Nursing Throught Life Process Adolescent

NURSING THROUGHOUT LIFE PROCESS ADOLESCENT INTRODUCTION A transitional stage of physical and mental human development generally occurring between puberty and legal adulthood (age of majority), but largely characterized as beginning and ending with the teenage stage is called adolescence. Adolescence (from Latin: adolescere meaning "to grow up") Adolescent development is multidimensional and includes biological, cognitive, and social change .In many societies; adolescence was not recognized as a phase of life. Most societies simply distinguished between childhood and adulthood. Stanley Hall is generally credited with "discovering" adolescence with his 1904 study "Adolescence" in which he describes the developmental phase now recognized as adolescence. Hall attributed the new stage to social changes at the turn of the 20th century. The precise boundaries of adolescence are difficult to define, but this period is customarily viewed as beginning with the gradual appearance of secondary sex characteristics at about 11 or 12 years of age and ending with cessation of body growth at 18 to 20 years.

DEFINITION Adolescence is a period of transition between childhood and adulthood – a time of rapid physical, cognitive, social and emotional maturation as the boy prepares for manhood and the girl prepares for womanhood. It involves three distinct subphases: Early adolescence – ages 11 to 14  Middle adolescence – ages 15 to 17  Late adolescence – ages 18 to 20 The term teenage years is used synonymously with adolescence to describe ages 13 through 19.

OVERVIEW OF GROWTH AND DEVELOPMENT PUBERTY The pubescent period may be considered a pause of 2 or 3 years between childhood and adolescence. It is a period of rapid physical change and personality growth when individuals achieve nearly their adult bodily stature. Girls begin their preadolescent growth spurt at about 10 years and boys at about 12 years. ADOLESCENCE Adolescence is characterized by a number of cognitive, emotional, physical and attitudinal changes, which can be a cause of conflict on one hand and positive personality development on the other. After the pubescent years, growth slows and the change in the body proportions occur more gradually. Usually by 15 to 16 years the secondary sex characteristics have developed fully and adolescents are capable of reproduction. They can perform tasks that require muscular control and skill.

1.Biologic growth

a. Weight and height With the onset of pubescence there is a rapid increase , or spurt, and the child becomes tall. Gain in weight is proportionately greater than gain in height Weight Male – approximately 38-60 kgs Female – approximately 40 – 60 kgs Height Male – approximately 154 – 172 cms Female – approximately 153 – 167 cms b. Body proportions The rate of growth of various organ system differs. The skeletal system often grows faster than its supporting muscles, which tends to cause clumsiness and poor posture. Since large muscles may grow faster than small ones , the youth is likely to lack coordination. The extremities , hands and feet may grow out of proportion to the rest of the body and cause more coordination problems. c. Dentition The number of permanent teeth increases. Second molar and tricuspid teeth erupt from 10 to 13 years of age. d. Physiologic development The specific physiologic explanation for the onset of puberty is unknown, however , it is believed to begin in the hypothalamus with a resultant neurohumoral stimulation to the pituitary gland. Gonadotrophic hormones from the pituitary stimulate the Leydig cells of the testes, which secrete testosterone, and the follicles of the ovary, which secrete estradiol. Simultaneously the adrenal cortex increases the production of androgen. The action of these hormones results in the production of secondary sex characteristics. Physical changes in boys include,  Increase in the size of the genitalia  Swelling of the breasts  Growth of pubic, axillary, facial and chest hair  Voice changes  Production of spermatozoa  Rapid growth in shoulder breadth from about the age of 13 years. Boys can become disturbed by nocturnal emissions and the loss of seminal fluid during sleep. Changes in girls include,  Increase in the transverse diameter of the pelvis  Development of the breasts  Change in the vaginal secretions  Growth of pubic and axillary hair Menstruation begins between the appearance of pubic hair and that of axillary hair. The average age for menarche is 12. Girls’hips begin to broaden from about the age of 12 years.

The stages of development of secondary sex characteristics and genital development have been defined as a guide for estimating sexual maturity and are referred to as Tanner stages.

