Physical Health Problems of Adolescence

Etiology

Numerous factors affect the development and course of acne. Research has shown a familial aspect to acne vulgaris, with a high occurrence of severe acne and increased sebum secretion among monozygotic twins. Forty-five percent of adolescent boys with acne have a positive family history, whereas only 8% of adolescent boys without acne have a positive family history. Premenstrual flares of acne occur in nearly 70% of girls, suggesting a hormonal cause. Scientific studies do not demonstrate a clear association between stress and acne; however, adolescents commonly cite stress as a cause for acne outbreaks. Cosmetics containing lanolin, petrolatum, vegetable oils, lauryl alcohol, butylstearate, and oleic acid can increase comedone production. Exposure to oils in cooking grease can be a precursor to acne in adolescents working in fast-food restaurants. There is no known link between dietary intake and the development or worsening of acne lesions.

Pathophysiology

Acne is a disease that involves the pilosebaceous unit, which consists of the sebaceous glands and hair follicles. Acne is most commonly found on the face, chest, upper back, and neck because of the large quantity of sebaceous glands on these skin areas. There are nearly 900 glands per square centimeter on the skin surfaces of the face, chest, neck, and upper back, compared with 100 glands per square centimeter on the rest of the body.

Three pathophysiologic factors have the greatest influence on acne development: excessive sebum production, comedogenesis, and the overgrowth of Propionibacterium acnes (Olutunmbi, Paley, and English, 2008). Increased sebum production begins at the time of adrenocortical maturation and subtly continues to increase until the late teens. Acne severity is proportional to the sebum secretion rate, which is genetically determined.

Comedogenesis (formation of comedones) results in a noninflammatory lesion that may be either an open comedone (blackhead) or a closed comedone (whitehead). Inflammation occurs with the proliferation of P. acnes, which draws in neutrophils, causing inflammatory papules, pustules, nodules, and cysts (Fig. 20-1). The traditional ice pick scarring results from macrophages that digest the inflamed skin along with the normal dermis in the process.

Psychosocial Ramifications

Adolescents are acutely aware of their physical appearance, and their cognitive development results in the feeling that they are constantly on stage. In one survey one third of teenagers reported that pimples were the first thing people noticed about them (Gupta and Gupta, 2003). A population-based study found that older adolescents with acne had lower self esteem, lower self-worth, and less body satisfaction than those without acne (Dalgard, Gieler, Holm, et al, 2008). The amount of psychologic stress does not directly correlate to the clinical severity of the acne. The importance of timely treatment has been underscored by research demonstrating the long-term psychologic impact of living with acne over critical developmental periods of life (Gupta and Gupta, 2003).

Therapeutic Management

Successful management of acne depends on a cooperative effort between the care provider, adolescent, and parents. The care provider must determine the adolescent’s goals and increase understanding of the cause and treatment of acne. Unlike many dermatologic conditions, the acne lesions resolve slowly, and improvement may not be apparent for at least 6 weeks. Individual comedones may take several weeks to months to resolve, and papules and pustules usually resolve in about 1 week.

The multifactorial causes of acne require a combined approach for successful treatment. Treatment consists of general measures of care and specific treatments determined by the type of lesions involved.

Medications

Treatment success depends on commitment from the adolescent. Before prescribing treatment, the clinician should determine the adolescent’s level of comfort and readiness to begin treatment. The teen should be reminded that clinical improvement may take weeks to months. Those who are impatient with speed of recovery may discontinue the medication or apply too much. Discussion about acne treatment should begin in early puberty. In young girls the early development of acne is the best predictor of future severe acne. Early intervention, most often with topical medications, may prevent the development of more severe acne.

Topical retinoids are the only drugs that effectively interrupt the abnormal follicular keratinization that produces microcomedones, the invisible precursors of the visible comedones. Retinoids are recommended as the first line of treatment for most forms of acne. Tretinoin has been the gold standard for topical retinoids and is available as a cream, gel, or liquid. The cream is less irritating than the gel, which is less irritating than the liquid. Newer formulations contain tretinoin trapped within porous copolymer microspheres that localize the medication to the follicle. These are less irritating to the skin because the medication is released over time, reducing the concentration on the skin (Guttman, 2009). The next-generation topical retinoids adapalene and tazarotene became available in the late 1990s. A comparison trial of the two medications found them to have similar efficacy, but adapalene gel 0.3% was better tolerated. After 12 weeks of treatment more than 50% of subjects in both treatment arms reported marked improvement or near clearing of acne (Thiboutot, Arsonnaud, and Pascale, 2008).

A gel combining 0.25% tretinoin and 1.2% clindamycin phosphate (Ziana gel) has been recently approved by the U.S. Food and Drug Administration (FDA). This gel has been shown to be more effective in treating acne than tretinoin or clindamycin monotherapy (Eichenfield and Wortzman, 2009).

Instruct the patient to begin with a pea-sized dot of medication, which is divided into the three main areas of the face and then gently rubbed into each area. The patient should not apply the medication until at least 20 to 30 minutes after washing to decrease the burning sensation. A daily moisturizer should be used along with retinoid treatment. Since sun exposure may easily result in severe sunburn, advise adolescents to avoid sun, apply the medication at night, and use a sunscreen with a sun protective factor (SPF) of at least 15 in the daytime.

Topical benzoyl peroxide is an antibacterial agent that inhibits the growth of P. acnes. Benzoyl peroxide is effective against both inflammatory and noninflammatory acne and is an effective first-line agent. The medication is available as a cream, lotion, gel, or wash. Using benzoyl peroxide is less likely to result in the development of antibiotic-resistant strains of P. acnes, which makes it an ideal adjunct when topical or oral antibiotic treatment is employed (Bowe and Shalita, 2008). Benzoyl peroxide soaps are convenient because they can be applied in the shower and assist in the treatment of acne on the chest and back. Benzoyl peroxide and salicylic acid are the most common ingredients in popular and effective acne treatment kits available over the counter. Patient education should include information regarding the bleaching effect of the peroxide on sheets, bedclothes, and towels. The adolescent can be reassured that skin bleaching will not occur. The drying effects of the medication can be accommodated with gradual increases in strength and frequency of application.

