Adult Growth and Development PDF

OBJECTIVES After mastering the contents of this chapter, you should be able to: 1936 1. Describe normal growth and development and common parental concerns of the adolescent period. 2. Identify 2020 National Health Goals related to adolescents that nurses could help the nation achieve. 3. Assess an...

OBJECTIVES After mastering the contents of this chapter, you should be able to: 1936 1. Describe normal growth and development and common parental concerns of the adolescent period. 2. Identify 2020 National Health Goals related to adolescents that nurses could help the nation achieve. 3. Assess an adolescent for normal growth and development milestones. 4. Formulate nursing diagnoses related to adolescent growth and development or common parental concerns. 5. Identify expected outcomes for nursing care of an adolescent as well as help parents manage seamless transitions across differing healthcare settings. 6. Using the nursing process, plan nursing care that includes the six competencies of Quality & Safety Education for Nurses (QSEN): Patient-Centered Care, Teamwork & Collaboration, Evidence-Based Practice (EBP), Quality Improvement (QI), Safety, and Informatics. 7. Implement nursing care related to growth and development or special needs of an adolescent, such as organizing a discussion group on ways to prevent substance use disorders. 8. Evaluate expected outcomes for achievement and effectiveness of care. 9. Integrate knowledge of adolescent growth and development with the interplay of nursing process, the six competencies of QSEN, and Family Nursing to promote quality maternal and child health nursing care. Adolescence is generally defined as the period between ages 13 and up to 20 years, a time that serves as a transition between childhood and becoming a late adolescent. It can be divided into an early period (13 to 14 years), a middle period (15 to 16 years), and a late period (17 to 20 years). During all periods, adolescence is defined not so much by chronologic age as by physiologic, psychological, and sociologic changes. The drastic change in physical appearance and the change in expectations of others (especially parents) that occur during the period can lead to both emotional and physical health concerns (Sass & Kaplan, 2016). Adolescents invariably feel a sense of pressure throughout this period because they are mature in some respects but still young in others. For example, an adolescent’s sexual interests are awakening, yet personal or parental pressures discourage sexual exploration. An adolescent may not feel mature enough to live away from home, yet parents and teachers may urge the adolescent to apply for an out-of-town college. This duality causes a major dilemma or conflict for an adolescent, leading to many of the growth and developmental concerns of the age (Ahern & Norris, 2011). The 2020 National Health Goals related to adolescence are shown in Box 33.1. BOX 33.1 Nursing Care Planning Based on 2020 National Health Goals 1937 Health teaching in the adolescent years is important because healthy habits begun at this time can influence health over a lifetime. For this reason, a number of 2020 National Health Goals relate to adolescent health, including: Reduce the number of adolescents who are obese from a prevalence of 17.9% to 16.1%. Reduce the proportion of high school students engaging in binge drinking from 25.2% to 22.7%. Reduce cigarette use by adolescents from 19.5% to 16%. Reduce the rate of smokeless tobacco use by adolescents from 8.9% to 6.9%. Reduce the proportion of adolescents who are offered, sold, or given an illegal drug on school property from 22.7% to 20.4%. Reduce the proportion of adolescents who report they rode, during the previous 30 days, with a driver who was drinking alcohol from 28.3% to 25.5%. Reduce the rate of suicide attempts by adolescents from 1.9% to 1.7%. Increase the proportion of adolescents who meet current federal physical activity guidelines for aerobic physical activity from 18.4% to 20.2% (U.S. Department of Health and Human Services, 2010; see www.healthypeople.gov). Nurses can help the nation achieve these goals by educating adolescents about the use of cigarettes, smokeless tobacco, alcohol, and substance use disorder and by acting as support people for adolescents during times of crisis to help prevent self-injury or suicide. Nursing Process Overview FOR HEALTHY DEVELOPMENT OF AN ADOLESCENT ASSESSMENT Health maintenance visits during adolescence may become more irregular because adolescents may not seek care from healthcare facilities on their own unless they are ill. Until adolescents need a physical examination for athletic or some other clearance, they are often not seen for health assessments. When adolescents are accompanied by their parents at health visits, it is best to obtain a health history separately from the adolescent to promote independence and responsibility for self care. When performing physical examinations on adolescents, be aware they may be very self-conscious of their body. They need health assurance and appreciate comments such as “Your blood pressure is 120/70, which is healthy,” so they can learn more about their rapidly changing bodies. NURSING DIAGNOSIS Nursing diagnoses for adolescents can cover a wide range of topics. Frequently used diagnoses related to adolescents and their families include: Health-seeking behaviors related to normal growth and development Low self-esteem related to facial acne 1938 Anxiety related to concerns about normal growth and development Risk for injury related to peer pressure to use alcohol and drugs Risk for disease related to sexual activity Readiness for enhanced parenting related to increased knowledge of teenage years OUTCOME IDENTIFICATION AND PLANNING When planning care with adolescents, respect the fact that they have a strong desire to exert independence or do things their own way. This means they are not likely to adhere to a plan of care that disrupts their lifestyle or makes them appear different from others their age. Because of this, including them in planning is essential so the plan will be agreeable and accepted. Establishing a contract, such as asking an adolescent to agree to take medication daily, may be the most effective means to reach a mutual understanding. Remember that adolescents are very oriented to the present, so a program that provides immediate results, such as increased respiratory function, will usually be carried out well. In contrast, a regimen oriented toward the future, with long-term goals such as preventing hypertension at middle age, may not be as successful. This does not mean it is not important to teach adolescents about the necessity of reducing future health risks—by eating well, not smoking, and generally taking care of their bodies—but that information will be best accepted if geared as much as possible to specific, short-term benefits to their health. Refer patients and families to helpful websites and other resources when appropriate (see Chapter 28). IMPLEMENTATION Adolescents tend to do poorly with tasks someone tells them they must do. Integrating the adolescents in their plan of care typically helps them be successful. Adolescents have little patience with adults who do not demonstrate the behavior they are being asked to achieve; a parent or nurse who smokes and asks an adolescent not to smoke, for example, will probably not be successful. For best results, evaluate how an intervention appears from an adolescent’s standpoint before beginning teaching. OUTCOME EVALUATION An evaluation of expected outcomes should include not only whether desired outcomes have been achieved but also whether adolescents are pleased with the outcome. Individuals will have difficulty accomplishing desired goals as adults unless they have high self-esteem that includes feeling secure in their new body image. Examples of outcome criteria that might be established include: Patient states she feels good about herself even though she is the shortest girl in her class. Patient states he has not consumed alcohol in 2 weeks. Parents state they feel more confident about their ability to parent an adolescent. Patient states she feels high self-esteem despite persistent facial acne. 1939 Growth and Development of an Adolescent Adolescents both grow rapidly and mature dramatically during the period from age 13 to 18 to 20 years. PHYSICAL GROWTH The major milestones of physical development in the adolescent period are the onset of puberty at 8 to 12 years of age and the cessation of body growth around 16 to 20 years (Sass & Kaplan, 2013). Between these milestones, physiologic growth and development of adult coordination occur. At first, the gain in physical growth is mostly in weight, leading to the stocky, slightly obese appearance of prepubescence; later comes the thin, gangly appearance of late adolescence. Most girls are 1 to 2 in. (2.4 to 5 cm) taller than boys coming into adolescence but generally stop growing within 3 years from menarche and so are shorter than boys by the end of adolescence. Boys typically grow about 4 to 12 in. (10 to 30 cm) in height and gain about 15 to 65 lb (7 to 30 kg) during their teenage years. Girls grow 2 to 8 in. (5 to 20 cm) in height and gain 15 to 55 lb (7 to 25 kg). Growth stops with closure of the epiphyseal lines of the long bones, which occurs at about 16 or 17 years of age in females and about 18 to 20 years of age in males. Because the heart and lungs increase in size more slowly than the rest of the body, adolescents may have insufficient energy and become fatigued trying to finish the various activities that interest them. Pulse rate and respiratory rate decrease slightly (to 70 beats/min and 20 breaths/min, respectively), and blood pressure increases slightly (to 120/70 mmHg) by late adolescence. With adulthood, blood pressure becomes slightly higher in males than in females because more force is necessary to distribute blood to the larger male body mass. All during adolescence, androgen stimulates sebaceous glands to extreme activity, sometimes resulting in acne, a common adolescent skin problem. Apocrine sweat glands (i.e., glands present in the axillae and genital area, which produce a strong odor in response to emotional stimulation) form shortly after puberty. Adolescents begin to notice they must shower or bathe more frequently than when they were younger in order to be free of body odor because of this change. Teeth Adolescents gain their second molars at about 13 years of age and their third molars (wisdom teeth) between 18 and 21 years of age. Third molars may erupt as early as 14 to 15 years of age. The jaw reaches adult size only toward the end of adolescence, however. As a result, adolescents whose third molars erupt before the lengthening of the jaw is complete may experience pain and may need these molars extracted because they do not fit their jawline (Marciani, 2012). 