NU 352 The Adolescent

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1

What are the ages of adolescence? What are the major changes of the adolescent period?

Because it’s a transition period, it can begin anywhere from 11-12 and end from 18-21.

Adolescence begins with the development of secondary sex characteristics.

Early-11-14y/o: Primary physical changes, boys develop slower than girls, like to compare themselves with their peers instead of family, don’t like to be different from peers

Middle-15-17 y/o: Major changes of puberty are complete during this period. They still are struggling with the changes to their body. By this time frame, the adolescent should have a strong ID with a peer group.

Late-18-21 y/o: Starts to take on adult roles and relationships. Usually have selected a partner, may have decided on a career path or have a job. By 20 years old, they should have reached physical and sexual maturity. More emotionally stable, more sophisticated reasoning.

2

What are the major biologic developments that take place during adolescence?

Puberty: secondary sex characteristics, most important one. Secondary changes are related to hormonal processes in the body, not reproductive organs. Facial hair, sebaceous glands, voice changes, breast development (in both male and female), pubic hair, fat deposits.

Hormones: estrogen (feminizing hormone) and testosterone (masculinizing hormone). Before puberty, both male and female have equal amounts of both hormones. During puberty, estrogen rises in the female and testosterone rises in the male.

Physical Growth: 9-14 in the girl, 10-16 in the boy for growth spurts. Things do not grow proportionally.

Hypertrophy of laryngeal mucosa: Both girls and boys have voice changes. Girl’s will deepen slightly and become more fuller. Boys will deepen a lot more.

Breasts: Both girls and boys. Boys’ is just temporary.

Sebaceous glands: Start getting an odor and acne especially on face and shoulders.

Hair: Pubic for M and F. Facial hair on M.

Heart rate decreases to adult level

BP increases to adult level

VS more adult like

Lab values adult

3

What is Erikson's psychosocial developmental stage for the adolescent? What does this imply about their development in this stage?

Identity vs Role Confusion

Who am I? Who can I be?

Develop a sense of themselves and see themselves as distinct individuals.

Group identity: fear being different than peer group. They like to latch on to a group of people who have similar interests. Usually they like similar things, dress similarly, have similar hair styles.

Individual identity: self concept, personal concept of who you are and what makes you different

Sex role identity: expectations from both peers and adults in their life

Emotionality: mature and childish, unpredictable mood; improves with age. They’re like a big kid. They want to be separate from parents but they’re not great with that responsibility all the time

4

What is Piaget's cognitive developmental stage for the adolescent? What does this imply about the adolescent's cognitive ability?

Formal Operational Thought – last stage of cognitive development.

The adolescent is capable of mature abstract thought. They can think beyond the present and they know about consequences. Usually beings around 11-14. Have more abstract thinking that lets them think of different possibilities.

5

What experiences are anticipated social developments in the adolescents?

Parents: No longer the protectors, typically go through a period of rebellion, want to move away from authority, but in the end move to a period of mutual respect and relationship. The parent becomes a support person.

Peer Groups: Cliques are usually within a peer group, a more intimate group that is usually of the same sex.

Schools: Things that affect school quality: Lack of parent support, large class size, large number of uncertified teachers, stressful environment, moving frequently can have an impact on social and school development.

Work: Many teenagers have to work, can influence social development

Sexuality: Best friend to intimate friend, influenced by all the changes (social, physical, and cognitive) going on.

Sexuality identity: Puberty starts this ball rolling, Usually during teenage years, the child starts a period of sexual identity. They form a pattern of attraction to a certain gender. Intimacy is not necessarily sexually active. Lots of way to be intimate that do not include sexual intimacy. More of an emotional attachment.

Sexual developmental milestones: Usually should be able to have some type of sexual ID or sexual orientation, should be in an intimate, committed sexual relationship,

Average age to have sexual intercourse is 17.

6

What are the stages of male puberty in order?

Enlargement of testicles

Pubic hair growth

Rapid increase in height

Voice changes and growth of penis

Nocturnal emissions “wet dreams”

Abrupt deceleration of linear growth

Usually should be started by age 14, if not see an endocrinologist

7

What are Tanner's Stages of sexual maturation for the male?

