Transcript WK 9 Adolescents 07Wteacher1700h

Adolescence
Week 8 63 277
2008W – teacher copy
Adolescence
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Transition from childhood to adulthood
Age 11-20 years
Early adolescence 11-14 years
 Middle adolescence 15-17 years
 Late adolescence 18-20 years
 Some function as adolescents into the 20s
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Relationship with parents
Relationship with peers
Period of Rapid Changes
Period of Rapid Growth
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Physical
Puberty: sexual maturity
 Growth spurts
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(Refer Fig 19.1 p 814)
Emotional
Identity vs Role Confusion
 Moral development & Spiritual development
 Peer relationships important
 Issues of sexuality, intimacy, body image
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Cognitive
Formal operations (Piaget)
 Develop sophisticated reasoning skills
 Begin to make educational & occupational decisions as
closer to adulthood
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Refer Table 19-1 p 813 G&D during adolescence
Physical Development
Girls
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Linear growth (ht) early
puberty (~12 yrs) 1½ -2
yr earlier boys
During adolescence
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Boys
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Linear growth (ht)
midpuberty (!14 yrs)
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During adolescence
Ht 5-20cm (2-8”)
Wt 7-25 kg (15-55 lb)
Puberty 9 ½-14 ½ years
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Ht 10-30 cm (4-12 “)
Wt 7-30 kg (15-65 lb)
Puberty 10.½ -16 years
Physical Development
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Growth includes accumulation of body mass
Size & strength of heart, blood volume, systolic
BP ↑, AHR ↓ (∆s earlier in girls)
Lungs ↑ in diameter & length;
RR= adult rate (↑ in boys d/t lge shoulder &
chest size)
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Neurological: reflexes = adult
Continued brain growth ↔ dev’p ↑ cognitive
capacities of youth
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Parker
age 17
Wt 132 lbs
Ht 6’1”
Where is he
on the
growth
chart?
Parker
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17 years
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6’1”
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132 lbs
Major Tasks of adolescence
1.
2.
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5.
6.
7.
Developing coherent sense of personal
identity
Establishing a clear gender identity
Establishing autonomy from parents
Beginning ability to be in intimate
relationship
Acquiring coping skills
Consolidating values
Developing educational/vocational values
Development of Self-concept
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Affected
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by own perspective
by interpretations of opinions of others
Body Image – perception of body
Self esteem – perception of self-worth
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Reliance on external evidence of worth
Development of own criteria to evaluate
Adolescents
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Are subject to turbulent, unpredictable
behaviour
Are struggling for independence
Are extremely sensitive to feelings &
behaviours that affect them
May receive a different message than what
was sent
Consider friends extremely important
Have a strong need to belong
RNAO Best Practice Guidelines:
Enhancing Healthy Adolescent
Development
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Recognize unique needs of adolescents
Partnership with agencies, government,
community, family, children services
Nurse
Advocacy
 School-based health promotion
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Highlights RNAO BPG
Why Best Practice Guidelines for
Adolescents ?
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Rates of mortality & morbidity have not decreased
Most related to unhealthy or risk behaviours
These behaviours are preventable
29% of teens smoke
67% drink alcohol
Pregnancy rates are high in 15-19 yr olds
Incidence of STDs is increasing ie chlamydia,
gonorrhea
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Healthy People 2010 adolescent goals include risk
reduction in :
mental health,
 substance use,
 sexual behaviour,
 violence,
 unintentional injury,
 nutrition,
 physical activity and fitness,
 oral health
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Why focus on these health issues?
