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


Six-Year Visit (School Readiness)

Pamela Meador Nickell

ADD, 314

Night terrors, 307.46


ADHD, 314.01

Nightmares, 307.47


Behavioral problems, 312.9

School phobia, 300.23


Bowel incontinence, 787.6

Urinary incontinence, 788.39


Emotional immaturity, 300.9



A. Six-year old will be attending school perhaps for first time and is quite excited about it. The 6-year old is becoming much more independent.


A. Caloric and nutrient needs.

1. 90 kcal/kg/day divided into three meals with two nutritious snacks.

2. Limit junk food, nonnutritious foods.

3. Refer to My Plate for serving size, food group recommendations (see Appendix E).

4. Encourage family meals as often as possible.

B. Oral hygiene.

1. Semiannual dental visits.

2. Regular tooth brushing twice/day.

3. Fluoride supplement in diet or drinking water (see Appendix B).

4. Discourage thumb sucking.


A. Most 6-year olds are toilet trained but may have occasional accidents.

B. Frequency of bowel movements varies. Obtain parental input for what is normal for child; 1-3 times/day to 1 time every 2-3 days is acceptable.

C. Normal urine volume should be similar to adult: 650-1500 mL/day.

D. Urination frequency approximately 5-6 times/day.

E. Approximately 5-7% have problematic enuresis.

F. Occasional incontinence due to miscues/deep sleep not uncommon.


A. 8-12 hours/night.

B. Encourage consistent bedtime routine.

C. Occasional nightmares are normal.

D. Night terrors/sleepwalking may emerge.


A. Average weight gain/year: 1.8-2.7 kg (4-6 lbs) for both boys and girls.

B. Average linear growth/year: 5 cm for both boys and girls.

C. Well-established vocabulary.

D. Can follow three-step directions.

E. Moving from magical thinking to concrete operations.

F. Mastered skills:

1. Personal.

a. Independent in dressing, hygiene; feeds self, monitoring only as needed.

b. Can recite address, phone number.

2. Fine motor.

a. Can draw/copy shapes.

b. Can draw a man with 6 parts.

c. Can print some letters, numbers.

3. Language.

a. Can articulate needs but semantics may be incorrect.

b. Recognizes most letters of alphabet.

c. Can define at least 7 words.

d. Can identify some opposites.

4. Gross motor.

a. Can balance on each foot for 6 seconds.

b. Can heel-toe walk forward and backward.

c. Rides tricycle without problems.