When inflammatory lesions accompany the comedones, a topical antibacterial agent may be prescribed. These agents are used to prevent new lesions and to treat preexisting acne. Clindamycin, erythromycin-metronidazole, and azelaic acid are currently available topical antibiotics. Side effects of these medications include erythema, dryness, and burning; using the medications every other day will decrease the adverse effects. Topical antimicrobials combined with benzoyl peroxide are more effective than either product alone. Retinoids in combination with antimicrobials also improve the penetration of these topical agents and are the only means to address three of the pathogenic causes of acne: keratinization, P. acnes, and inflammation. Combination therapy is usually more effective than either component alone (Krakowski, Stendardo, and Eichenfield, 2008).

Systemic antibiotic therapy is initiated when moderate to severe acne does not respond to topical treatments. The foundation for using systemic antibiotics in acne treatment has been the elimination of the inflammatory effects of P. acnes by suppressing the bacteria. Tetracycline, erythromycin, minocycline, doxycycline, and amoxicillin are systemic antibiotics used to treat acne (Olutunmbi, Paley, and English, 2008; Yan, 2006). They are relatively free of side effects with the exception of occasional gastrointestinal upset, photosensitivity, or vaginal candidiasis. Minocycline is more expensive but is less likely to cause gastrointestinal side effects and is very effective against severe inflammatory acne. Resistance to antibiotics may develop, especially with tetracycline and erythromycin. Judicious use of oral antibiotics and avoidance of topical antibiotics in combination with oral treatment can prevent resistance. Providers should avoid use of multiple antibiotic classes and shorten the course by using the full dose of systemic antibiotics for 1 month and then begin to taper the dosage. The adolescent can then be maintained on topical treatment (Krakowski, Stendardo, and Eichenfield, 2008).

Girls with mild to moderate acne may respond to topical treatment and the addition of an oral contraceptive pill (OCP). OCPs reduce the endogenous androgen production and decrease the bioavailability of the woman’s circulating androgens. Combination OCPs containing levonorgestrel, gestodene, and desogestrel as the progestin decrease acne in women. The FDA has approved multiple combination OCPs for the treatment of acne in girls. Visible improvement may take up to 4 months.

Isotretinoin 12-cis-retinoic acid (Accutane), a potent and effective oral agent, is reserved for severe, cystic acne that has not responded to other treatments. Isotretinoin is the only agent available that affects all factors in the development of acne. Only physicians who have taken a comprehensive educational program about the medication, necessary monitoring of patients, and parameters for pregnancy prevention may manage treatment with isotretinoin. Adolescents with multiple, active, deep dermal or subcutaneous cystic and nodular acne lesions are treated for 20 weeks. Long-term remissions occur with this highly effective drug. However, multiple cutaneous side effects can occur, which vary from mild to moderate in severity. Dry skin, dry eyes, dry mucous membranes, nasal irritation, decreased night vision, photosensitivity, arthralgia, headaches, mood changes, depression, and suicidal ideation may occur. There is some concern that isotretinoin may be associated with increased incidence of depression and suicide despite several findings to the contrary (Webster, 2009). Careful monitoring for signs of depression among all adolescents taking isotretinoin is recommended as part of all health visits for acne treatment (Hull and D’Arcy, 2003; Jacobs, Deutsch, and Brewer, 2001). The most significant side effects are the teratogenic effects, causing limb and skull abnormalities. Isotretinoin is absolutely contraindicated in pregnant women. Sexually active young women must use an effective contraceptive method during treatment and for 1 month after treatment. Providers should also monitor patients receiving isotretinoin for elevated cholesterol and triglyceride levels. Significant elevation may require discontinuation of the medication.

Scarring begins early in all types of acne, from papulopustular to nodulocystic. Most of the scarring is a result of loss of tissue rather than thickening. Chemical peels have been traditionally used for the treatment of scarring in acne. Only the mildest acne scarring will actually resolve with chemical peels. Fractional photothermolysis using laser technology is considered to be as effective as carbon dioxide lasers for treating acne scarring; some side effects are associated with carbon dioxide laser therapy (Chapas, Brightman, Sukai, et al, 2008; Walgrave, Ortiz, MacFalls, et al, 2009).

Nursing Care Management

The health screening interview should contain questions regarding the adolescent’s concern about acne. Because acne is so common and its appearance may seem so mild, the health care provider may underestimate the relative importance of the disease to the adolescent. The nurse should assess the individual adolescent’s level of distress, current management, and perceived success of any regimen before initiating a referral. If the adolescent does not perceive the acne to be a problem, he or she may lack motivation to follow the treatment plan. The primary care provider can manage most cases of acne without referral to a dermatologist.

The nurse can provide ongoing support for the adolescent when a treatment plan has been initiated. Encourage the family to support the adolescent in his or her efforts. Discuss the use of the medications and basic skin care information in detail with the adolescent. Written information to accompany the discussion is helpful. Inform patients that it will take 6 to 8 weeks to appreciate improvement in their skin. Information to dispel myths regarding the use of abrasive cleansing products as a means of removing blackheads can prevent unnecessary costs and trauma to the skin. Teenagers also need to be educated about factors that may aggravate acne and damage skin, such as too vigorous scrubbing. Picking, squeezing, and manual expression with fingernails breaks down ductal walls and causes acne to worsen. Mechanical irritation, such as vinyl helmet straps that rub areas predisposed to acne, can cause the development of lesions.

Nursing Care Management

To supplement routine health assessment, every adolescent boy should learn to perform monthly testicular self-examination (TSE). This provides an opportunity for the adolescent to familiarize himself with his own anatomy and to ensure early detection of any abnormality. In the TSE each testicle is examined individually, preferably after a warm bath or shower, when scrotal skin is more relaxed, using the thumbs and fingers of both hands and applying a small amount of firm, gentle pressure. The normal testicle is a firm organ with a smooth, egg-shaped contour. The epididymis can be palpated as a raised swelling on the superior aspect of the testicle and should not be confused with an abnormality. The nurse can play an important role in providing anticipatory guidance to all adolescent boys. This guidance includes an explanation of the rationale for TSE and how to perform this procedure (see Critical Thinking Exercise).

Nursing Care Management

Nurses should be alert to the possibility of testicular torsion in adolescents who complain of scrotal pain. Because torsion often results from trauma to the scrotum, school nurses are likely to encounter such injuries and should refer the adolescent for medical evaluation immediately.