Healthy People 2010
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Primary causes of mortality during adolescence:
injuries, homicide, and suicide;
 Account for 75% of all adolescent deaths
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Major causes of morbidity include:
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injury & disability assoc with motor & recreational
vehicles, the sequelae of sexual & physical abuse,
consequences of sexual activity such as pregnancy
& STDs, and outcomes of substance abuse
Nursing considerations
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Nursing role – buddy, mentor, parental
Establishment of trust
Privacy, confidentiality
Atraumatic care
Safe sex education
Birth control
Injury prevention
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drinking & driving
preventing sports injuries etc
Adolescent Health Screening
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Interview
 Listening
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Maintain objectivity
Avoid assumptions, judgments & lecturing
Open ended questions
 Responding
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to emotions
Show concern for teen’s perspective
Non threatening explanation
 Confidentiality
& privacy
Use of “SAAFE TIMES”
interview technique
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Sexuality
Affect
Abuse
Family
Examination
Timing of Development
Immunization
Minerals
Education/employment
Safety
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(Begin in reverse order – from less sensitive to more sensitive issues)
Health Concerns of adolescents
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Family concerns/parenting
Psychosocial development
Clinical depression
School problems & teacher
Risk for intentional & unintentional injury
Dietary habits, eating disorders, diabetes
Physical fitness
Sexual development
Lifestyle Threats
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Sports injuries
MVAs
Drowning
Burns
Violence
Unprotected sexual activity
Chemical toxins
Mood alterations
Lifestyle Threats
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Use of tobacco
Use of alcohol
Use of other substances
Severe or recurrent depression & suicide
Physical, sexual, emotional abuse
Learning & school problems
Hypertension
Hyperlipidemia
Infectious diseases
Teens at Increased Risk
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Family problems
Mothers who were teen mothers
Early puberty
Sexually abused
School absenteeism / no goals
Use of ETOH, drugs & tobacco
Living in group homes, detention centers or on
the street
With siblings who were pregnant during
adolescence
Teens at Risk
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Cultural considerations
Gay, Lesbian, Bisexual adolescents
Rural adolescents
Adolescent parents
Side effects of prescribed medications
for depression SSRIs
 Birth control pills
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Behaviours Viewed as Risky
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Substance use
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Sexual activity
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Risks related to use of recreational & motor
vehicles
p. 829
Leading causes of death
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Accidents
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Suicide
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784 deaths in 2001; 2 out of 3 were vehicle accidents1
2001 6.4% of deaths, down from 9.5% in 20001
gunshot wounds leading cause of death in Canadian adolescents
& young adults
1991 309 firearm deaths in 15-24 year
2
olds
Cancer
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1991 202 cancer deaths2
 1 Statistics Canada’s Internet Site, http://142.206.72.67/02/02b/02b_004_e.htm
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2
Retrieved February 4, 2006.
www.statcan.ca
Haddon’s Matrix: Factors
Factors
Host/Human
Agent
Environment
Yanochko, P. California Conference on Childhood
Injury Control. September, 2004
Haddon’s Matrix:
Phases of Injury Prevention
P
h
a
s
e
s
Pre-Event
Reduce # of events with the
potential to cause injury
Event
Reduce # of injuries that occur
Post-Event
Reduce severity of injury and
optimize outcome
Haddon Phase-Factor Matrix
Phase/ Host
Factor (Human)
PreEvent
Event
PostEvent
Vector
(Vehicle)
Physical
Social/
Environment Cultural Env
Will an event with the potential to cause injury
occur?
Will an injury occur?
What will the outcome be (e.g. how severe)?
Haddon’s Matrix Slides Adapted From: Community Action Training, Community Health Education Section, San
Francisco Department of Public Health, 6/4/02
Haddon’s Matrix Example:
Motor Vehicle Crash
Phase
Host
(Human)
Vector
(Vehicle)
Physical
Cultural
Environment Environment
PreEvent
Alcohol
Experience
Judgment
Brake status
Tires
Night,
Rain
Event
No seat belt
No air bag
Hardness of
surfaces
Tree too close to Speed limits
road, no guard rail Enforcement of
seat belt laws
PostEvent
Physical
condition
Fuel system
integrity
Cell phone
Distance of
emergency
response
Acceptance of
drinking and
driving
Support for
trauma systems
Training level of
EMS personnel
Development of Sexuality
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Preadolsecent sex play
Masturbation
Pubertal sexual maturation
Tanner stages (see p 805-808)
Sexual identity
Sexual orientation
Sexual abuse
Intimacy
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Self -focused
Role -focused
Individual-connected
Discussion of sexual orientation
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John age 17 comes into the school-based clinic
and tells the nurse practitioner that he thinks he
is gay.
