Chapter 19
Health Promotion of the Adolescent
and Family
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PROMOTING OPTIMUM GROWTH
AND DEVELOPMENT
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Complex interplay of biologic, cognitive,
psychologic, and social change, perhaps
more so than at any other time of life
Change on multiple levels
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Biologic maturation
Cognitive development
Psychologic development
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Misguided Views of Adolescence
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Raging hormones determine behaviors
Risky and misguided behavior is the norm
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Adolescence
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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)
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Biologic Development
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Neuroendocrine events of puberty
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Gonadotropin releasing hormone (GnRH) from the
hypothalamus
See diagram on next slide.
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Hormonal Interaction Between
Hypothalamus, Pituitary, and Gonads
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Changes in Reproductive Hormones
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Females
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Thelarche
Menarche
Ovulation
Males
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Testicular enlargement
Increasing muscularity & voice changes
Gynecomastia—resolves within 2 yrs
Penile enlargement & ejaculation
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Pubertal Sexual Maturation
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Tanner stages 1 through 5 —pp. 742-743 9th ed.
pp. 654-657 10 ed.
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Sequence is predictable--know
Age of occurrence varies
Average age of menarche in United States
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12.55 years for Caucasian
12.06 years for African-American
12.25 years for Mexican-American
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Physiologic Growth During Puberty
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Pubertal growth spurt—increase in growth of
skeletal muscles and internal organs
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BOYS:14 years
GIRLS: 12 years-[generally 1 ½ -2 years before boys]
Gains in growth
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Final 20% to 25% of linear growth
Up to 50% of ideal adult body weight
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Pubertal Changes in Boys
http://www.kalwnews.org/audio/2011/12/01/reducing-nurses-stress-pays-kaiserpatients_1488191.html
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Pubertal Changes in Girls vs Boys
http://www.merckmanuals.com/home/childrens_health_issues/adolescents/physical_and_sexual_development.html.
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Physiologic Changes
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Heart, blood volume, and systolic BP
increase in size and strength
Heart rate decreases
Respiratory vital capacity increases
Change in BMR
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COGNITIVE DEVELOPMENT
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Piaget: Emergence of Formal
Operational Thought
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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”
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Adolescent Conceptions of Self
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Adolescent egocentrism
Self-absorption
Health-related beliefs
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Imaginary audience (everyone is watching)
Personal fable (won’t happen to me)
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Changes in Social Cognition
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Understanding of others’ thoughts and
feelings
Mutual role taking
Effect on health-related choices
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Development of Value Autonomy
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Struggle to clarify values
Development of a personal value system
Gradual process in late adolescence
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Moral Development
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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.)
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Spiritual Development
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Religious beliefs may become more abstract
during adolescence
Late adolescents may reexamine and
reevaluate beliefs and values of their
childhood
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Psychosocial Development
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Identity Development
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Social forces shape sense of self—adolescents
may move through these phases in different
sequences
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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
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Development of Autonomy
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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
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Achievement
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Development of motives, capabilities,
interests, and behaviors
Progress toward occupational achievement
Relationship between social class and
educational and occupational achievement
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Sexuality
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Hormonal, physical, cognitive, and social
changes affect sexual development
Body image
Sexual identity—experimenting with sex,
developing more intimate friendships
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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
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Intimacy
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Intimate relationship begins to emerge in
adolescence—NOT necessarily sexual in nature
Developmental course of intimacy
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Self-focused—meeting personal needs
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Role-focused—more concerned with conforming
to appropriate roles and norms of relationship
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Individual-connected—more intimate relationships
that acknowledge the complexity and
contradictions in close relationships
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Social Environments
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Ecologic model:
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Microsystems—most proximal social context
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Mesosystems—formed by linkages between
microsystems
Exosystems—settings that influence
adolescent behavior & development
Macrosystems—culturally-based belief
systems & economic & political systems
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Family, peer groups, school, workplace
Can have profound effect on health-related
behaviors & development
All are intertwined and to effect health, nurses
must look at all these systems.
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Families
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Changes in family structure and parent
employment
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Parenting styles
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Family structures vary greatly!
Video from son of lesbian parents.
Effective conflict resolution and family cohesion
contribute to healthy adolescent behaviors
Socioeconomic influences
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Peer Groups
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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.