Male stage Genital I Prepubertal II Long, fine , straight hair at base of penis, testes larger, penis thicker, scrotal skin thinning III Hair longer, coarser, spreading laterally, testes larger, penis growing longer, scrotal skin thin IV Coarse, curly hair at base of penis, testes nearly adult, varicocele may be present, penis nearly adult V Adult

Extra genital Prepubertal Axillary and facial hair absent, voice childlike

Facial hair on upper lip, axillary hair may be present, voice cracking

Female Genital Prepubertal Sparse, long, fine, straight hair on labia, labia majora thicken, vaginal epithelium thicken, vaginal pH falls Coarse , curly hair over pubis, uterus enlarging, vaginal pH low, labia enlarged, menses

Upper lip hair coarse, chin hair present, perianal hair present, axillary hair starting, voice deepening

Adult hair over smaller area, vaginal rugae, uterus enlarging, ovulation

Adult

Adult

Extra genital Prepubertal Breast and papilla elevated, areola enlarges, axillary hair absent Breasts enlarged without separation of contours, axillary hair may be present Papilla and areola project and separation of breast contour begins, axillary hair begins Adult

e. Integumentary system  The sebaceous glands of the face, back, and chest become more active. If the pores are too small, sebaceous material cannot escape, it collects beneath the skin and produces pimples or acne.  Perspiration is increased  Vasomotor instability produces blushing f. Cardiovascular/ respiratory system The size and strength of the heart, blood volume, and systolic blood pressure increases. Blood volume, which has increased steadily during childhood reaches a higher value in boys than in girls, a fact that may be related to the increased muscle mass in pubertal boys. Respiratory volume and vital capacity are increased, and to a far greater extent in males than in females.

2. Psychosocial development Psychosocial Stage 5 - Identity vs. role Confusion During adolescence, the transition from childhood to adulthood is most important. Children are becoming more independent, and begin to look at the future in terms of career, relationships, families, housing, etc. During this period, they explore possibilities and begin to form their own identity based upon the outcome of their explorations. This sense of who they are can be hindered, which results in a sense of confusion ("I don’t

know what I want to be when I grow up") about themselves and their role in the world A group identity During the early stage of adolescence, pressure to belong to a group is intensified. Teenagers find it essential to belong to a group from which they can derive status. They dress as the group dresses and wear makeup and hairstyles according to group criteria, all of which are different from those of the parental generation .the evidence of adolescent conformity to the peer group and nonconformity to the adult group provides teenagers with a frame of self assertion and a rejection of the identity of their parents’ generation. B individual identity The quest for personal identity is part of the ongoing identification process. As adolescents establish identity within a group, they also attempt to incorporate multiple body changes into a concept of self . body awareness is part of self awareness. The process of evolving a personal identity is time consuming with periods of confusion, depression and discouragement. Although the sense of identity is difficult to achieve, young persons must gain it in order to be saved from emotional turmoil. This means they must be able to find for themselves a meaning to life and be able to see clearly that life has continuity for them as individuals. C sex- role identity Adolescence is the time for consolidation of a sex-role identity. During early adolescence the peer group begins to communicate expectations regarding heterosexual relationships, and as development progresses, adolescents encounter expectations for mature sex-role behavior from both peers and adults. D emotionality Unpredictable but essentially normal, mood swings are common during this time. One minute they are exuberant and enthusiastic , the next minute they are depressed and withdrawn. Because of these mood swings, adolescents are frequently labelled as unstable, inconsistent and unpredictable. Teenagers are better able to control their emotions in later adolescence. They can approach problems more calmly and rationally, and although they are still subjected to periods of sadness, their feelings are less vulnerable and they begin to demonstrate the more mature emotions of later adolescence. 3. Psychosexual development Genital stage The fifth stage of psychosexual development is the genital stage that spans puberty and adult life, and thus occupies most of the life of a man and of a woman; its purpose is the psychologic detachment and independence from the parents. The genital stage affords the person the ability to confront and resolve his or her remaining psychosexual childhood conflicts. As in the phallic stage, the genital stage is centered upon the genitalia, but the sexuality is consensual and adult, rather than solitary and infantile. The psychological difference between the phallic and genital stages is that the ego is established in the latter; the person's concern shifts from primary-drive gratification (instinct) to applying secondary process-thinking to gratify desire symbolically and intellectually by means of friendships, a love relationship, family and adult responsibilities For young adolescence the process of sexual identity development usually involves forming close relationships with same sex peers. Many teenagers began to make a shift from relationships with same sex peer to intimate relationships with members of the opposite sex during middle adolescence. Opposite sex relationships