Nursing Care Management

Management usually consists of assuring the adolescent and his parents that this situation is benign and temporary. The adolescent may benefit from the knowledge that it occurs in more than 50% of his peers.

Amenorrhea

The causes of amenorrhea can be divided into organ system and estrogen status. The most common cause of amenorrhea is pregnancy. A pregnancy test is an essential part of the evaluation for all females with amenorrhea, regardless of the sexual history. The next most prevalent causes of amenorrhea in adolescents are polycystic ovary syndrome and hypothalamic amenorrhea. For girls who are more than 2 or 3 years past menarche, the most common hypothalamic causes of amenorrhea are eating disorders, excessive exercise, medication, and stress (Wiksten-Almstromer, Hirschberg, and Hagenfeldt, 2007).

Polycystic ovary syndrome (PCOS) is a common endocrine disorder. There are no formal diagnostic criteria for teens with PCOS, and the cause is unclear. The characteristic findings are hyperandrogenism, chronic anovulation, and polycystic ovaries. Other ovarian causes of amenorrhea include gonadal dysgenesis; the most common form is Turner syndrome. Girls with Turner syndrome have delayed puberty, short stature, webbed neck, widely spaced nipples, and cardiac and kidney abnormalities. Premature ovarian failure, galactosemia, and ovarian tumor are other ovarian causes of amenorrhea.

Thyroid disease is not uncommon in adolescents and is more common in females than males. Both hypothyroidism and hyperthyroidism may result in menstrual irregularities, with the latter more likely to cause amenorrhea.

Adrenal causes of amenorrhea include congenital adrenal hyperplasia, which is an autosomal recessive disorder of steroidogenesis. Nonclassic adrenal hyperplasia is characterized in adolescents by hirsutism or amenorrhea. Pituitary causes of amenorrhea include prolactinoma, Cushing syndrome, and sarcoidosis.

Primary amenorrhea in an adolescent complaining of periodic (usually monthly) lower abdominal pain with evidence of estrogen production and sexual maturation may be related to an imperforate hymen, closed hymen from female circumcision, or transverse vaginal septum. The treatment is simple surgical perforation and drainage. Other anatomic causes of the amenorrhea include intrauterine adhesions and congenital absence of a uterus.

Menstrual Irregularities in the Female Athlete

The most common clinical indications of potentially adverse effects of exercise on an adolescent’s reproductive cycle include (1) delayed menarche, (2) anovulation associated with dysfunctional uterine bleeding, and (3) oligomenorrhea or amenorrhea with hypoestrogenic states. Researchers have not been able to identify the exact mechanism of these menstrual changes. The most probable cause is at the hypothalamic level as a result of an imbalance of the amount of energy in (food) compared to the energy out (exercise). Amenorrhea is so common among female athletes that it is misinterpreted as normal by athletes, coaches, and some health care providers. Prevalence of amenorrhea has been found to be as high as 69% among ballet dancers and 65% among distance runners. Eating disorders are often part of the syndrome with exercise-induced amenorrhea (Warren and Chua, 2008). Adolescents who exercise intensely and have menstrual bleeding more frequently than every 21 days or at intervals of 35 to 120 days are likely to have chronic anovulation. They usually produce estrogen but have inadequate levels of progesterone. Unopposed estrogen can lead to endometrial hyperplasia and theoretic risk of endometrial adenocarcinoma.

In addition to menstrual dysfunction, female athletes also may be at risk for eating disorders and decreased bone mineral density (Joy, Van Hala, and Cooper, 2009). Any adolescent athlete who becomes amenorrheic requires medical evaluation to rule out other causes of amenorrhea and to assess for disordered eating (Sherman and Thompson, 2004). Sometimes a trial of decreasing the intensity or duration of exercise and improving nutrition will relieve irregularities. Careful evaluation by a health care provider who specializes in the treatment of eating disorders and athletes is essential. (See Chapter 39.)

Dysmenorrhea

Dysmenorrhea is defined as painful menstrual flow. Primary dysmenorrhea is painful menses without any identifiable pathologic disorder. Primary dysmenorrhea is the most common cause of painful menses in adolescents. Secondary dysmenorrhea is defined as painful menses with a pathologic condition such as endometriosis, salpingitis, or congenital anomalies of the müllerian system. The incidence of dysmenorrhea increases as adolescents mature; at age 12 years the prevalence is reported at 38%, and it increases to 66% to 77% by age 17 (Slap, 2003). It is a leading cause of recurrent absence from work and school.

Nursing Care Management

Adolescents require careful counseling about the use of the medications prescribed. The hormonal treatments have common side effects that are not well tolerated by adolescents, requiring education and support throughout the course of treatment.

Nursing Care Management

Ordinarily, only reassurance and attention to general health status are needed, with emphasis on a well-balanced diet, adequate rest, and moderate exercise. The nurse should instruct the adolescent to use a menstrual calendar to track improvement and guide future interventions. When OCPs are prescribed, the adolescent and her parents need careful explanation of the use of these medications. The high-dose estrogen OCPs can result in nausea and vomiting. Anticipatory supportive care includes preparation for procedures if these are a possibility.

Nursing Care Management

The adolescent who comes in for treatment of a vaginal discharge provides an opportunity for health teaching. Teach the young woman how to differentiate normal vaginal discharge from a potential infection. The discussion may elicit questions and concerns the adolescent has regarding other aspects of her developing body and sexuality. The nurse should stress the importance of an evaluation whenever the adolescent notices a change in her normal vaginal discharge.

When an infection is identified, the nurse can explain how the etiologic agents produced the irritation and the principles behind management. The prescription of a vaginal cream requires a careful explanation and demonstration of use. Girls who have never used a tampon will be less familiar with insertion of the vaginal applicator. Instruct the adolescent to apply the cream before bedtime to avoid leakage of the medication while in an upright position. The use of oil-based vaginal creams may break down the latex condom.

Health teaching should include the prevention of future infections. Teach girls at an early age to wipe front to back after toileting. Avoiding tight fitting clothes and nylon panties can assist in prevention. Douching is a common practice among adolescents and should be discouraged because it leads to changes in the normal vaginal microflora. Also, stress the use of condoms for prevention of T. vaginalis and other STIs.

