Chapter 21 Young and middle adulthood
Mastery of content will enable you to:
• Define the key terms listed.
• Discuss developmental theories of young and middle-aged adults.
• List and discuss major life events of young and middle-aged adults and the childbearing family.
• Describe developmental tasks of the young adult, the childbearing family and the middle-aged adult.
• Discuss the significance of family in the life of the adult.
• Describe normal physiological changes in young and middle adulthood and in pregnancy.
• Discuss cognitive and psychosocial changes occurring during the adult years.
• Describe health concerns of the young adult, the childbearing family and the middle-aged adult.
• Apply the nursing process to administer care to young and middle-aged adults.
Developmental changes in adult years are based on earlier experiences that help shape subsequent behaviour and characteristics. The development pathway, however, is unique to each person. Young and middle adulthood is a period of challenges, rewards and crises. The proportion of young and middle-aged persons in the population is similar in Australia and in New Zealand. In 2010, 25- to 64-year-olds made up 67.5% of the Australian population and this has not changed significantly since 1990 when it was 66.9% (Australian Bureau of Statistics, 2010a). New Zealand’s demographic trends show that in 2010, 61.2% of the population was between 15 and 59 years of age (Statistics New Zealand, 2010).
Although adults can be rewarded by successes in their career endeavours and in their personal lives, they are also likely to face the challenges of meeting the demands of work and raising families. They may face crises such as job loss in a changing economic environment, and dealing with their own developmental needs as well as those of their family members. Women, in particular, may carry the burden of caring for young families often while also caring for their ageing parents.
Young adulthood is the period between the late teens and the mid- to late 30s. Young adults constitute about a quarter of the populations of Australia and New Zealand. The changes experienced by young adults include the natural processes of maturation and socialisation. During young adulthood, individuals are active and must adapt to new experiences. They increasingly separate from their families of origin, establish career goals and decide whether to marry and begin families or remain single. Young adults pass through alternating periods of stability and change. During periods of stability, they make certain choices and build structures around them. In periods of change, they re-evaluate these choices and consider new alternatives (Erikson, 1968, 1982).
Middle age occurs between the mid- to late 30s and the mid-60s. The transition into middle age occurs when young people become aware that changes in reproductive and physical abilities signify the beginning of another stage in life. This is a time of continuing transitions when individuals may reassess their goals in life and add new goals.
Ideally, middle-aged people reach a mature balance of growth in physiological, psychosocial and cognitive areas. They tend to feel comfortable with the abilities, knowledge and responses that they have developed over the years and look at the world with a broad view, based on a blend of insight, emotion and imagination. They take on problems that can be solved but recognise and learn to live with insoluble problems.
Such balanced people tend to be open to suggestions and to accept constructive criticism without a major loss of self-esteem. They weigh other people’s input and recommendations when making decisions but are not overly influenced or intimidated by others. Above all, mature people develop by learning from their own and others’ experiences.
Other characteristics of maturity are related to interpersonal communication and behaviour. Mature people tend to acknowledge accomplishments and shortcomings in themselves and others. Mature adults are able to confront tasks openly, use decision-making techniques to solve problems and be accountable and responsible for their actions.
Classic work by such developmental theorists as Erikson (1963, 1982), and Havighurst (1972) has attempted to describe the phases of young and middle adulthood and related developmental tasks (see Chapter 19 for an in-depth discussion of developmental theories). It has been proposed that intellectual and moral development differ between men and women. According to Gilligan (1992), women struggle with the issues of care and responsibility, and in turn their relationships progress towards a maturity of interdependence. As women progress towards adulthood, the moral dilemma changes from how to exercise their rights without interfering with the rights of others to ‘how to lead a moral life’, which includes meeting obligations to themselves and their families and people in general (Gilligan, 1992). However, women may become frustrated in their development when the responsibility of caring for the family is not shared by their partner, and often nurturing becomes a gender-specific responsibility (Miller and Sassler, 2010).
In many cultures familial authority has historically been associated with males, who have traditionally assumed the overwhelming majority of positions of power. Boys learn how to be men by absorbing messages about manliness from parents, siblings, peers, teachers, television and action movies. These messages encourage boys to be competitive, focus on external success, rely on their intellect, withstand physical pain and repress their vulnerable emotions. Traditional masculine roles include providing and protecting. As times change women have also taken on these roles, and men have tended to move into greater disequilibrium. Faced with a societal structure that differs greatly from the norm faced by their fathers, many men are challenged with determining what it means to be a man and how to feel good about it in today’s society (Brooks, 2010). As a provider, for example, a man is traditionally viewed as the main supporter of the family, but with more women entering the workforce and pursuing successful careers, the relative importance of the male breadwinner has declined. In the last two decades, real family income has been maintained only by the increased participation of women in the workforce.
Developmental theories provide nurses with a basis for understanding the life events and developmental tasks of the young and middle-aged adult. Each person, however, brings unique characteristics and needs to their developmental stage. Clients may present challenges to nurses who themselves may be young or middle-aged adults coping with the demands of their respective developmental period. Nurses must be careful to recognise the needs of their clients even if they are not experiencing the same challenges and events.
Young adulthood
Physical changes
Except for pregnant or lactating women, young adults have completed physical growth by the age of 20. The physical, cognitive and psychosocial changes and the health concerns of the pregnant woman and the childbearing family are extensive.
Young adults are usually quite active. As they experience severe illnesses less commonly than older age groups, they tend to ignore physical symptoms, and often postpone seeking healthcare. Physical characteristics of young adults begin to change as middle age approaches. Unless clients have illnesses, assessment findings are generally within normal limits. Young men may be especially reluctant to seek medical advice which they may regard as a sign of weakness. Such a view may also be inadvertently reinforced by healthcare professionals (Hale and others, 2010). Nurses should take great care to encourage healthcare activities in both young men and young women.
Clients in this developmental stage may benefit from a personal lifestyle assessment. A personal lifestyle assessment can help nurses and clients identify habits that increase the risk of cardiac, malignant, pulmonary, renal or other chronic diseases. A personal lifestyle assessment of the young adult includes assessment of general life satisfaction; hobbies and interests; habits such as diet, sleeping, exercise, sexual habits, and use of caffeine, alcohol and illicit drugs; home conditions, including housing, economic condition, pets and type of health insurance; and their occupational environment, including type of work, exposure to hazardous substances, and physical or mental strain.
