Nursing Care of a Family With an Adolescent how an intervention appears from an

adolescent’s standpoint before beginning

Adolescence is generally defined as the period teaching.
between 13 and 18 or 20 years, a time that
serves as a transition between childhood and GROWTH AND DEVELOPMENT
young adulthood. Adolescents grow both rapidly and mature
dramatically during this period.
early period (13 to 14 years) Socioeconomic factors definitely influence the
middle period (15 to 16 years) length of adolescence across all cultures.
late period (17 to 20 years) Recognizing that adolescents may have differing
responsibilities and life experiences based on
During all periods, adolescence is defined not so cultural expectations can be useful when making
much by chronologic age as by physiologic, an assessment.
psychological, and sociologic changes. The
drastic change in physical appearance and the Physical Growth
change in expectations The major milestones of development- 9 to
of others (esp. parents) that occur during the 12 years of age, and the cessation of body
period can lead to both emotional and physical growth at 16 to 20 years. Between these
health problems. milestones, physiologic growth and development
Adolescents feel a sense of pressure of adult coordination occur.
throughout this period because they are mature At first, the gain in physical growth is mostly
in some respects but still young in others. in weight, leading to the stocky, slightly obese
Communication problems begin when a appearance of prepubescent; later comes the
teenager refuses to respect parents’ opinions or thin, gangly appearance of late adolescence.
stops asking for them.
Most girls are 1 to 2 in (2.4 to 5 cm) taller than
NURSING DIAGNOSIS boys coming into adolescence but generally
• Health-seeking behaviors related to normal stop growing within 3 years from menarche.
growth and development Those girls who started menstruating at 10
• Low self-esteem related to facial acne years of age, therefore, may reach their adult
• Anxiety related to concerns about normal height by age 13.
growth and development Boys grow about 4 to 12 in (10 to 30 cm) in
• Risk for injury related to peer pressure to use height and gain about 15 to 65 lb (7 to 30 kg)
alcohol and drugs Girls grow 2 to 8 in (5 to 20 cm) in height and
• Readiness for enhanced parenting related to gain 15 to 55 lb (7 to 25 kg).
increased knowledge of teenage years Growth stops with closure of the epiphyseal
lines of long bones. Occurs at about 16 or 17
Outcome Identification and Planning respect the years of age in females and about 18 to 20
fact they have a strong desire to exert years of age in males.
independence or do things their own way.
Including them in planning is essential so the The increase in body size does not occur in
plan will be agreeable and accepted. all organ systems at the same rate. These
Teaching by peers is another effective way to differences in growth rates make adolescents
motivate teens. appear long-legged and awkward during a
rapid growth spurt because their extremities
Implementation elongate first, followed by trunk growth. Both
Adolescents do poorly with tasks that sexes may lack coordination during these times.
someone tells them they must do. evaluate
The heart and lungs increase in size more Secondary Sex Changes
slowly than the rest of the body, blood flow Such as body hair configuration and breast
and oxygen availability are reduced. This growth are those characteristics which
means adolescents may have insufficient distinguish the sexes from each other but play
energy and become fatigued. no direct part in reproduction. The secondary
sex characteristics that began in the late
Pulse rate and respiratory rate decrease school-age period continue to develop
slightly (to 70 beats per minute and 20 during adolescence.
breaths per minute, respectively), and blood Sexual maturity in males and females is
pressure increases slightly (to 120/70 mm classified according to Tanner stages, named
Hg), reaching adult levels by late adolescence. after the original researcher on sexual maturity
In adulthood, blood pressure is slightly higher (Tanner, 1962).
in males than females because more force is
necessary to distribute blood to the larger male Sexual Maturation in Adolescent
body mass.

Androgen stimulates sebaceous glands to

extreme activity, sometimes resulting in acne,
a common adolescent skin problem.

Apocrine sweat glands produce a strong odor

in response to emotional stimulation.