Stage 2 : First s/s of puberty

(9 ½ -14 y/o)

Testes enlargement

Scrotal skin – thinner and red looking, kind of loose

Fuzz – fine scant light-colored hair, facial peach fuzz

Muscles – become more developed

Voice – may hear a cracking sound

Stage 3

Penis enlargement, usually gets longer

Testes & scrotum – also enlarge

Hair – becoming darker and a little bit more abundant, more curly too.

Voice – Deepening of the voice

Stage 4

Penis – Becomes wider in this stage

Scrotum - Darker

Hair – much more abundant, also have downy facial hair and under arm hair

Growth velocity – begins to slow down

Stage 5-Complete

Penis & scrotum and testicles – Adult size and shape

Pubic Hair – Begins to spread to abdomen and thighs

Height – Usually by age 18-20, you’ve reached adult height

Voice – Permanent voice change

The whole process takes about 3 years

8

What are the principles of nutrition in the adolescent?

Rapid growth and high metabolism

Need additional calcium, iron and zinc: Ca helps develop bone growth, also develop Ca stores so you don’t get osteoporosis. Iron helps muscle mass development. Zinc helps with bone development. Sources: Cashews, shellfish, oysters, wheat germ, beans.

Overeating and under eating: Sets up for obesity later in life, chronic health problems like hyperlipidemia, HTN. Bc of peer and body image issues, girls are more likely to under eat during adolescence which can lead to long-term health problems. Need calories based on activity level. Recent recommendations to treat obesity is to reduce saturated fats ( no more than 25-30% of total calories), reduce added sugar (sports drinks, sodas), and avoid trans fats. Girls need extra iron bc of menstruation.

9

What are the principles of body art in the adolescent?

25% of adolescence and young adults have tattoos and body piercings

Why do adolescents get tattoos? Peers have them and a sense of pulling away from parents/claiming the body as their own. Tend to be impulsive especially when with peer group. Doesn’t think about the future consequences of actions.

Source of infection – using dirty, contaminated instruments, not caring for the wound at home, can affect your future lifestyle (getting a boyfriend’s name). Most common infections from tattoos and peircings are endocarditis (inflammation of the heart), hep B,C, and HIV.

Affect on future lifestyle

10

What are the health risks of the adolescent?

Health-damaging behaviors: Impulsive actions with peer group, alcohol and drugs

Morbidity/Mortality: MVAs, drinking and driving

11

What are the testicular problems that may afflict an adolescent?

Testicular self-exams should be performed monthly after a bath or warm shower. Typically those who are 20-34 are at most risk.

Testicular Cancer: Usually presents as a hard, heavy presence on one side of the testes. In 40% of cases, this mass is painful. Can be smooth or nodular. Will not transluminate. One testicle may appear to hang lower than the other. Treatment is surgery first, chemo and radiation if metastasized to the lymph nodes.

Inguinal Hernia: Some type of abdominal tissue is coming through the inguinal canal. Usually this can be bowel. The hernia can become strangulated, cut off blood supply, and cause bowel necrosis. Often it’s bilateral. Treatment is usually surgical closure. If the bowel is strangulated, they’ll do a resection. After surgery, there is a good bit of scrotal swelling, the men have to wear something to support. Do not cough, deep breath. Don’t lift heavy things after surgery for 4-6 weeks.

Testicular Torsion: It is a surgical emergency – the testicle rotates itself around and cuts off the blood supply. Risk for engorgement and ischemia. Boys younger than 25 are at risk. Intense pain, redness and swelling of the scrotum. Must have surgery within 6 hours to prevent tissue damage or necrosis. If after 6 hours, they have to remove it. Called orcheopexy. If it’s caught in time, fertility is not affected. If the testicle is removed, it will affect fertility. No heavy lifting for 4-6 weeks and no sports for 2 weeks.

12

What are the principles of acne?

Chronic inflammatory disorder

Caused by: androgens trigger the sebaceous glands to secrete sebum (oil)

Comedones

Propionibacterium acnes

Papules and pustules

13

What are the triggers for acne?

