CHAPTER 12. The Adolescent Patient
Maureen Schnur and Kerrie Talbot
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Identify the stages of adolescence and three developmental considerations for each one.
2. Identify two legal issues related to the adolescent patient.
3. List two common responses of the adolescent to surgery/hospitalization and effective communication techniques to use in caring for them.
4. Name two interventions that may enhance care of the adolescent patient with sensory challenges.
5. Identify two suggested approaches to performing a physical examination in an adolescent.
6. Identify two potential risks related to the perianesthesia care of adolescents with body piercing(s).
7. Identify an optimal postoperative position for the obese patient.
8. Identify two safety concerns to discuss with the adolescent upon discharge.
I. CLASSIFICATION BY AGE
A. Eleven through 21 years of age
B. Transition from childhood to adulthood
1. Biologic changes
2. Psychosocial changes
C. Three stages
1. Early adolescence
2. Middle adolescence
3. Late adolescence
II. GROWTH AND DEVELOPMENTAL CONSIDERATIONS (Table 12-1)
A. Early adolescence
1. Eleven to 14 years of age
2. Period of growth acceleration
a. Increase in appetite in response to rapid growth
3. Biologic development
a. Girls
(1) Development of breast tissue
(2) Begin to put on fat
(3) Slightly taller and heavier than boys
(4) Beginning of hair growth
(a) Pubic
(b) Axillary
(5) Menarche
b. Boys
(1) Enlargement of testes
(2) Transient gynecomastia
(3) Spermatogenesis
4. Motor development
a. Increase in gross muscle mass
b. Increase in fine motor coordination
c. Prone to ligament tears
d. Awkward, gangly period
5. Psychosocial development
a. Erikson theory
(1) Stage of identity versus role confusion (12-18 years of age)
(a) Corresponds to Freud’s genital stage
(b) Characterized by rapid physical changes
(c) Adolescents become preoccupied with appearance (how they look to others).
b. Freud theory
(1) Genital stage (age 12 and older)
(a) Begins with puberty
(b) Reproductive system and sex hormones mature.
(c) Genital organs become major source of sexual tensions and pleasures.
(d) Period of forming relationships and preparing for marriage
c. Other characteristics
(1) Shy, awkward
(2) Adjusting to middle school
(3) Move from operational thinking to formal, logical operations and increasingly able to:
(a) Manipulate abstractions
(b) Reason from principles
(c) Weigh multiple points of view according to varying criteria
(4) More at ease with same sex
(a) Increased activity with peers
(i) Conformity and cliques
(b) Less activity with family
(5) Increase in self-consciousness
(a) Adolescents meticulous about their appearance
(b) Think everyone is looking at them
(6) Low self-esteem
(7) Increase in rebellious behavior
(8) Increase in independence
(9) Increase in sexual interest
(a) Interest is greater than sexual activity
(b) Often have questions about sexual changes they are experiencing
B. Middle adolescence
1. Fifteen to 17 years of age
2. Biologic development
a. Girls
(1) Height increases.
(2) Breast size increases.
(3) Growth of pubic hair increases.
(4) Sexual maturation occurs.
(5) Shoulder-to-hip proportions are becoming those of an adult woman.
(6) Growth acceleration declines.
(7) Appetite decreases.
b. Boys
(1) Voice changes.
(2) Larynx enlarges.
(3) Muscle mass enlarges.
(4) Strength increases.
(5) Shoulders widen.
(6) Facial hair growth begins.
(7) Height increases rapidly.
(8) Appetite increases.
(9) Size of genitalia increases.
(10) Transient gynecomastia decreases.
c. Both sexes
(1) Acne may develop and be a problem.
(2) Body odor increases as sweat glands further develop.
(3) Dentition is completed.
(4) Sensory and language development are complete.
(5) Capacity of cardiovascular pump increases.
(a) Heart size doubles.
(b) Blood pressure, blood volume, and hematocrit increase.
(6) Lung capacity doubles.
(7) Physiologic need for sleep increases.