Cognitive changes
Rational thinking habits increase steadily through the young and middle adult years. By the mid-twenties the prefrontal cortex of the brain is fully developed. The prefrontal cortex area governs the person’s ability to reason in a mature way and to control reckless impulses. In addition, formal and informal educational experiences, general life experiences and occupational opportunities dramatically increase the individual’s conceptual, problem-solving and motor skills.
Identifying preferred occupational areas is a major task of young adults. When people know their skills, talents and personality characteristics, educational preparation and occupational choices are easier and more satisfying. Many young adults, however, lack either the resources or the support systems to facilitate further education or the development of skills necessary for many positions in the workplace. As a result, some young adults may have limited occupational choices.
An understanding of how adults learn helps nurses develop teaching plans (see Chapter 13). Adults enter the teaching–learning situation with a background of unique life experiences, including illnesses; therefore, nurses always view adults as individuals. Their compliance with regimens such as medications, treatments or lifestyle changes (such as quitting smoking) involves decision-making processes. When determining the amount of information the individual needs to make decisions about the prescribed course of therapy, the nurse should consider those factors that may affect the individual’s compliance with the regimen, including educational level, socioeconomic factors, motivation and desire to learn.
Because young adults are continually evolving and adjusting to changes in the home, workplace and personal lives, their decision-making processes need to be flexible. The more secure young adults are in their roles, the more flexible and open they are to change. Insecure people tend to be more rigid and less confident in making decisions.
Psychosocial changes
The emotional health of the young adult is related to the individual’s ability to resolve personal and social tasks. Young adults are often caught between wanting to prolong the irresponsibility of adolescence and wanting to assume adult commitments. Certain patterns or trends, however, are relatively predictable. Between the ages of 23 and 28, the person refines self-perception and ability for intimacy. From 29 to 34 the person directs enormous energy towards achievement and mastery of the surrounding world. The years from 35 to 43 are a time of vigorous examination of life goals and relationships. Alterations are made in personal, social and occupational lives. Often the stresses of this re-examination result in a ‘midlife crisis’ in which marital partner, lifestyle and occupation may change.
During the young adult years, people generally give more attention to occupational and social pursuits. In this period, individuals attempt to improve their socioeconomic status. Upward mobility is sought through career choices. Trends towards corporate downsizing, however, are leading to fewer high-level positions. Consequently, many young adults are facing the added stress of greater competition in the workplace for fewer positions. For many young adults, two incomes are needed to provide for their families. Career and personal counselling can help individuals identify career choices and set realistic goals.
Ethnic and gender factors have sociological and psychological influences in an adult’s life, and these factors can pose a distinct challenge for nursing care. Each person holds culture-bound definitions of health and illness. Nurses and other healthcare professionals bring with them distinct practices for the prevention and treatment of illness. Knowing too little about a client’s self-perception or beliefs regarding health and illness may create conflict between the nurse and the client. It is critically important that healthcare professionals are prepared to actively listen to the clients and thus gain an understanding of the way the client understands illness and health. The skills required to listen effectively are described in Chapter 12.
Changes in the traditional role-expectations of both men and women in young and middle adulthood have also led to greater challenges for nursing care. Women often continue to work during the child-rearing years, and many women struggle with the enormity of balancing three careers: wife, mother and employee. This is a potential source of stress for the adult working woman. Men become more aware of parental and household responsibilities and find themselves having more responsibilities at home while achieving their own career goals (Haber and others, 1997). An understanding of ethnicity, race and gender differences enables nurses to provide individualised care (see Chapter 17).
Support from the nurse, access to information, and appropriate referrals provide opportunities for achievement of a client’s potential. Because health is not merely the absence of disease but involves wellness in all human dimensions, acknowledging the importance of the young adult’s psychosocial needs and needs in other dimensions is a significant aspect of nursing practice.
The young adult must make decisions concerning career, marriage and parenthood. Although each person makes these decisions based on individual factors, the nurse should understand the general principles involved in these aspects of psychosocial development while assessing the young adult’s psychosocial status and tailoring support in times of illness.
Lifestyle
Health and wellbeing are organised in professional and policy spheres based on measurement of a wide range of physical, psychological and social population characteristics. Certain lifestyle behaviours such as smoking, stress, lack of exercise and poor personal hygiene increase the risk of future illness. Family history of cardiovascular, renal, endocrine or neoplastic disease increases the risk of illness as well. The nurse’s role in health promotion is to identify factors that increase the young adult’s risk of health problems and to provide client education and support to reduce unhealthy lifestyle behaviours.
Those lifestyle habits that activate the stress response also increase the risk of illness. Smoking is a well-documented risk factor for pulmonary, cardiac and vascular diseases in both smokers and those who receive secondhand smoke. Inhaled cigarette pollutants increase the risk of lung cancer, emphysema and chronic bronchitis. The nicotine in tobacco is a vasoconstrictor that acts on the coronary arteries, increasing the risk of angina, myocardial infarction and coronary artery disease. Nicotine also causes peripheral vasoconstriction and may lead to vascular problems. Alcohol consumption and especially ‘binge’ drinking is an increasing problem among young people. Young males are particularly at risk of developing major alcohol problems (Chartier and others, 2011). Prolonged stress increases wear and tear on the body’s capacity to adapt, leading to the development of stress-related diseases such as emotional disorders and infections.
Career
Young men and women hope to have careers that will enable them to realise their occupational dreams. They may formulate short- and long-term goals in traditional or non-traditional careers. A successful vocational adjustment is important in the lives of most people. Successful employment not only ensures economic security but also leads to friendships, social activities, and support and respect from co-workers. Career-related stressors include changes in one’s work demands, location or financial security, or in those of a partner. The combined demands of the adult members of a household may place stress on domestic needs. These stressors may be managed through division of labour among family members or by outsourcing some domestic activities, such as house-cleaning and gardening. Outsourcing strategies, of course, depend on the adequacy of the family income.
Ken is a 24-year-old man who smokes two packets of cigarettes per day. He began smoking when he was 14 years old. During a work-based nursing assessment, Ken complains, ‘I just can’t seem to kick the habit no matter how hard I try.’
1. What does the nurse need to know about quit-smoking programs in order to negotiate with this client?
2. What questions would the nurse ask Ken in order to assess his motivation and opportunities to quit smoking?
3. What physical assessment would the nurse conduct, and for what reasons?
4. What follow-up plan might the nurse negotiate in order to provide support for Ken’s efforts if he attempts a quit program?