1940 What If... 33.1 Raul, a 15-year-old male, asks the nurse if he’s going to grow some more; being the shortest boy in his gym class makes him feel “left out.” Also, he asks if his teeth are white enough. Are these common concerns of adolescents? Puberty Puberty is the time at which an individual first becomes capable of sexual reproduction. A girl has entered puberty when she begins to menstruate; a boy enters puberty when he begins to produce spermatozoa. These events usually occur between ages 11 and 14 years. The age of first menstruation in girls is gradually decreasing from a mean of 13 years to 12.4 years, which is probably related to more weight gain in girls (Ledger, 2012). Puberty creates many questions for early teenagers about what is normal and what is not (Marván & Molina-Abolnik, 2012). Secondary Sex Changes Secondary sex characteristics, such as body hair configuration and breast growth, are those characteristics that distinguish the sexes from each other but that play no direct part in reproduction. The secondary sex characteristics that began in the late school-age period (see Chapter 32) continue to develop during adolescence. Typical stages of sexual maturation are shown in Table 33.1. TABLE 33.1 SEXUAL MATURATION IN ADOLESCENTS Age (years) Males Females 13–15 Growth spurt continuing; pubic hair abundant and curly; testes, scrotum, and penis enlarging further; axillary hair present; facial hair fine and downy; voice changes happen with annoying frequency Pubic hair thick and curly, triangular in distribution; breast areola and papilla form secondary mound; menstruation is ovulatory, making pregnancy possible 15–16 Genitalia adult; scrotum dark and heavily rugated; facial and body hair present; sperm production mature Pubic hair curly and abundant; may extend onto medial aspect of thighs; breast tissue appears adult; nipples protrude; areolas no longer project as separate ridges from breasts; may have some degree of facial acne 1941 16–17 Pubic hair may extend along medial aspect of thighs; testes, scrotum, and penis adult in size; may have some degree of facial acne; gynecomastia (enlarged breast tissue), if present, fades End of skeletal growth 17–18 End of skeletal growth From Tanner, J. M. (1962). Growth at adolescence (2nd ed.). Oxford, United Kingdom: Blackwell. Sexual maturity in males and females is classified according to Tanner stages, named after the original researcher on sexual maturity (Tanner, 1962). Tanner stages of female sexual development are shown in Figure 33.1, and stages of male genital growth are shown in Figure 33.2. Figure 33.1 (A) Female breast development. Sex maturity rating 1 (not shown): Prepubertal; elevation of papilla only. Sex maturity 1942 rating 2: Breast buds appear; areola is slightly widened and projects as a small mound. Sex maturity rating 3: Enlargement of the entire breast with no protrusion of the papilla or the nipple. Sex maturity rating 4: Enlargement of the breast and projection of areola and papilla as a secondary mound. Sex maturity rating 5: Adult configuration of the breast with protrusion of the nipple; areola no longer projects separately from remainder of breast. (B) Female pubic hair development. Sex maturity rating 1: Prepubertal; no pubic hair. Sex maturity rating 2: Straight hair extends along the labia and, between rating 2 and 3, begins on the pubis. Sex maturity rating 3: Pubic hair increases in quantity, becomes darker, and is present in the typical female triangle but in a smaller quantity. Sex maturity rating 4: Pubic hair more dense, curled, and adult in distribution but less abundant. Sex maturity rating 5: Abundant, adult-type pattern; hair may extend onto the medial part of the thighs. (Adapted from Tanner, J. M.. Growth at adolescence [2nd ed.]. Oxford, United Kingdom: Blackwell.) Figure 33.2 Male genital and pubic hair development. Ratings for pubic hair and for genital development can differ in a typical boy at any given time because pubic hair and genitalia do not necessarily develop at the same rate. Sex maturity rating 1: Prepubertal; no pubic hair; genitalia unchanged from early childhood. Sex maturity rating 2: Light, downy hair develops laterally and later becomes dark; penis and testes may be slightly larger; scrotum becomes more textured. Sex 1943 maturity rating 3: Pubic hair extends across the pubis; testes and scrotum are further enlarged; penis is larger, especially in length. Sex maturity rating 4: More abundant pubic hair with curling; genitalia resemble those of an adult; glans has become larger and broader; scrotum is darker. Sex maturity rating 5: Adult quantity and pattern of pubic hair, with hair present along inner borders of thighs; testes and scrotum are adult in size. (Adapted from Tanner, J. M.. Growth at adolescence [2nd ed.]. Oxford, United Kingdom: Blackwell.) QSEN Checkpoint Question 33.1 INFORMATICS The nurse realizes Raul is concerned about developing body odor and that he has consulted some websites that address this problem. The nurse recognizes a valid and reliable website would cite which aspect is true of body odor in adolescents? a. It is largely dependent on ethnicity and body type. b. It is caused by an increase in the activity of apocrine glands. c. Poor hygiene is the main cause of adolescent body odor. d. Body odor can result from clogged sebaceous glands. Look in Appendix A for the best answer and rationale. DEVELOPMENTAL MILESTONES The same assessment categories of younger children continue to apply to adolescents. Play or Recreation Thirteen-year-old children change from school-age activities of active games to more adult forms of recreation such as listening to music, texting or chatting, or following a sports team’s wins and losses. Team (or school) loyalty becomes intense and following a coach’s instructions becomes mandatory, similar to the loyalty 6-year-old children showed toward their first-grade teacher. Overuse injuries from athletics occur in early adolescence until adolescents learn more about their limits and begin to respect the advice of adults on being well prepared and trained for sports participation. Most adolescents spend a great deal of time just talking with peers as social interaction, either face-to-face or through electronic media. Conflict can arise if parents disapprove of the number of hours spent in this activity, afraid their children are wasting important hours, or at least exchanging a great deal of trivial conversation. For an adolescent, however, talking is no more a waste of time than was imaginative play as a preschooler. It is a major way they learn about values and responsibilities (Box 33.2). BOX 33.2 Nursing Care Planning to Respect Cultural Diversity 1944 In the United States, as in most developed countries, adolescence covers a long time span. In developing countries, in contrast, adolescence tends to be much shorter because children must take full-time jobs early in life to help support their families. Socioeconomic factors also influence the length of adolescence across all cultures. Recognizing that adolescents may have differing responsibilities and life experiences based on cultural expectations can be useful when making a progress assessment. In a family in which an adolescent is expected to begin working full-time or marry at an early age, you may need to include in health teaching factors such as occupational hazards or the effects of a job, family, and financial stress on an adolescent. Readiness for early childbearing may also be important. Beginning at age 16 years, most adolescents want part-time jobs to earn money. Such jobs can teach young people how to work with others, accept responsibility, and how to save and spend money wisely. For their own sake and that of the children they will care for, if adolescents plan to babysit, they first need to learn basic rules of childcare and safety. In most communities, schools or Red Cross organizations offer courses in babysitting just for the teenager. Many adolescents engage in charitable endeavors during middle to late adolescence as a form of recreation. They do well organizing and supervising swimming or gym programs for physically challenged children or participating in marathons. A high school club may be organized to send money to children overseas. These activities fulfill an adolescent’s need for satisfying interaction with others as well as indicators of maturity and willingness to accept adult roles. EMOTIONAL DEVELOPMENT According to Erikson (Dunkel & Harbke, 2017), the developmental task in early and mid-adolescence is to form a sense of identity versus role confusion. In late adolescence, it is to form a sense of intimacy versus isolation. Early Adolescent Developmental Task: Identity Versus Role Confusion The task of forming a sense of identity is for adolescents to decide whom they are and what kind of person they will be. The four main areas in which they must make gains to achieve a sense of identity include: 1. Accepting their changed body image 2. Establishing a value system or what kind of person they want to be 3. Making a career decision 4. Becoming emancipated from parents If young people do not achieve a sense of identity, they can have little idea what kind of person they are or may develop a sense of role confusion (Dunkel & Harbke, 2017).This can lead to difficulty functioning effectively as adults because they are unable, for example, to decide what stand to take on a particular issue or how to 1945 approach new challenges or situations. This can lead them to exhibit acting-out (attention-getting) behaviors because they believe it is better to have a negative image than to have none at all. Body Image Adolescents who were able to develop a strong sense of industry during their school-age years learned to solve problems and are best equipped to adjust to the changing body image that comes with adolescence. This adjustment to changes is not always easy, however, because adolescents can feel disappointed with their final height or general appearance. As adolescents are usually their own worst critics with regard to their bodies, they may need help from healthcare providers to realize the characteristics that make someone creative, compassionate, and fun to be with, not one’s physical appearance, are the qualities on which lasting relationships are built. Self-Esteem Like body image, self-esteem may undergo major changes during the adolescent years and can be challenged by all the changes that occur during adolescence (Garzon & Dunn, 2013). Help parents understand how important it is for adolescents to have immediate successes such as making the high school basketball team or having a date for the senior prom. Parental comments, such as “When you’re older, these things won’t be so important,” are not likely to erase the hurt that comes from being 16 years old and not being included in such major events. Compassionate understanding (“It’s hard to be left out”) is a better communication technique. In recent years, a number of researchers have looked at the differences in the way boys and girls handle these emotional crises of adolescence. Several researchers have proposed that adolescence is a period of particular crisis for girls who are trying to find a place in a male-dominated society. The sociologist Carol Gilligan and her colleagues interviewed more than 500 girls between the ages of 7 and 16 years over a 5-year period and found many girls who, at age 11 years, were feisty, confident, and eager to speak their minds became hesitant to voice their opinions aloud by early adolescence, having pushed their earlier resistance “underground” (Gilligan, 1982; Taylor, Gilligan, & Sullivan, 1995). Gilligan (Gilligan, 1982; Taylor et al., 1995) tied this change to a growing realization among girls that their forthrightness may not be appealing to boys. They begin to self-censor, hoping to become more popular. Girls also struggle with a tug of war between valuing academic (or athletic) success (i.e., men’s values) over maintaining close friendships (i.e., women’s values). Although the turmoil of adolescence can be just as confusing to boys as it is to girls, Gilligan (Gilligan, 1982; Taylor et al., 1995) hypothesized boys may feel less pressure as they become adults because they learn more easily to be competitive, independent, and separated from feelings. Girls, because they are encouraged to maintain their 1946 concern for people throughout their lives, are caught in a conflict between that and being independent and competitive. This makes girls at risk for more conflicting feelings throughout adolescence. Long-term psychological problems, notably eating disorders, which occur in both boys and girls, may be one unfortunate result of repressing inborn feelings in order to conform. Parents can help both girls and boys deal with these conflicts by encouraging them to maintain their honesty and integrity. Value System Adolescents develop their values throughout their childhood as they interact with their family. As they increase the amount of time they spend with their peer group, they may question these values and participate in experiences that may put them at risk for physical and/or psychological harm. Identifying risk-taking behaviors and offering guidance and support is important in promoting the health of the adolescent. Social Coupling In early adolescence, individuals tend to dress and behave similarly to other members of their peer group (Fig. 33.3). Bullying behavior may be directed at individuals who don’t conform to or associate with a peer group. Bullying behaviors should be identified, and the appropriate interventions should be initiated. Figure 33.3 Adolescents have a need to interact with peers to learn more about themselves and others. During adolescence, individuals begin to explore their sexual preferences