Medical Aspects

Adolescents often receive delayed or inadequate prenatal care. Prenatal care may be delayed because the adolescent does not realize she is pregnant or denies the pregnancy until the second or third trimester. Health care providers working with adolescents should have a high index of suspicion for pregnancy. She may or may not have considered the possibility of pregnancy no matter how at risk for pregnancy she is. A pregnant adolescent may give vague reports of irregular periods or missed periods; the bleeding that occurs with implantation may be mistaken for a period, further delaying the diagnosis. Lacking adequate care, adolescent mothers and their unborn infants are at greater risk for low-birth-weight infants and infant deaths. It remains unclear whether this is a result of biologic immaturity or sociodemographic factors.

The obstetric risk and risk to the infant during a second pregnancy for the teenager is much higher. An adolescent with a poor outcome in the first pregnancy has a threefold risk of repeating the poor outcome in the second pregnancy. In teenagers the risk for a preterm delivery recurring is double the rate found in mature women. However, the mean birth weight for second deliveries is higher, related to an increase in the maternal prepregnancy body mass index (BMI).

Diagnosis of Pregnancy

A detailed menstrual and sexual history should be a routine part of health care for adolescents. Review specific symptoms of pregnancy, including amenorrhea, breast tenderness, urinary frequency, fatigue, and nausea. Absence of these symptoms does not exclude pregnancy. It is best not to perform a pregnancy test without the adolescent’s knowledge. Before the pregnancy test, discuss with the adolescent what she will do if the test is positive and determine who else is aware she is sexually active and possibly pregnant.

After confirming that a pregnancy test is positive, inform the adolescent privately. Common reactions are ambivalence, shock, fear, or apparent apathy. The nurse should be supportive at this time and assure her the feelings are normal. Review the facts about the pregnancy, including the duration of pregnancy and anticipated due date. The next step is to determine who she plans to inform and, if she is under 18, how she would like to tell her parents. Some girls may want to take some time before notifying their parent. The nurse should schedule a follow-up appointment in 24 to 48 hours to assist with parental notification. Usually, the adolescent informs her parent on her own terms during this period. The nurse can assist with notification by offering to tell the parent for the teen or to be present when she tells her parent. Nonjudgmental support is critical at this time for the safety of the teen and her pregnancy.

Complications of Pregnancy

Bleeding is common in early pregnancy (occurring in 20% to 25% of cases), and about half of these pregnancies end in spontaneous abortion. Most spontaneous abortions occur in the first trimester as a result of abnormal chromosomal complement, uterine or cervical abnormalities, maternal systemic illness, or infection. Ultrasound evaluation can assist in determining the prognosis for the pregnancy. Bed rest is usually recommended when bleeding occurs; however, there is little evidence to demonstrate its effectiveness in preventing spontaneous abortions (Sotiriadis, Papatheodorou, and Makrydimas, 2004).

When a young woman is seen with bleeding and abdominal pain, an ectopic pregnancy must be ruled out. Ectopic pregnancy occurs when the fertilized egg implants outside of the uterus, usually in the fallopian tube. Damage to the fallopian tube is the most frequent cause of ectopic pregnancy. This damage occurs as a result of tubal surgery, PID, and previous ectopic pregnancy. Smoking is another risk factor for ectopic pregnancy; however, the mechanism is not known (Vichnin, 2008). When ectopic pregnancy is suspected, prompt evaluation and treatment are necessary. If the adolescent is seen with hypotension and abdominal pain, the ectopic pregnancy may have ruptured and emergency surgery is indicated.

Social and Economic Aspects

Poor school performance usually precedes adolescent pregnancy. Unable to achieve academically, the girl views motherhood as a rite of passage into adult status. Adolescents with high educational expectations are less likely than others to become pregnant. Another significant aspect of school dropout and accelerated maturity is the girl’s alienation and isolation from her peers during a stage of development when identity formation is closely allied with peer identification. She is deprived of the interrelationship with the adolescent social system that is so essential to the development of a sense of identity. The girl may believe that she no longer “belongs” to the peer group and does not qualify for membership in the older peer group of mothers. On the other hand, the pregnancy may give the adolescent an entrance into a peer group. One study found that absenteeism and dropout rates were lower when adolescents received prenatal care in a school-based health center in an alternative school. Programs such as this can help reduce the long-term negative outcomes of adolescent parenting (Barnet, Arroyo, Devoe, et al, 2004).

Mother-Infant Relationship

Adolescents often have unrealistic expectations for the child. The young mother may view the infant as a plaything or a love object for herself. Children of adolescent mothers experience more developmental problems than children of adult mothers. The amount of cognitive stimulation in the child’s early home environment is associated with the child’s level of cognitive attainment. Many children of adolescents are raised by a grandparent. Although living with a grandparent may have positive effects on child outcomes, coresidence with the grandmother may have negative effects if the mother and grandmother are in conflict. Nurses need to stress the importance of the adolescent caring for the child even when other adults (e.g., mother or grandmother) are involved. The other adults present need education and support to allow optimum development of the infant and adolescent mother.

Several factors influence the mother-infant relationship. Maternal stresses, including changes in circumstances, influence coping ability and sensitivity to the infant’s needs. Teenage mothers may consider an argument with a parent, boyfriend, or husband stressful, whereas adult mothers focus on problems directly involving the infant. Vocational and educational disadvantages of both teenage mothers and fathers further affect their coping abilities. It is important to recognize that not all adolescent mothers are alike. Some teenagers adjust well to the stresses and responsibilities of parenting, whereas others may lack the maturity or confidence to nurture optimally.

When socioeconomic status is controlled for, it has been found that younger adolescent mothers have lower acceptance of their children compared with older adolescent mothers. Studies in the literature indicate that specific family variables, including the mother’s age (<19 years), are risk indicators for child abuse and neglect (Lounds, Borkowski, and Whitman, 2006; Murray, Baker, and Lewin, 2000).

A positive correlation exists between the total amount of social support and the frequency of appropriate maternal behavior. An assessment of whom the adolescent thinks she receives the most support from (her family, her partner, his family, or a close friend) allows the nurse to help the young mother benefit from this support (see Family-Centered Care box).

The cognitive development of the adolescent influences the development of attitudes and realistic expectations regarding childbearing. To cope effectively and solve situational dilemmas, pregnant teenagers must be able to use the problem-solving approach to assess and evaluate consequences. The concrete thought and egocentrism of early adolescence can influence the mother’s ability to evaluate the infant’s needs. Adolescent mothers lack knowledge of normal infant growth and development. This deficit may directly affect their perception, interpretation, and responsiveness to infant cues.