Teeth
Gain second molars at about 13 years of age
and their third molars (wisdom teeth) between
Developmental Milestones
18 and 21 years of age. Third molars may
Play or Recreation
erupt as early as 14 to 15 years of age. The
Thirteen-year-old children change from school-
jaw reaches adult size only toward the end of
age activities of active games to more adult
adolescence, however. As a result, adolescents
forms of recreation such as listening to
whose third molars erupt before the lengthening
music, chatting on computers, or following a
of the jaw is complete may experience pain and
sports team’s wins and losses. Team (or
may need these molars extracted because they
school) loyalty is intense, and following a
do not fit their jawline
coach’s instructions becomes mandatory. This
attitude is similar to the loyalty 6-year-old
Puberty
children show toward their first-grade teacher.
Puberty is the time at which an individual first
Young adolescents who do not have the
becomes capable of sexual reproduction. A
physical ability to compete in sports do their
girl has entered puberty when she begins to
best to avoid these activities.
menstruate; a boy enters puberty when he
If adolescents thought they would be successful
begins to produce spermatozoa. Usually
at a sport, they need a sympathetic person to
occur between ages 11 and 14 years. The age
listen to the frustration they feel and to be
of first menstruation in girls is gradually
encouraged to try other activities in which they
decreasing from a mean of 13 years to 12.4
can excel.
years, probably related to more weight gain in
girls.
Talking is no more a waste of time than
Puberty creates many questions for early
imaginative play as a preschooler. It is a major
teenagers about what is normal and what is
way to learn about the world.
not (Cousineau et al., 2007).
Fifteen-year-old may spend a great deal of Some adolescents may become delinquent or
time in their room or, in a quiet corner of the exhibit acting-out (attention-getting)
home. If they cannot find privacy somewhere in behavior because they believe it is better to
the house, they tend to spend time elsewhere. have a negative image than to be nobody at all.
Those who do not develop a sense of
Beginning at age 16, most adolescents want intimacy at the end of adolescence can have
part-time jobs to earn money. Such jobs can difficulty forming long-term or intimate
teach young people how to work with others, relationships.
accept responsibility, and spend money wisely.
Body Image.
When families were larger, each older child Adolescents who developed a strong sense of
had responsibility for a younger sibling and industry during their school-age years have
baby care was a natural activity. learned to solve problems and are best
equipped to adjust to their new body image.
Many adolescents during middle to late
adolescence engage in charitable endeavors. Adolescents are usually their own worst
These activities fulfill an adolescent’s need for critics, never pleased with any aspect of their
satisfying interaction with others and are bodies. They may need help to realize the
indications of maturity and willingness to characteristics that make someone creative,
accept adult roles. compassionate, and fun to be with are the
qualities on which lasting relationships are built.
Emotional Development
Developmental Task: Identity Versus Role Self-Esteem. Like body image, self-esteem may
Confusion undergo major changes
According to Erikson (1993), the developmental Changes that occur during adolescence,
task in early and mid-adolescence is to form a including:
sense of identity or decide who they are and • Changes in one’s body and physiologic
what kind of person they will be. functioning
• Changes in feelings and emotional focus
In late adolescence, the task is to form a • Changes in social relationships (including
sense of intimacy or form close relationships relationships with both family and friends)
with persons of the opposite as well as the • Changes in family and school expectations
same sex. It is the concentration on these two All of these factors can have an effect on
tasks that leads to typical adolescent behavior. adolescents’ feelings about themselves,
The four main areas in which adolescents must sometimes resulting in crisis.
make gains to achieve a sense of identity are:
Adolescence is a period of particular crisis for
1. Accepting their changed body image girls who are trying to find a place in a male-
2. Establishing a value system or what kind dominated society.
of person they want to be
3. Making a career decision Although the turmoil of adolescence can be just
4. Becoming emancipated from their parents as confusing to boys as it is to girls, Gilligan
hypothesized there may be less pressure on
If young people do not achieve a sense of boys, who may have already learned to be
identity, they develop a sense of role competitive, independent, and separated from
confusion or can have little idea what kind of feelings.
person they are. This can lead to their having
difficulty functioning effectively as adults.
Gilligan describes the rearing of boys as severe can be their struggle. Because they
including separation from emotions and feelings love and feel loved, severing bonds is difficult.
at an earlier age, whereas girls are encouraged In some instances, friction and
to maintain their concern for people throughout misunderstandings arise because parents
their childhood. This makes girls at risk for had such traumatic experiences as
more conflicting feelings throughout adolescents themselves that they fear seeing
adolescence. their children reach this stage.

Value System. This makes adolescents feel they have

Adolescents develop values through talking offended their parents in some way. They do
to peers. They also need an attentive adult not understand that the parental attitudes are
ear, someone who will listen to their fears, based not on anything they may have done,
hopes, dreams, and the pressure they feel to be but on old, unresolved conflicts. In other
somebody, the pressure of wanting to do instances, parents may view adolescent
something and yet not knowing what or how. growth as threatening. Seeing their
adolescence grow up may make them feel old
In early adolescence, girls tend to band or fear that once their child becomes
together with girls and boys with boys. They independent, marriage may dissolve. They
dress identically with other members of their may strive to keep their child immature
group. On the surface, this makes adolescents (producing conflict) in an effort to keep these
appear to be losing their identities rather thoughts from entering the corners of their
than finding them. minds.
Adolescents must feel secure and pleased
with their own sex before they can relate Both parents and adolescents may need help to
comfortably to the opposite sex. understand that emancipation does not
mean severance but a change in a
Career Decisions. Part of the feeling of relationship. There are no ex-children.
knowing what kind of person you are is knowing
what kind of occupation will be a fit. Some Many 18-year-olds so enjoy their new
school age children do poorly in school independence they find it difficult to
during preadolescence but, as adolescents, understand why adulthood is thought to be
show increased interest in learning as they challenging. A little more maturity will help them
select a job field and come to see education as realize that beginning adult life may be far
relevant to their future. easier than continuing it in the years ahead.