and may question their gender identity. Encourage an open dialogue with adolescents to assist them to process their feelings and establish their own identity. Counseling may be helpful to assist with family communication if the family is not accepting. Career Decisions 1947 The adolescent may identify an educational and career trajectory during self-discovery of personal positive attributes. This process may take several years to achieve, and it varies for each individual. It is common for adolescents to seek and experiment with multiple roles before reaching a decision that is rewarding. Some school-age children do poorly in school during preadolescence but, as soon as they choose a career, show increased interest in learning as they come to see education as relevant to their future. Emancipation From Parents Emancipation from parents can become a major issue during the middle and late adolescent years for two reasons. Some parents may not yet be ready for their child to be totally independent, and some adolescents may not yet be sure they want to be on their own. They may fight bitterly for a right—for example, to stay out until midnight or later on a weekend—and then never use the privilege once they have gained it. Winning the battle may be more important than exercising the newly won right. In many instances, the closer the tie adolescents feel with their parents, the more severe can be their struggle. As long as parents are reasonable in their restrictions, the amount of noise being made may be proof the ties are strong and separation or emancipation is not easy. Encourage parents to give adolescents more freedom in areas such as choosing their own clothes or after-school activities; at the same time, help parents continue to place some restrictions on adolescent behavior (“You must drive the car safely,” “We must know where you go after school”). These are not unreasonable rules and actually help adolescents accept the responsibility that comes with independence. Both parents and adolescents may need help to understand that emancipation does not mean severance of a relationship but rather a change in a relationship because people who are independent of one another can have even better relationships than those who are dependent on one another. It can be helpful to remind parents this step is actually no different from the one children accomplished when they grew from infants to toddlers, when they changed from wanting to be held and rocked to wanting to run. If parents can think of it in this light, they will gain a better perspective and may realize they will not lose the children because they become adults. There are ex-wives and ex husbands. There are no ex-children. Late Adolescent Developmental Task: Intimacy Versus Isolation Developing a sense of intimacy means a late adolescent is able to form long-term, meaningful relationships with persons of the opposite as well as their same sex (Erikson, 1950, 1968). Those who do not develop a sense of intimacy are left feeling isolated; in a crisis situation, they have no one to whom they feel they can turn to for help or support. A sense of intimacy is closely related to the sense of trust learned in the first year of life because, without the feeling that one can trust others, building a sense of intimacy is difficult. 1948 Some adolescents require help from parents or other adults to differentiate between sound relationships and those that are based only on sexual attraction. Never do adolescents need an adult to listen to them more than when they are struggling with the heart-rending feelings of young love or wondering whether a particular love relationship is temporary or lasting. Some parents may not be able to listen to their adolescent without interjecting their own opinions because they worry that relationships based on infatuation will lead to a sexual relationship. Parents should feel an obligation to inform their children of their feelings about early sexual relationships. At the same time, they have to be realistic that some adolescents will not follow their advice as shown by the rising rates of teenage pregnancy and sexually transmitted diseases, including HIV (Centers for Disease Control and Prevention [CDC], 2012c). If parents suspect their adolescent is sexually active, counsel them to be certain their child is knowledgeable about safer sex practices (see Chapter 22 for a discussion of adolescent pregnancy). Some adolescents may believe intense sexual yearnings or peer pressure can be alleviated only by a sexual act. They can be reassured that they are pleasant people to be with because of the many fine qualities they possess and that sexual intercourse can be delayed until two persons have come to know these qualities in each other and have made a mutual commitment based on a deeper level than simply physical passion. In our busy modern society in which adolescents engage in such a variety of activities, they may need help learning how to project themselves into another person’s situation and to ask themselves how the world looks from that position. This concept, empathy, is the ability to understand the feelings of another, or, in other words, a developed sense of intimacy in its finest form. Socialization Early teenagers may feel more self-doubt than self-confidence when they meet another adolescent with whom they would like to begin a lasting relationship. The voices of most boys have not yet dependably deepened; this makes them unable to trust their voices to carry the serious tone they wish to convey. Most girls’ bodies have not yet fully developed; they may look at themselves in a mirror, compare their profiles with those of models in popular magazines, and feel inadequate. Both male and female early adolescents tend to be loud and boisterous, particularly when someone whose attention they would like to attract is nearby. They are impulsive and very much like 2-year-old children in that they want what they want immediately, not when it is convenient for others. Many 13-year-olds begin to experience “crushes,” or infatuations with schoolmates. At this age, however, they may spend more time longing for someone than they do instituting an in-depth and rewarding relationship. They have too little experience with life and too limited a frame of reference yet to know how to offer a deep commitment to another or accept one from that person. By age 14 years, teenagers have become quieter and more introspective. They are 1949 becoming used to their changing bodies, have more confidence in themselves, and feel more self-esteem. Adolescents watch adults carefully during this period, searching for good role models with whom they can identify. They usually have a hero—a film star, writer, scientist, or athlete—whom they want to grow up to be like. They may form a friendship with an older adolescent, trying to imitate that person in everything from thoughts to clothing. If the older adolescent has dropped out of school or plays a particular sport, the younger person may express a wish to drop out or train for that sport, too. Idolization of famous people or older adolescents of this nature fades as adolescents become more interested in forming reciprocal friendships. Attachments to older adolescents are often severed abruptly and painfully as older teenagers make it clear they are more interested in being with people their own age. Rejection by an older member of a pair forces the younger member to turn to his or her own-age friends and ends the intense hero worship so typical of early adolescence. Most 15-year-olds fall “in love” five or six times a year. However, many of these relationships are based on attraction because of physical appearance, not because of inner qualities or characteristics that are compatible with their own. Because infatuation is fleeting, it can lead to extremely intense but brief attachments that fade once the two young people discover they have little in common. Beginning romantic attachments this often, however, does not mean their feelings are any less strong or that they feel any less pain when the relationship ends (Fig. 33.4). 1950 Figure 33.4 Although infatuation or love can be fleeting, adolescents may feel intensely for another. By age 16 years, boys are becoming sexually mature (although they continue to grow taller until about 18 years of age). Both sexes are better able to trust their bodies than they were the year before. By age 17 years, they tend to have adult values and responses to events. They have left behind the childish behaviors they used in early adolescence—shoving and punching—to get the attention of others. COGNITIVE DEVELOPMENT The final stage of cognitive development, the stage of formal operational thought, begins at age 12 or 13 years and grows in depth over the adolescent years, although it may not be complete until about age 25 years (Piaget, 1969). This step involves the ability to think in abstract terms and use the scientific method (i.e., deductive reasoning) to arrive at conclusions. The problems that adolescents are asked to solve in school depend on this type of thought. Problem solving in any situation depends on the ability to think abstractly and logically. With the ability to use scientific reasoning, adolescents can plan their future. They 1951 can create a hypothesis (What if I go to college? What if I don’t?) and think through the probable consequences (In the long run, I’ll earn more money, or I could begin earning money immediately). MORAL AND SPIRITUAL DEVELOPMENT Because adolescents enlarge their thought processes to include formal reasoning, they are able to respond to the question “Why is it wrong to steal from your neighbor’s house?” with “It would hurt my neighbor by requiring him to spend money to replace what I stole,” rather than with the immature response of the school-age child, “The police will punish me.” Some adolescents, however, may have difficulty envisioning a department store or a large corporation as capable of suffering economic loss from stealing, a concept that can contribute to the frequent practice of petty shoplifting at this age. Almost all adolescents question the existence of God and any religious practices they have been taught (Kohlberg, 1984). This questioning is a natural part of forming a sense of identity and establishing a value system at a time in life when they draw away from their families. QSEN Checkpoint Question 33.2 QUALITY IMPROVEMENT The nurse evaluates some of the anticipatory guidance that provided to Raul with the goal of fostering his sense of identity. The nurse identifies which statement as suggesting he is successfully working toward this goal? Select all that apply. a. “I’m debating whether I’d like to be a pilot or a race car driver.” b. “I ask my parents at least once a week to let me do more things.” c. “I handle money at my part-time job and it’s sometimes tempting to take some of it.” d. “I’m getting used to being so much taller than my younger sister.” Look in Appendix A for the best answer and rationale. Health Promotion for an Adolescent and Family Because their judgments are still limited, adolescents still need guidelines in reference to safety, nutrition, and daily care. These are always excellent topics for discussion at healthcare visits. PROMOTING ADOLESCENT SAFETY Unintentional injuries, most commonly those involving motor vehicles, are the leading cause of death among adolescents. Although teenagers are at the peak of physical and sensorimotor functioning, their need to rebel against authority or to gain attention 1952 through risk-taking leads them to take careless actions, such as speeding or driving while intoxicated. In the interest of an adolescent’s safety and that of others, parents need to have the courage to insist on emotional maturity rather than age as the qualification for obtaining a driver’s license. Adolescents need to take seriously the graduated licensing requirements for their state so they not only learn the techniques of safe driving but also learn a sense of responsibility toward others (Williams, McCartt, & Sims, 2016). Some adolescents dismiss seat belts as childish and so need extra instruction that it is wise to use every safety precaution available when in a motor vehicle (Chen, Cao, & Logan, 2012). Equally dangerous for adolescents are motorcycles, motorbikes, and motor scooters, which are appealing because