Infant characteristics also influence parental behavior. Teenage parents view their children as more temperamentally difficult than do adult parents. Temperamentally difficult infants have an adverse effect on the parents’ sensitivity and responsiveness. Parent-infant interaction that is not mutually satisfying can also alter the parents’ feelings of effectiveness and self-worth.

Adolescent Fathers

Little information is available about adolescent fathers. Most studies have small sample sizes and rely on reporting from the mother rather than the young man himself. Most teen fathers are involved with and interested in their children (Savio Beers, and Hollo, 2009). This involvement has positive effects on the mother’s self-esteem and decreases her level of distress and depression. The teen mother and her mother largely influence the level of participation a teen father has with his children. Social supports and parenting classes are often lacking for adolescent fathers. The nurse should take advantage of opportunities to involve young fathers in educational programs.

Nursing Care Management

It is evident from the preceding discussion that nurses play a central role in meeting the needs of pregnant teenagers. The nurse may be the one to whom the young girl turns for help and guidance in her dilemma and on whom she relies for support and reassurance.

The first goal in nursing care of the pregnant teenager is to help her obtain health care whether she elects to continue or terminate the pregnancy. Typically, adolescents are reluctant to seek medical help, in part because of anxiety but more often because of a tendency to deny the pregnancy. Early prenatal care is essential for the welfare of both mother and infant. For guidelines, teaching, and general support measures during pregnancy, the reader is directed to the excellent textbooks available on nursing care throughout the maternity cycle.

Basic to the implementation of any care program is communication and the establishment of a trusting relationship. Initially the adolescent may appear apathetic and display little interest in discussing her pregnancy. The nurse must make every effort to put the adolescent at ease and avoid undue pressure. The young girl may have encountered rejection and open criticism from authority figures and peers. Conveying a nonjudgmental and genuine caring acceptance of the adolescent and her goals will assist the nurse in gaining the adolescent’s confidence and trust.

Communication takes time and patience. Asking open-ended questions and listening for cues will help identify physical, emotional, social, and cultural influences that might affect the adolescent’s progress through the maternity cycle. Factors that might affect her physical status, such as smoking, drug use, and nutritional state and habits, need to be explored and confronted. Each teenager represents a unique situation in terms of background, lifestyle, support structure, and coping mechanisms. Listening to the teenager and understanding the situation from her perspective are essential for a trusting relationship and effective communication.

Nutrition assessment should focus on the dietary adequacy of iron and calcium; multivitamins with folic acid are prescribed. Refer the adolescent for food supplement programs and other financial assistance, such as Women, Infants, and Children; Medicaid; Temporary Assistance for Needy Families (formerly Aid to Families with Dependent Children); and housing. Social work referral for thorough psychosocial assessment and planning may be initiated. Programs that have been most successful are comprehensive and use an interdisciplinary team concept.

The adolescent needs to know what is happening to her, what is expected of her, and how she can help in developing a care plan. Adolescents have their own ideas about the type of help and support they need. Nurses should consult with them and provide them an opportunity to share their ideas. It is important to jointly choose goals that the adolescent believes are beneficial, attainable, and able to be maintained over time. When developing a plan with a teen parent, the nurse should include the family, school, and community; involve the young father early in the relationship; and respect and understand the grandmothers’ role.

The adolescent needs help to improve her altered self-image, a crucial factor in adolescence. Giving her as much individual attention as possible; being a sympathetic listener; providing the opportunity for her to know, support, and be supported by other girls in the same situation; and helping her experience success will facilitate progress toward achieving this goal.

The nurse should involve the family whenever possible. The parents of the adolescent mother and the father of the child need to express feelings and attitudes about the situation. The nurse should not make assumptions about whether the girl wishes to have these persons involved in her decisions and care.

Direct postpartum care of adolescents to prevent subsequent pregnancies and enhance life outcomes for the teen parents and child. Health care programs that provide contraceptive services for the young mother at the time of her child’s appointment are helpful. Merely dispensing contraception is not enough. Comprehensive programs to promote positive parenting, self-esteem, vocational or academic assessment, career goals, and family cohesiveness are necessary.

Nursing Care Management

Early identification of pregnancy is essential, and nurses are in an optimum position to provide counseling on pregnancy options. Whatever option the adolescent chooses, initiate referral as quickly as possible to eliminate risk. Pelvic ultrasound may be indicated to assess gestational age correctly for those adolescents who cannot recall the date of their last menstrual period and when a bimanual examination is inconclusive.

Patient education regarding the medical aspects of the abortion should be conducted verbally, and the patient should be provided with written instructions before the procedure. Reviewing relaxation strategies that can be used during the procedure is helpful. Encourage the parents or other significant adults to be present during the medical procedure.

Conduct discussions about future contraceptive needs before the abortion. The adolescent may be started on a hormonal method of contraception immediately after the abortion. The young woman should be seen 3 weeks after an abortion to receive medical, contraceptive, and psychologic follow-up care.

Contraceptive Methods

To be safe and effective, a contraceptive method must be suited to the individual. The choice is based on the adolescent’s preference after being informed of all the benefits and disadvantages of the methods available. The adolescent must be motivated to use whatever method is chosen. Factors associated with successful use of contraception include education, expectations, availability, cost, parent education level, perception of high likelihood of pregnancy, perception of disadvantages of having a pregnancy, and low rate of disadvantages of birth control methods.

Providing a birth control device is only part of a comprehensive sex education program. Partner involvement, when possible, is important to enhance user compliance. To make truly informed choices about contraception, adolescents need to know not only the efficacy of methods as they are actually used but also their efficacy when used consistently. Contraceptive efficacy is a representation of the number of unintended pregnancies that occur per year while using a particular method. Sexual intercourse with no protection is estimated to result in 85% of the women becoming pregnant. Table 20-1 outlines the advantages and disadvantages of various contraceptive methods recommended for use in adolescents.

Use of Contraception

The birth control pill and condoms remain the most popular methods for adolescents. Adolescents commonly delay seeking contraceptive information. The typical interval from onset of sexual intercourse until the first visit for contraception is 1 year. A pregnancy scare is usually the precipitating event for the contraception appointment. Fear of the pelvic examination is a common reason that girls postpone seeking contraception. The World Health Organization, American College of Obstetricians and Gynecologists, and Planned Parenthood Federation of America have all recommended unbundling these services. Box 20-2 lists additional reasons adolescents give for not making better use of contraception.