3. Motor development
a. Physical endurance increases.
b. Skill in sports increases.
c. Fine and gross muscle coordination increases.
4. Psychosocial development
a. Increased conflicts with parents
b. Mood swings
(1) Impulsive
(2) Impatient
(3) Narcissistic
(4) Moody
c. Test established limits
d. Privacy very important
e. Peer group very important
f. Abstract thoughts increase.
(1) Tend to question and analyze everything
(2) Become more self-centered
5. Sexual development
a. Sexual experimentation begins.
b. Degree of sexual activity varies.
c. Begin to sort out sexual identity
(1) Form beliefs regarding love, honesty, and propriety
d. May choose monogamous or polygamous experimentation, or celibacy
e. Knowledgeable regarding risk of pregnancy, acquired immunodeficiency syndrome, and other sexually transmitted diseases
(1) Knowledge does not necessarily influence behavior.
6. Development of self-concept
a. Period of experimentation
(1) Peers less important
(2) Change style of dress
(3) May change group of friends
b. Deal with inner turmoil
7. Development of relationships
a. Parental relationship strained
(1) May become distant
(2) Dating may become source of conflict.
b. Physical attractiveness remains important.
c. Acceptance by a peer group promotes positive peer relationships and self-esteem.
d. Begin to identify career path
(1) Life skills
(2) Opportunities
e. Positive role models crucial at this stage of development
C. Late adolescence
1. Eighteen to 20 years of age or beyond
2. Biologic development
a. Growth slows
b. No neurological developmental changes apparent
c. Cardiopulmonary capacity relatively mature
3. Psychosocial development
a. Aware of own strengths and limitations
b. Establish own value system
c. Cognition tends to be less self-centered.
(1) Able to express thoughts and feelings about various aspects of life (e.g., justice, patriotism, history)
(2) Idealistic about love, social issues, ethics and lifestyles
d. Social relationships more mature
e. Conformity less important
f. Turbulence with parents decreases.
g. Prepare to leave home
4. Sexual development
a. More commitment to intimate relationships
b. More realistic concept of a partner’s role
5. Self-concept
a. Self-esteem increases.
(1) More stable body image
b. Social roles defined and articulated
(1) Career decisions become important.
(2) Self-concept increasingly tied to role in society (e.g., student, worker, parent)
6. Relationships
a. Separation from parents
(1) Emotional and physical
b. Gain independence from family
| Early Adolescence (11-14 yr) | Middle Adolescence (15-17 yr) | Late Adolescence (18-20 yr) | |
|---|---|---|---|
| Growth |
▪ Rapidly accelerating growth
▪ Reaches peak velocity
▪ Secondary sexual characteristics appear
|
▪ Growth decelerating in girls
▪ Stature reaches 95% of adult height
▪ Secondary sexual characteristics well advanced
|
▪ Physically mature
▪ Structure and reproductive growth almost complete
|
| Cognition |
▪ Explores newfound ability for limited abstract thought
▪ Clumsy groping for new values and energies
▪ Comparison of “normality” with peers of same sex
|
▪ Developing capacity for abstract thinking
▪ Enjoys intellectual powers, often in idealistic terms
▪ Concern with philosophic, political, and social problems
|
▪ Established abstract thought
▪ Can perceive and act on long-range options
▪ Able to view problems comprehensively
▪ Intellectual and functional identity established
|
| Identity |
▪ Preoccupied with rapid body changes
▪ Trying out of various roles
▪ Measurement of attractiveness by acceptance or rejection by peers
▪ Conformity to group norms
|
▪ Modifies body image
▪ Very self-centered, increased narcissism
▪ Tendency toward inner experience and self-discovery
▪ Has rich fantasy life
▪ Idealistic
▪ Able to perceive future implications of current behavior and decisions; variable application
|
▪ Body image and gender role definition nearly secured
▪ Mature sexual identity
▪ Phase of consolidation of identity
▪ Stability of self-esteem
▪ Comfortable with physical growth
▪ Social roles defined and articulated
|
| Relationships with parents |