Sexuality
The development of secondary sexual characteristics occurs during the adolescent years (see Chapter 20). Physical development is accompanied by the ability to perform sexual acts. The young adult usually has emotional and cognitive maturity to complement the physical ability, and is therefore able to develop mature sexual relationships. Young adults who have failed to achieve the developmental task of personal integration may, however, develop relationships that are superficial and stereotyped (Haber and others, 1997). Masters and Johnson (1970) have contributed important information about the physiological characteristics of the adult sexual response. Detailed discussion of the sexual response occurs in Chapter 24.
The psychodynamic aspect of sexual activity is as important as the type or frequency of sexual intercourse to young adults. Psychological beliefs and expectations give feelings of pleasure and satisfaction to adults. To maintain total wellness, adults should be encouraged to explore various aspects of their sexuality and be aware that their sexual needs and concerns evolve. As the age of initiation of sexual intercourse continues to decrease, young adults are at risk of sexually transmitted diseases. Consequently, they need education regarding mode of transmission, prevention and symptom recognition and management.
Lifestyle and relationships
During young adulthood most people are single and have the opportunity to be on their own. Those who eventually marry or establish long-term de facto relationships experience several changes as they take on new responsibilities. Many couples choose to become parents.
THE SINGLE STATE
Social pressure to get married is not as great as it once was. In Australia (Australian Bureau of Statistics, 2007a) and New Zealand (Baker, 2001), the median age for women to marry was 25 in 1988 and 29 in 2007. The corresponding ages for men were 27 and 29. Many young adults do not marry at all, but some form de facto unions of the same or opposite sex. For young adults who remain single and childless, parents and siblings may become the nucleus of a family, although the young adult maintains independence from parental controls. Close friends and associates of the single and childless young adult may also be viewed as the individual’s ‘family’.
One cause for the increased single population is the expanding career opportunities for women. Women enter the job market with greater career potential and have greater opportunities for financial independence. More single people are choosing to live together outside of marriage as well as become parents either biologically or through adoption. Similarly, many married couples choose to separate or divorce if they find their marital situation unsatisfactory. The divorce rates for New Zealand and Australia are similar, at around 2.5–2.6 divorces per 1000 people (Australian Bureau of Statistics, 2007b). In the 1970s and 1980s the divorce rate rose quite sharply in both countries because of changes to family legislation.
PARTNERS AND MARRIAGE
Every couple’s relationship is unique. Although a successful partnership or marriage can never be guaranteed, some guidelines are useful for building a happy relationship. Compatible beliefs and values are important, as are motivations for committing. When establishing a household and family, a couple must begin to work on the following tasks:
• establishing an intimate relationship
• deciding on and working towards mutual goals
• establishing guidelines for power and decision-making issues
• setting standards for extra-family interactions
• finding companionship with other people for a social life
• choosing morals, values, and ideologies acceptable to both.
These major tasks of adults require considerable psychosocial and cognitive maturity and self-esteem. When accomplished, however, they provide the foundation for a stable relationship. Growth in marriage extends over many years. Success in solving the challenging problems that occur in any intimate and committed relationship offers partners insight into each other.
A range of challenges exist. The couple learns patterns of sexual expression and ways to live intimately with each other. To live harmoniously they need to learn styles of conflict resolution, decision making and role patterns. In addition, each partner may experience a sense of loss of individuality and self in the transition from me to we.
The family orientation stage is directed at childbearing and child-rearing activities. Parenting roles must be defined and practised. Nurturing and socialisation needs of the children can put pressure on the couple’s intimate relationship. In addition, parents’ images of the ‘perfect parent’ may be unreasonable and conflict with reality.
Alisha, aged 32 and 34 weeks pregnant, attends the outpatient prenatal clinic at the local public hospital. During her interview with the midwife, Alisha describes feeling very tired and complains that her husband wants to engage in sexual intercourse a number of times a week. This is distressing her because of her fatigue and because she finds coitus uncomfortable.
Consider the assessment and plan that the midwife might develop with Alisha to respond to these issues.
PARENTHOOD
The availability of contraception makes it easier for today’s couples to decide when and if to start a family (see Figure 21-1). One factor influencing this decision is the reason for wanting a child. Social pressures may encourage a couple to have a child or may influence them to limit the number of children they have. Economic considerations frequently enter into the decision-making process, because bringing up children is expensive. General health status and age are also considerations in decisions about parenthood because couples are getting married later and postponing pregnancies.
HALLMARKS OF EMOTIONAL HEALTH
Most young adults have the physical and emotional resources and support systems to meet the many challenges, tasks and responsibilities they face. During psychosocial assessment of young adults, the nurse can assess for 10 hallmarks of emotional health (Box 21-1) that indicate successful maturation in this developmental stage.
BOX 21-1 TEN HALLMARKS OF EMOTIONAL HEALTH
1. A sense of meaning and direction in life
2. Successful negotiation through transitions
3. Absence of feelings of being cheated or disappointed by life
4. Attainment of several long-term goals
5. Satisfaction with personal growth and development
6. When married, feelings of mutual love for partner; when single, satisfaction with social interactions
7. Satisfaction with friendships
8. Generally cheerful attitude
Modified from Stanhope M, Lancaster J 1996 Community health nursing: process and practice for promoting health, ed 4. St Louis, Mosby.
Health risks
Risk factors
Risk factors for the young adult’s health originate in the community, lifestyle and family history.
FAMILY HISTORY
A family history of a disease may put a young adult at risk of developing it in the middle or older adult years. For example, a young man whose father and paternal grandfather had myocardial infarctions (heart attacks) in their 50s has a risk of myocardial infarction. The presence of certain chronic illnesses in the family increases the family member’s risk of developing a disease. This family risk is distinct from hereditary disease.
PERSONAL HYGIENE HABITS
As in all age groups, personal hygiene habits in the young adult can be risk factors. Sharing eating utensils with a person who has a contagious disease increases the risk of illness. Poor dental hygiene increases the risk of periodontal disease. Gingivitis (inflammation of the gums) and periodontitis (loss of tooth support) can be avoided through good oral hygiene (see Chapter 34).
VIOLENT DEATH AND INJURY
Violence is the greatest cause of mortality and morbidity in the young adult population. Death and injury can occur from physical assaults, motor vehicle or other accidents and intentional self-harm (suicide). In Australia 25% of male deaths and 17% of female deaths between the ages of 15 and 24 years are due to suicide (Harrison and others, 2010). In Australia (Australian Institute of Health and Welfare, 2006) and New Zealand (Ministry of Health, 2011), young adults are much more likely to die from suicide or accidents (including road accidents or homicide) than disease. However, the number of deaths of children and young adults from motor vehicle accidents has reduced considerably in the last two decades (Australian Institute of Health and Welfare, 2010).