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What would be an appropriate response if you
were the nurse ? See p 823-824
Problems Associated with Sexual
Development
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Precocious puberty
Gay identity & suicide
STDs ie chlamydia, genital warts, genital
herpes, syphillis, gonnorrhea, PID
Unintended pregnancy
Gay or lesbian family
Sexual Abuse
Incest
 Molestation
 Pornography
 Prostitution
 Pedophilia
 Rape
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Common physical health problems
of adolescence - STDs
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Major cause of morbidity
Adolescents group at highest risk
Chlamydia* - most common bacterial
Human papilloma virus* (HPV) (aka genital warts)
Genital herpes
Gonorrhea
HIV / AIDS
PID
Syphillis
* not required to be reported
Nursing Considerations
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Obtain detailed history
Physical exam by sexual assault examiner
Encourage parent’s presence if supportive
Obtain specimens
Prophylactic antibiotics
Pregnancy prophylaxis
Application of stress reduction techniques
Follow-up care
Prevention programs
Substance Abuse
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Experimentation vs daily use
Biologic disposition coupled with psychosocial
risk factors
Medical & legal concerns
(see p 886 table 21-3)
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Most prevalent
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alcohol, tobacco, marijuana, heroin, hallucinogens,
inhalants, prescription drugs, cocaine, designer drugs ie
ecstasy, GHB
Drug misuse by athletes
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Ergogenic aids –increase strength & endurance
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Psychomotor stimulants
 Amphetamines
 Ritalin
 Caffeine
Anabolic steroids
Side effects : hypertension, virilization in females,
infertility, gynecomastia, premature closure of
epiphyses, acne, increased blood cholesterol,
hepatocellular ca, mood swings, ”roid rage”
Nursing implications –consider when doing health
history & assessment
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TOBACCO
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Marked increase in high school age
Cigarette smoking is chief avoidable cause of
death
High probability of leading to lifetime habit
Related to health risk & deviant behaviours
Link between use of cigarettes and use of other
drugs
Alcohol
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Social factors
Associated with increased incidence of injury
Sociodemographic factors
Psychosocial factors
Biologic factors
Nursing Considerations
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Prevention programs
Peer led
 media
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Antismoking initiatives
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Stop smoking programs
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Smoking bans in schools
Accessible, affordable
Assessment & recognition of problem
behaviour
Addictive Behaviours
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Use of alcohol & tobacco not uncommon
marijuana has been tried by many
Viewed as opportunity to challenge authority,
demonstrate autonomy, gain peer acceptance,
relieve stress of growing up
OUTCOMES:
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Drinking & driving leading cause of death
NSG CONSIDERATIONS:
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See health screening
Suicide
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2nd leading cause of death
36% girls; 22% boys have reported depression
~20% of grade 9-12 students reported seriously
considered suicide past year
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(Centre for Disease Control & Prevention, 2004)
Girls more likely to attempt
Cultural factors
Related terms:
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Suicidal ideation
Suicidal attempt
Parasuicide
World Health Organization, Geneva, 2005
www.who.int/mental_health/prevention/suicide/country_reports/en/
Suicide thought: Factors in
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Individual factors
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Introspection
Social experiences
Peer relationships
Coping with intense emotions
Need to belong
Presence of psychiatric disorder
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Depression
Bi-polar
Substance abuse
Conduct disorder
Suicide thought: Factors in
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Past history
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Previous suicide attempt
Family history
History of child abuse or neglect
Death of parent when child was young
Social factors
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Firearms in house
Incarceration
Lack of social support system
Isolation
Few opportunities
Suicide: precipitating factors
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Break-up of important relationship
Failure in important area
Shameful or humiliating experience
Changing schools or moving
Involvement in legal system
Pregnancy assoc with family crisis & rejection
Death of close friend, relative or pet
(see pathway p 914 fig 21-4)
See Handout re choking
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Rise in choking episodes again for highs
videotaped on You –Tube
Web site for survivors G.A.S.P.