of their low cost and convenience in parking. Both drivers and riders should wear safety helmets to prevent head injury, long pants to prevent leg burns from exhaust pipes, and a full body covering to prevent abrasions in case of an accident. Advise adolescents who choose these forms of transportation to be as familiar with safety rules as automobile drivers and to wait until they are emotionally mature enough to use sound driving judgment. Although drowning tends to occur in younger children, it does occur in adolescents when good swimmers go beyond their capabilities on dares or in hopes of impressing friends. Teaching water safety, such as not swimming alone or when tired, is as important as teaching the mechanics of swimming (CDC, 2012b). Other common causes of death in adolescents are homicide and self-harm (i.e., suicide) (Swahn, Ali, Bossarte, et al., 2012). These are related to the easy accessibility of guns when added to depression, binge drinking, and impulsivity. Gang violence and the desire to protect themselves are additional factors. Unintentional gunshot injuries increase in early adolescence, often for the same reason that drowning increases: Youngsters want to impress friends by showing they can handle guns. Be certain that firearm safety is taught creatively through problem solving rather than lecturing because teenagers tend to rebel against such lectures or claim that they have heard it all before. Athletic injuries, especially overuse injuries from poor conditioning, tend to increase in number during adolescence because of the vigorous level of competition that occurs in organized sports (Khan, Thompson, Blair, et al., 2012). Types of athletic injuries are discussed in Chapter 52. Health teaching measures to prevent unintentional injuries, especially while participating in athletics, are summarized in Box 33.3. BOX 33.3 Nursing Care Planning to Empower a Family MEASURES TO PREVENT UNINTENTIONAL INJURIES IN ADOLESCENTS Q. Raul’s mother tells you, “My son doesn’t always use mature judgment. How can I keep him safe from accidents?” 1953 A. Teaching the following points can be helpful to him: Unintentional Injury Health Teaching Measure Motor vehicle Always use a seat belt whether a driver or a passenger. Never use a cell phone or text while driving. Do not drink alcohol while driving and always refuse to ride with anyone who has been drinking (name a designated driver or arrange with your parents to be picked up or provide money for a taxi). Wear a helmet and long trousers as driver or passenger on a motorcycle. Accepting dares has no place in safe driving. Take graduated driver programs seriously so you learn safe driving habits for both two-wheel and four-wheel vehicles. Firearms Always consider all guns loaded and potentially lethal. Learn safe gun handling before attempting to clean a gun or hunt. Drowning Learn how to swim. Follow safe water rules, such as never swimming alone, no diving into the shallow end of swimming pools, no hyperventilating before swimming underwater, and no swimming beyond one’s own limit. Taking dares has no place in water safety. Sports Use protective equipment, such as facemasks for hockey and pads and a helmet for football. Do not attempt to participate beyond physical limits. Keep well hydrated by drinking fluid before and after play. Careful preparation for sports through training is essential to safety. Recognize and set one’s own limit for sports participation. PROMOTING NUTRITIONAL HEALTH FOR AN ADOLESCENT Adolescents experience such rapid growth that they may always feel hungry (Fig. 33.5). If their eating habits are unsupervised, because of peer pressure and when in a hurry to get to other activities, they tend to eat faddish or quick snack foods rather than more nutritionally sound ones. Some adolescents turn away from the basic MyPlate food groups to eat sweets, soft drinks, or empty-calorie snacks and so are left poorly nourished. This type of eating pattern, combined with a lack of exercise, also leads to obesity (Wengle, Hamilton, Manlhiot, et al., 2012). 1954 Figure 33.5 Adolescents experience rapid physical growth, so typically, they eat frequently. (© Billy Barnes/Stock Boston.) One form of adolescent rebellion is to refuse to eat foods that parents stress as important. Parents who stock their kitchens with healthy snacks such as fruit and vegetables and who are willing to meet their adolescents halfway in terms of food preferences can be more certain their child is eating nutritious foods than if such food aren’t available. Giving an adolescent some responsibility for food planning or meals, such as making dinner every Wednesday night, can teach some important lessons about nutrition without conflict. Adolescents who are slightly obese because of prepubertal changes may begin low calorie or starvation diets during adolescence to lose weight. Some diet so excessively they develop eating disorders such as bulimia or anorexia nervosa (see Chapter 54). A weight-loss diet is appropriate during adolescence, but it must be supervised to ensure the adolescent is consuming sufficient calories and nutrients for growth. For example, many adolescents entirely omit breads and cereals to lose weight rather than just reducing the amounts they eat. Diets such as these can be deficient in vitamins B1 (thiamine) and B2 (riboflavin), which are necessary for growth. Recommended Dietary Reference Intakes An adolescent needs an increased number of calories over that needed previously to support the rapid body growth that occurs. Foods must come from a variety of sources to supply necessary amounts of carbohydrates, vitamins, protein, and minerals. The nutrients that are most apt to be deficient in both male and female adolescent diets are iron, calcium, and zinc. Iron is necessary to meet expanding blood volume requirements. Females require a high iron intake not only because of this increasing blood volume but also because iron begins to be lost with menstruation. Girls with a 1955 heavy menstrual flow (i.e., menorrhagia) and especially those who participate in strenuous athletics may need to take an additional iron supplement to prevent iron deficiency anemia (Bruinvels, Burden, Brown, et al., 2016). Increased calcium and vitamin D plus physical exercise are necessary for rapid skeletal growth as well as to “stockpile” calcium to prevent osteoporosis later in life (Chouinard, Randall Simpson, & Buchholz, 2012). Zinc is necessary for sexual maturation and final body growth. Good sources of iron are meat and green vegetables, calcium is abundant in milk and milk products, and meat and milk are also high in zinc. Promoting Nutritional Health With a Varied Diet Vegetarian Diets Because vegetables generally contain fewer calories than meat, adolescents need to consume large amounts of them to achieve an adequate caloric intake from a vegetarian diet. Textured vegetable protein or tofu can be added to meals to increase the amount of protein supplied and help meet adolescent growth needs (Case, 2016). Some adolescents may find it difficult to follow a vegetarian diet because it makes them different from their peers and limits the foods they can eat at parties or at school, such as pizza, meat tortillas, or hot dogs. Whether to continue to follow this type of diet is a decision an adolescent must make as part of achieving a sense of identity. Be certain that adolescents who have become semi-vegetarians in order to lose weight add enough protein to their food intake to sustain their rapid body growth (Timko, Hormes, & Chubski, 2012). Glycogen Loading Athletes need more carbohydrate or energy than those who do not engage in strenuous activity; the source of carbohydrate that best sustains athletes comes from the breakdown of glycogen because this supplies a slow and steady release of glucose. Glycogen loading is a procedure used to ensure there is adequate glycogen to sustain energy through an athletic event. Several days before a sports event, athletes lower their carbohydrate intake and exercise heavily to deplete muscle glycogen stores. They then switch to a diet high in carbohydrate. With the renewed carbohydrate intake, muscle glycogen is stored at two to three times the usual level, which supplies them with up to twice the glucose needed for sustained energy (Bagnulo, 2006). Although used by many high school athletes, the effects of frequent glycogen loading in this age group are not well studied and so should be done cautiously. As a rule, the goals of nutrition that are best for everyone, such as eating a well-balanced diet rather than a diet that interferes with carbohydrate, fluid, or fat intake, are also the best rules for athletes. PROMOTING DEVELOPMENT OF AN ADOLESCENT IN DAILY 1956 ACTIVITIES Adequate sleep, hygiene, and exercise are important health education topics for adolescents as these become an adolescent’s responsibility rather than the responsibility of the parents. Dress and Hygiene Adolescents are capable of total self-care and, because of their body awareness, may even be overly conscientious about personal hygiene and appearance. Both sexes try many types of shampoo, deodorant, breath fresheners, and toothpaste. They may take seriously (without admitting it) the content of ads showing that toothpastes or deodorants can help win an attractive person or gain instant success. Remember that when caring for hospitalized adolescents, providing time for self-care, such as shampooing hair, is important to include in an adolescent’s nursing care plan. Adolescents can be acutely aware of how their peers dress. When hospitalized, most teenagers seem to improve markedly when allowed to wear their own clothing rather than a hospital gown. Needing to look like everyone else is undoubtedly a factor in adolescent shoplifting. Only during late adolescence do teenagers discover that who they really are shows through their clothing. Care of Teeth Adolescents are generally very conscientious about tooth brushing because of a fear of developing bad breath. They should continue to use a fluoride paste rather than a brand advertised as providing white teeth. They should also continue to drink fluoridated water to ensure firm enamel growth (Armfield, Spencer, Roberts-Thomson, et al., 2013), but they should also be careful to not use so much fluoride through the use of mouth rinses or toothpaste that they develop fluorosis (i.e., a blue discoloration of teeth). Teens with braces must be extremely conscientious about tooth brushing to prevent plaque buildup on hidden tooth surfaces. If they snack a great deal, and so their teeth are always exposed to bacterial erosion, some may develop a cavity for the first time during this period. Sleep Although it is widely believed everyone needs 8 hours of sleep a night, some need more and others can adjust to considerably less. Because protein synthesis occurs most readily during sleep and adolescents are building so many new cells, this age group may need proportionately more sleep than any other age group (Short, Gradisar, Lack, et al., 2013). In addition, because this is a busy time with extracurricular activities and also a stressful period similar to first grade, adolescents may sleep restlessly as their mind reworks the day’s tensions. Even long periods of sleep, therefore, may not leave them feeling refreshed. This is why adolescents, admitted to a hospital for even a minor illness, for example, may sleep as if exhausted. Even though frequent lack of sleep can 1957 lead to chronic fatigue or depression, medication is not usually recommended for adolescents; instead, they are urged to reduce activity to get more sleep (Frost & Burns, 2012). Exercise Just as with younger children, adolescents need exercise every day both to maintain muscle tone and to provide an outlet for tension. Unlike younger children, however, and although they are constantly on the go, adolescents often receive very little real exercise. They may ride a bus to school, sit for classes, and sit at a mall after school and talk to friends. They have put in a full day, yet most of their time was spent sitting. Because of this, adolescents who have had an injury and must learn an activity such as crutch walking usually need to do muscle-strengthening exercises at first, just as adults must. Adolescents who are involved in structured athletic activities do receive daily exercise. If they