Emancipation From Parents Sense of Intimacy

Emancipation from parents can become a major Once adolescents have achieved a sense of
issue during the middle and late adolescent identity in early or mid-adolescence, they are
years Some parents may not yet be ready for ready to work on a second developmental
their child to be totally independent, and task, achieving a sense of intimacy (Erikson,
some adolescents may not yet be sure they 1993). The ability to form intimate
want to be on their own. They may fight bitterly relationships is strongly correlated with the
for a right then never use the privilege once they sense of trust, the first developmental task in
have gained it. Winning the battle was more infancy.
important than exercising the newly won Some adolescents require help from parents or
right. other adults to differentiate between sound
In some instances, the closer the tie relationships and those that are based only
adolescents feel with their parents, the more on sexual attraction.
Never do adolescents need an adult to listen Adolescents watch adults carefully during this
to them more than when they are struggling period, searching for good role models with
with the heart-rending feelings of young love whom they can identify.
or wondering whether a particular love Fourteen-year-olds often form a friendship
relationship is temporary or lasting. with an older adolescent of the same sex,
trying to imitate that person in everything
Some adolescents may believe that intense from thoughts to clothing.
sexual yearnings or peer pressure can be
alleviated only by a sexual act. Older adolescents become more interested in
forming reciprocal friendships. Attachments
Intimacy involves this deeper level of to older adolescents are often severed abruptly
relationships or developing a sense of and painfully as older teenagers make it clear
compassion or concern for people of both they are more interested in being with people
sexes. they may need help learning how to their own age.
project themselves into another person’s
situation and to ask themselves how the Most 15-year-olds fall in love five or six times
world looks from that position. This ability, a year. However, many of these relationships
empathy, is feeling for another or a developed are based on attraction because of physical
sense of intimacy in its finest form. appearance, not because of inner qualities.
Because infatuation is fleeting, it can lead to
Socialization extremely intense but brief attachments that
Early teenagers may feel more self-doubt fade once the two young people discover they
than self-confidence. They want to look grown really have little in common.
up, but they still look like children. The voices of By age 16, boys are becoming sexually
most boys have not yet dependably mature (although they continue to grow taller
deepened; this makes them unable to trust their until about 18 years of age). Both sexes are
voices to carry the serious tone they wish to better able to trust their bodies
convey. Most girls’ bodies have not yet fully By age 17, they tend to be quieter and
developed thoughtful about interactions. They have left
behind the childish behaviors they used in
Both male and female 13-year-olds tend to be early adolescence—shoving and punching—to
loud and boisterous, particularly when peers of get the attention of the opposite sex.
the opposite sex whose attention they would like
to attract are nearby. They are impulsive and Cognitive Development
very much like 2-year-old children in that The final stage, stage of formal operational
they want what they want immediately, not thought, begins at age 12 or 13 years and
when it is convenient for others. grows in depth over the adolescent years
Many 13-year-olds fall “in love.” At this age, (Piaget, 1969). This step involves the ability to
however, they may spend more time longing think in abstract terms and use the scientific
for someone than they do instituting an in- method to arrive at conclusions.
depth and rewarding relationship. With the ability to use scientific reasoning,
adolescents can plan their future. They can
Fourteen-year-olds are often quieter and create a hypothesis and think through the
more introspective They are becoming used probable consequences. Thinking abstractly
to their changing bodies, have more is what allows adolescents to project
confidence in themselves, and feel more self- themselves into the minds of others and
esteem. imagine how others view them or their
actions (display compassion).
Moral and Spiritual Development empty-calorie snacks so they are left poorly
Almost all adolescents question the existence nourished despite their large intake. One form
of God and any religious practices they have of adolescent rebellion is to refuse to eat
been taught (Kohlberg, foods that parents stress are good for them.
1984). This questioning is a natural part of
forming a sense of identity and establishing Adolescents who are slightly obese because of
a value system at a time in life when they draw prepubertal changes may begin low-calorie or
away from their families. starvation diets to lose excess weight. Some
develop eating disorders such as bulimia or
HEALTH PROMOTION FOR AN anorexia nervosa. A weight-loss diet may be
ADOLESCENT AND FAMILY appropriate but ensure that an adolescent
consumes sufficient calories and nutrients
Promoting Adolescent Safety for growth.
Parents need to have the courage to insist on
emotional maturity rather than age as the Recommended Dietary Reference Intakes
qualification for obtaining a driver’s license. An adolescent needs an increased number of
Some adolescents dismiss seat belts as calories to support rapid body growth. Foods
childish with carbohydrates, vitamins, protein, and
minerals are essential.
Drowning is another chief accident of The nutrients that are most apt to be
adolescence. Teaching all children to swim is deficient in diets are iron, calcium, and zinc.
not the only preventive measure, because some Females require a high iron intake not only
occur when good swimmers go beyond their because of increasing blood volume but also
capabilities on dares or in hopes of because iron begins to be lost with
impressing friends. menstruation. Girls with a heavy menstrual flow
(menorrhagia) may need to take an additional
Homicide and suicide, related to the easy iron supplement to prevent iron-deficiency
accessibility of guns to teenagers. Gang anemia
violence and the desire to protect themselves
from this can add to this problem. Accidental Increased calcium plus physical exercise is
gunshot in juries increase in early necessary for rapid skeletal growth as well as
adolescence, often for the same reason to “stockpile” calcium to prevent
youngsters want to impress friends. osteoporosis later in life.
It is important that both water and firearm
safety be taught creatively to adolescents by Zinc is necessary for sexual maturation and
encouraging problem solving rather than by final body growth. Good sources of iron are
lecturing, because they tend to rebel against meat and green vegetables; calcium is an
such lectures or claim that they have heard it abundant milk product; meat and milk are also
all before. high in zinc.