Nursing Considerations
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Role is pivotal in prevention
Foster healthy development
Anticipatory guidance to parents
Community education awareness programs
Reduction of social isolation
Enhanced opportunities
Recognition of warning signs
Local suicide prevention services
Protective Factors for Youth Suicide
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Warm caring family relationship
Self esteem, internal locus of control, self confidence
Social skills
Problem solving skills
Regular attendance at religious ceremonies
An adult who listens
Supportive friendships
Perception of school personnel as caring
(see p 914 Box 21-13)
Suicide: Method of
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Firearms
Hanging
Overdose
Self-inflicted laceration
Screening for suicide
Routine health exam should include screening for
suicidal thoughts or intent
1.
Do you consider yourself to be happy, unhappy or
somewhere in the middle?
2.
Have you ever been so unhappy or upset that you
felt like being dead ?
3.
Have you ever thought about hurting yourself ?
4.
Have you ever developed a plan to hurt yourself or
kill your self ?
5.
Have you ever attempted to kill yourself ?
(see p 915 Box 21-15 – warning signs of suicide)
Care of suicidal adolescent
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Ensure safety is 1st response
Suicidal remarks must be taken seriously!!
Do not leave alone
Ask about plan
Ask about method
Ask about location
Demonstrate caring and understanding
Eating problems - disorders
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Pica
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Obesity
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Anorexia Nervosa
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Etiology unclear
Distinct psychological component
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Bulimia
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“Fear of Fat” syndrome
Early signs of anorexia
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Inappropriate diet
Peculiar eating habits or rituals
Excessive exercising
Withdraws from social interaction
No menstrual period (amenorrhea)
Laxative abuse
Vomits deliberately especially after meals
Distorted body image
Below 25th percentile on growth chart
LIFE THREATENING!
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(see case study p 898)
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Treatment
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Counselling
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Behaviour modification
Diet education
Hospitalization in severe cases
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Treat life-threatening malnutrition
IV, tube feedings
 Monitor CV status
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Parental and patient education
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long-term (lifelong?) treatment & management
Bulimia
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Eating disorder characterized by binge eating
May be followed by purging behaviors
Laxative abuse
 Self-induced vomiting
 Diuretic abuse
 Rigorous exercise regimens
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Up to eight or more cycles per day
Bulimia (cont.)
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Weight may be normal or slightly above
Weight may be low: bulimarexia
Tooth erosion, esophageal damage, other GI
concerns
Psychologic issues
Self-deprecating thoughts, depressed mood
 History of unsuccessful dieting, overweight in
childhood
 Low impulse control
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Therapeutic Management
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Similar to anorexia management
Hospitalization to treat potassium depletion,
esophageal damage
Cardiac monitoring indicated
Behavioral management
Characteristics of eating disorders
Anorexia Nervosa
 Turns away from food to cope
 Introverted
 Avoids intimacy
 Negates feminism
 Model child
 Obsessive compulsive
 High achiever
 Rigid control
 Body distortion
 Denies illness
 Body wt 85% less than expected
 Not sexually active
 ↓BP, bradycardia
 Dry skin, brittle hair & nails
Bulimia
 Turns to food to cope
 Extroverted
 Seeks intimacy
 Aspires to feminine role
 Acts out
 Impulsive
 Variable school performance
 Loses control
 Less frequent body distortion
 Recognizes illness
 Close to normal body wt or
overwt
 Often sexually active