Media attention has focused on the increase in violent crime among youth, but adults still commit the majority of crimes. Factors that may predispose to violence, with subsequent injury or death, include poverty, family breakdown, child abuse and neglect and repeated exposure to violence. Domestic violence is a major cause of homelessness among women (Australian Institute of Health and Welfare, 2005). It is important that the nurse perform a thorough psychosocial assessment, including such factors as behaviour patterns, history of physical abuse and substance abuse, education, work history and social support systems, to detect personal and environmental risk factors for violence.
SUBSTANCE ABUSE
Substance abuse directly or indirectly contributes to mortality and morbidity in young adults. Intoxicated young adults may be severely injured in motor vehicle accidents that may result in death or permanent disability to other young adults as well. Increases in binge-drinking have led to alarming increases in emergency department presentations in recent years. One third of Australian young people have been found to drink sufficient quantities of alcohol to put them at risk of short-term alcohol-related harm (Australian Institute of Health and Welfare, 2007).
Dependence on stimulant or depressant drugs can result in death. Overdose of a stimulant drug (‘upper’) can stress the cardiovascular and nervous systems to the extent that death occurs. The use of depressants (‘downers’) can lead to an accidental or intentional overdose and death.
Caffeine is a naturally occurring legal stimulant that is readily available in carbonated beverages, chocolate-containing foods, coffee and tea, and over-the-counter medications such as cold tablets, allergy and analgesic preparations, appetite suppressants and increasingly popular ‘energy drinks’. It is the most widely ingested stimulant in Australia. Caffeine can stimulate catecholamine release which, in turn, stimulates the central nervous system; increases gastric acid secretion, heart rate and basal metabolic rate; alters blood pressure; increases diuresis; and relaxes smooth muscle (Mitchell, 1997). Consumption of large amounts of caffeine can result in restlessness, anxiety, irritability, agitation, muscle tremor, sensory disturbances, heart palpitations, nausea or vomiting and diarrhoea in some individuals.
Substance abuse is not always diagnosable, particularly in its early stages. Non-judgmental questions about use of legal drugs (prescribed drugs, tobacco and alcohol), use of soft drugs (marijuana) and use of more-problematic drugs (cocaine, heroin or ‘ice’) should be a routine part of any physical assessment. Important information may be obtained by making specific inquiries about past medical problems, changes in food intake or sleep patterns, or problems of emotional instability. Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct should alert the healthcare provider to probe the possibility of drug abuse more carefully.
UNPLANNED PREGNANCIES
Young adults sometimes have educational and career goals that take precedence over family development. Interference with these goals can affect future relationships and affects later parent–child relationships. An unplanned or even a planned pregnancy may thus be a stressor and present health risks. Determination of situational factors that may affect the progress and outcome of an unplanned pregnancy is important. Exploration of problems such as finance, career, living accommodation, family support systems, potential parenting disorders, depression and coping mechanisms is important in assessing the woman with an unplanned pregnancy.
SEXUALLY TRANSMITTED DISEASES
Sexually transmitted diseases (STDs) are a major health problem. STDs include syphilis, chlamydia, gonorrhoea, genital herpes and acquired immune deficiency syndrome (AIDS). Sexually transmitted diseases have immediate effects such as discharge, discomfort and infection. They may also lead to chronic disorders, which can result from genital herpes; infertility, which can result from gonorrhoea; and death from AIDS. These diseases may occur in sexually active people.
ENVIRONMENTAL OR OCCUPATIONAL FACTORS
A common environmental or occupational risk factor is exposure to airborne particles, which may cause lung diseases and cancer. Such lung diseases include silicosis from inhalation of talcum and silicon dust, and emphysema from inhalation of smoke. Cancers resulting from occupational exposures may involve the lung, liver, brain, blood or skin. Questions regarding occupational exposure to hazardous materials should be a routine part of the nurse’s assessment (Table 21-1).
TABLE 21-1 OCCUPATIONAL HAZARDS ASSOCIATED WITH DISEASES
| OCCUPATIONAL HAZARD | WORK-RELATED CONDITION |
|---|---|
| Asbestos | Asbestosis, mesothelioma (pleural and peritoneal), lung cancer |
| Sunlight | Skin cancer |
| Wood dust | Nasopharyngeal cancer |
| Metal dust | Lung disease |
| Anaesthetic gases | Reproductive effects, cancer |
| Cement dust | Dermatitis, bronchitis |
| Solvents | Liver disease, dermatitis |
| Metal powders | Cataracts |
| Repetitive wrist motion on computers | Tendonitis, carpal tunnel syndrome, tenosynovitis |
| Petroleum distillates | Cancer of lung, larynx |
| Vinyl chloride (plastics) | Liver cancer (haemangiosarcoma) |
| Vibration (as in jackhammer use) | Raynaud’s phenomenon |
| Dyestuffs | Bladder cancer, dermatitis |
| Pesticides | Pesticide poisoning |
| Cleansers, latex gloves | Allergies |
Modified from Stanhope M, Lancaster J 2008 Community and public health nursing, ed 7. St Louis, Mosby.
Health concerns
Health promotion
Young adults are generally active and have a minimum of major health problems. However, their lifestyles may put them at risk of illnesses or disabilities during their middle or older adult years. Young adults may also be genetically susceptible to certain chronic diseases such as diabetes mellitus and familial hypercholesterolaemia (McCance and Huether, 1998). Crohn’s disease, a chronic inflammatory disease of the small intestine, most commonly occurs between 15 and 35 years of age. Many young adults have misconceptions regarding transmission and treatment of STDs. Nurses should take opportunities to correct such misunderstandings. Partners are encouraged to know one another’s previous sexual history and sexual practices.
Nurses should be alert for STDs when clients come to clinics with complaints of urological or gynaecological problems (see Chapter 27). Young adults should be assessed for their knowledge of genital self-examination.
INFERTILITY
Infertility is the involuntary inability to conceive. To most healthcare professionals, it is the inability to conceive after a year or more of regular sexual intercourse. While the fertility rate has increased in Australia and New Zealand (Australian Bureau of Statistics, 2007c; Statistics New Zealand, 2011), an estimated 15–20% of otherwise healthy adults are infertile and many infertile clients are young adults. However, about 50% of the couples evaluated and treated in infertility clinics become pregnant. In about 10–20% of couples, the cause of infertility is unknown and they remain infertile. In the remaining 30%, the cause of the infertility is diagnosed but the couples remain infertile because of endometriosis, blocked fallopian tubes or decreased sperm motility. For some infertile couples a nurse may be the first person they talk to about it. Nursing assessment of the infertile couple should include comprehensive histories of both the male and the female to determine factors that may have affected fertility, as well as pertinent physical findings.