Promoting Nutritional Health Promoting Nutritional Health With a Varied

Adolescents are experiencing so much growth Diet
they may always feel hungry. If adolescents’
eating habits are unsupervised, they tend to eat Vegetarian Diets.
faddish or quick snack foods rather than more Vegetables generally contain fewer calories than
nutritionally sound ones because of both meat, adolescents need to consume large
hunger and peer pressure. Some adolescents amounts of vegetables to achieve an
turn away from the five pyramid food groups to adequate caloric intake with a vegetarian
eat great quantities of sweets, soft drinks, or diet. Textured vegetable protein such as tofu or
Quom can be added to meals to increase the Care of Teeth
amount of protein supplied and Adolescents are generally very conscientious
to help meet adolescent growth needs about tooth brushing because of a fear of
(Theobald, 2007). developing bad breath. They should continue
to use a fluoride paste rather than a brand
Some adolescents may find it difficult to advertised as providing white teeth. They should
follow a vegetarian diet because it makes continue to drink fluoridated water to ensure firm
them different from their peers and limits the enamel growth
foods they can eat. Be certain all adolescent
vegetarians are following a diet and not Sleep
eating only fruits and vegetables as a Although it is widely believed that everyone
method to lose weight. needs 8 hours of sleep a night, some need
more and others can adjust to considerably
Glycogen loading less. Because protein synthesis occurs most
Athletes need more carbohydrate or energy than readily during sleep and adolescents are
do people who do not engage in strenuous building so many new cells, adolescents may
activity, and the source of carbohydrate that best need proportionately more sleep than any
sustains athletes comes from the breakdown of other age group. In addition, since this is a
glycogen because this supplies a slow steady stress period similar to first grade,
release of glucose. It is a procedure used to adolescents may sleep restlessly as their
ensure there is adequate glycogen to sustain mind reworks the day’s tensions; even long
energy through an athletic event. periods of sleep, therefore, may not leave them
feeling refreshed. Attempting to get by with
Promoting Development of an Adolescent in too little sleep, because they are constantly
Daily Activities busy and because staying up late is a
Adequate sleep, hygiene, and exercise are symbol of the adult status they long for.
also important and should become an Frequent lack of sleep can lead to chronic
adolescent’s responsibility rather than the fatigue or depression.
parents’.
Exercise
Dress and Hygiene Adolescents need exercise every day both to
Adolescents are capable of total self-care and, maintain muscle tone and to provide an
because of their body awareness, may even be outlet for tension. Although they are
overly conscientious about personal hygiene constantly on the go, adolescents often
and appearance.They may take seriously receive little real exercise.
(without admitting it.. Providing time for self-
care, such as shampooing hair, is important to Promoting Healthy Family Functioning
include in an adolescent’s nursing care plan. Early adolescents may have many
When adolescents cannot trust or are disagreements with parents that stem partly
disappointed in their bodies, it is very from wanting more independence and partly
reassuring to be dressed exactly like from being so disappointed in their bodies. It
everyone else. is frustrating for children to be told by parents
Many adolescents spend their first paychecks they are too old to behave in a certain
entirely on clothing. Adolescents may have to manner when they still do not feel or look
mature fully, however, before they discover older. At other times, just when they begin to
their real person shows through their accept their maturing appearance, parents
clothing. tell them they are too young to do
something.
When a child reaches about age 15, parent– around them. Girls may also slouch to
child friction tends to peak. By this age, diminish the appearance of their breast size.
adolescents have discovered from careful This also can occur from carrying backpacks
observation that most adults are far from that are too heavy
perfect. School marks may slump as a reflection
of this “fallen angel” syndrome. Body Piercing and Tattoos
Body piercing and tattoos are a strong mark of
By the time 16 years old, adolescents generally adolescence (Armstrong, 2007). These acts
become more willing to listen and to talk have become a way for adolescents to make a
about problems. As a result, they may learn statement that they are different from their
that adults are not as inadequate as they parents. Be certain they know the symptoms of
previously thought. infection at a piercing or tattoo site (redness,
16-year-old children can understand adults are warmness, drainage, swelling, mild pain) and
only human. This changed perception does to report these to a health care provider if they
not mean an adolescent of 16 is calm and occur as serious staphylococcal or
quiet, free of parent–child discord. streptococcal infections can occur at piercing
sites.
Seventeen-year-olds who have stayed in
school are usually high school seniors; for most Fatigue
of them, this year is likely to be stormy. So many adolescents feel fatigued to some
Looking ahead to leaving a school system degree that this can be considered normal
with which they have been involved since they for the age group. Assess an diet, sleep
were very young may give a feeling of losing patterns, and activity schedules.. Note when
security. the fatigue began. A short period of extreme
Unfortunately, to prove they are old enough to tiredness is more likely to suggest disease
leave high school adolescents of this age may than a long, ill-defined report of always feeling
begin to experiment with drugs or alcohol, tired. If an adolescent’s sleep and diet appear
interpreting their use as the mark of being an to be adequate, the activity schedule is
adult. reasonable, and physical assessment suggests
no illness, then the fatigue may be of
Common Health Problems of an Adolescent emotional origin. It can be a means of
avoiding school, avoiding conflict with
Hypertension parents (when children appear ill, parents are
Hypertension is present if blood pressure is more sympathetic), or avoiding social
above the 95th percentile, or 127/81 mm Hg situations. Those who are understimulated by
for 16-year-old girls and 131/81 for 16-year- school may develop fatigue as a sign of
old boys for two consecutive readings in boredom.
different settings
Menstrual Irregularities
Poor Posture Menstrual irregularities can be a major health
Many adolescents demonstrate poor posture, a concern of adolescent girls as they learn to