Emergency contraception (ECP) is the administration of an effective contraceptive method after sexual intercourse. It is appropriate to use after any unprotected sexual intercourse, after condom breakage, when it is too late for injectable contraception, after missed pills, or after rape. The FDA has approved a progestin-only method for ECP (levonorgestrel [Plan B]) with high effectiveness and low rates of side effects. ECP must be given within 3 days (72 hours) of unprotected sexual intercourse, with highest efficacy closest to the time of sexual intercourse. There are no contraindications to use of the progestin-only method. Plan B is available to adult women over the counter without a prescription.

Compliance in contraceptive use is related to many factors, including those discussed in the following sections.

Nursing Care Management

Much of contraceptive education and service are delivered by nurses as part of sex education programs, family planning services, or postpartum health services. The introduction of contraceptive methods should ideally be associated with ongoing sex education. When they are included in this education process, sexually active adolescents will consider contraceptives as a natural and logical part of intercourse. Education about sexuality, conception, and contraception should be accurate, straightforward, and nonjudgmental.

Although sexual abstinence is highly desirable as a form of contraception, it is difficult for many adolescents to “just say no.” Postponing sexual involvement requires effective communication and decision-making skills. Adolescents benefit from role-playing refusal skills in a safe environment. The nurse should also discuss with the adolescent how to introduce condoms into an existing or new relationship. Young women who have asked a partner to use a condom are more likely to use a condom consistently than women who have never made the request. The nurse plays an important role in offering appropriate education, helping build confidence in adolescents’ ability to make requests of their partners, and providing social support to the sexually active adolescent.

To make an informed decision, the adolescent needs a careful review of all methods available, including their advantages and disadvantages. Discontinuation rates of prescription methods are high among all women, particularly adolescents. A critical aspect of counseling about a contraceptive method is education about use, noncontraceptive benefits, and expected side effects. Clear verbal explanations and demonstrations with the actual methods assist the concrete thinker in understanding the complicated instructions. Whenever possible, the parent or partner should be included in the teaching. Provide written instructions and a phone number for questions. When adolescents choose hormonal methods, they should also use condoms for the prevention of STIs (see Community Focus box). The nurse should demonstrate the correct use of condoms to all sexually active adolescents. Frequent follow-up with a review of side effects, usage patterns, and an opportunity to voice concerns increases the likelihood that the adolescent will continue to use contraception effectively.

An organization that provides education and services for adolescents, including both individual and group counseling, is the Planned Parenthood Federation of America.* It has branches in most cities in the United States.

Assailants

Three relationships are identified for assault: stranger, nonstranger, and incest. Although all can have serious and long-lasting effects, they are presumed to be different in a number of important ways: in the nature of the dominant psychologic and cognitive behaviors they provoke, in the issues they raise for service providers and other potential helpers, and in the techniques that may be helpful for treating existing and new cases.

Clinical Manifestations

Adolescents who have been raped arrive at the emergency department or practitioner’s office under a variety of circumstances. They are usually brought in by parents, friends, or the police, but some girls may seek medical help on their own. They may display a variety of manifestations, such as hysterical crying or giggling; agitation; feelings of degradation, rage, or helplessness; nervousness; and rapid mood swings. Adolescents may alternately appear calm and controlled, masking inner turmoil; they may be angry, confused, and filled with self-blame.

The rape victim may manifest evidence of physical force, including roughness, nonbrutal beating (slapping), brutal beating (slugging, kicking), and choking or gagging. The predominant reaction of the victim is fear of the rape and of injury. Thus the victim is faced with the dilemma of submission or resistance. Resistance increases the victim’s chance of escape but also increases the likelihood of violence against the victim.

Therapeutic Management

It is advisable to obtain parental consent for examination, but the examination may be performed without consent if the adolescent is legally mature or the parents are unavailable. A female observer should be present during the history taking and examination of female victims who are examined by a male practitioner. Whether a parent should be present during the examination is determined on an individual basis. The parent’s presence is usually encouraged, but only if the parent is supportive. Often the presence of a parent or a police officer inhibits the person’s ability to describe the incident.

The medical assessment of the sexual assault victim includes the assessment and treatment of physical injury with focus on the genitalia. Pregnancy assessment and prevention, as well as evaluation and treatment for STIs, are performed. Obtaining forensic evidence requires training and should be conducted as soon after the incident as possible. Psychologic assessment and ongoing support are essential.

Nursing Care Management

Many of the approaches described for the sexually abused child apply to the adolescent. (See Chapter 16.) Sexual assault is a devastating experience with long-lasting effects. The primary goal of nursing care is to not inflict further stress on the victim, who is often angry, confused, frightened, embarrassed, and filled with self-blame. Young rape victims fear pregnancy, bodily injury, and the reactions of their parents and peers. Some believe that their bodies are permanently damaged and may even fear death as a consequence of the experience.

The nurse must do everything possible to reduce the stress of the interrogation and examination. Application of stress reduction techniques during the process can help the adolescent manage the immediate experience. Although most health professionals and law enforcement officers are sensitive to the needs of the victim and attempt to make the process as nonstressful as possible, the nurse acts as the advocate for the adolescent and is alert for cues that the victim is being overstressed.

Follow-up care of the rape victim extends over a long time. Rape victims typically show high levels of distress within the first week, which peak in severity by 3 weeks after the assault, continue at high levels for the next month, and then begin to decrease by 2 to 3 months after the assault. Make a referral to a public health agency or mental health agency as soon as possible. Victims who live in areas with established rape crisis centers are referred to these facilities.*

Aside from the universal need for emotional support, no firm guidelines exist for meeting the needs of rape victims. Trauma-focused cognitive behavioral therapy has been shown to be helpful for adolescents who have been abused or assaulted (Kaufman and American Academy of Pediatrics, 2008). In general, their needs vary widely and depend on the nature of the incident, when it took place, the physical and emotional injuries sustained, actions being considered as a result, resources available for informal support, and anticipated reactions of persons in the informal support network (see Family-Centered Care box). Posttraumatic stress disorder occurs in many victims of rape. (See Chapter 18.) Acquaintance rape is as devastating to the victim as stranger rape. There are few reliable predictors of positive readjustment among rape survivors. In general, a young age at the time of assault is associated with increased distress. Women victimized in childhood are more likely than nonvictims to be assaulted as adults.

