New Era University

College of Nursing

NCM 107-18 Care of Mother, Child and Adolescent (Well)

S.Y. 2024-2025 | 1st Semester | Final Period
Module 14: Care of the Family with an Adolescent Child
Introduction

This module will provide students with an understanding of the care of the family with an adolescent and the physical
and psychological changes that occurs during this period Adolescence is generally defined as the period between ages
13 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).

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 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. It is said that dealing with adolescents is like a
roller coaster ride for some parents, it is therefore important for the family to be educated on how to address the
challenges in raising and adolescent.

Learning Outcomes

1. Integrate knowledge and principles of adolescent’s growth and development with application of appropriate
nursing care to the child and family.
2. Assess the adolescent for normal growth and developmental milestones

3. Formulate nursing diagnosis/es that address related to growth and development of a adolescent and parental
concerns.
4. Implement safe and quality nursing interventions related to normal growth and development of a adolescent.
5. Evaluate with the mother and family the health outcomes of nurse-client relationship.

Topic Outline

I. Physiologic Development

III. Freud’s Theory of Psychosexual Development

IV. Erikson’s Theory of Psychosocial Development

V. Piaget’s Theory of Cognitive Development

VI. Kohlberg’s Theory of Moral Development

VII. Nutrition of the adolescent

VIII. Concerns and Problems Related to Normal Development of adolescent

IX. Assessment of an adolescent

X. Nursing diagnosis for an adolescent and family

XI. Implementation of safe and quality nursing interventions

XII. Evaluation

I. PHYSIOLOGIC DEVELOPMENT

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. 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 inches (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 inches (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 inches (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 to 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 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 (glands present in the axillae and genital area,
which produce a strong odor in response to emotional stimulation) form shortly after puberty 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.

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.
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 continue to develop during adolescence.

SEXUAL MATURATION IN ADOLESCENTS

AGE FEMALES
MALES

Growth spurt continuing; pubic hair Pubic hair thick and curly, triangular in
abundant and curly; testes, scrotum, and distribution; breast areola and papilla form
penis enlarging further; axillary hair present; secondary mound; menstruation is
13 – 15
facial hair fine and downy; voice changes ovulatory, making pregnancy possible
happen with annoying frequency

Genitalia adult; scrotum dark and heavily Pubic hair curly and abundant; may extend
rugated; facial and body hair present; sperm onto medial aspect of thighs; breast tissue
production mature appears adult; nipples protrude; areolas
15 – 16 no longer project as separate ridges from
breast; may have some degree of facial
acne

Pubic hair may extend along medial aspect of End of skeletal growth
thighs; testes, scrotum, and penis adult in size;
16 – 17 may have some degree of facial acne;
gynecomastia (enlarged breast tissue), if
present, fades

17 - 18 End of skeletal growth

Sexual maturity in males and females is classified according to Tanner stages (Fig 1).
 Figure1. Tanner’ s stages of sexual maturity II. FREUD’S
THEORY OF PSYCHOSEXUAL DEVELOPMENT

GENITAL STAGE

• Site of gratification: genitalia

• Activity: Learns to establish satisfactory relationship to the opposite sex.

• Nursing significance: Give an opportunity to relate to the opposite sex.

• Resurgence of sexual drives

• Sexual pleasure through genitals

• Sexual identification

• Heterosexual is normal

• Basic Concept: Matured Sexuality

• Major Conflict: Develops ability to love and work

• Maturation of the reproductive system

• Mastery of this period results in the development of the ability to love and to work

• Psychological theme: Maturity, creation and enhancement of life(intellectual and artistic creativity).

• Task: Learn how to add something to life and society.

 • How to achieve this state: Balance both love and work.

III. Erikson’s Theory of Psychosocial Development

According to Erikson, 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 the adolescent 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. This can lead to difficulty functioning effectively as adults because they are unable
to decide what stand to take on a particular issue or how to 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.

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. 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. Some adolescents require help from parents or other adults
to differentiate between sound relationships and those that are based only on sexual attraction.

A. Socialization

Early teenagers may feel more self-doubt than self-confidence when they meet new adolescent with
whom they would like to begin a lasting relationship. The voices of most boys have not yet dependably deepened,
and most girls’ bodies have not yet fully developed. These make them unable to trust themselves to carry out what
they wish to convey.

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 also impulsive 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. They may spend more time
longing for someone than they do instituting an in-depth and rewarding relationship.

By age 14 years, teenagers have become quieter and more introspective. They are becoming used to their
changing bodies, have more confidence in themselves, and feel more self-esteem.
 Adolescents watch adults carefully, searching for good role models with whom they can identify. They usually
have a hero whom they want to grow up to be like.

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.

By age 16 years, boys are becoming sexually mature. Both sexes are better able to trust their bodies than 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 to get the attention of others.