tendency to round shoulders, and a adjust to their individual body cycles.
shambling, slouchy walk. This is due in part to
the imbalance of growth that arises from the Acne
skeletal system growing a little more rapidly Acne is a self-limiting inflammatory disease
than the muscles attached to it. Poor posture that involves the sebaceous glands that empty
particularly seems to develop in adolescents into hair shafts (the pilosebaceous unit). It is
who reach adult height before their peers. the most common skin disorder of
They slouch to appear no taller than anyone adolescence, occurring in as many as 80% to
95% of adolescents (Knox, 2008). It occurs months, probably because of increased
slightly more frequently in boys than in girls. exposure to the sun, which increases
The peak age for the lesions to occur in girls is epidermic peeling, or the reduction in stress
14 to 17 years; for boys, 16 to 19 years. as a result of being out of school.
Although not proved, genetic factors may play a
part in their development. Cigarette smoking Therapeutic Management.
may also increase the number of The goal of therapy for acne is threefold:
inflammatory lesions. (a) decrease sebum formation,
Before the rapid increase in androgen secretion, (b) prevent comedones, and
the sebaceous glands that enter into hair (c) control bacterial proliferation.
follicles are small and relatively inactive, so acne
is nonexistent. Changes associated with puberty External Medication. Medications that are
cause acne: applied externally peel away the superficial
• As androgen levels rise in both sexes, skin layer to prevent sebum plugs from
sebaceous glands become active. forming and are sufficient if only comedones
• Abnormal keratinization (cell growth) of the are present. The most frequently used over-the-
lining of the ducts occurs; this overgrowth counter medications contain benzoyl
obstructs the ducts. peroxide.Caution adolescents using a vitamin
• The output of sebum increases. Sebum is A cream to avoid prolonged sun exposure or
largely composed of lipids, mainly triglycerides. to use a sunblock of SPF 15 or higher,
• If all of the material formed cannot be because the preparation makes their skin more
eliminated to the skin surface because of the susceptible than usual to ultraviolet rays.
narrow gland ducts, the glands enlarge, and
trapped sebum causes whiteheads, or closed Systemic Medication. Isotretinoin
comedones. (Accutane), a form of vitamin A, is an
• As trapped sebum darkens from accumulation extremely effective oral drug for reducing
of melanin and oxidation of the fatty acid sebum production and abnormal
component on exposure to air, blackheads, or keratinization of gland ducts; it is prescribed
open comedones, form. for cystic acne. Without noticeable
• Bacteria (generally, Propionibacterium acnes) improvement, adolescents have a tendency to
lodge and thrive in the retained secretions, continue taking the higher dose or even
forming papules. increase the dose, hoping to initiate a faster
• Leakage of free fatty acid causes a dermal effect.
inflammatory reaction.
• If glands rupture, sebum is extruded into Other Treatment Methods. If inflammatory
adjacent skin, which produces reddened reactions from acne are extreme, a
inflammatory cysts. corticosteroid such as prednisone or a
nonsteroidal anti-inflammatory drug (NSAID)
> Acne is categorized as: may be prescribed. Cortisone may be injected
mild (comedones are present), directly into cystic lesions to reduce
moderate (papules and pustules are also inflammation. This type of injection may reduce
present), or keloid formation, which is why it is usually
severe (cysts are present). The most common reserved for adolescents who are prone to this
locations of acne lesions are the face, neck, permanent form of scarring. isotretinoin is
back, upper arms, and chest. Flare-ups are more often prescribed instead of estrogen for
associated with emotional stress, menstrual two reasons: (a) high estrogen levels tend to
periods, or the use of greasy hair creams or close epiphyseal centers of long bones, causing
makeup that can further plug gland ducts. bone growth to stop; and (b) long-term therapy
Lesions are less noticeable in summer does have potential side effects, including
embolism and thrombophlebitis and possibly • Making a detailed log of the amount they
breast and uterine cancer. Laser therapy is a eat, the time, and the circumstances
follow-up possibility to reduce the effect of (including how they felt while they were eating),
scarring. and then changing those circumstances
• Always eating in one place (the kitchen table)
Obesity instead of while walking home from school or
Most overweight adolescents have obese watching television
parents, suggesting that both inheritance and • Slowing the process of eating by counting
environment play a part in the development of mouthfuls and putting the fork down beside the
adolescent obesity. It can be difficult for plate between bites, and being served food on
adolescents to learn to like themselves small plates so helpings look larger
(achieve a sense of identity) if they do not These measures may be of little use, however,
like their reflection in a mirror. It is equally unless they are combined with a suitable diet
difficult if they are always excluded from and adequate exercise.
groups because of their weight. Led to the Despite all these interventions, weight reduction
suicide rate for obese adolescents being may not always be effective with adolescents.
higher than for non-obese adolescents For some, a more realistic goal might be to
(Whetstone, Morrissey, & Cummings, 2007). prevent additional weight gain until they
reach adulthood.
Health teaching with these adolescents needs to
begin with a discussion of “normal” weight. Concerns Regarding Sexuality and Sexual
If they do not begin this as adolescents, they will Activity
become obese adults. Exposure and acceptance of premarital sexual
relations in society, more adolescents engage in
A reducing diet of fewer than 1400 to 1600 high-risk sexual behaviors exposing them to
calories per day can rarely be tolerated by sexually transmitted infections or conception
adolescents. Such a diet would not provide (Fergus, Zimmerman, & Caldwell, 2007).
sufficient protein and could be deficient in As part of routine health assessment of
vitamins. If adolescents eat a diet that is too low adolescents and preadolescents, ask if they are
in protein for any length of time, they can sexually active or are concerned about
develop a faulty nitrogen balance, which can sexual risk behaviors (Hornor, 2007).
lead to seriously impaired growth. They
generally can adhere to a diet closer to 1800 Adolescents are usually interested in
calories per day. discussing sexuality concerns with a health
Adolescents could perhaps walk to school care provider because they are concerned
rather than ride, or walk the dog for three they are exposing themselves to HIV