EXERCISE
Exercise patterns can affect health status. This is a particularly important area of health promotion in first-world countries where sedentary lifestyle and lack of physical activity and exercise are creating health problems. Exercise that produces a sustained increase in the pulse rate for about 30 minutes every day improves cardiopulmonary function by lowering blood pressure and heart rate. In addition, exercise decreases fatiguability, insomnia, tension and irritability. Assessment includes musculoskeletal assessment, joint mobility and muscle tone, and psychosocial assessment in order to help a client plan appropriate exercise.
ROUTINE HEALTH SCREENING
Routine health screening has beneficial outcomes for the detection, management and prevention of a range of health disorders. It is a risk-reducing activity (see Chapter 43). In Australia there are eight National Health Priority Areas: arthritis and musculoskeletal conditions, asthma, cancer control, cardiovascular health, diabetes mellitus, injury prevention and control, mental health and obesity (Australian Institute of Health and Welfare, 2011). These priority areas have been associated with 91% of all deaths. In New Zealand the national health targets for 2011–12 are shorter stays in emergency departments; improved access to elective surgery; shorter waits for cancer treatment; increased immunisation; better help for smokers to quit; and better diabetes and cardiovascular services (Ministry of Health, 2011a).
Breast screening is included in the current initiatives since breast cancer continues to be one of the most common causes of cancer deaths among women in Australia and New Zealand (Breast Cancer Australia, 2011; Ministry of Health, 2011b). Health screening not only involves professional activities but relies on individuals conducting self-assessments, for example of their skin, breasts or genitalia. Nurses have a role in helping clients understand the importance and techniques of how to integrate regular self-assessment into their daily lives. It is vital that nurses have the skills to engage in effective educational processes to support these health promotion measures (see Chapters 13 and 27).
PSYCHOSOCIAL HEALTH
The psychosocial health concerns of the young adult are often related to stress, such as job or family stress. As noted in Chapter 42, stress can be valuable because it motivates a client to change. However, if the stress is prolonged and the client is unable to adapt to the stressor, health problems can develop. Mental health is an increasingly important health issue for New Zealanders and Australians. Young adults are more likely to die from suicide than any other age group and the rate is higher for young men than women (Australian Bureau of Statistics, 2010b). Suicide continues to occur at significantly higher rates in Māri (16.1 per 100,000) than non-Māri (9.9 per 100,000) (Ministry of Health, 2009).
JOB STRESS
Job stress can occur every day or from time to time. Most young adults are able to handle day-to-day crises. Situational job stress may occur when a new boss enters the workplace, a deadline is approaching or the worker is given new or greater responsibilities. A trend in today’s business world and a risk factor for job stress is corporate downsizing, leading to increased responsibilities for employees, with fewer positions within the corporate structure. Job stress also occurs when a person becomes dissatisfied with a job or responsibilities. Because individuals perceive jobs differently, the types of job stressor vary from client to client.
The nurse’s assessment of the young adult should include a description of the usual work performed and present work if different. Job assessment also includes conditions and hours, duration of employment, changes in sleep or eating habits, and evidence of increased irritability or nervousness.
FAMILY STRESS
Family stressors can occur at any time in family life (see Chapter 18). Family life has peaks, when everyone in the family works together; and troughs, when everyone appears to pull apart. Situational stressors occur during events such as births, deaths, illnesses, marriages and job losses. Because of the multiplicity of changing relationships and structures in the emerging young adult family, stress is frequently high. Stress may be related to a number of variables, including the paid and unpaid work responsibilities of both partners, and may lead to dysfunction in the young adult family. The highest divorce rate occurs during the first 3–5 years of marriage for young adults under the age of 30. When a client seeks healthcare and presents with stress-related symptoms, the nurse should assess for the occurrence of a life-change event.
Each family has certain roles or jobs for members. These roles enable the family to function and be an effective part of society. One necessary role is the family leader. In most families one parent is the leader, or both parents act as co-leaders. In single-parent families the parent or occasionally a member of the extended family is the family leader. When this changes as a result of illness, a situational crisis may occur. Indeed, any illness in the family has flow-on effects for all members, creating family strain. The nurse should assess environmental and familial factors, including support systems and coping mechanisms commonly used by family members.
CHILDBEARING CYCLE
A developmental task for many young adults is the decision to parent children (Figure 21-2). Physiological, cognitive, emotional and psychosocial changes and transitions are part of a woman’s pregnancy and childbearing (see Figure 21-3). The significant family of a woman, particularly a partner but also other family members such as her parents, will also experience psychosocial transitions associated with pregnancy and childbirth. Fetal development and some aspects of health promotion and childbirth options are discussed in Chapter 20.
FIGURE 21-2 Ongoing prenatal care reduces complications of pregnancy.
Image: iStockphoto/Gene Chutka.
FIGURE 21-3 The ability to handle day-to-day challenges at work minimises stress.
From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.
Conception, pregnancy, birth and the puerperium are major phases of the childbearing cycle. The changes during these phases are complex. Women experience significant changes in physiological condition, emotion and body image during pregnancy and into early motherhood.
HEALTH PRACTICES
Women who are anticipating pregnancy benefit from good health practices before conception; these include a balanced diet including increased intake of folates (National Health and Medical Research Council, 2003), check-ups, avoidance of alcohol and cessation of smoking. Women trying to become pregnant should not try weight-reduction diets. The physiological changes and needs of the pregnant woman vary with each trimester (Table 21-2).
TABLE 21-2 MAJOR PHYSIOLOGICAL CHANGES DURING PREGNANCY
| SIGNS AND SYMPTOMS | CAUSES |
|---|---|
| FIRST TRIMESTER | |
| Amenorrhoea | Fertilisation and implantation of egg |
| Morning sickness | Increased serum hormone levels |
| Increased oestrogen levels | |
| Urinary frequency | Pressure of uterus on bladder |
| Fatigue | |
| SECOND TRIMESTER | |
| Increased levels of melanocyte-stimulating hormone | |
| Hypertrophy of gums causing gingival swelling and bleeding | Proliferation of interdental papillary blood vessels, resulting in local inflammation and hyperplasia |
| Increasing size of uterine fundus | Growth of fetus |
| Sensation of movement or gas-like movements (quickening) | Fetal movement |
| Braxton Hicks contractions | Expanding uterus and preparation of uterus for labour |
| THIRD TRIMESTER | |
| Increased colostrum | Hormonal influence; preparation of breasts for lactation |
| Increased urinary frequency | Pressure on bladder from enlarged fetus |
Data from Dickason E and others 1998 Maternal–infant nursing care. St Louis, Mosby; Lowdermilk D, Perry S 1998 Maternity nursing, ed 6. St Louis, Mosby.