Gonorrhea

Chlamydial Infection

Chlamydial infection is the most common bacterial STI in the United States. Rates are highest among adolescents and young adults. The sequelae of untreated chlamydial infections include PID, ectopic pregnancy, epididymitis, and infertility. Infants born to infected mothers may be born prematurely and develop conjunctivitis and pneumonia. Annual screening of all sexually active adolescent females for chlamydia is recommended (American College of Obstetricians and Gynecologists, 2006; US Preventive Services Task Force, 2007).

Pelvic Inflammatory Disease

PID is an infection of the upper genital tract (endometrium, fallopian tubes, and ovaries), most commonly caused by sexually transmitted bacteria, such as N. gonorrhoeae, C. trachomatis, and a variety of other anaerobic bacteria.

Animation—Pelvic Inflammatory Disease

The long-term effects of PID include infertility because of tubal scarring, ectopic pregnancy, and chronic abdominal pain. It is estimated that each year 1 million females of reproductive age experience an episode of PID, with approximately 20% of cases occurring in teenagers. Women under the age of 25 years have a one in eight chance of experiencing PID, compared with a 1 in 8 risk in those over age 25 years. Menstruation at the time of initial infection can increase the risk for the development of PID. The loss of the mucous plug allows the infecting organism to ascend to the upper tract more readily. The blood itself acts as a culture medium for growth of the infecting organisms. Other mechanical factors such as douching may increase the risk of PID; sperm and motile Trichomonas organisms may also carry other infections up the genital tract. Another risk factor for adolescents is lack of access to health care that is affordable, convenient, and confidential. Lack of access results in delays of diagnosis and treatment of abdominal pain, which increases the risk for severe PID (Banikarim and Chacko, 2004).

PID can have acute complications, such as tubo-ovarian abscess and the Fitz-Hugh–Curtis syndrome. This syndrome occurs in about 5% to 20% of women who have acute salpingitis (infection of the fallopian tubes). The same organisms that cause the salpingitis produce an acute inflammation of the covering surrounding the liver (the hepatic capsule) and the peritoneum in contact with the hepatic capsule. The Fitz-Hugh–Curtis syndrome causes acute or chronic right upper quadrant abdominal pain and can lead to chronic adhesions between the hepatic capsule and the peritoneum. In some individuals the pain and tenderness associated with this syndrome may be more pronounced than the pelvic signs and symptoms.

Symptoms in the adolescent may be generalized, with lower abdominal pain; urinary tract symptoms; and vague influenza-like manifestations, such as malaise, nausea, diarrhea, or constipation. A pelvic examination to evaluate the possibility of PID is indicated for every sexually active female who complains of lower abdominal pain.

The diagnosis of PID is based on clinical findings. The 2006 STI guidelines (Centers for Disease Control and Prevention, 2006a) list the minimum criteria for diagnosis as uterine or adnexal tenderness and cervical motion tenderness. Additional criteria to support the diagnosis include oral temperature of 38° C (100.4° F), abnormal cervical discharge, presence of white blood cells on wet mount, elevated erythrocyte sedimentation rate or elevated C-reactive protein, and laboratory documentation of chlamydia or gonorrhea.

The potential for sequelae even after one episode of PID is as high as 25%. The adolescent with PID is at increased risk for infertility, ectopic pregnancy, and recurrent PID. Chronic pelvic pain and dyspareunia are not uncommon after an episode of PID.

The risk of sequelae requires aggressive management of PID in the adolescent. The two outpatient treatment recommendations are ofloxacin, 400 mg twice daily for 14 days, or levofloxacin, 500 mg once daily for 14 days, with or without metronidazole, 500 mg twice daily for 14 days; an alternative is ceftriaxone, 250 mg given intramuscularly, or cefoxitin, 2 g given intramuscularly, plus doxycycline, 100 mg orally twice daily for 14 days, with or without metronidazole. Inpatient therapy includes intravenous antibiotics such as cefoxitin, cefotetan, doxycycline, clindamycin, or gentamicin. On discharge, the adolescent receives a 14-day course of oral doxycycline or metronidazole.

Adolescents with PID need counseling to prevent future infections. Partner notification and treatment are necessary to avert recurrent infection. The adolescent should be instructed to abstain from sexual intercourse while taking the medication and until after her partner is treated. A discussion of negotiating condom usage is beneficial for the prevention of future infections.

Human Papillomavirus

Anogenital warts, caused by HPV infection, are the most common STI in the United States. The highest prevalence of HPV is among women 18 to 24 years of age. Persistent HPV infection is associated with cervical dysplasia and cervical cancer. HPV deoxyribonucleic acid (DNA) has been found in 99.7% of cervical cancer tissues (Kahn and Hillard, 2004). HPV types are classified by genomes with almost 120 genotypes described, 40 of which infect the genital tract. The HPV types are classified as low risk or high risk based on their potential for causing cancer. Either of the risk types may regress spontaneously. Risk factors for HPV infection include sexual behavior (multiple partners), lack of condom use, young age at first sexual intercourse, and history of prior infection (Kahn, Rosenthal, Succop, et al, 2002).

The most visible type of wart is condyloma acuminatum, a raised, polypoid mass with an irregular fingerlike surface and fissures, commonly described as having a “cauliflower” appearance. In females these warts are most commonly seen on the external genitalia or the vagina, cervix, or rectum. The shaft of the penis is the most common site in males, but warts may also appear on the meatus, anus, and scrotum. The presence of warts on the rectum or anus of males is frequently associated with anal intercourse; anal warts in females can be associated with autoinoculation.

Subclinical genital HPV infection is much more common than the warts that are exophytic (growing outward from surface). The previously common practice of treating areas that give a white appearance after application of acetic acid is no longer recommended. Acetowhitening is not a specific test for HPV. Subclinical infections often regress spontaneously without treatment.