typically begin with peer activities involving both boys and girls. Pairing off as couples becomes more common as middle adolescence progresses. The relationship between love and sexual expression is brought into focus during middle adolescence. 4. Spiritual development Adolescents according to Fowler are in the stage of Synthetic-Conventional Faith. In this stage, diverse self-images are integrated into a coherent identity –a deity. Personal and social values evolve to support this identity, and the adolescent is united with others in emotional solidarity. During this time the adolescent begins to question religious concepts and beliefs of childhood and explores various religious affiliations and cults. A young person without religious ties may be attracted to any new or different religious cult. Greater levels of religiosity and spirituality are associated with fewer high-risk behaviors and more health promoting behavior. 5. Intellectual and cognitive development Jean Piaget’s theory of cognitive development Cognitive thinking culminates with the capacity for abstract thinking. This stage , the period of formal operations, is Piaget’s fourth and last stage. Adolescents are no longer restricted to the real and actual, which was typical of the period of concrete thought, now they are also concerned with the possible. They think beyond the present. They can imagine the sequence of events that might occur , such as college and occupational possibilities, how things might change in the future, such as relationship with parents , and the consequences of their actions, such as dropping out of school. Adolescents are capable of mentally manipulating more than two categories of variables at the same time. For eg they can consider the relationship between speed, distance and time in planning a trip. In adolescence, young people begin to consider both their own thinking and the thinking of others. They wonder what opinion others have of them, and they are able to imagine the thought of others. As they become aware that other cultures and communities have different norms and standards from their own, it becomes easier for them to accept members of other culture and the decision to behave in their own culture in an accepted manner becomes a more conscious commitment. 6. Moral development Kohlberg moral development theory The post-conventional level, also known as the principled level, is marked by a growing realization that individuals are separate entities from society, and that the individual’s own perspective may take precedence over society’s view; individuals may disobey rules inconsistent with their own principles In Stage five (social contract driven), the world is viewed as holding different opinions, rights and values. Such perspectives should be mutually respected as unique to each person or community. Laws are regarded as social contracts rather than rigid edicts. Those that do not promote the general welfare should be changed when necessary to meet “the greatest good for the greatest number of people”. This is achieved through majority decision, and inevitable compromise. Democratic government is ostensibly based on stage five reasoning.

In Stage six (universal ethical principles driven), moral reasoning is based on abstract reasoning using universal ethical principles. Laws are valid only insofar as they are grounded in justice, and a commitment to justice carries with it an obligation to disobey unjust laws Although younger children merely accept the decisions or point of view of adults, adolescents, to gain autonomy from adults must substitute their own set of morals and values. When old principles are challenged but new independent values have not yet emerged to take their place, young people search for a moral code that preserves their personal integrity and guides their behaviour , especially in the face of strong pressure to violate the old beliefs. Late adolescence is characterized by serious questioning of existing moral values and their relevance to society and the individual. Adolescents can easily take the role of another. They understand duty and obligation based on reciprocal rights of others and the concept of justice that is founded on making amends for misdeeds and repairing or replacing what has been spoiled by wrongdoing. 7. Language and speech development Adolescents continue to learn new words and new concepts, in addition they learn the relationship between thought and speech. Vocabulary continues to accrue throughout the lifespan. During these years, ‘slang’ or ‘jargon’ appears as a result of peer group interaction which provides adolescents with a sense of belonging. Language is basic to communication, which is essential to developing and maturing adolescents. Adolescents need parents who can express their needs and desires yet listen to the adolescent point of view 8. Health risks