have not participated in competitive sports before, however, they may need advice on increasing exercise gradually so they do not overdo it and consequently develop muscle sprains or other overuse injuries (Hoang, Coel, Vidal, et al., 2012). Sun Exposure Because some adolescents spend a great deal of time outdoors participating in athletics, it is a critical time for them to avoid excessive sun exposure so they don’t develop skin cancer (i.e., melanoma) from ultraviolet rays. Encourage teenagers to use sunscreen, avoid tanning beds, and report to their primary healthcare provider any skin mole that changes in shape or color. Do this as creatively as possible because teenagers have difficulty looking to the future and imagining how drastically the development of melanoma could affect their lives (Cohen, Brown, Haukness, et al., 2013). PROMOTING HEALTHY FAMILY FUNCTIONING Early adolescents may have many disagreements with parents that stem partly from wanting more independence and partly from being so disappointed in their bodies. It may be helpful to counsel parents to appreciate that although it is not easy to live with a teenager, it is equally difficult to be the teenager. When a child reaches about age 15 years, parent–child friction tends to peak. By this age, adolescents have discovered from careful observation that most adults are far from perfect. Teachers they previously thought were all knowing are revealed to have very human shortcomings. School marks may slump as a reflection of this “fallen angel” syndrome. Adolescents discover even more faults in their parents and wonder, for instance, how they can exist with such outdated ideas. Adolescents may follow health advice poorly because they view healthcare personnel in the same light. By the time they are 16 years old, adolescents generally become more willing to 1958 listen and talk about problems. As a result, they may learn adults are not as inadequate as they previously thought. This changed perception does not mean an adolescent of 16 years is calm and quiet and free of parent–child discord. Adolescents may comprehend how hard it was for parents to get where they are, but they may not understand, for example, why they themselves are not allowed to stay out later than midnight on weekends. Most 17-year-old adolescents, who have stayed in school, are usually high school seniors; for most of them, this year is likely to be stormy. Looking ahead to leaving a school system with which they may have been involved since they were very young may give them a feeling of losing security. Even if going away to college or beginning a full-time job seems exciting, it can also be an unwelcome change from the people and routines they feel so comfortable with to new contacts and new regulations that appear strange and even hostile. The ambivalence that such feelings create makes some 17-year-olds enjoy having parents perpetuating family traditions such as the house decorated for a holiday in the same way as usual or being served a traditional birthday meal. This clinging to security is not a step backward but a preliminary working through to a time of separation that will be a major milestone in reaching maturity. Unfortunately, as another way to prove they are old enough to leave high school and enter into a more mature college or work world, older adolescents may begin to experiment with drugs or alcohol, interpreting the use of these as the mark of being an adult (Lewis & Hession, 2012). COMMON HEALTH PROBLEMS OF AN ADOLESCENT A health maintenance schedule for the adolescent period and the assessments to be included at visits are shown in Table 33.2. TABLE 33.2 HEALTH MAINTENANCE SCHEDULE, ADOLESCENT PERIOD Area of Focus Methods Frequency Assessment Developmental milestones History, observation Every visit Growth milestones Height, weight plotted on standard growth chart; body mass index (BMI), physical examination Every visit Hypertension Blood pressure Every visit Nutrition History, observation; height/weight, BMI information Every visit Dyslipidemia Total cholesterol and triglycerides At 18 years of age; earlier screening for 1959 children who have family members with the disorder Parent–child relationship History, observation Every visit Behavior or school problems History, observation Every visit Substance use disorder History, observation Every visit Vision and hearing disorders History, observation Every visit Formal Snellen or Titmus testing At 15 and 18 years of age Audiometer testing If concern or high risk is present Dental health History, physical examination Every visit; recommend a yearly checkup with dental health provider Cervical dysplasia (scoliosis) Physical examination Every visit at least to 16 years of age Thyroid disease Physical examination, history Every visit Tuberculosis Purified protein derivative (PPD) test Depending on prevalence of tuberculosis in community Bacteriuria Dipstick Annually if sexually active Anemia Hematocrit or hemoglobin Annually for menstruating females Cervical or vaginal cancer Pap test, pelvic examination Three years after first coitus, or at age 21 years Sexually transmitted diseases History, observation Every visit if sexually active Immunizations 1960 Check history and past records; inform caregiver about any risks and side effects; administer vaccine in accordance with healthcare agency policies. Hepatitis A vaccine HepA If not previously immunized Hepatitis B vaccine HepB If not previously immunized Human papillomavirus vaccine HPV If not previously vaccinated Influenza vaccine TIV (trivalent influenza vaccine) or LAIV Yearly Measles, mumps, rubella vaccine MMR If not previously vaccinated; do not give to pregnant adolescents Meningococcal vaccine MPV4 (meningococcal polysaccharide vaccine) Booster at 16 years Pneumococcal vaccine PCV (pneumococcal conjugate vaccine) To high-risk groups if not previously vaccinated Tetanus and diphtheria vaccine Tdap If not previously immunized Varicella vaccine VAR If not previously vaccinated Anticipatory Guidance Adolescent care including violence and nutrition counseling Active listening and health teaching Every visit Expected growth and developmental milestones before next Active listening and health teaching Every visit 1961 visit Unintentional injury prevention Counseling about street and personal safety Every visit Any problems expressed by caregiver or adolescent during visit Active listening and health teaching Every visit LAIV, live attenuated influenza vaccine. From American Academy of Pediatrics. (2012). Recommendations for preventive pediatric health care. Evanston, IL: Author. Hypertension Hypertension is present if blood pressure is above the 95th percentile, or 127/81 mmHg for 16-year-old girls and 131/81 for 16-year-old boys for two consecutive readings in different settings. (Pulse, respiration, and blood pressure value charts are available at http://thePoint.lww.com/Flagg8e.) Adolescents who are obese, who are Black, who eat a diet high in salt, or who have a family history of hypertension are most susceptible to developing the condition. All children older than 3 years of age should have their blood pressure routinely taken at all health assessments to detect this (Hagan, Shaw, & Duncan, 2017). This is particularly important for adolescents because new medications plus education can help to greatly reduce the incidence of cardiovascular disease as they reach adulthood (Flynn & Falkner, 2011). Prevention and management of hypertension in children and adolescents are discussed in Chapter 41. Poor Posture Many adolescents, particularly those who reach adult height before their peers, demonstrate poor posture, a tendency to round shoulders and a shambling, slouchy walk to not be taller than those around them. This is also due to the imbalance of growth that arises from the skeletal system growing a little more rapidly than the muscles attached to it. Girls, especially, may slouch so as not to appear taller than boys or to diminish the appearance of their breast size if they are developing more rapidly than their friends. Yet another reason may be related to carrying backpacks that are too heavy (Kistner, Fiebert, & Roach, 2012). Urge children of both sexes to use good posture during these rapid-growth years. Assess posture at all adolescent health appraisals to detect the difference between simple poor posture and the beginning of spinal dysplasia or scoliosis (i.e., lateral curvature of the spine) (see Chapters 34 and 51). Body Piercing and Tattoos Body piercing and tattoos are a strong mark of adolescence (Stein & Jordan, 2012). 1962 Both sexes may have ears, lips, chins, navels, and breasts pierced and filled with studs or tattoos applied to arms, legs, or their central body. Body piercings and tattoos have become a way for adolescents to make a statement of who they are and that they are different from their parents. Be certain they know the symptoms of infection at a piercing or tattoo site (e.g., redness, warmness, drainage, swelling, mild pain) and to report these to their healthcare provider if they occur because serious staphylococcal or streptococcal infections can occur at piercing sites. It is important to caution adolescents that sharing needles for piercing or tattooing carries the same risk for contacting a blood-borne disease as sharing needles for intravenous drug use. Fatigue Because so many adolescents comment that they feel fatigued to some degree, it can be considered normal for the age group. However, fatigue may also be a beginning symptom of disease, so it is important that it is not underestimated as a concern. Always assess the diet, sleep patterns, and activity schedules of fatigued adolescents. Be aware that if the fatigue began as a short period of extreme tiredness, it suggests disease more so than a long, ill-defined report of always feeling tired. If an adolescent’s sleep and diet appear to be adequate, his or her activity schedule is reasonable, and a physical assessment suggests no illness, then the fatigue may be of emotional origin. It can be a means of avoiding school, conflict with parents (e.g., when children appear ill, parents are more sympathetic), or social situations (e.g., too tired to go to the mall). Those who are under stimulated by school may develop fatigue as a sign of boredom. Blood tests may be indicated to rule out anemia and common infections in adolescents, such as infectious mononucleosis (see Chapter 43). Chronic fatigue syndrome, although not seen as often in this age group as in adults, may also need to be ruled out (Lloyd, Chalder, & Rimes, 2012). If tests for these categories of conditions are normal, teenagers can be assured they are healthy and should be offered guidance to solve the problem with better diet, more sleep, fewer activities, and better problem solving techniques to relieve tension. Menstrual Irregularities Menstrual irregularities can be a major health concern of adolescent girls as they learn to adjust to their individual body cycles. Chapter 47 discusses these problems in detail. Acne Acne is a self-limiting inflammatory disease that involves the sebaceous glands, which empty into hair shafts (the pilosebaceous unit). It is the most common skin disorder of adolescence, occurring in as many as 80% to 95% of adolescents (Morelli & Prok, 2016). It occurs slightly more frequently in boys than in girls. The peak age for the lesions occurring in girls is 14 to 17 years of age; for boys, 16 to 19 years of age. 1963 Although not proven, genetic factors may play a part in their development. Changes associated with puberty that cause acne to develop include: As androgen levels rise in both sexes, sebaceous glands become active. The output of sebum, which is largely composed of lipids, mainly triglycerides, increases. Trapped sebum causes whiteheads, or closed comedones. As trapped sebum darkens from accumulation of melanin and oxidation of the fatty acid component on exposure to air, blackheads, or open comedones, form. Leakage of fatty acids causes a dermal inflammatory reaction. Bacteria (generally, Propionibacterium acnes) lodge and thrive in the retained secretions and ducts. Acne is categorized as mild (i.e., comedones or blocked hair follicle), moderate (i.e., papules and pustules are also present), or severe (i.e., cysts are present). The most common locations of acne lesions are the face, neck, back, upper arms, and chest (Fig. 33.6). Flare-ups are associated with emotional stress, menstrual periods, or the use of greasy hair creams or makeup that can further plug gland ducts. Lesions are less noticeable in summer months, probably because of increased exposure to the sun, which increases epidermal peeling, or because of a reduction in stress as a result of being out of school. Figure 33.6 Facial acne in an adolescent. Assessment Always ask adolescents at health assessments if they are troubled with acne and to what extent it interferes with their self-image because this can be a major cause of stress in adolescents. Inspect for facial, chest, and back lesions on physical examination. Therapeutic Management The goal of therapy for acne is threefold: (a) decrease sebum formation, (b) prevent comedones, and (c) control bacterial proliferation. 