Promoting Optimum Growth and Development in Adolescents and Families

1. Chapter 19 Health Promotion of the Adolescent and Family

2. PROMOTING OPTIMUM GROWTH AND DEVELOPMENT • Complex interplay of biologic, cognitive, psychologic, and social change, perhaps more so than at any other time of life • Change on multiple levels • Biologic maturation • Cognitive development • Psychologic development

3. Misguided Views of Adolescence • Raging hormones determine behaviors • Risky and misguided behavior is the norm

4. Adolescence • Early—ages 11 to 14 • Middle—ages 15 to 17 • Late—ages 18 to 20 • See chart Table 19-1 p. 740 (9th ed) p. 652 (10th ed)

5. Biologic Development • Neuroendocrine events of puberty • Gonadotropin releasing hormone (GnRH) from the hypothalamus • See diagram on next slide.

6. Hormonal Interaction Between Hypothalamus, Pituitary, and Gonads

7. Changes in Reproductive Hormones • Females • Thelarche • Menarche • Ovulation • Males • Testicular enlargement • Increasing muscularity & voice changes • Gynecomastia—resolves within 2 yrs • Penile enlargement & ejaculation

8. Pubertal Sexual Maturation • Tanner stages 1 through 5 —pp. 742-743 9th ed. pp. 654-657 10 ed. • Sequence is predictable--know • Age of occurrence varies • Average age of menarche in United States • 12.55 years for Caucasian • 12.06 years for African-American • 12.25 years for Mexican-American

9. Physiologic Growth During Puberty • Pubertal growth spurt—increase in growth of skeletal muscles and internal organs • BOYS:14 years • GIRLS: 12 years-[generally 1 ½ -2 years before boys] • Gains in growth • Final 20% to 25% of linear growth • Up to 50% of ideal adult body weight

10. Pubertal Changes in Boys http://www.kalwnews.org/audio/2011/12/01/reducing-nurses-stress-pays-kaiser-patients_1488191.html

11. Pubertal Changes in Girls vs Boys http://www.merckmanuals.com/home/childrens_health_issues/adolescents/physical_and_sexual_development.html.

12. Physiologic Changes • Heart, blood volume, and systolic BP increase in size and strength • Heart rate decreases • Respiratory vital capacity increases • Change in BMR

13. COGNITIVE DEVELOPMENT

14. Piaget: Emergence of Formal Operational Thought • Formal operational thinking—ages 11 to 14 • Abstract terms, possibilities, and hypotheses • Decision-making abilities increase • May not use formal operational thought and reasoned decision making all the time— “choices”

15. Adolescent Conceptions of Self • Adolescent egocentrism • Self-absorption • Health-related beliefs • Imaginary audience (everyone is watching) • Personal fable (won’t happen to me)

16. Changes in Social Cognition • Understanding of others’ thoughts and feelings • Mutual role taking • Effect on health-related choices

17. Development of Value Autonomy • Struggle to clarify values • Development of a personal value system • Gradual process in late adolescence

18. Moral Development • Parallels advances in reasoning and social cognition • Conventional level of moral reasoning--absolute moral guidelines are seen to emanate from authorities such as parents and teachers. • Principled moral reasoning—adolescents question absolutes and rules and view moral standards as subjective and based on points of view that are subject to disagreement (p747 9th ed., p. 660 10th ed.)

19. Spiritual Development • Religious beliefs may become more abstract during adolescence • Late adolescents may reexamine and reevaluate beliefs and values of their childhood

20. Psychosocial Development

21. Identity Development • Social forces shape sense of self—adolescents may move through these phases in different sequences • Identity achievement—establishing a coherent identity after exploring options • “Moratorium”—currently engaged in exploration of identity options • “Foreclosure”—making identity commitments without exploring and experimenting • “Diffusion”—lack of firm identity commitments

22. Development of Autonomy • Emotional autonomy—beginning to become > separated from parents, < separated from friends • Cognitive autonomy—ability to think for yourself • Behavioral autonomy—ability to turn to others for advice when appropriate, weigh alternatives, & reach an independent conclusion; making your own choices rather than comforming

