouses several times a night.

D. May have night terrors or nightmares.

1. Night terrors: occur early after going to bed.

a. Partial arousal from very deep sleep, screams, thrashes during the terror, returns to sleep without fully awakening.

b. Will have no memory of incident in morning.

2. Nightmares: occur usually during the second half of night.

a. Scary dream followed by complete awakening, crying and fearful after awakening; parent should reassure child.

b. May have trouble falling back to sleep.

c. Remembers and may talk about it in the morning.


A. Continues to follow individual growth chart curve.

B. Pelvis straightens.

C. Graceful and agile with good posture.

D. Physical.

1. Height: grows 2-4 in./year.

2. Weight: gains 4-6 lbs.

3. Head: grows about 1 in./year.

4. Blood pressure averages 100/60.

5. Heart rate range is 73-137.

6. Respiratory rate approximately 22-25.

7. Twenty primary teeth; growth is mainly under the gums.

E. Gross motor.

1. Alternates feet when going up stairs.

2. Rides tricycle.

3. Dresses self, may need help with buttons.

4. Puts on shoes.

5. Climbs, jumps, hops.

F. Fine motor.

1. Holds crayon with fingers.

2. Copies circle and cross.

3. Draws a person with two body parts.

G.  Language.

1. Approximately 900 words by age 3; up to 1500 by age 4.

2. 85-90 of speech understandable by people outside the family.

3. Knows name, gender, age.

4. Longer sentences; puts 2-3 sentences together.

5. Uses plurals, pronouns, some prepositions (under, on, in, out).

6. Understands concepts of big/little, up/down.

7. Can tell you some colors

8. Can name a friend


A. Can separate easily from parents if they want to.

B. Can take turns.

C. Helps with simple chores.

D. Needs other children to play with in order to learn socialization.

E. Discipline method: continue with time out.


A. No scheduled immunizations at this visit.

B. Check for currency, only need if immunizations were delayed or new vaccines have come out since 2.5-year visit.


A. Share meals as family if possible, but otherwise child should eat first and get down from table.

B. Do not get in food fights. Offer food; if does not eat, child gets down and no food or milk until next meal.

C. Improve (if necessary) nutritional quality of meals and snacks; limit fast food to less than once a week.

D. Promote toilet training if not already accomplished.

E. Limit TV viewing to 1-2 hours/day.

F. Promote active play. Indoor: have imagination station with safe, active toys; outdoor: play with balls, jump ropes, games, etc.

G. Consistent discipline: use as a way to learn rules, not just punishment; set limits, because if child knows limits, she/he can relax.

H. Find ways to praise child.

I. Encourage choices; link with consequences.

J. Realize need for constant vigilance, supervision, patience.

K. Safety-proof house (if not already done); reinforce safety issues.

L. Use car seat. Continue to keep in backseat of car.

M. Practice water safety.

N. Use sunscreen of SPF 15 or higher.

O. Wear helmet when riding tricycles, scooters, or other toys with wheels.

P. Teach gun safety. Keep guns out of reach, locked, unloaded. Store ammunition and guns separately.

Q. Teach about “good touch/bad touch.”

R. Promote dental health; visits to the dentist and brushing 2 times a day.


Berkowitz, CD. Berkowitz's Pediatrics: A Primary Care Approach. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Burns CE, Brady MA, Dunn AM, et al., eds. Pediatric Primary Care. 4th ed. Philadelphia, PA: Elsevier Health Sciences; 2008.

Dixon SD, Stein MT. Encounters with Children: Pediatric Behavior and Development. St. Louis, MO: Mosby; 2006.

Hagan JF, Shaw JS, Duncan P, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Kleinman RE, ed. Pediatric Nutrition Handbook. 6th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Polen EU, Taylor DR. Journey Across the Life Span: Human Development and Health Promotion. Philadelphia: F.A. Davis; 2007.

Puckett, MB. et al. The Young Child: Development from Prebirth Through Age Eight. 5th ed. Upper Saddle River, NJ: Prentice Hall; 2008.

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