A. Accidents Accidents remain the leading cause of death in adolescence. motor vehicle accidents, which are the most common cause of death, resulted in almost half of the fatalities among 16-19 year olds(edelman and mandle 2002). Such accidents are often associated with alcohol intoxication or drug abuse. Other frequent causes of accidental deaths are drowning and firearms

B. Homicide Homicide is the second leading cause of death in the 15 to 24 year age group. Males and african-americans have shown the greatest increases. Individuals 12 years of age and older are most likely to be killed by an acquaintance or gang member and most frequently with a firearm. Firearm injuries are the second leading cause of death in young people10-20 years of age.(ahmann 2001)

C. Suicide Suicide is the leading cause of death in adolescents between 15 and 24 years of age (edelman and mandle 2002). Depression and social isolation commonly precede a suicide attempt, but suicide probably results from a combination of several factors Individual factors  Hopelessness  Marked, persistent depression  Alcohol or drug abuse  Feelings of self-hatred or excessive guilt, humiliation  Physical / body image problem  Gender identity concerns

 Sees self as totally helpless – a victim of fate Family factors  Difficult home situation  Rejection by one or both parent  Divorce or separation of parents  Exposure to unrealistically high parental expectation Social/environmental factors  Lack of effective social support system  Isolation  Few social, vocational, educational opportunities

D. Substance abuse Adolescents may believe that mood altering substances create a sense of wellbeing or improve level of performance. All adolescents are at risk for experimental or recreational substance use, but those who have dysfunctional families are more at risk for chronic use and physical dependency. Some adolescents believe that substance use makes them more mature. Tobacco use continues to be a problem among adolescents. The average age at which a teen begins to smoke is between 10 and 12, and the average age by which these teens become addicted is 14.5 years.(la sala and todd, 2000)

E. Eating disorder The number of eating disorders is on the rise in adolescent girls, and knowledge of growth progression may be a way to discourage radical weight reduction activities. Weight extremes resulting from excessive or inadequate calorie intake are common during the adolescent years. Allowing the adolescent to see when and how the weight curve changed can be a first step in identifying the problem and implementing dietary changes. Anorexia nervosa is considered a clinical syndrome with both physical and psychosocial components. The majority of clients are adolescents and young women. Persons with anorexia nervosa have an intense fear of gaining weight and refuse to maintain body weight at the minimal normal weight foe their age and height. Bulemia nervosa is most identified with binge eating and behaviors to prevent weight gain. Behaviors include self induced vomiting, misuse of laxatives and other medications and excessive exercise.

F. Sexual experimentation Sexual experimentation is common among adolescents. Peer pressure, physiological and emotional changes, contribute to early heterosexual and homosexual relations. Two prominent consequences of adolescent sexual activity are sexually transmitted disease and teenage pregnancy. PROMOTING OPTIMAL HEALTH DURING ADOLESCENCE The major causes of morbidity and mortality in adolescence are not diseases, but health damaging behaviors. Health promotion for this age group consists mainly of teaching and guidance to avoid risk taking activities and health damaging behavior. In response to changes in adolescent morbidity and mortality, the American

Medical Association (1997) developed the guidelines for adolescent preventive services which provide a framework for health care providers to use in their clinical practice.