PRENATAL CARE
Prenatal care (also known as antenatal care) is the routine examination of the pregnant woman by a midwife, obstetrician or general practitioner. Prenatal care includes physical assessment, for example, of the pregnant woman’s weight, blood pressure, urine for glucose, acetone and protein, and measurement of the fundus. Information should be provided from the beginning regarding sexually transmitted diseases, other vaginal infections and urinary infections that could adversely affect the fetus or woman. In addition, the pregnant woman may be counselled about exercise patterns, diet and child care. Regular healthcare can overcome health concerns such as preeclampsia, eclampsia, gestational diabetes, excessive weight gain and the high-risk infant.
FIRST TRIMESTER
All women experience some physiological changes in the first trimester, but some changes affect only certain women. These are outlined in Table 21-2. The midwife can help the woman assess the symptoms and signs and suggest strategies to minimise discomfort, as well as refer the woman to medical services if any signs suggest a maternal or fetal problem.
SECOND TRIMESTER
During the second trimester, growth of the uterus and fetus results in some of the physical signs of pregnancy. Women often report increased energy levels and, for most, nausea reduces or disappears. Urinary frequency often experienced in the first trimester ceases. A woman’s shape changes quite visibly during this trimester.
THIRD TRIMESTER
During the third trimester some women feel increasingly fatigued and some experience the return of uncomfortable symptoms such as urinary frequency and heartburn. Many but not all will experience Braxton Hicks contractions (irregular, short contractions) during this trimester. These are often mistaken for the beginning of labour and this in itself can be frustrating as time moves on. Women prepare for childbirth and parenting in a range of ways during this time and their efforts can be supported in prenatal care.
PUERPERIUM
The puerperium is a period of approximately 6 weeks after childbirth. During this time the woman’s body reverts to its pre-pregnant physical status. The nurse supports early parenting and the transition to motherhood in the first instance through systematic assessment of the woman’s physical status as well as psychosocial wellbeing and issues.
SENSORY PERCEPTION
The pregnant woman generally experiences changes in sensory perception. Temporary changes occur in visual and hearing acuity, taste and smell. Many pregnant women frequently stroke the abdomen, possibly because of a change in the sensation of touch or other sensory need. The woman may be using the sensation of touch to initiate attachment processes with her child.
EDUCATION
The entire childbearing family may choose to be supported through educational processes about aspects of pregnancy, labour, birth, breastfeeding, sleep and settling practices, as well as the more general transitions to parenthood and integration of the newborn into the family. Traditionally, childbirth classes help parents plan for the birth of the child and focus on the normal physiological changes of pregnancy, symptoms of impending labour, methods of pain control, the processes of labour and birth, and care of the newborn. Many healthcare centres also have sibling and grandparent preparation classes. Not all pregnant women, however, attend childbirth classes, for a variety of reasons. Childbirth education classes may not be accessible to women of all socioeconomic classes, and women may choose not to attend because of cultural beliefs about childbirth or lack of knowledge about the importance of childbirth education.
Education such as prenatal classes can prepare pregnant women, their partners and other support people to participate in the birthing process. Social support has also been associated with improved pregnant women’s health practices (Cannella, 2006; Schaffer and Lia-Hoagberg, 1997) and has been associated with a lower incidence of post-natal depression (Xie and others, 2009). A current trend in some healthcare agencies is to provide a support person to be present during labour to help women who have no other source of support. The personal and social changes occurring in the lives of women and their partners cannot be underestimated.
PSYCHOSOCIAL CHANGES
Like the physiological changes of pregnancy, psychosocial changes may occur at various times during the nine months of pregnancy and in the puerperium. The major categories of psychosocial changes involve body image, role, sexuality, coping mechanisms and stresses during the puerperium. Table 21-3 summarises these psychosocial changes and implications for nursing intervention.
TABLE 21-3 MAJOR PSYCHOSOCIAL CHANGES DURING PREGNANCY
Acute care
The young adult years are generally a time of good physical and emotional health. Potential health hazards may be related to lifestyle. Acute care for young adults is frequently related to accidents, substance abuse, exposure to environmental and occupational hazards, stress-related illnesses, respiratory infections, gastroenteritis, influenza, urinary tract infections and minor surgery. An acute minor illness can cause a disruption in life activities of the young adult and increase stress in an already hectic lifestyle. Dependency and limitations posed by treatment regimens can also increase frustration for the young adult. To give young adults a sense of maintaining control of their healthcare choices, it is important to keep them informed about their health status and involve them in healthcare decisions.
Restorative and continuing care
Chronic conditions are not common in young adulthood, but they can occur. Chronic illnesses such as hypertension, coronary artery disease and diabetes may have their onset in young adulthood without being known to the young adult until later in life. Causes of chronic illness and disability in the young adult can include accidents, multiple sclerosis, rheumatoid arthritis, AIDS and cancer. Chronic illness and disability can affect the accomplishment of important developmental tasks in young adulthood. The threat to the young adult’s independence that is caused by chronic illness or disability can result in the need to change personal, family and career goals. Nursing interventions for the young adult faced with chronic illness or disability should include potential developmental problems related to sense of identity, the establishment of independence, reorganisation of intimate relationships and family structure and launching of a chosen career (Brown and Edwards, 2007).
Middle adulthood
In middle adulthood, the individual makes lasting contributions through involvement with others. Generally, the middle adult years begin around the early to mid-30s and last through to the late 60s. During this period, personal and career achievements have often already been experienced. Although there is reasonable socioeconomic stability for many middle-aged adults, there are also many pressures on domestic finances; mortgages, consumables and family-related expenses tend to be high. Changes in workplace organisation have altered employment patterns, and although the overall unemployment rate is lower than in the late 20th century, many more adults work part-time and often have to organise their lives around more than one part-time job.
Many middle-aged adults find particular satisfaction in helping their children and other young people to become productive and responsible adults. They may also begin to help ageing parents. This is particularly true for women, daughters and daughters-in-law (Perrig-Chiello and Hutchison, 2010) (see Chapter 22). Using leisure time in satisfying and creative ways is a challenge that, if met satisfactorily, enables middle-aged adults to prepare for a successful retirement.