blocks rather than one. These activities are infection or other sexually transmitted
generally preferable to formal exercises, such diseases and to pregnancy. At the same time,
push-ups, which can be viewed as punishment. it is a difficult topic for them to discuss. For
Adolescents who use overeating as their main adolescents who want to have intercourse, the
reaction to stress may require psychological primary reasons given are sexual curiosity
counseling rather than diet counseling if they (50% of boys; 24% of girls) and affection for
are to develop a more mature emotional their partner (25% of boys; 48% of girls). For
response. Behavior modification might be those who agree to have intercourse but do not
suggested really want to, the primary reasons given are
If the obesity is causing serious body image peer pressure (about 30%), curiosity (50% of
problems, lowered self-esteem, and depression. boys; 25% of girls), and affection for their
General measures to help adolescents partner (> 33%) (Nusbaum & Katsufrakis,
decrease overeating include: 2008).
Counseling can help improve their Repetitive, intrusive, and unwanted actions
perspective and learn how to say no. In to gain the individual’s attention or evoke
contrast, some adolescents would like to be fear. The usual stalker is a male who stalks a
sexually active but are not because they believe female who has rejected him. Stalkers instill fear
myths: early sexual relations will drain their into their victims by constant and threatening
strength and make them poor athletes; pursuit. In some instances, can resort to
having sex too early in life will stretch the attacking a victim and even murder if further
vagina and make sexual relations later on rejected.
unenjoyable. Unless these falsehoods are
explored through discussion. Stalking behavior begins as early as
Adolescence is also the time when they deal adolescence; May take place mainly through
with the realization they are gay or lesbian. the Internet (cyberstalking), but sending
Although this orientation is something they have unwanted e-mails or instant messages is still
been aware of for years, actually facing it and stalking. Advising adolescents not to put
accepting it is another step—and for many themselves in positions where they will be
families, a difficult one (Benson et al., 2007). vulnerable to being alone with a stalker, and
Offer support to adolescents who are having report stalking to law enforcement officers so
difficulty telling their parents about their they can obtain a restraining order to prevent the
perceived sexual orientation. To their surprise, stalker from coming near them any longer.
they often discover their parents already
know what they are going to say before it is Concerns Regarding Hazing
voiced. Hazing refers to demeaning or humiliating
rituals that prospective members have to
Sometimes adolescents use a mild cold or a undergo to join sororities, fraternities,
mild acne condition, where they hope that adolescent gangs, or sports teams (MASH,
someone will stumble onto their real concern 2008). Most rituals are secret and in the past
about sexual activity. Ask any questions or were accepted as “rites of passage.” In recent
problems they want to discuss with you about years, hazing has become so extreme that the
this. Ask if they are interested in learning practice has moved out of the “just fun”
more about contraception. Be certain they are category into activities that can cause physical
practicing safer sex measures and certainly psychological harm. Rituals
Caution adolescents about the dangers of may be as subtle as being called names,
flunitrazepam (Rohypnol), the “date-rape forced to wear ridiculous clothing, or engage
drug,” a colorless, odorless, and flavorless in crude or lewd skits.
benzodiazepine drug that, if dropped into a They also can be played to an extreme where
drink, can remain undetected but cause they’re punched or kicked, asked to pretend
drowsiness, impaired motor skills, and to perform a sexual act towards another,
amnesia (Karch, 2009). Adolescents who are sodomized, left out in the cold so long,
seen for sexual assault who appear frostbite develops, or forced to drink alcohol
intoxicated or have amnesia for the event until they vomit or pass out or even die from
should be suspected of unknowingly ingesting alcohol intoxication. Many of the rituals found
flunitrazepam. In these instances, a urine in this last category constitute criminal acts
specimen analysis will reveal the drug’s which will hold up in court if the evidence is
metabolites. If a clinic does not have the ability available (Sodl et al., 2008). Initiation for street
to do this type of test, the manufacturer of the gangs can require prospective members to
drug (Hoffmann-LaRoche Inc.) will assess steal or destroy property or even kill.
the presence of the drug. Parents need to be aware of what clubs or
organizations their adolescent is attempting to
Stalking join and what the requirements for
membership will be. Health care providers can Ketamine is an anesthetic used in veterinary
help adolescents make sound decisions about medicine that is also frequently abused. Every
what type of hazing their organization advocates house has a number of inhalants, such as a
by asking teenagers about the subject at health spray-type oil for cooking or gas, butane, or
assessments. lighter fluid, that can also be abused by
adolescents. Screening for abuse of inhalants
Concerns Regarding Substance Abuse or readiness to abuse such substances is
Substance abuse refers to the use of important, as inhalants can lead to cardiac
chemicals to improve a mental state or failure even on a first-time use (Williams &
induce euphoria. This is so common among Storck, 2007)
adolescents. Drug use occurs in adolescence
from a desire to expand consciousness or to Tobacco. Although it is well documented that
feel more confident cigarette smoking leads to increased
and mature; it also can be a response to peer cardiovascular and respiratory illnesses by
pressure or a form of adolescent rebellion. middle age. Adolescents usually begin smoking
This type of rebellion is more emotionally because the habit conveys a stamp of
charged than acts such as staying out late or maturity; smoking may be viewed as
wearing clothing other than those approved by especially desirable by those who are having
parents, because it is not only harmful but difficulty demonstrating maturity in other
also illegal. areas. One of the strongest determinants of
whether adolescents will begin smoking is
Types of Abused Substances whether their friends smoke. Although at one
Drugs that adolescents abuse are those they time proportionately more males than females
can obtain on limited budgets and through smoked, adolescent girls now are the
limited contacts. population most likely to begin smoking.