1964 External Medication Medications that are applied externally peel away the superficial skin layer to prevent sebum plugs from forming and are sufficient if only comedones are present. A common prescription medication is tretinoin (Retin-A cream). This reduces keratin formation and plugging of ducts. Caution adolescents using a vitamin A cream to avoid prolonged sun exposure and to use a sunblock of SPF 15 or higher because the preparation makes their skin more susceptible to ultraviolet rays (Karch, 2013). Additional creams frequently prescribed contain benzoyl peroxide or azelaic acid. Caution adolescents that for the first week or two of therapy, peeling or oxidizing agents may make the complexion appear worse. If the adolescent has inflammatory lesions, topical antibiotic creams such as dapsone, tetracycline, or doxycycline may be prescribed to reduce the bacterial level on the skin. Tetracycline is not prescribed for children under age 12 years because it can cause permanent staining of teeth and may possibly interfere with growth of long bones. It is contraindicated for adolescents who are or may become pregnant as it is teratogenic (Simonart, 2012). Systemic Medication In pustular and cystic acne, systemic (i.e., oral) antibiotics can be helpful. Systemic antibiotics have anti-inflammatory properties, and they are effective against P. acnes. Tetracycline (500 mg twice daily the first week and then tapered to 250 mg daily for maintenance) is effective against the anaerobic bacteria that break down sebum to form irritating acids. However, the more lipophilic antibiotics, such as doxycycline and minocycline, are generally more effective than tetracycline (Zaenglein, Pathy, Schlosser, et al., 2016). Improvement is not generally seen for 2 to 4 weeks, so you may need to support adolescents to continue to take the medication during the waiting period. Without noticeable improvement, adolescents have a tendency to continue taking the higher dose or even increase the dose, hoping to initiate a faster effect. Food impairs the absorption of oral tetracycline so the drug should be taken on an empty stomach (2 hours before or after eating). Adolescents must be certain of the date of expiration of the drug; outdated tetracycline breaks down into an extremely toxic composition. Females taking systemic antibiotics for long periods of time become susceptible to developing candidal vaginitis and need to be instructed about the symptoms of this: a white, pruritic vaginal discharge. As yet another precaution, because antibiotic use may interfere with oral contraceptives, adolescent girls who are sexually active should use another method of birth control while taking the antibiotic. Alternative antibiotics prescribed are erythromycin or clindamycin. Although these drugs avoid the complications of tetracycline, they may not produce the same effective results. Other Treatment Methods Estrogen, alone or in combination with progesterone, suppresses sebaceous gland 1965 activity and, therefore, oral contraceptives are useful therapy in some girls with acne (Neuhaus, Nagler, & Orlow, 2017). Oral contraceptives taken for this reason carry the same precautions as when they are prescribed as a reproductive planning method: Estrogen tends to close epiphyseal centers of long bones, causing bone growth to halt, and long-term therapy does have potential side effects, including embolism and thrombophlebitis. A last resort is administration of isotretinoin (a retinoid or vitamin A compound) for a short time (Lyon, 1978; Rathi, 2011). Isotretinoin must be taken with caution, however, because it is extremely teratogenic and also has been linked to inflammatory bowel disease. It should not be taken at the same time as tetracycline or it can lead to brain edema. Many adolescents are left with some degree of scarring following teenage acne lesions. Laser therapy is a follow-up possibility to reduce the effect of scarring. Nursing Diagnoses and Related Interventions Nursing Diagnosis: Risk for low self-esteem related to the development of acne during adolescence and lack of knowledge regarding treatment possibilities Outcome Evaluation: Adolescent verbalizes positive aspects of self; states acne does not affect self-image, or if patient admits to feelings of negative self-esteem, is able to discuss feelings and concerns about condition; describes ways to prevent or reduce acne outbreaks and states realistic short- and long-term goals of treatment. It is necessary to respect how devastating acne can be to some adolescents. The actual extent of the condition often is not as important as an adolescent’s feelings about it. With a face constantly covered by red marks, it may be extremely difficult for adolescents to feel good about themselves. When carrying out interventions, remember that acne is a potentially destructive disease; if left untreated, it can cause irreparable physical and emotional scarring. Therefore, advise parents and adolescents to seek medical treatment rather than self medicate if the condition is severe. At the same time, being overly concerned may lead to becoming unduly self-conscious, which may affect performance in school and the establishment of social relationships. Common health teaching measures for the prevention and treatment of acne are summarized in Box 33.4. BOX 33.4 Nursing Care Planning Based on Family Teaching GUIDELINES FOR THE PREVENTION AND TREATMENT OF ACNE Q. Raul says to you, “I’ve had acne for the last 3 months. How can I make this go away?” 1966 A. Most adolescents have some acne lesions. Try the following suggestions: Do not pick or squeeze acne lesions, which ruptures glands and spreads sebum into the skin, thus increasing inflammation. The times you are most likely to do this are during periods of stress, such as when you are taking a test. When you find your hand on your face, distract yourself with some other motion, such as interlocking your fingers. Greasy hair preparations or tight sweatbands can both plug ducts of glands and increase comedone formation, so avoid these, if possible. For girls, makeup can plug ducts; using medicated makeup both covers and helps lesions heal. Topical acne preparations work by unplugging glands, so you must use them consistently for them to be effective. Plan enough time in the morning before school and a time in the evening to apply these. Post a chart by your bathroom mirror to remind yourself. Washing daily to remove irritating fatty acids is helpful. Excessive washing is not necessary and, in fact, can actually harm healing by rupturing glands. Oral medications work by reducing sebum secretions or preventing bacterial invasion. Again, these work only if you take them conscientiously. Make a chart to post in your bathroom or kitchen to remind you to take these. Remember, tetracycline must be taken on an empty stomach or it is not effective. Both topical and oral vitamin A makes your skin very sensitive to sunlight. Avoid long exposures to sunlight, or you will sunburn readily. Although diet does not influence the development of acne lesions, you should eat a healthy, well-balanced diet for good general health. No acne medication works immediately. While you are waiting for lesions to heal, keep yourself occupied with a new activity (e.g., join a school club, try dancing lessons). When your skin is clear, these experiences will help make you an interesting person as well as one with clear skin. QSEN Checkpoint Question 33.3 PATIENT-CENTERED CARE Raul is prescribed both a topical cream and oral tetracycline to treat his acne. The nurse identifies that he needs additional health information from which statements (list all that apply)? a. “I know acne is not contagious even though all my friends seem to have it.” b. “My girlfriend wants to borrow my tetracycline; I don’t mind sharing it.” c. “I know not to take hot showers as hot water can create new lesions.” d. “I know not to eat chocolate because that always makes lesions worse.” Look in Appendix A for the best answer and rationale. Obesity 1967 Most overweight adolescents have obese parents, suggesting that both inheritance and environment play a part in the development of adolescent obesity. Obesity can interfere with developing a sense of identity if it is difficult for adolescents to like their reflection in a mirror or if they are always excluded from groups because of their weight. Because of stress related to weight, the attempted suicide rate for obese female adolescents is higher than for non-obese adolescents (Perera, Eisen, Dennis, et al., 2016). Some adolescents may be unaware that their food intake is excessive because they have been told they need excess nutrients for healthy adolescent growth and everyone in their family eats large portions. Health teaching with these adolescents may need to begin with a discussion of “normal” weight and standard food portions because, if they do not begin to own this problem as adolescents, they run a high risk of becoming obese adults. If adolescents eat a diet too low in protein for any length of time, they can develop a faulty nitrogen balance, which can lead to seriously impaired growth. Therefore, a diet of fewer than 1,400 to 1,600 calories per day can rarely be tolerated by adolescents. They generally do better and will stick with a diet closer to 1,800 calories per day. Nursing Diagnoses and Related Interventions Nursing Diagnosis: Ineffective individual coping by overeating related to stresses of the adolescent period, which has led to obesity Outcome Evaluation: Adolescent identifies stressful situations that lead to overeating; describes ways to avoid those situations or methods that would help coping with them. Adolescents who are overweight because of stress need support until their pleasure in eating diminishes and their satisfaction with themselves as a “new” person or until their friends’ satisfaction with them can sustain them. They may need to visit a healthcare facility once or twice a week for encouragement and praise for their efforts. National weight-control organizations are good to use if other adolescents also attend the meetings. They tend to be less effective if all the other members are adults because adolescents generally cannot relate to adult concerns. It’s important an adolescent’s self-esteem is maintained while losing weight or an adolescent may switch to binge eating or such severe dieting that the opposite—extreme weight loss —can occur (Sánchez-Carracedo, Neumark-Sztainer, & López-Guimerà, 2012). In addition to reducing calories consumed, encourage activities that burn calories, such as swimming, gym classes, or walking their dog (Loprinzi, Cardinal, Loprinzi, et al., 2012). These activities are generally preferable to formal exercises, such as sit-ups and push-ups, which may be viewed as punishment. 