B. PLAY OR RECREATION

Thirteen-year-old children’s activities change to more adult forms of recreation such as listening to
music, texting or chatting, or following a sports team wins and losses. Team loyalty becomes intense and
following a coach’s instructions becomes mandatory. 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-
toface or through electronic media. For an adolescent, talking is a major way they learn about values and
responsibilities.

Beginning age 16 years, most adolescents want part-time jobs to earn money. Such jobs can teach them
how to work with others, accept responsibility and how to save and spend money wisely. Many of them also
engage in charitable endeavors during middle to late adolescence as a form of recreation. These activities fulfill
an adolescent’s need for satisfying interaction with others as well as indicators of maturity and willingness to
accept adult roles.

IV. PIAGET’S THEORY OF COGNITIVE DEVELOPMENT

The final stage of cognitive development, the 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. This step
involves the ability to think in abstract terms and use the scientific method (deductive reasoning) to arrive at
conclusions. Problem solving in any situation depends on the ability to think abstractly and logically.

• Develops abstract thinking abilities

• Is capable of scientific reasoning and formal logic

• Enjoys intellectual abilities

• Is able to view problems comprehensively

 V. KOHLBER’G MORAL THEORY

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 o
spend money to replace what I stole”

Almost all adolescents question the existence of God any religious practices they have been taught. 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.

VI. FEEDING AND NUTRITION

Adolescent needs an increased number of calories to support the rapid body growth that occurs. Iron is
necessary to meet expanding blood volume requirements. 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. Zinc is
necessary for sexual maturation and final body growth.

For high school athletes, they need more carbohydrate or energy. A source of carbohydrate that best
sustains them 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.

VII. CONCERNS AND PROBLEMS RELATED TO NORMAL ADOLESCENT DEVELOPMENT

A. 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 through risk-taking leads them to take careless actions, such as speeding
or driving while intoxicated.

Use of safety precautions, safe driving and sense of responsibility toward others; motorcycle riders on the other
hand should wear safety helmets to prevent head injury, long pants to prevent leg burns, and full body covering to
prevent abrasions in case of accidents.

Drowning also occur in adolescents when even good swimmers go beyond their capabilities on dares or
in hopes of impressing friends. Teaching water safety and the mechanics of swimming is of utmost importance.

Homicide and self-harm are other causes of death in adolescents. 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.

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.

B. 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. Carrying too heavy backpacks can also be a reason.
 C. BODY PIERCING AND TATTOOS

Body piercing and tattoos are a strong mark of adolescence. Body piercing and tattoos have become a way for
adolescents to make a statement of who they are and that they are different from their parents.

Sharing needles for piercing or tattooing carries the same risk for contacting an infection or blood-borne disease.
Be sure the adolescent knows the symptoms of infection and to report these immediately to their health care
providers.

D. FATIGUE

Protein synthesis occurs most readily during sleep and adolescents are building so many new cells, this
age group need more sleep than any other age group. This is a busy time with extracurricular activities and also a
stressful period; adolescents sleep restlessly as their mind reworks the day’s tensions. Even long periods of sleep may
not leave them feeling refreshed. Lack of sleep can lead to chronic fatigue or depression. Thus, they are usually
advised to reduce activity to get more sleep. If an adolescent’s sleep and diet are adequate, the activity schedule is
reasonable, and physical assessment suggests no illness, then the fatigue may be of emotional origin. It can be a
means of avoiding school, conflict with parents, or social situations, or may be under stimulated by school.

E. 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. 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.

Changes associated with puberty that cause acne to develop include:

1. As androgen levels rise in both sexes, sebaceous glands become active

2. The output of sebum, which is largely composed of lipids, mainly triglycerides, increases.

3. Trapped sebum causes whiteheads, or closed comedones

4. As trapped sebum darkens from accumulation of melanin and oxidation of the fatty acid components on
exposure to air, blackheads, or open comedones, form. Leakage of fatty acids causes a dermal inflammatory
reaction

5. Bacteria (generally, Propionibacterium acne) lodge and thrive in the retained secretions and ducts.

Acne is categorized as mild (comedones or blocked hair follicle), moderate (papules and pustules are also
present), or severe (cysts are present). The most common locations of acne lesions are the face, neck, back, upper
arms, and chest. Flare- ups are associated with emotional stress, menstrual periods, or the use of greasy hair creams
or make-up that can further plug gland ducts.

The goal of therapy for acne is threefold: (a) decrease sebum formation, (b) prevent comedones and
(c) control bacterial proliferation.
 F. OBESITY

Most overweight adolescents have obese parents, suggesting that both inheritance and environment
play a role 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.

A diet closer to 1,800 calories per day, encourage activities that burn calories are preferred but for
adolescents who overeat, psychological counselling is needed

General measures to help adolescents decrease overeating include:

1. Make a detailed log of the amount they eat, the time, and the circumstances and then change those
circumstances

2. Always eating in one place instead of while walking home from school or watching television

3. 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.