23. Achievement • Development of motives, capabilities, interests, and behaviors • Progress toward occupational achievement • Relationship between social class and educational and occupational achievement

24. Sexuality • Hormonal, physical, cognitive, and social changes affect sexual development • Body image • Sexual identity—experimenting with sex, developing more intimate friendships • 9th grade: 38% of boys and 27% of girls report having had sexual intercourse • 12th grade: 62% of boys and 68% of girls • > masturbation among boys than girls • Sexual orientation—involves several dimensions including attraction, fantasy, actual sexual behavior, self-labeling or group affiliation

25. Intimacy • Intimate relationship begins to emerge in adolescence—NOT necessarily sexual in nature • Developmental course of intimacy • Self-focused—meeting personal needs • Role-focused—more concerned with conforming to appropriate roles and norms of relationship • Individual-connected—more intimate relationships that acknowledge the complexity and contradictions in close relationships

26. Social Environments • Ecologic model: • Microsystems—most proximal social context • Family, peer groups, school, workplace • Mesosystems—formed by linkages between microsystems • Exosystems—settings that influence adolescent behavior & development • Macrosystems—culturally-based belief systems & economic & political systems • Can have profound effect on health-related behaviors & development • All are intertwined and to effect health, nurses must look at all these systems.

27. Families • Changes in family structure and parent employment • Family structures vary greatly! • Parenting styles • Effective conflict resolution and family cohesion contribute to healthy adolescent behaviors • Socioeconomic influences

28. Peer Groups • Significance in socialization—can be an asset or a detriment • Significance in development—strongly influenced by socioeconomic factors, family strengths and weaknesses • Value placed on peer relationships—influence of peer relationships is individual, but highly influenced by family support, and social support.

29. The Peer Group Influences Adolescent Development

30. Schools • Play increasingly important role in preparation for adulthood • Parental involvement in schools • Effect of academic success or failure on self-esteem

31. Work • Workplace as fourth microsystem • Positive or negative • May encourage development of intellectual and social skills, autonomy • May result in decreased interest in school, fewer extracurricular activities, and poorer grades

32. Technology as a Social Environment • Internet chatrooms and social networking sites have created “virtual” communities • Try out identities and interpersonal skills with wider network of people • Anonymity • Risks Sexting chat rooms

33. Community and Society • Media influences • Availability of alcohol, tobacco, sexuality, violence in TV, movies, video games, etc. • Community’s economic resources play role in health and well-being of young people • High employment vs unemployment as well as socioeconomic status affect behaviors and outlook • Resources for health promotion • Influence quality of local schools and health-related services

34. PROMOTING OPTIMUM HEALTH DURING ADOLESCENCE • Empowering individuals, families, and communities • Power, authority, and opportunities to make healthy choices • Risk reduction in areas of mental health, substance use, sexual behavior, violence, unintentional injury, nutrition, physical activity and fitness, and oral health • Causes of 75% of adolescent death: injuries, homicide, and suicide

35. Adolescents’ Perspectives on Health • Factors promoting adolescent health and well-being • Contexts for adolescent health promotion • School-based and school-linked health services • Adolescent health screening • “SAFE TIMES”: method for screening interviews with teens (p. 761, 9th ed.) • Nursing Care Guidelines: Interviewing Adolescents (p. 672, 10th ed) • Confidentiality is essential • State laws have changed since 2001 to require notification of parents for a variety of health care services

36. Health Concerns of Adolescence • Parenting and family adjustment • Psychosocial adjustment • Intentional and unintentional injury • Dietary habits, eating disorders, and obesity • Physical fitness

37. Nursing Implications • Following AAP recommendations (2007): • Assess Ht and Wt annually along with BMI • BMI Table 19-2, p. 764, 9thed; Table 17-2, p. 675, 10th ed. • Assess, “Do you feel that you are too heavy, too thin, or about the right weight?” • AMA Committee on Prevention & Treatmentof Adolescent Overweight and Obesity • Screen for Hypertension, Family Hx of Obesity, Type 2 Diabetes. • BMI 85th – 95th %ile= overweight • BMI > 95th %ile= obese