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The Peer Group Influences
Adolescent Development
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Schools
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Play increasingly important role in preparation
for adulthood
Parental involvement in schools
Effect of academic success or failure on selfesteem
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Work
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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
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Technology as a Social Environment
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Internet chatrooms and social networking
sites have created “virtual” communities
Try out identities and interpersonal skills with
wider network of people
Anonymity
Risks
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Community and Society
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Media influences
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Community’s economic resources play role in
health and well-being of young people
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Availability of alcohol, tobacco, sexuality, violence
in TV, movies, video games, etc.
High employment vs unemployment as well as
socioeconomic status affect behaviors and outlook
Resources for health promotion
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Influence quality of local schools and healthrelated services
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PROMOTING OPTIMUM HEALTH
DURING ADOLESCENCE
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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
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Adolescents’ Perspectives on Health
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Factors promoting adolescent health and
well-being
Contexts for adolescent health promotion
School-based and school-linked health
services
Adolescent health screening (Link on approach)
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“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
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Health Concerns of Adolescence
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Parenting and family adjustment
Psychosocial adjustment
Intentional and unintentional injury
Dietary habits, eating disorders, and obesity
Physical fitness
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Nursing Implications
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Following AAP recommendations (2007):
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Assess Ht and Wt annually along with BMI
BMI Table 19-2, p. 764, 9th ed; 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 & Treatment
of Adolescent Overweight and Obesity
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Screen for Hypertension, Family Hx of Obesity,
Type 2 Diabetes.
BMI 85th – 95th %ile= overweight
BMI > 95th %ile= obese
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Merits of Exercise
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Advocate for physical fitness
Assess physical activity and discuss
emotional, social, and physical benefits fo
exercise
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Health Concerns of Adolescence— cont’d
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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!
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Healthy lifestyle; consequences of abuse
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Health Concerns of Adolescence—
cont’d
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School and learning problems
Hypertension
Hyperlipidemia
Infectious diseases/immunizations
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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
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Other Topics
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Body Art—piercing and tattooing—
big factor in establishing ‘identity’.
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Sleep deprivation & Insomnia
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Recommend having them done in ‘safe setting’ to
decrease risk of infections or risk of HIV
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
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Educate about detrimental effects of frequent
tanning—premature aging, skin cancer
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Health Promotion Among
Special Groups of Adolescents
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Minority Adolescents—children of African
American, Latino-Hispanic, Asian, Ntive
American and Alaskan Native descent—are
the fastest growing population
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Gay, lesbian, and bisexual adolescents
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Advocate against bullying that may put these
teens at risk for alienation
Rural adolescents—
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Provide health promotion strategies if at risk for
poverty or poor family support
improve safety practices with farm machinery.
See Guidance During Adolescence p. 772 (9
th
ed.);
p. 683 (10th ed.)
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Acne
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More than 50% of adolescents affected
Etiology
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Familial aspect—increased tendency
Hormonal influence—aeb premenstrual flare-ups
Other influences—stress, exposure to oils in many
different venues.
Pathophys:
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Excessive sebum produxn,
Comedogenesis
Involves hair follicle and sebaceous glands &
overgrowth of Propionibacterium acnes
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Acne—cont’d
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Psychosocial ramifications
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Self-esteem issues
Therapeutic management
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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
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Nursing considerations
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Vision Changes
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Refractory errors peak in adolescence due to
growth spurts
Vision screening
Myopia most common
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Scoliosis pp 1168-71
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A complex deformity of
the spine that also affects
the ribs
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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.
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Therapeutic procedures for scoliosis: Bracing
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Bracing & Exercise
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Slows progression
2 types: “Boston”underarm
prefabricated plastic ‘shells’
OR TLSO, underarm orthosis
made of plastic that is
custom-molded
Gold standard for mildmoderate scoliosis but may
NOT CURE
Exercise should be used with
the brace
Wear it 23 hr/day ideally
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Therapeutic procedures for scoliosis: Surgery
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Usually indicated for
>45 degree.
Arthrodesis
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Realigns, straightens
w/ internal fixation,
instrumentation
w/bony fusion
Instrumentation
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Harrington system
Nat’l Scoliosis Fdn
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Nursing Care (p.1672 9
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Pre-op
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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
th
ed., p. 1590 10th ed.)
Post-op
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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
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