G. SEXUALITY AND SEXUAL ACTIVITY

Adolescents who engage in sexual risk behaviors can have unintended health outcomes, including
unplanned pregnancies and sexually transmitted infections such as HIV. When discussing sexuality with adolescents,
the nurse should avoid assumptions about the gender of the adolescent’s partner. Ask open-ended questions so
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 sexual intercourse but who do not really want to, the primary
reasons given are peer pressure, curiosity, and affection for their partner.

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. The overall
term for these methods is electronic aggression. 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

H. BULLYING OR HAZING

Bullying began from school age can continue into adolescence and 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 is a form of organized bullying which refers to demeaning or humiliating rituals that prospective
members have to undergo to join sororities, fraternities, adolescent gangs or sports teams. Most rituals are secret
and in the past were accepted as “rites of passage”

To help prevent this from happening to their child, parents should be aware of what clubs or
organizations their child joins and what requirements for membership are.
 I. 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. 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.

As many as 90 % of high school seniors report having consumed alcohol. Alcohol use cannot be taken lightly
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.

Adolescents usually begin smoking because the habit conveys a stamp of maturity. As cigar smoking is becoming
popular with adolescence, smokeless tobacco or chewing tobacco is also becoming more popular. It had been
documented that adolescents are influenced to begin smoking by advertising.

Steroids may also be taken to enhance lean body mass and muscular development and so improve their athletic
ability or appearance. It can also 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. Athletes
using them and playing vigorous sports can die from ventricular hypertrophy.

J. DEPRESSION AND SELF-INJURY

Self-injury includes a range of self-destructive actions from cutting to suicide, the planned intent to end
one’s life. Successful suicide occurs more frequently in males although more females apparently attempt suicide than
males. Adolescent suicides tend to be attempted most often in the spring or the fall, reflecting school stress at these
times of the year, and between 3 pm and midnight, reflecting depression that increases with the dark. Some degree
of depression is present in most adolescents because they are losing not only their parents while they grow apart
from them but also their carefree childhood.

Reasons for adolescent suicide are varied. These may be school failure, loss of a girlfriend or boyfriend,
loss of a competition with loss of self-esteem or rejection by a peer group, incest, maltreatment, increased chemical
dependency, marital instability in the family, and poor problem- solving ability, or maybe anger with others, trying to
get even, and manipulation (psychological blackmail) as a way of having one’s needs met. Many adolescents may
decide death may be easier than coping with overwhelming problems.

VIII. ASSESMENT OF AN ADOLESCENT

Health maintenance visits during adolescence may become more irregular because adolescents may not
seek care from health care 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 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 appreciative comments.
 IX. NURSING DIAGNOSIS

Nursing diagnoses for adolescents can cover a wide range of topics. Frequently used diagnoses related

to adolescent and their families include:

1. Health-seeking behaviors related to normal growth and development

2. Low self-esteem related to facial acne

3. Anxiety related to concerns about normal growth and development

4. Risk for injury related to peer pressure to use alcohol and drugs

5. Risk for disease related to sexual activity

6. Readiness for enhanced parenting related to increased knowledge of teenage years

X. IMPLEMENTATION OF SAFE AND QUALITY NURSING INTERVENTIONS

When planning care with adolescents, respect the fact that they have a strong desire to exert

independence or do things their 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 agreeable and accepted. Establishing a contract 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 will usually be carried out well. In contrast, a regimen oriented toward the future, with long-term goals may
not be as successful.

Adolescents tend to do poorly with tasks someone tells they must do. Integrating the adolescent in their

plan of care typically helps them be successful. They have little patience with adults who do not demonstrate the
behavior they are being asked to achieve. For best results, evaluate how an intervention appears from an adolescent’s
standpoint before beginning teaching.

XI. 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:

1. Patient states she feels good about herself even though she is the shortest girl in her class

2. Patient states he has not consumed alcohol in 2 weeks

3. Parents state they feel more confident about their ability to parent an adolescent
 New Era University
College of Nursing

NCM 107-18 Care of Mother, Child and Adolescent (Well)

S.Y. 2023-2024 | 1st Semester | Finals

4. Patient states she feels high self-esteem despite persistent facial acne.

References:

Bowden, V. R., & Greenberg, C.S. (2016). Pediatric nursing procedures (4thed.). Philadelphia, PA:
Wolters Kluwer.
Flagg, J. (2018). Maternal and child health nursing: Care of the childbearing and childbearing family
(8thed.). Philadelphia, PA: WoltersKluwer.
 New Era University
College of Nursing

NCM 107-18 Care of Mother, Child and Adolescent (Well)

S.Y. 2023-2024 | 1st Semester | Finals

Module 14: Care of a Family with an Adolescent