Premenstrual flares

Cosmetics

Cooking grease

No known association with stress or diet

14

What are the medications for acne?

Topical retinoids: tretinoin

Benzoyl Peroxide

Antibiotics

Oral contraceptives

Isotretinoin (Accutane):

Only for most severe: teratogenous. Will cause premature birth.

iPLEDGE: Can only be prescribed by doctors who’ve completed a certification program.

Because of Accutane's teratogenicity & to minimize fetal exposure, Accutane is approved for marketing only under a special restricted distribution program approved by FDA.

Must be on two forms of birth control. Have to take birth control fom one month before starting the drug and cannot get pregnant until one month after stopping the drug.

If you have unprotected sex or if you have a late period, stop the drug immediately and go to the doctor.

15

What are the characteristics of cystic fibrosis?

Most common pediatric deadly condition, affects mostly caucasian.

Autosommal recessive type.

Lethal genetic multisystem disease

However, improved life-expectancy

Pathomade simple: OBSTRUCTION from excessive mucus

Life-expectancy: 37+ yrs

Bc of abnormal mucus production. Produced in every organ, resp system, digestive system, and reproductive system.

Going to have chronic obstructive problems and chronic pneumonia bc the mucus helps bacteria get stuck in the lungs where it grows and festers. Children are on chronic steroid use which immunosuppresses them.

16

What are the s/s of CF?

One of the first symptoms in a newborn with CF is a meconium ileus. 10% of newborns will have that. Also see rectal prolapse in these kids. They are not able to absorb a lot of nutrition and lack pancreatic enzymes to digest certain foods (amylase and lipase). Also insulin deficiency, at risk for diabetes. They have very fatty, bad smelling stools that float in the toilet.

The reproductive system is affected. Decreased functioning sperm counts, cervical mucus build-up can prevent pregnancy. Typically fertility is an issue for both men and women.

Typically shorter, thinner, and malnourished appearing. Will have FTT and chronic resp infections. Diarrhea and constipation.

17

What are the diagnostics for CF?

Diagnostic tests – Sweat-chloride test: Put electrodes on your arm and stimulate the sweat glands to sweat. Collect it on a filter paper and examine it. Looking for how much chloride is in the sweat. Over 60 is a diagnostic for CF. 40 is normal.

Screening – This is part of routine newborn screening in 29 states.

Benefits – Best if diagnosed early bc you can start treating. Start enzymes, start nebulizers to prevent long-term damage and scarring.

18

What are the key nursing management principles of CF?

Prevention of complications – Best if we can prevent by meds, nebulizers, and enzymes.

Pulmonary: Frequent nebulizers of bronchodilators, steroids, and Hypersal-high-concentrate sodium. A lot of the day is spent on nebulizers. Some children are on long-term antibiotics that get changed all the time bc the bacteria get resistant.

GI: Must take enzyme supplements within 30 min of each meal or snack. For infants, you sprinkle the enzyme the food. Judge the amount of enzymes by how much you’re gaiing weigh and your stools. High protein, high calorie diet. Need to take supplemental fat-soluble vitamins. Extra salt in the diet.

Assessment: Priority is respiratory, next is GI.

Testing – Not only diagnostic, but they undergo routine testing like pulmonary function, x-rays, etc. Best if you live next to a pulmonary center or a regional CF center to see all specialists.

Home care: Many of these kids have central lines, home antibiotics, kind of like a home hospital at a CF patient’s house.

19

How is scoliosis classified?

Structural scoliosis

Idiopathic is no known reason and is the most common. Seen in girls especially during their growth spurt from 10-13 years old.

Compensatory has a pathologic cause.

Causes: congenital, idiopathic, or acquired

20

What are the symptoms, diagnosis, and treatments for scoliosis?

Symptoms:

  • Truncal asymmetry
  • Uneven shoulder and hip height
  • One sided rib hump
  • Prominent scapula

Diagnosed by: physical exam and x-ray

Treatment depends on degree of curvature

-Mild scoliosis: 10-20 degrees: exercise, re-evaluate in 3 months

-Moderate scoliosis: 20-40 degree curvature

Boston brace: Prevents it from getting any worse. Maintain the current curvature. Can remove it for bathing only.