Prescription and Over-the-Counter Drugs It is well documented that adolescents are

May begin drug experimentation by taking influenced to begin smoking by advertising
sedatives, pain medication, or cough syrup (Lovato et al., 2009). Most school systems have
containing dextromethorphan, abbreviated extensive programs as early as grade school to
DXM, prescribed for another family member or a caution children against cigarette smoking
pet. A small amount of DXM causes and advertising. Unfortunately, the ultimate
lightheadedness. In larger doses, it can result danger of illness or death in middle age is
in distortions of color and sound, visual not a strong threat to young persons who are
hallucinations, or “out-of-body” experiences. interested only in the present.
This is called “pharming”; unaware of usual More effective, therefore, might be campaigns
dosages, adolescents who use drugs this way that point out cigarette smoking causes foul-
can easily overdose (Levine et al., 2007). smelling hair, clothes, and breath and this
detracts from physical appearance. Helping
Methylphenidate (Ritalin) is a drug frequently adolescents find other methods to
prescribed for attention-deficit/hyperactivity demonstrate their maturity, emphasizing that
disorder. When oral Ritalin tablets are crushed being able not to smoke is a sign of true
and injected intravenously, they offer a feeling maturity, may also be effective.
of giddiness and extreme well-being. Adolescents can be urged to quit cigarette
Unfortunately, because they do not completely smoking through enrolling in a formal
dissolve, the resultant small particles remaining cigarette withdrawal program.
in the bloodstream can result in pulmonary Nicotine gum and nicotine patches have both
embolus or emphysema. been successfully used with adolescents.
Remember that adolescents are very reluctant
to follow instructions that are given from a “do enhance lean body mass and muscular
as I say, not as I do” standpoint. Nurses who development and so improve their athletic
smoke, therefore, can have extreme difficulty ability or appearance. Anabolic steroids also
launching an effective campaign against the have the side effects of euphoria and lessened
habit with adolescents. fatigue, which make them doubly appealing
(Vertalino et al., 2007).
Stopping smoking is especially difficult
during periods of stress or inactivity. A return To obtain maximum effects, teenagers may be
visit for follow-up and health maintenance taking up to 30 times the therapeutic dose.
care might be a better time to introduce the This can lead to adverse effects, such as early
topic. closure of the epiphyseal line of long bones,
acne, elevated triglyceride levels,
Another source of nicotine that school-age hypertension, aggressiveness, possibly
children and adolescents may abuse is psychosis, abnormal liver function, and,
“smokeless tobacco,” or chewing tobacco perhaps, liver cancer.
(Percy, 2008). Although chewing tobacco does Need to be identified so they can be cautioned
not have the potential dangers of smoking that the use of such drugs is illegal in sports
tobacco in relation to lung disease, it can cause competition as well as being detrimental to
gingival recession and lip and mouth cancer their health. There is also concern that the use
and can be just as habit forming as of such drugs serves as a gateway to
cigarettes. additional drug use (Wagner & Anthony,
2007). If needles are shared, this can lead to
Alcohol. hepatitis B or HIV infection. Human growth
As many as 90% of high school seniors report hormone has the ability to increase muscle
having used alcohol. As many as 25% of high strength and stamina and is more difficult to
school students report having engaged in detect.
episodic heavy or binge drinking. Alcohol use Marijuana.
cannot be taken lightly,mit is linked to diseases (widely known as pot or grass) is derived from
such as cirrhosis, cognitive challenge, and the leaves and stems of the Indian hemp
destructive behaviors such as addiction, plant, Cannabis sativa. It is generally rolled
depression, and vulnerability to date rape. into cigarettes (“joints” or “reefers”) and
Environment has a definite role in the use of smoked, although it can be mixed with food or
alcohol, but heredity may play a part in sniffed. Scraping the resin from the flowering
whether an adolescent becomes addicted. leaves produces a much stronger substance
Many adolescents are not primary alcohol called hashish.
abusers but are the children of alcoholic
parents. Make an effort to identify this group of Sinsemilla is a seedless form that is even
children as well, not only to prevent them from more potent. Breakdown products of marijuana
becoming users of alcohol but also to help are not readily eliminated from the body but
them build self-esteem and coping abilities remain in the fatty cells of the brain. This
for the difficulties they face living in a possibly residue results in synaptic gaps that can delay
disorganized household. electrical brain waves and memory storage,
especially for short-term memory.
Performance-Enhancing Drug Abuse. Physical and psychological effects of
Anabolic steroids are derivatives of the marijuana are euphoria and a sense of well-
natural hormone testosterone. Common being, temporary impairment of coordination
names are stanozolol, an oral compound, and or motor activities, altered sensory
testosterone propionate, an injectable form. perceptions, rapid mood swings, altered self-
Adolescents take steroids (obtained illegally) to image, decreased attention span, and loss of
memory for recent events (up to 1 hour time). Crack, A stronger form, is manufactured by
Withdrawal symptoms include irritability, heating cocaine powder with baking soda
drowsiness, and cravings for high- and water. This preparation process is
carbohydrate snacks (Mendelson & Mello, dangerous in itself because it involves using
2008). volatile solvents that can ignite or explode.
Long-term side effects can include disorders The resulting drug, often called freebase or
such as sinusitis, bronchitis, emphysema, and rock, is so strong it can cause immediate
perhaps lung cancer (can develop after only 1 cardiac and respiratory arrhythmias