1968 Adolescents who use overeating as their main reaction to stress may require psychological counseling rather than diet counseling if they are to develop a more mature emotional response to stress. Behavior modification is sometimes successful with adolescents as a means of helping them lose weight, but it is rarely recommended for obesity alone (see Chapter 35). General measures to help adolescents decrease overeating include:  Making a detailed log of the amount they eat, the time, and the circumstances (including how they felt while they were eating) and then changing those circumstances Always eating in one place (the kitchen table) instead of while walking home from school or watching television Slowing the process of eating by counting mouthfuls and putting the fork down between bites, or being served food on small plates so helpings look larger These measures may be of little use, however, unless they are combined with a suitable diet and adequate exercise. Despite all these interventions, weight reduction may not always be effective with adolescents. For some, a more realistic goal might be to prevent additional weight gain until they reach adulthood. CONCERNS REGARDING SEXUALITY AND SEXUAL ACTIVITY Adolescents who engage in sexual risk behaviors can have unintended health outcomes, including unplanned pregnancies and sexually transmitted infections (STIs) such as HIV. During routine health assessments of adolescents and preadolescents, this topic should be explored. According to a 2015 CDC survey report, 41% of U.S. high school students have had sexual intercourse, and of that number, 30% was in the previous 3 months. The survey also reported 43% did not use a condom the last time they had sex. Only 10% had ever been tested for HIV. Yet, those age 13 to 24 years accounted for an estimated 22% of all new HIV diagnoses in the United States in 2014, and within this group, 80% were gay and bisexual males. Half of the nearly 20 million new STIs reported each year were among adolescents and late adolescents age 15 to 24 years in 2014. Pregnancy in adolescence, although decreasing, is still a concern. Nearly 250,000 births were to girls ages 15 to 24 years in 2014 (CDC, 2017d). When discussing sexuality with adolescents, the nurse should avoid assumptions about the gender of the adolescent’s partner. Ask open-ended questions when providing education on health promoting behaviors. This will also help the adolescent feel more open to asking questions. Counseling can assist adolescents improve their perspective and also learn how to say no. For adolescents who agree to have intercourse but who do not really want to, the primary reasons given are peer pressure, curiosity, and affection for their partner (Fuzzell, Fedesco, Alexander, et al., 2016; Katsufrakis & Nusbaum, 2011). According to the CDC (2017b), most lesbian, gay, bisexual, and transgender (LGBT) youth are well adjusted during their adolescent years. The nurse should explore 1969 the school and home environment, as adjustment can be promoted by a supportive learning environment and caring and accepting parents (CDC, 2017b). If the adolescent is not provided with this environment, they may have difficulties in their lives and possibly be at risk for violence from bullying behaviors. Bullying is described in more detail in this chapter. Adolescents may seek a healthcare appointment for an unrelated health concern as a reason to discuss a sexual health question with a healthcare professional. During routine health visits, it is important to obtain a complete sexual health history and offer health related education appropriate to the adolescent’s individualized history. General guidelines on counseling an adolescent with respect to sexual activity are summarized in Box 33.5. BOX 33.5 Nursing Care Planning Based on Family Teaching HEALTH TEACHING GUIDELINES FOR ADOLESCENTS REGARDING SEXUALITY Q. Raul asks you, “How will I know when I’m ready for sex?” A. Here are a few common guidelines: It is your choice whether to participate in sexual relations. Do not be influenced by friends who may be exaggerating stories to impress you or who ask you to do something you do not want to do. When you say no, be firm and clear about your wishes. There is no 100% method to prevent pregnancy or a sexually transmitted infection (STI) except abstinence. Be direct with a sexual partner in discussing abstinence or reproductive and infection prevention measures. Sexual relations neither add to nor detract from your physical strength or general wellness. The mark of an adult sexual relationship is that the activity is pleasurable to both partners. If sexual partners are not interested in your enjoyment as well as their own, you should reconsider the relationship. There is no “normal” mode of sexual expression. Any activity that is pleasurable to both partners is “normal.” Learn about safer sex techniques and practice them. Information on date rape and rape prevention should be provided as adolescents are in a high-risk age group for date rape (Makin-Byrd & Bierman, 2013) (see Chapter 55). One form of date rape occurs when flunitrazepam (Rohypnol) (i.e., the “date-rape drug”), a colorless, odorless, and flavorless benzodiazepine drug, is dropped into a drink, causing drowsiness, impaired motor skills, and amnesia for a time (Karch, 2013). Adolescents who are seen for sexual assault who appear intoxicated or have amnesia for 1970 the event should be suspected of unknowingly ingesting flunitrazepam or another drug such as ketamine. In these instances, a urine specimen analysis will reveal the drug’s metabolites or that the drug was ingested (D’Aloise & Chen, 2012). Stalking Stalking refers to repetitive, intrusive, and unwanted actions such as constant and threatening pursuit directed at an individual to gain the individual’s attention or to evoke fear. Electronic media can be used for cyberstalking, Internet harassment, and Internet bullying to embarrass, harass, or threaten adolescents (CDC, 2017c). The overall term for these methods is electronic aggression (CDC, 2017c). It can result in the same victim responses as that from aggression that is not inflicted electronically. To avoid stalking, adolescents should be aware of and avoid situations where they will be vulnerable to being alone with a stalker and, with assistance, report stalking to law enforcement. QSEN Checkpoint Question 33.4 SAFETY Raul is depressed because his girlfriend broke up with him. Which of his statements could be interpreted as stalking? a. “I keep her photo on my bedside stand so I can kiss her goodnight.” b. “We take the same route to school every day so I often still see her.” c. “I e-mail her every night to tell her what a huge mistake she’s made.” d. “I took down her photo from Facebook but wish I could put it back.” Look in Appendix A for the best answer and rationale. CONCERNS REGARDING HAZING OR BULLYING Bullying, which began during school age (see Chapter 32), can easily continue into adolescence and actually becomes more serious because this can be the time the bullied child has the ability to retaliate through self-destructive behavior or school violence. Hazing, a form of organized bullying, refers to demeaning or humiliating rituals that prospective members have to undergo to join sororities, fraternities, adolescent gangs, or sports teams (Diamond, Callahan, Chain, et al., 2016). Most rituals are secret and in the past were accepted as “rites of passage.” In recent years, hazing has become so extreme the practice has moved out of the “just fun” category into activities that can cause physical and certainly psychological harm, such as being forced to wear demeaning clothing or engaging in crude or lewd skits. They can be extended to such an extreme that adolescents may be punched or kicked, sodomized, left out in the cold so long that frostbite develops, or forced to drink alcohol until they vomit, pass out, or even die from alcohol intoxication. Initiation for street gangs can require prospective members to steal or destroy property or even kill another person. 1971 To help prevent this from happening to their child, urge parents to be aware of what clubs or organizations their adolescent joins and what the requirements for membership are. Help adolescents make sound decisions about what type of hazing their organization advocates by asking them about the subject at health assessments. CONCERNS REGARDING SUBSTANCE USE DISORDER Substance use disorder (formerly referred to as substance abuse disorder) refers to the use of chemicals to improve a mental state or induce euphoria. This is so common among adolescents that as many as 50% of high school seniors report having experimented with some form of drug (CDC, 2012a). Use of drugs occurs in adolescence from a desire to expand consciousness, peer pressure, or a desire to feel more confident and mature; it also can be a form of adolescent rebellion related to childhood adversity or violence. Stages of drug use range from experimentation where teenagers try drugs to enhance social acceptance to regular use, where they actively seek the effect of drugs to relieve everyday stress (Benjet, Borges, Medina-Mora, et al., 2012). Types of Abused Substances Because adolescents may not have a large source of money, the drugs they most frequently abuse are those they can obtain on a limited budget and through limited contacts. Prescription and Over-the-Counter Drugs Adolescents may first begin drug experimentation by taking drugs prescribed for another family member or a pet such as sedatives, pain medication, ketamine (an anesthetic used in veterinary medicine), or cough syrup containing codeine or dextromethorphan (DXM). Called “pharming,” adolescents who use drugs this way can easily overdose because they are unaware of usual dosages (Storck, Black, & Liddell, 2016). Methylphenidate (Ritalin) is a drug frequently prescribed for attention deficit hyperactivity disorder. Because methylphenidate (Ritalin) is a stimulant, when oral tablets are crushed and injected intravenously, they produce a feeling of giddiness and extreme well-being. Unfortunately, because they do not completely dissolve, the resultant small particles remaining in the bloodstream can result in complications such as pulmonary embolus or emphysema, so this is a very dangerous practice. Every house has a number of inhalants, such as oil-based cooking spray, gas, butane, or lighter fluid, which may be abused by adolescents. Inhalants can lead to cardiac failure from suffocation. Mephedrone, commonly called “bath salts,” is a stimulant that creates an enjoyable “high” and is available for purchase online and so is easily obtained by adolescents (Nguyen, O’Brien, & Schapp, 2016). The effect of using it is seen more regularly in emergency departments as the cause of reckless driving or unconsciousness 1972 (Baumann, Partilla, & Lehner, 2013). Listed as a schedule 1 drug, it is now illegal to obtain. Alcohol As many as 90% of high school seniors report having consumed alcohol, and as many as 25% of high school students report having engaged in episodic heavy or binge drinking. At least 10% of high school students report driving a car or other vehicle when they had been drinking alcohol. Nearly 30% of students report having ridden in a car or other vehicle driven by someone who had been drinking alcohol (CDC, 2012a). Although alcohol use is correlated with motor vehicle accidents, homicide, and suicide in adolescents, it has never carried the social stigma of other drugs. Some parents are actually relieved when they learn their child’s strange behavior on returning home from a party was caused by drunkenness and not illegal drugs. Alcohol use cannot be taken lightly, however, because it can cause diseases such as cirrhosis and is linked to destructive behaviors such as addiction, depression, and vulnerability to date rape. Heredity has a definite role in the use of alcohol, but environment plays an equal part in whether an adolescent becomes a frequent user (Maimon & Browning, 2012). Remind parents they have a responsibility to set good examples for adolescents in the use of alcohol by not drinking indiscriminately. Most adolescents will admit they use alcohol if asked two specific questions: “Do you drink alcohol?” and “When was your last drink?” Adolescents who answer yes to the first and “within the last 24 hours” to the second are candidates for further assessment. Once adolescents admit they have come to rely on alcohol as a way to feel popular or reduce stress, an organization such as Alcoholics Anonymous can be invaluable in helping them stop drinking; innovative online programs geared especially for adolescents are also available. Encourage the remainder of their family to join Al-Anon, the organization for families of alcoholics, so both children and their families can restructure their lives to find satisfaction without the use of this drug. Many adolescents are not the primary alcohol abuser in a family but are the children of alcoholic parents. Make an effort to identify this group of children as well, not only to prevent them from