1. Health Promotion of the Adolescent and Family
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 th ed pp 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

11. Pubertal Changes in Girls vs Boys

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 th 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, 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
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– Zipcode 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 Pathophys:
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 Therapeutic management
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. Scoliosis pp
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