Cytologic screening techniques provide high sensitivity in the diagnosis of cervical dysplasia, especially high-grade dysplasia. These liquid-based screening tests filter out the noncellular debris, thus allowing a single layer of cells on the slide. The liquid supernatant may be used to test for HPV DNA. Screening guidelines from the American Cancer Society recommend initiating Pap screening in adolescents 3 years after initiation of sexual intercourse or by age 21; thereafter it is recommended women have annual screening with traditional Pap smears or every 2 years with liquid-based cervical cytologic screening (Saslow, Runowicz, Solomon, et al, 2002). Recent American College of Obstetricians and Gynecologists guidelines recommend that women receive their first cervical cancer screening at age 21 instead of 3 years after initiation of sexual intercourse. In addition, women aged 21 to 30 years should be screened once every 2 years, and women aged 30 years and older who have had three negative cervical cancer tests may be screened once every 3 years (American College of Obstetricians and Gynecologists, 2009).

Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome

Preliminary surveillance data from the Centers for Disease Control and Prevention (2006b) indicate that the number of deaths from AIDS in U.S. children younger than 13 years declined from 945 in 1992 to 55 in 2004; preliminary data show a further decrease to an estimated 28 cases in 2007 (Centers for Disease Control and Prevention, 2009). In 2006 a study of 50 states estimated that 56,300 new cases of HIV were diagnosed in adolescents and adults, for an overall rate of 22.8 per 100,000. The most significant increase in new HIV cases was reported among African-Americans males (Centers for Disease Control and Prevention, 2009). In 2006 estimates indicated that the rate of new HIV infections in African-Americans was seven times the rate in Caucasians. Seventy-three percent of all newly diagnosed cases were in men, and 27% were in women; 53% of the new cases were transmitted via males having sex with males, and 31% were transmitted through high-risk heterosexual contact (Hall, Song, Rhodes, et al, 2008). (See Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome, Chapter 35.)

Hepatitis B Virus

Hepatitis B virus (HBV) is an infection of the liver that affects 300,000 persons annually, 10,000 of whom require hospitalization. (See Chapter 33.) Major concerns have been voiced because of the increased rate of infection, particularly among high-risk populations: intravenous drug users, sexual partners of HBV-infected individuals, homosexual males, and infants of HBV-infected pregnant women. It is estimated that infants whose mothers are positive for HBV have a 70% to 90% chance of becoming infected, and nearly all these infants develop chronic HBV carrier status. Another area of concern is transmission of HBV through contaminated body fluids to health care workers.

Many potential negative outcomes can be avoided through immunization. Current immunization guidelines recommend beginning the hepatitis B vaccine series at birth or, in unimmunized children, at 11 to 12 years of age. (See Immunizations, Chapter 12.) The immunization consists of a series of three intramuscular injections. The goal of universal immunization is to target uninfected infants and adolescents before the onset of high-risk behaviors.

Other Sexually Transmitted Genital Infections

Many sores or lesions that appear on the genitalia are the result of STIs. Experienced clinicians can correctly diagnose these lesions by visual examination only about half of the time. A complete health history, physical examination, and appropriate diagnostic cultures are needed to determine the causative factors. Nurses who interact with adolescents are in a primary position to obtain a health history and refer any sexually active adolescent for appropriate evaluation. Follow-up health education regarding any treatment regimen and prevention strategies is a major nursing role. Because many of the lesions are viral, nurses can assist the adolescent with communication techniques to inform future sexual partners about the potential for infection with an STI. Table 20-3 summarizes the most common genital lesions seen in adolescents.

Nursing Care Management

Nursing responsibilities encompass all aspects of STI education, prevention, and treatment. Primary prevention by avoiding exposure is the least expensive and most effective approach. The nurse can play a role in offering this education to young people before they initiate sexual intercourse. Sexuality education should include information about these diseases, such as their symptoms or lack of symptoms and treatment, and information dispelling the myths associated with their mode of transmission. These diseases are not contracted from toilet seats, drinking glasses, or bath towels. Most teens are uninformed or misinformed about STIs.

Promoting the inclusion of STI information, access to care, and interpersonal and social skill building in school sexuality education programs is an important function of the nurse. No matter what their area of practice, nurses are in a position to disseminate information, identify probable cases of STIs, and refer these cases for treatment.

The increasing incidence of STIs in young people is influenced to a great extent by the number of adolescents who engage in sexual activity. Improvements in testing methods and availability of testing for diseases will result in increased reporting of STIs. The hormonal contraceptive methods provide no protection against STIs. Unfortunately, many girls using these methods mistakenly believe they are also protected against STIs. To decrease the likelihood of infection, encourage sexually active adolescents to always use a condom.

Essential measures for control of the disease include treating the disease, reporting it promptly, and tracking and treating contacts. When working with adolescents, nurses need highly developed interviewing skills and a nonjudgmental approach to elicit an accurate sexual history. Several characteristics of teenagers influence the way health professionals address specific issues related to STIs. Teenagers are often concrete thinkers, which affects the way they process information. Teenagers also have limited coping mechanisms to draw on to assist in dealing with such information. To gain the adolescent’s cooperation and trust, the nurse must convey acceptance and assure the adolescent of confidentiality. The nurse should always consider the early involvement of parents with permission from the adolescent. Family support may make access to health services easier and decrease the emotional stressors associated with acquiring an STI.

For additional information on STIs and abortion, refer to a women’s health or maternity text such as Perry, Hockenberry, Lowdermilk, and colleagues (2010).

• Adolescent health-seeking behaviors center on skin problems, abdominal discomfort, menstrual symptoms, and anxieties about physical development and sexual changes.

• Acne is prevalent in the adolescent years; medication and gentle facial cleansing are the treatments of choice.

• The most frequent problems related to the male reproductive system are infections, scrotal conditions, and gynecomastia.

• The most frequent problems of the female reproductive system involve menstruation delays, irregularities, discomfort, and infections.

• Adolescent pregnancy has profound social, educational, psychologic, and economic ramifications. The pregnancy necessitates special attention to nutrition and psychologic and emotional support for the mother and father.

• Abortion as an alternative to birth is a highly controversial issue; there is evidence that it has no long-term psychologic sequelae for most women.

• Adolescents often do not use contraception because of lack of information, anxiety regarding use, conflict over sexual activity, or desire for pregnancy.

• Rape is a serious problem among adolescents; common forms are rape by a nonstranger, rape by a stranger, and incest.

• STIs are the most frequently occurring infectious diseases and a major cause of adolescent morbidity. HIV infection is an increasingly important adolescent health problem.

Testicular Self-Examination