A. The child is beginning to move from family relationships as primary focus to peer relationships as primary focus.

B. Continues to use play to develop skills, competencies, and learn about his world.

C. Social cooperation, morality, critical thinking, and self-concept are developing.

D. Demonstrates cooperative play.

E. Team/group activities encouraged (arts programs, organized clubs/sports, etc.); regular exercise encouraged.

F. Making friends is primary social goal; developing “best friends.”

G. Developing conflict resolution skills.


A. Recommended:

1. DTaP #5 if not done previously.

2. IPV #4 if not done previously.

3. MMR #2 if not done previously.

4. PPD #1 if not done previously.

5. Varicella.

6. Influenza annually.

B. Catch-up.

1. Hepatitis B series.

2. Varicella.

3. Pneumococcal vaccine.

4. MMR.

5. DTaP.

C. High-risk children.

1. Influenza (yearly).

2. Hepatitis A series.

3. Pneumococcal pneumonia vaccine.

4. PPD (yearly).

5. Meningococcal.


A. Motor vehicle.

1. Consistent use of appropriate safety restraints in motor vehicles.

2. Knows appropriate pedestrian safety rules.

3. Riding a motorcycle is discouraged. However, consistent helmet use when passenger on motorcycle.

B. Sports/recreation.

1. Consistent use of appropriate protective equipment for all activities (biking, rollerblading, sports, boating, etc.).

2. Ensure appropriate safety instruction provided for all activities.

3. Obtain swim lessons.

4. Ensure safety of sports/play areas and proper supervision provided.

5. Use sunscreen of SPF 15 or higher.

6. Discourage use of mini-bikes and ATVs.

C. Household.

1. Never leave child without appropriate supervision.

2. Teach appliance safety and monitor use.

3. Teach hazardous materials/medication safety. Keep out of reach and monitor use.

4. Teach fire safety. Develop family plan.

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

D. Social.

1. Teach phone number, address.

2. Teach use of 911.

3. Teach stranger safety.

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


A. Preventive care.

1. Annual physical.

2. Semiannual dental visits.

3. Immunizations on schedule.

B. Home.

1. Establish family rules and remain consistent in enforcement.

2. Avoid corporal punishment for breaking rules.

3. Limit TV viewing to 1 hour/day.

4. Enforce good personal hygiene.

5. Avoid punishment for urinary or bowel incontinence.

6. Encourage family meals.

7. Encourage continued reading to and with child.

8. If parents work, ensure appropriate, safe supervision is provided before and after school.

9. Encourage responsibility for age-appropriate chores.

10. Develop fire safety plan for home.

C. Family/community.

1. Encourage and praise school activity, accomplishments.

2. Encourage socialization with peer groups in organized and unorganized activities.

3. Encourage consistent exercise; ensure proper supervision for all activities.

4. Discourage “hurried child syndrome”; no more than 1-2 activities/week.

5. Reinforce school/bus rules; encourage parents to become actively involved in school/community parent groups.

6. Encourage parents to teach/model moral behavior, good citizenship (“Do unto others as you would have them do unto you.”).

D. Safety.

1. Ensure proper motor vehicle restraints consistently used.

2. Encourage swim lessons.

3. Reinforce proper bicycle use, rules, and use of helmet.

4. Reinforce use of proper safety equipment for all activities including sunscreen SPF 15 or higher applied 30 minutes before going outdoors.

5. Reinforce proper pedestrian rules.

6. Reinforce proper gun safety and storing of ammunition separately.

7. Reinforce “good touch/bad touch” concepts.

8. Teach “just say no” concepts.

9. Reinforce how to use telephone to call 911 in an emergency.

10. Ensure child knows address and phone number.

11. Reinforce age-appropriate child-proofing in residence and use of smoke detectors.

12 Reinforce fire safety; ensure family has plan for evacuation.

13. Don't leave child without proper supervision.

14. Discourage mini-bike and ATV use.


A. Physical readiness.

1. Has met developmental milestones in cognitive, gross and fine motor areas.

2. Cognitive, visual, hearing deficits addressed.

B. Emotional readiness.

1. Able to separate easily from parent.

2. Dresses without supervision.

3. Toilet trained.

4. Follows instructions.

C. Screening and assessment tools.

1. Physical exam including full neurologic evaluation.

2. Vision and hearing screening.

3. Developmental testing (draw a man and Denver II recommended for ease of administration).

D. Anticipatory guidance.

1. Encourage and reinforce positive parental attitudes regarding school.

2. Prepare parent and child for separation, change in routine.

3. Have parent obtain list of school/classroom rules and review.

4. Have parent tour school and meet teacher prior to first day of school.

5. Prepare parent for child's potential fear/anxiety.

6. Prepare family to advocate for child in positive, supportive manner.

E. Potential concerns.

1. School phobia.

2. Lack of expected intellectual ability/progress.


4. Emotional immaturity.

5. Behavioral problems related to classroom.


Burns CE, et al. Pediatric Primary Care: A Handbook for Nurse Practitioners. 4th ed. Philadelphia, PA: W.B. Saunders; 2009.

Dixon SD, Stein MT. Encounters with Children: Pediatric Behavior and Development. 4th ed. 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.

Pulcini J. Assessing school readiness. In: Fox J, ed. Primary Health Care of Infants, Children and Adolescents. 2nd ed. St. Louis: Mosby; 2002.

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