A. Immunizations An immunization is an important part of adolescent preventive care. Meningococcal vaccine (MCV4) should be given to adolescents 11 to 12 years of age. The human papilloma virus (HPV) vaccine series is recommended only for girls based on research results at this time. The series may be started as early as 9 years of age, with the second and third doses at 2 months and 6 months, respectively. With exception of pregnant teenagers, all adolescents should receive a second measles-mumps-rubella(MMR) vaccine unless they have documentation of two MMR vaccination during childhood. They should also receive 3 doses of hepatitis B vaccine, and hepatitis A as part of routine immunization schedule. Annual influenza vaccination with either the live attenuated influenza vaccine or trivalent influenza vaccine is now encouraged for all children and adolescents. Vaccination with varicella vaccine is recommended and the vaccine may be given in two doses 4 or more weeks apart to adolescents 13 years or older. B. Nutrition The rapid and extensive increase in height, weight, muscle mass and sexual maturity of adolescence is accompanied by increased nutritional requirements. The caloric and protein requirements during this time are higher than at almost any other time of life. Normal requirements Calories- females require 2200 Cal./day and males 2500-3000. A guideline recently developed by American Heart Association (2005), aims at providing balanced nutrient intake in children and adolescents with an overall decrease in fat intake and discretionary calories or snacks that increase the propensity for obesity and cardiovascular disease. It also encourage limiting sweetened beverage consumption and moderating caloric intake to activity levels. Adolescents usually have sufficient intake of proteins to meet their needs, except for those who limit their food intake because of economic problems or in attempt to lose weight. There is substantial increase in the need for minerals. Calcium for skeletal growth, iron for expansion of muscle mass and blood volume, and zinc for the generation of both skeletal and bone tissue. C. Sleep and rest Teenagers vary in their need for sleep and rest. Sleep daily requirement is 8.5 to 9.5 hours. Rapid physical growth, the tendency towards overexertion, and the overall increased activity of this age contribute to fatigue in adolescents. During growth spurts the need for sleep is increased. Adequate sleep and rest at this time are important to a total health regime. D. Exercise and activity To improve health outcomes, school-age children and adolescents should engage in 60 minutes or more of moderate to vigorous physical activity daily. The practice of sports, games and even dancing contributes significantly to growth and development, the education process and better health. Because physical fitness appears to be a major influence on one’s lifelong health status, they should be encouraged to participate in activities that contribute to lifelong physical fitness. E. Dental health

Dental health should not be neglected during adolescence. Dental care is an aspect of preventive care that is not received by substantial proportions of children. Early adolescence is usually when corrective orthodontic appliances are worn, and these are frequently a source of embarrassment and concern to the youngster. It is also important to reinforce the orthodontist’s directions regarding use and care of the appliances and to emphasize careful attention to tooth brushing during this time. F. Personal care Body changes associated with puberty bring special needs.

I Vision Regular vision testing is an important part of health care and supervision during adolescence. During adolescence, visual refractive difficulties reach a peak that is not exceeded until the fifth decade of life. The increased demands of schoolwork make adequate vision essential for academic success.

ii Hearing Cochlear damage from relatively continuous exposure to the loud sound levels of rock music has been documented. The popularity of personal music players with lightweight earphones that are inserted into the ear canal is of particular concern yo health care professionals. When these units are used for extended periods, permanent hearing loss can occur.

iii Body art It is estimated that 3% to 5% of people in western society have a tattoo and 13% of the population in the United States has at least one tattoo. Body art (tattooing and piercing) is an aspect of adolescent identity formation. The adolescent often seeks body art as an expression of his or her personal identity and style. Piercing the ear, nose, nipple, eyebrow, navel may sometimes create a health problem. There is always a danger of infection, cyst or keloid formation, bleeding , dermatitis or metal allergy.it also presents the risk of HIV, hepatitis C, and hepatitis B virus transmission due to unsterilized needle. G. Stress reduction The multiple changes occurring in adolescence can result in great stress such as scholastic pressures, relationship with parents, siblings, peers, career planning, and body image, pressure for use of drugs, alcohol, cigarettes and potentially dangerous physical activities. Early maturing girls and late maturing children are especially sensitive to the stresses of being different from their peers. H. Sexuality education and guidance Our society does a poor job of educating adolescents about pubertal growth and development. Omar and zakharia(2003) found that 36% of boys and 2% of girls have never been spoken to about pubertal development and sexuality issues. Girls received education at a mean age of 13 years and boys at an average age of 15 years. A large portion of their knowledge is acquired from peers, television, movies and magazines. In addition some information obtained from their parents may be inaccurate. As a result, the information they accumulate may be incomplete , inaccurate and not very helpful. Sexuality education should consist of instruction concerning normal body functions and should be presented in a straightforward manner using correct terminology. When discussing nurse should use simple but correct language.