▪ Defining independence and dependence boundaries
▪ Strong desire to remain dependent on parents while trying to detach
▪ No major conflicts over parental control
|
▪ Major conflicts over independence and control
▪ Low point in parent and child relationship
▪ Greatest push for emancipation; disengagement
▪ Final and irreversible emotional detachment from parents; mourning
|
▪ Emotional and physical separation from parents completed
▪ Independence from family with less conflict
▪ Emancipation nearly secured
|
| Relationships with peers |
▪ Seeks peer affiliations to counter instability generated by rapid change
▪ Upsurge of close, idealized friendships with members of same sex
▪ Struggle with mastery within peer group
|
▪ Strong need for identity to affirm self-image
▪ Behavioral standards set by peer group
▪ Acceptance by peers extremely important—fear of rejection
▪ Exploration of ability to attract opposite sex
|
▪ Peer group recedes in importance in favor of individual friendship
▪ Testing of romantic relationships against possibility of permanent alliance
▪ Relationships characterized by giving and sharing
|
| Sexuality |
▪ Self-exploration and evaluation
▪ Limited dating, usually group
▪ Limited intimacy
|
▪ Multiple plural relationships
▪ Internal identification of heterosexual, homosexual, or bisexual attractions
▪ Exploration of “self-appeal”
▪ Feeling of “being in love”
▪ Tentative establishment of relationships
|
▪ Forms stable relationships and attachment to another
▪ Growing capacity for mutuality and reciprocity
▪ Dating as a romantic pair
▪ May publicly identify as gay, lesbian, or bisexual
▪ Intimacy involves commitment rather than exploration and romanticism
|
| Psychological health |
▪ Wide mood swings
▪ Intense daydreaming
▪ Anger outwardly expressed with moodiness, temper outbursts, verbal insults and name calling
|
▪ Tendency toward inner experiences, more introspective
▪ Tendency to withdraw when upset or feelings are hurt
▪ Vacillation of emotions in time and range
▪ Feelings of inadequacy common, difficulty asking for help
|
▪ More constancy of emotion
▪ Anger more likely to be concealed
|
III. ADOLESCENT RESPONSE TO SURGERY/HOSPITALIZATION
A. Loss of control
1. A planned procedure (scheduled surgery) allows a greater sense of control than an unplanned (emergency) procedure.
2. Want to be in control
3. May resist dependence
4. May react to loss of control with anger, withdrawal, uncooperativeness, or refusal to follow rules
5. Often feel isolated and unable to obtain adequate support
B. Fear
1. Fear bodily injury, pain and how illness is viewed by peers
a. Activity limitations
b. Appearance
2. May refuse to cooperate if treatment does not fit into lifestyle
3. May project image of “calm and cool” even though they are anxious and/or scared
4. May question everything or appear confident
5. Able to describe degree of pain
C. Separation anxiety
1. May or may not want parents involved
2. May become more dependent on parents
3. Separation from friends increases anxiety.
D. Emotional and behavioral considerations
1. Adolescents use a range of modalities from sophisticated verbal or written expression to motor activity.
2. May regress in behavior
3. Thoughts, feelings, and fears may be shared with friends, especially peers.
4. Major fears and worries
a. Uncertainty about self as a person
b. Concerned about whether or not body, thoughts, and feelings are normal
IV. FAMILY-CENTERED CARE (see Chapter 11)
A. Support system
1. Recognize the increasing maturity and independence of the adolescent, respecting his or her wishes for involvement of family/accompanying significant others as appropriate.
2. Determine the responsible adult accompanying the adolescent.
3. Provide education that it is not unusual for the adolescent to regress, withdraw, or act out.
B. Emergency situations
1. Parents experience stress.
a. Fear and anxiety most common emotions
b. Parent fears that adolescent may:
(1) Experience pain
(2) Suffer permanent changes
(3) Be diagnosed with chronic or terminal illness, or even die
2. Cause of stress is unique to circumstances.
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