Men and women must adjust to inevitable biological changes. As in adolescence, middle-aged adults use considerable energy to adapt self-concept and body image to physiological realities, changes in physical appearance and societal pressures and values. High self-esteem, a favourable body image and a positive attitude towards physiological changes are fostered when adults engage in physical exercise, balanced diets, adequate sleep and good hygiene practices that promote vigorous, healthy bodies.
Physical changes
Major physiological changes occur between 40 and 65 years of age. Table 21-4 summarises these normal developmental changes that the nurse considers when conducting a physical examination.
TABLE 21-4 PHYSICAL ASSESSMENT FINDINGS IN THE MIDDLE-AGED ADULT
| BODY SYSTEM | FINDINGS |
|---|---|
| Integument | |
| Head and neck | |
| Eyes | |
| Ears | Normal auditory structures and acuity |
| Nose, sinuses and throat | |
| Thorax and lungs | |
| Heart and vascular system | |
| Breasts | |
| Abdomen | |
| Female reproductive system | |
| Male reproductive system | |
| Musculoskeletal system | |
| Neurological system |
The most visible changes are greying of the hair, wrinkling of the skin and thickening of the waist. Balding commonly begins during the middle years, but it may also occur in young adult males. Decreases in hearing and visual acuity are often noted during this period. Often these physiological changes have an impact on self-concept and body image. The most significant physiological changes during middle age are menopause in women and the climacteric in men.
Menopause
Menstruation and ovulation occur in a cyclical rhythm in the woman from adolescence into middle adulthood. Menopause is the disruption of this cycle, mainly because of the inability of the neurohormonal system to maintain its periodic stimulation of the endocrine system. The ovaries no longer produce oestrogen and progesterone, and the blood levels of these hormones drop markedly. Menopause typically occurs between 45 and 60 years of age (see Chapter 22). Menopause is a particularly challenging transition in women’s lives if it occurs before the age of 40 (see Research highlight). Approximately 10% of women have no symptoms of menopause other than cessation of menstruation, 70–80% are aware of other changes but have no problems and approximately 10% experience changes severe enough to interfere with activities of daily living (Lowdermilk and others, 2011). While a universal phenomenon, it is important to understand that menopause can be perceived and experienced very differently by individual women (see Working with diversity).
Research abstract
Menopause is a universal life experience. Historically, menopause has been conceived as a pathological condition and, therefore, medicalised by healthcare providers. The purpose of the study was to give voice to the menopausal experiences of women. The research question was: What has your experience been with perimenopause and/or menopause? Thirteen women, meeting inclusion criteria and obtained through snowball effect, were interviewed. Data were collected through semi-structured interviews and drawings. The women interviewed repeatedly had questions and concerns regarding perimenopause, and often reported receiving conflicting and confusing information. Transition theory was used to understand the thematic results. The major themes that emerged were My Body, Sharing with Others, Not My Mother and Going on with Life.
Evidence-based practice
• Menopause is a universal life event for women.
• Women lack information regarding menopause and are often confused and anxious about it.
• The information they receive is often inadequate and presents menopause as a deficit condition and a negative experience.
• Nurses and other healthcare practitioners should provide accurate and positive information to women well before they have symptoms and thus decrease some of the anxiety and misunderstanding associated with it.
Climacteric
The climacteric occurs in men in their late 40s or early 50s (see Chapter 24). It is caused by decreased levels of androgens. Throughout this period and thereafter, a man is still capable of producing fertile sperm and fathering a child. However, penile erection is less firm, ejaculation is less frequent and the refractory period is longer.
WORKING WITH DIVERSITY FOCUS ON CULTURAL CARE
Understanding women’s perceptions of menopause and its impacts on their lives, health and wellbeing is at the heart of engaging in illness prevention and health promotion strategies with perimenopausal women. In Western societies, perceptions of menopause have been dominated by biophysical changes and the medical treatments that potentially minimise symptoms and reduce the risk of other disorders that may increase in likelihood following menopause. However, perceptions of menopause, its symptoms and challenges vary greatly between different cultures and ethnic groups. The cultural value placed on reproductive ability, social status in midlife and understandings of the links between menstruation and good health are just a few of the perceptions that form the basis for the way women understand and respond to menopause. Although there is high reporting of physical symptoms in Western countries, this is not the case in many societies, although there are differences between rural and urban groupings in some cultures. The way women respond to menopause issues also varies. They use traditional, complementary, Western and spiritual practices. Many women will use a combination of strategies; some are more focused on managing issues and some on preventing ill effects. Culturally competent nursing practice requires the provision of culturally appropriate care.
IMPLICATIONS FOR PRACTICE
• Understanding of women’s perceptions of their health, the transitions they face and the implications of menopause, on an individual basis, is critical.
• Listening to women’s perceptions and issues without cultural bias and setting aside one’s own imperatives is important in order to support women’s needs.
• Accessible and appropriate health services with adequate language support are required.
• Peer support is valued and helps many women learn strategies that are appropriate for their sociocultural context—nurses can facilitate community advocates.
• Information and explanation of symptoms and treatment options need to be provided in culturally appropriate forms.
Al-Qutob R 2001 Menopause-associated problems: types and magnitude. A study in Ain Al Basha area, Jordan. J Adv Nurs 33(5):613; Chirawatkul S, Patanasri K, Koochiayasit C 2002 Perceptions about menopause and health practices among women in northeast Thailand. Nurs Health Sci 4:113; National Multicultural Advisory Council 1999 Australian multiculturalism for a new century: toward inclusiveness. Canberra, AGPS; Tsao L-I 2002 Relieving discomforts: the help seeking experiences of Chinese perimenopausal women in Taiwan. J Adv Nurs 39(6):580.
Cognitive changes
Changes in the cognitive function of middle-aged adults are rare except with illness or trauma. The middle-aged adult can learn new skills and information. Some enter educational or vocational programs to prepare themselves for entering the job market or changing jobs.
Psychosocial changes
The psychosocial changes in the middle-aged adult may involve expected events, such as children moving away from home, or unexpected events, such as a marital separation or the death of a close friend. These changes may result in stress that can affect the adult’s overall level of health. Nurses should assess the major life changes occurring and the impact that the changes have on that person’s state of health. Nursing assessment should also include individual psychosocial factors such as coping mechanisms and sources of social support.