becoming users of alcohol but also to help them build self-esteem and coping abilities for the difficulties they face living in a possibly disorganized household. QSEN Checkpoint Question 33.5 EVIDENCE-BASED PRACTICE It has long been theorized there may be a “gateway” drug or one that, when used first, leads to further and more dangerous substance use disorders. To determine whether alcohol, tobacco, or marijuana was the gateway drug, researchers obtained information on the drug use of a nationally representative sample of high school 1973 seniors. Results of the study showed alcohol was the gateway drug, leading to tobacco, marijuana, and then other illicit substances (Barry, King, Sears, et al., 2016). Based on the previous study, which statement by Raul would give you the most concern? a. “Some of my friends got hammered last weekend but I decided not to stick around.” b. “Some of my friends use weed; they tell me it really helps them relax.” c. “My parents said I could celebrate my next birthday by drinking my first beer.” d. “My mother eats some kind of chocolate almost every day. Is that hereditary?” Look in Appendix A for the best answer and rationale. Tobacco Although it is well documented that cigarette smoking leads to increased cardiovascular and respiratory illnesses by middle age, every day, approximately 4,000 American youth aged 12 to 17 years try their first cigarette. As many as 20% of high school students report current cigarette use, and about 14% report current cigar use. Eight percent of high school students report current smokeless tobacco use (CDC, 2012d). Adolescents usually begin smoking because the habit conveys a stamp of maturity; those who are having difficulty demonstrating maturity in other areas may view smoking as especially desirable. Although at one time, proportionately more males than females smoked, adolescent girls now are the population most likely to begin smoking. One of the strongest determinants of whether adolescents will smoke a first cigarette is whether their friends smoke. As cigar smoking is becoming more popular with adults, it also is becoming more popular with adolescents. “Smokeless tobacco” or chewing tobacco is also becoming more popular (Kozlowski & Sweanor, 2017). Although chewing tobacco does not have the potential dangers of smoking tobacco in relation to lung disease, it can cause gingival recession and lip and mouth cancer, and it can be just as habit forming as cigarettes. It has been well documented that adolescents are influenced to begin smoking by advertising (Widome, Brock, Noble, et al., 2013). Most school systems have extensive programs as early as grade school to caution children not to listen to cigarette advertising. Unfortunately, the ultimate danger of illness or death in middle age is not a strong threat to young persons who are interested only in the present. More effective campaigns, therefore, might be those that point out that cigarette smoking causes foul-smelling hair, clothes, and breath, which detracts from physical appearance (i.e., “now” concerns). Helping adolescents find other methods to demonstrate their maturity, such as allowing them opportunities for increased decision making and emphasizing that being able to not smoke is a sign of true maturity, needs to 1974 be investigated. Urge adolescents who want to quit cigarette smoking to enroll in a group cigarette or online withdrawal program. Nicotine gum and nicotine patches have both been successfully used with adolescents (Harvey & Chadi, 2016). Additionally, in recent years, the use of e-cigarettes and vaping has increased significantly among adolescents. Their use has been demonstrated to actually increase the use of cigarette consumption. This is because they become addicted to the nicotine in the e-cigarette (Gostin & Glasner, 2014). The lack of regulations regarding the sale of vaping products causes additional problems for their use among adolescents. To purchase cigarettes, all persons must show identification and be older than 18 years of age. However, less than half of the states require identification to purchase e-cigarettes (Gostin & Glasner, 2014). Adolescents are very reluctant to follow instructions that are given from a “do as I say, not as I do” standpoint. Nurses who smoke, therefore, can have extreme difficulty launching an effective campaign against the habit with adolescents. Stopping smoking can be especially difficult during periods of stress or inactivity. Trying to introduce such an action during exam week, for example, is not good planning. During an illness is also a bad time, unless not feeling well has reduced the urge to smoke. A return visit for follow-up and health maintenance care might be a better time to introduce the topic. What If... 33.2 Raul tells the nurse during a history assessment that he does not smoke, but the nurse smells cigarette smoke on his clothing. Although he says he doesn’t use drugs, a number of blue-and-white capsules fall out of his shirt pocket when he unbuttons his shirt. What questions would the nurse want to ask him to determine if he is smoking cigarettes or using drugs? What would be the nurse’s next action if he does admit he is not only heavily into drugs but also does not intend to stop using them? Performance-Enhancing Substance Use Disorder Anabolic steroids are derivatives of the natural hormone testosterone. Common names are stanozolol, an oral compound, and testosterone propionate, an injectable form. Adolescents take steroids (obtained illegally) to enhance lean body mass and muscular development and so improve their athletic ability or appearance. These substances have side effects of euphoria and lessened fatigue, which make them doubly appealing. Unfortunately, steroid use can lead to early closure of the epiphyseal line of long bones, acne, elevated triglyceride levels, hypertension, aggressiveness, possibly psychosis, abnormal liver function, and perhaps liver cancer. In addition, athletes using them and paying vigorous sports can die from ventricular hypertrophy (Montisci, El Mazloum, Cecchetto, et al., 2012). Students using anabolic steroids need to be identified so they can be cautioned that 1975 the use of such drugs is illegal in sports competitions as well as being detrimental to their health. If needles are shared for administration, they additionally run the risk of acquiring hepatitis B or HIV infections. Human growth hormone is a second drug used to enhance athletic performance. This increases muscle strength and stamina and is more difficult to detect than steroid use and so is also becoming a commonly abused substance in athletes (Albertson, Chenoweth, Colby, et al., 2016). It’s dangerous in adolescents because side effects are joint pain and swelling and the development of diabetes. Marijuana Marijuana (widely known as “pot,” “grass,” or “weed”), derived from the leaves and stems of the Indian hemp plant Cannabis sativa, is the most frequently abused illicit substance, next to alcohol, used by adolescents (Kaul, 2016). It is generally rolled into cigarettes (“joints” or “reefers”) and smoked, although it can also be mixed with food or sniffed. Scraping the resin from the flowering leaves produces a much stronger substance called hashish. Sinsemilla is a seedless form that is even more potent. Breakdown products of marijuana are not readily eliminated from the body and remain in the fatty cells of the brain. This residue can create synaptic gaps that interfere with electrical brain waves and memory storage, especially for short-term memory. Physical and psychological effects of all forms of marijuana are euphoria and a sense of well-being, temporary impairment of coordination, rapid mood swings, decreased attention span, and loss of memory for recent events (up to 1 hour’s time). Withdrawal symptoms include irritability, drowsiness, and cravings for high-carbohydrate snacks. Long-term side effects can include pulmonary disorders such as sinusitis, bronchitis, emphysema, and perhaps lung cancer (which can develop after only 1 year of continual use compared with 20 years of cigarette use) as well as lack of sperm formation or subfertility in males (Fronczak, Kim, & Barqawi, 2012). Because the drug is prescribed to relieve nausea and vomiting, adolescents may view it as harmless. Help them to realize marijuana is more than an amusing leisure activity or a way to relieve stress so they can put its long-term effects into perspective. Amphetamines Amphetamines are a group of drugs used in the treatment of hyperactivity and narcolepsy, among other central nervous system disorders. They are easily manufactured in “meth labs” in people’s homes and so may be readily available to adolescents. Amphetamines are called “uppers” or “speed” because they give the user a false sense of well-being, alertness, or self-esteem. A newer, stronger form that produces intense symptoms is known as “ice.” Some of the side effects of either form are aggressive or demanding behavior, paranoia, and extreme restlessness. Chronic methamphetamine abuse results in destruction of teeth enamel or blackened, crumbling teeth (Auten, Matteucci, Gaspary, et al., 2012). Amphetamines can be especially 1976 appealing to obese adolescents as they suppress the appetite and result in weight loss. Cocaine Cocaine is one of the most popular drugs of abuse for late adolescents; its use can begin in adolescents. The drug may be sniffed into the nose (snorted), smoked, or injected intravenously. Occasionally, it is combined with heroin (termed a “speedball”) and injected. Common street names for cocaine are “snow” and “white lady” because of its fine, white powder. A stronger form, called “crack,” is manufactured by heating cocaine powder with baking soda and water. This preparation process is dangerous in itself because it involves using volatile solvents that can ignite or explode. The resulting drug, often called “freebase” or “rock,” is so strong it can cause immediate cardiac and respiratory arrhythmias (Paczynski & Gold, 2011). It is difficult to document how many adolescents use cocaine, but estimates range from 3% to 9%. After absorption, blood levels rise rapidly for the first 20 minutes, peak at 60 minutes, and then decline over the next 3 hours. Although a toxic dose of cocaine is usually considered to be 600 to 700 mg, toxicity has been reported in as low as a 20 mg dose (a single line). Cocaine produces the physical effects of increased pulse and respiration rates, increased temperature, increased blood pressure, and decreased appetite. Psychological effects produced are euphoria, excitement and restlessness, increased sociability, and possible hallucinations. Toxic symptoms include seizures, tachyarrhythmias, tachypnea, hypertension, nausea and vomiting, abdominal pain, headaches, chills, and fever. It can be a major cause of cardiovascular arrest in late adolescents (Eisendrath & Lichtmacher, 2013). It may be a cause of adolescent automobile accidents because it creates such a sense of well-being and safety (Stoduto, Mann, Ialomiteanu, et al., 2012). Cocaine is rarely ingested orally, but occasionally, adolescents swallow it when trying to hide a supply from parents or school personnel. Gastric acid destroys the action of cocaine, so unless the amount is extremely large, it is potentially harmless when swallowed in this way. Teach adolescents that although cocaine sniffing may be fascinating and offer temporary pleasure and relief from stress, it also causes psychological dependency and is potentially extremely dangerous because of its cardiac and respiratory effects. Chronic inhalation of cocaine can cause ulceration in the mucous membrane of the nose, and injection of the substance exposes an adolescent to the risk of HIV and AIDS or hepatitis B. During pregnancy, it can cause separation of the placenta with potential fetal and maternal death (Mbah, Alio, Fombo, et al., 2012). Hallucinogens Examples of hallucinogenic drugs used by adolescents are lysergic acid diethylamide (LSD), dimethyltryptamine (DMT), 2,5-dimethoxy-4-methylamphetamine (STP), 1977 phencyclidine (PCP) hydrochloride, Salvia divinorum, mephedrone (“bath salts”), and methaqualone (Quaalude). The use of LSD has substantially increased in popularity since the 1960s when it first became available because it is a drug that can be manufactured by an informed adolescent in a “kitchen lab