-Severe scoliosis: 40-50 degrees: surgery and orthotics. Will do a spinal fusion and wear the brace afterwards.

Post-op care:

  • Pain control and PCA
  • Respiratory problems due to hypoventilation
  • Neurovascular checks on all extremities q2h for first 24 h.

Discharge teaching: no lifting, bending or twisting at waist or sports for 6-8 months, meticulous skin care, teach the log roll, extensive PT

Screening – Usually done by the school nurse. Will make referrals to a primary care physician who will make a referral to an ortho doc.

21

What are the dangers of e-cigarettes?

Adolescents are using e-cigs 3x more than the other population. The message is that e-cigs are safer. E-cigs are a gateway drug to other drugs and alcohol. It still gets you addicted to nicotine.

22

What is Kawasaki Disease? What are the symptoms, diagnosis, and treatment?

Mucocutaneous Lymph Node Syndrome: Acute vasculitis, inflammation of the vessels. Very common in toddlers. 75% of cases occur in children under 5.

Most cases late winter and early spring

Symptoms:

  • Extensive inflammation
  • Changes in extremities: redness of extremities especially the hands and feet.
  • Bilateral conjunctivitis
  • Polymorphous rash
  • Cervical lymph node enlargement

Usually self-limiting (goes away w/o treatment). 20% of those who do not receive treatment will have coronary artery aneurysms and dilation of the arteries.Treatment for severe disease is high dose IVGG, a blood product that helps suppress whatever is causing the disease.

No diagnosis for it. Diagnosed by symptoms.

23

What are the stages of Kawasaki and the symptoms associated with disease in children?

3 stages:

Acute stage: high fever can last a long time, very irritable

Subacute: resolution of fever, other symptoms resolve, remains irritable

Convalescent stage: lab values remain abnormal

Whole illness can take anywhere from 6-8 weeks

MI symptoms in children

  • Abdominal pain
  • Vomiting
  • Restlessness
  • Inconsolable crying
  • Pallor
  • Shock
  • Chest pain and pressure
24

What are appropriate nursing interventions for Kawasaki disease?

Monitor cardiac status

Monitor of signs of heart failure: Decreased urine output, galloped rhythm, resp distress, tachycardia.

Administer IVIG: blood product- assess for blood reactions

Mouth care

Fever – monitor and treat, offer clear liquids, soft cool foods.

Irritability: Could use distraction, calming environment, lessened noise and light, offer respite and assistance for the parents

25

What should a nurse teach on discharge for the Kawasaki patient?

Progression of disease: periungal desquamation (the fingers and feet peel at the end of the disease, the skin underneath is tender), arthritis of joints (ROM, hot baths)

Defer live viruses for 11 months after –MMRI, Variella

Teach CPR, signs of MI – They are at risk for MI: Abdominal pain, vomiting, restlessness, inconsolable crying, pallor, shock, chest pain and pressure.

Long term anticoagulation therapy

Need for follow-up

26

What are the risk factors for teen pregnancy? What might make teen pregnancy desirable?

Risk factors: Single parent homes, older boyfriends, peer pressure, drinking and drug abuse, early puberty, mom was a teen parent, early puberty, dating at an early age, lack of parent-child communication, lack of future goals, poverty

What are the reasons a teenager may choose to become pregnant?: Want the boyfriend to stay/marking territory, need love, peer pressure, pressure from the boyfriend, money from the government, attention, Latino culture, social media/TV glamorization.

27

What are some outcomes of teen pregnancy?

Psychosocial issues, depression from social isolation, no future (high school dropout rate is high), preterm labor, premature birth.

28

What are some appropriate nursing interventions for preventing teen pregnancy?

For preventing pregnancy: Ensure confidentiality, remain unbiased and un-judgmental, ask about goals and discuss the impact of teenage pregnancy on those goals, be knowledgeable of different types of birth control and STD protection.