year of use compared with 20 years of use estimates range from 3% to 9%. adolescents
for cigarette smoking), and lack of sperm used cocaine.
formation or testicular cancer in males It is a major cause of cardiovascular arrest in
Despite its known dangers, marijuana is the young adults
most common illicit substance, next to
alcohol, used by adolescents. Because it is Cocaine is rarely ingested orally, but
used medically to relieve nausea and vomiting, occasionally adolescents swallow it when
adolescents may view it as harmless. trying to hide from parents. Gastric acid
Amphetamines. destroys the action of cocaine, so it is
Group of drugs sometimes used in the potentially harmless when swallowed in this
treatment of hyperactivity and narcolepsy, way.
among other central nervous system disorders. Teach adolescents that although cocaine
They are easily manufactured in “meth labs” sniffing may be fascinating and offer
in people’s homes and so are readily temporary pleasure and relief from stress, it
available to adolescents. Amphetamines are also causes psychological dependency and
called uppers or speed because they give the is potentially extremely dangerous because
user a false sense of well-being, alertness, or of its cardiac and respiratory effects. Injection
self-esteem (Degenhardt et al., 2007). of the substance exposes an adolescent to the
Ice- newer, stronger form that produces risk of HIV/acquired immunodeficiency
intense symptoms. Some of the side effects syndrome (AIDS), hepatitis.Cocaine taken
that can occur are aggressive or demanding during pregnancy can cause separation of the
behavior, paranoia, and extreme placenta with potential fetal and maternal
restlessness. death.
Chronic methamphetamine abuse results in
severe blackened, crumbling teeth. Because Hallucinogens.
amphetamines suppress the appetite, Examples of hallucinogenic drugs used by
adolescents may lose weight or eat only adolescents are:
sporadically while taking them. Their use lysergic acid diethylamide (LSD),
without a prescription is illegal. dimethyltryptamine (DMT), 2,5-dimethoxy-4-
methamphetamine(STP), phencyclidine
Cocaine hydrochloride (PCP), and methaqualone
One of the most popular drugs of abuse for (Quaalude).
young adults and its use may begin in Adolescents report seeing colors more vividly
adolescents. The drug may be sniffed into the than they have ever seen before, hearing
nose (snorted), smoked, or injected sounds so clear they cause physical pain,
intravenously. Occasionally it is combined with and perceiving themselves as being totally
heroin and injected (termed a speedball). impervious to harm. The effect of such drugs
Common street names for cocaine are snow can be extremely pleasurable (described as a
and white lady, because of its fine, white “good trip”) or extremely terrifying (a “bad
powder. trip”). Recurrences or flashbacks of drug-
induced experiences may recur at ● The developmental task of an adolescent
unpredictable times and in unexpected places. according to Erikson is to establish
independence from parents by gaining a sense
Opiates. of identity versus role confusion.
Drugs such as heroin, meperidine (Demerol), Adolescents, therefore, usually respond best to
and morphine. Opiates can be extremely health care personnel who respect their
dangerous because of their tendency to attempts at independence and allow them as
decrease respiratory rate. Addiction to opiates many choices as possible in care.
can cause such a Physiologic craving that ● Adolescents reach a point of cognitive
adolescents, like adults, will steal, defraud, turn development termed formal operational
to prostitution, or resort to whatever method thought. With this gained, they are able to
is available to secure enough money to buy a think in abstract terms and use the scientific
day’s supply. In addition, risk the danger of method to arrive at conclusions.
contracting HIV/AIDS and hepatitis B ● Adolescents need to consume adequate
infection if they share contaminated needles. calories and especially protein, iron, calcium,
“Snorting” heroin can lead to acute cerebral and zinc to meet their increased growth
vascular accident and death. needs.
● To appear older than they are, some
Assessment of Substance Abuse adolescents present an assured, “I know that”
If adolescents trust health care personnel, attitude. To be effective, health teaching may
they will generally admit they have engaged have to be introduced with “I know you know
in drug experimentation: this, so I’ll just review it” approach that
• Failure to complete assignments in school allows an adolescent to maintain a mature
• Demonstration of poor reasoning ability front, while gaining additional information.
• Decreased school attendance ● Being an adolescent is difficult in today’s
• Frequent mood swings world. Be aware that, to reduce stress, some
• Deteriorating physical appearance adolescents begin to use substances of
• Recent change in peer group abuse. Asking about an adolescent’s drug
•Expressed negative perceptions of parents experiences, if any, during a health assessment
These are not necessarily diagnostic findings, is not intruding on privacy; it is conducting safe
however, they can also be part of an health interviewing.
adolescent’s search for identity. Substance ● Promoting adolescent safety is an important
abuse can be strongly suspected in an nursing role. Motor vehicle accidents,
adolescent who is hospitalized for hepatitis B homicide, drowning, and suicide are leading
or who is HIV positive, causes of death in this age group.
● Common health problems in an adolescent
are sometimes minor and include poor posture,
fatigue, or acne; they can also be serious, such
Key Points for Review as beginning hypertension, substance abuse,
● The major milestones of development in the and scoliosis. Identifying these problems and
adolescent period are the onset of puberty and referring an adolescent for help are important
the cessation of body growth. Between these nursing actions.
milestones, physical growth is rapid, although
the development of adult coordination and
thought processes is slow.
● The development of secondary sex
characteristics is completed during
adolescence. These are rated according to
Tanner stages.