I. Injury prevention Physical injuries are the greatest single cause of death in the adolescent age-group and claim more lives than all other cases combined. The most vulnerable ages are the years 15 to 24, when accidental injuries account for about60% of deaths in boys and 40% of death in girls. During adolescence, peak physical, sensory and psychomotor function gives teenagers a feeling of strength and confidence that they have never experienced before, and the physiologic changes of puberty give impetus to many basic instinctual forces. Some of the injury prevention suggestions are: Motor or nonmotor vehicles  Pedestrian- emphasize and encourage safe pedestrian behaviour  At night, walk with a friend  If someone is following you , go to nearest place with people  Do not walk in secluded areas  Passenger – promote appropriate behaviour while riding in a motor vehicle. Refuse to ride with an impaired person or one who is driving recklessly  Driver – provide competent driver education Maintain vehicle in proper condition Discourage racing  Teach and promote safety and maintenance of two and three wheeled vehicles  Promote and encourage wearing of safety apparel such as helmet, long trousers  Reinforce the dangers of drugs including alcohol when operating a motor  Drowning  Teach non swimmer to swim  Teach basic rules of water safety  Judicious selection of place to swim  Sufficient water depth for diving  Swimming with companion

 Falls – teach and encourage general safety measures in all activities  Bodily damage  Promote acquisition of proper instruction in sports and use of sports equipment.  Instruct in safe use of firearms and other devices with potential danger eg firecracker  Provide access to or provision of safe sports and recreational facilities  Be alert for signs of depression  Instruct regarding proper use of corrective devices eg contact lenses, hearing aids ROLE OF NURSE  promotion of self care by rest, sleep, exercise, hygiene, balanced diet with adequate energy consumption and healthy eating habit  arrangement of regular health check up and breast self examination and dental examination

 preventive education on accidents, addictive behavior, adolescent problems, STDs, unwanted pregnancy  encouraging independence and allowing to handle own affairs and problems and financial independence by earning own money  supporting to control emotions , frustrations, depression and preventing self destruction and antisocial activities  understanding the conflict of the adolescence and helping them for crisis intervention and resolution of conflicts  helping them to accept body image and changes during puberty  promoting adjustment with wide range of experiences. parents should limit rules and regulation and induce realistic consistent behavior in the context of present value system  arranging sex education to assist for development of universally approved heterosexual relationship and to prevent sexual problems thus to promote respectful healthy sexual behavior towards healthy parenthood

CONCLUSION Adolescence is a time of many transitions for both teens and their families. To ensure that teens navigate these transitions successfully, it is important to understand what is happening to the teen physically, cognitively, and socially; how these transitions affect teens; what can be done; and what support resources are available.

BIBLIOGRAPHY    

Hockenberry Marilyn J, Wilson David. Wong’s Essential of Paediatric Nursing. 8th edition , Missouri: Elsevier; 2009. Page no 514-533 Marlow Dorothy R, Redding Barbara A. Textbook of Paediatric Nursing. 6th edition reprinted . Pennsylvania: W.B.Saunders Company; 2010. Page no 1114- 1141 Potter Patricia A, Perry Anne Griffin. Fundamentals of Nursing . 6th edition, missouri: elsevier; 2005. Page no 205-213 Pillitteri Adele. Maternal and Child Health Nursing, 6th edition. Philadelphia: Lippincott Williams and Wilkins;2010. page no 915 - 944

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NURSING THROUGHOUT LIFE PROCESS ADOLESCENT

SUBMITTED TO MADAM T SAHA READER

SUBMITTED BY HATNEILHING SIMTE M SC NURSING

1ST YEAR WBGCON

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