38. Merits of Exercise • Advocate for physical fitness– 95210Zipcode for Health • Assess physical activity and discuss emotional, social, and physical benefits fo exercise

39. Health Concerns of Adolescence— cont’d • Sexual behavior, STDs, and unintended pregnancy • Use of tobacco, alcohol, and other substances • Depression and suicide • Physical, sexual, and emotional abuse • Nurse’s role—assess, screen, teach, teach, teach! • Healthy lifestyle; consequences of abuse

40. Health Concerns of Adolescence— cont’d • School and learning problems • Hypertension • Hyperlipidemia • Infectious diseases/immunizations • Safe practices including immunizations • Tdap booster, • Meningococcal vaccine (MCV4), • HPV, • MMR booster, • 2-dose Hepatitis A vaccine, • Varicella if never had it and hasn’t had disease, • Annual flu vaccine

41. Other Topics • Body Art—piercing and tattooing—big factor in establishing ‘identity’. • Recommend having them done in ‘safe setting’ to decrease risk of infections or risk of HIV • Sleep deprivation & Insomnia • Adolescents need 9 hours/night! Allow to sleep in to catch up and allow for proper growth • Homeless may suffer further due to lack of food • Tanning • Educate about detrimental effects of frequent tanning—premature aging, skin cancer

42. Health Promotion Among Special Groups of Adolescents • Minority Adolescents—children of African American, Latino-Hispanic, Asian, Ntive American and Alaskan Native descent—are the fastest growing population • Provide health promotion strategies if at risk for poverty or poor family support • Gay, lesbian, and bisexual adolescents • Advocate against bullying that may put these teens at risk for alienation • Rural adolescents— • improve safety practices with farm machinery. • See Guidance During Adolescence p. 772 (9th ed.); p. 683 (10th ed.)

43. Acne • More than 50% of adolescents affected • Etiology • Familial aspect—increased tendency • Hormonal influence—aeb premenstrual flare-ups • Other influences—stress, exposure to oils in many different venues. • Pathophys: • Excessive sebum produxn, • Comedogenesis • Involves hair follicle and sebaceous glands & overgrowth of Propionibacterium acnes

44. Acne—cont’d • Psychosocial ramifications • Self-esteem issues • Therapeutic management • General measures/overall health • Cleansing—BID adequate with mild cleanser • Medications— • topical retinoids, topical benzoyl peroxide, topical antibacterials, • then oral antibacterials; • OCP—reduce endogenous androgen production • Nursing considerations

45. Vision Changes • Refractory errors peak in adolescence due to growth spurts • Vision screening • Myopia most common—might excess screen time contribute to  incidence?

46. Scoliosispp 1168-71 • A complex deformity of the spine that also affects the ribs • Lateral curvature of the spine and spinal rotation causes rib asymmetry. • Significant if > 10 degrees. • Should be assessed at all school physicals by having child bend forward and observing from behind.

47. Therapeutic procedures for scoliosis: Bracing • Bracing & Exercise • Slows progression • 2 types: “Boston”underarm prefabricated plastic ‘shells’ OR TLSO, underarm orthosis made of plastic that is custom-molded • Gold standard for mild-moderate scoliosis but may NOT CURE • Exercise should be used with the brace • Wear it 23 hr/day ideally

48. Therapeutic procedures for scoliosis: Surgery • Usually indicated for >45 degree. • Arthrodesis • Realigns, straightens w/internal fixation, instrumentation w/bony fusion • Instrumentation • Harrington system • Nat’l Scoliosis Fdn

49. Nursing Care (p.1672 9th ed., p. 1590 10th ed.) • Pre-op • Teaching is a priority • Pain management • Catheter post op • Mobility post op • Testing: x-rays, pulmonary function tests, PT, PTT, Bleeding times, CBC, BMP, UA • Possible autologous blood donation • Bring ‘security item’ prn • Post-op • Pain management-PCA • Log-rolling to prevent damage • Brace worn sometimes • Skin care—important • Neuro status—critical • Respiratory function • Vital signs—infection, blood loss • Bedrest usu. 24 hr then sit up, and stand after 2nd day • I&0—catheter care