In the middle adult years, as children depart from the household, the family enters the post-parental family stage. Time and financial demands alter, and adults face the task of redefining their own relationships. As grandchildren arrive, grandparenting styles must be chosen. It is during this period that many middle-aged adults begin to take on a healthier lifestyle. Although it is not advisable to wait until this stage in life to think about health promotion, ‘better late than never’ does apply. Assessment of health promotion needs for the middle-aged adult include adequate rest, leisure activities, regular exercise, good nutrition, reduction or cessation in the use of tobacco or alcohol, and regular screening examinations. Assessment of the middle-aged adult’s social environment is also important, including relationship concerns; communication and relationships with children, grandchildren and ageing parents; and caregiver concerns with their own ageing or disabled parents.
According to Erikson’s developmental theory, the main developmental task of the middle years is to achieve generativity (Erikson, 1968, 1982). Middle-aged people who have successfully negotiated the task of young adulthood are well placed to contribute to the development of those younger than themselves. Generativity is the willingness to care for and guide others and can be a great source of satisfaction and fulfilment. Middle-aged adults can achieve generativity though guidance of their own children, junior work colleagues, the children of close friends or through social interactions with younger generations. Such people have the satisfaction of knowing that they have helped those who will outlive them. If they have not achieved successful development in their young adult years, they tend to be socially isolated and are likely to be too self-absorbed to achieve generativity, and may thus stagnate personally. Such stagnation may be expressed by excessive concern with themselves at the expense of those younger, or destructive behaviour towards their children and the community.
Career transition
Career changes may occur by choice or as a result of changes in the workplace or society. In recent decades, middle-aged adults have changed occupations for a variety of reasons, including limited upward mobility, decreasing availability of jobs, and seeking an occupation that is more challenging to the individual. In some cases technological advances or other changes force middle-aged adults to seek new jobs. Such changes, particularly when unanticipated, may result in stress that can affect health, family relationships, self-concept and other dimensions. Being made redundant or losing a job can be a major source of stress as the middle-aged person worries about their ability to find another job (Gabriel and others, 2010).
Sexuality
Sexuality and sexual relationships undergo transition in middle adult years. For some people, refocusing on an existing partnership leads to increasing sexual satisfaction. For others, new relationships and partnerships are formed. Sexual practices are affected not only by realignment of relationships but also by biophysical changes. The onset of menopause can affect the sexual health of a woman. During middle age, a man may notice changes in the strength of his erection and a decrease in his ability to experience repeated orgasm. If not well educated by healthcare professionals, he may become vulnerable to hoax remedies. Other factors influencing sexuality during this period include work stress, diminished health of one or both partners, and the use of prescription medications, such as antihypertensive agents, with side effects that may influence sexual desire or functioning. Middle-aged adults may experience stresses related to sexual changes or a conflict between their sexual needs and self-perceptions and social attitudes or expectations (see Chapter 24).
Family types and transitions
Psychosocial factors involving the family may include the stresses of singlehood, marital changes, transition of the family as children leave home, and the care of ageing parents. The departure of the last child from the home may be a stressor. Many parents welcome freedom from child-rearing responsibilities, whereas others feel lonely or without direction because of this change. Eventually, parents must reassess their relationships and plan for the future, whether in their parenting partnerships or in new ways.
RELATIONSHIP CHANGES
Changes in marriage and partnerships that may occur during middle age include death of a spouse, separation, divorce and the choice of remarrying or remaining single. A widowed, separated or divorced client goes through a period of grief and loss in which it is necessary to adapt to the change in marital status. Grieving is complex and involves a series of phases taking time to resolve. How much time is difficult to assess, but it may be measured in years for many people.
CARE OF AGEING PARENTS
Increasing lifespans in Australasia have led to increased numbers of older adults in the population. Therefore, greater numbers of middle-aged adults must attend to the personal and social issues confronting their ageing parents. Many middle-aged adults, particularly women, find themselves in the sandwich generation, caught between the responsibilities of caring for dependent children and those of caring for ageing and ailing parents.
Housing, employment, health and economic realities have changed the traditional social expectations between generations in families. The middle-aged adult and the older adult parent may have conflicting priorities related to their relationship while the older adult strives to remain independent. Negotiations and compromises help in defining and resolving problems. Nurses deal with middle-aged and older adults in the community, extended-care facilities and hospitals. The nurse can help identify the health needs of both groups and can help the multigenerational family determine the health and community resources available to them as they make decisions and plans. The nurse should also assess family relationships to determine family members’ perceptions of responsibility and loyalty in relation to caring for older adult members. Assessment of environmental resources (e.g. number of rooms in the house, stairwells) in relation to the complexity of healthcare demands for the older adult is also important.
Health concerns
Health promotion
The leading cause of death among Australians aged 25–64 is coronary artery disease for males and breast cancer for females (Australian Institute of Health and Welfare, 2010). In 2000 in New Zealand, heart attacks and strokes accounted for 38% and cancer accounted for 29% of deaths; a further 8% of deaths were due to respiratory diseases (Statistics New Zealand, 2009). Concerns for the middle-aged adult include stress, level of wellness and the formation of positive health habits that can protect them from ill-health.
STRESS AND STRESS REDUCTION
Because middle-aged adults are experiencing physiological changes and face certain health realities, their perceptions of health and health behaviours are often important factors in maintaining health. In addition, they are frequently at the top of their career with its attendant demands and are likely to have responsibilities for teenage or young adult children as well as ageing parents. Today’s complex world makes individuals more prone to stress-related illnesses such as heart attacks, hypertension, migraine headaches, ulcers, colitis, autoimmune disease, backache, arthritis and cancer.
When adults seek healthcare, the nurse’s focus on the goal of wellness can guide clients to evaluate health behaviours, lifestyle and environment. Attention to risk factors that can be altered to improve the client’s health, such as stress, obesity, use of tobacco, excessive alcohol consumption, poor nutrition and unsafe sexual practices, can increase the quality of life and add years to it.
Throughout life, people are exposed to many stressors (see Chapter 42). After these stressors are identified, the client and nurse can work together to intervene and modify the stress response. Specific interventions for stress reduction can fall into three categories. First, the frequency of stress-producing situations is minimised. Together the nurse and client identify approaches to prevent stressful situations, such as habituation, change-avoidance, time blocking, time management and environmental modification. The second category is psychophysiological preparation to increase stress resistance, such as increasing self-esteem, improving assertiveness, redirecting goal alternatives and reorienting cognitive appraisal. Last, the physiological response to stress is avoided. The nurse uses relaxation techniques (see Chapter 42), imagery and biofeedback to recondition the client’s response to stress. These general interventions are explained in greater detail in Chapter 42.
LEVELS OF WELLNESS
The nurse must be able to assess the health status of the middle adult client. Such assessment offers direction for planning nursing care and is useful in evaluating the effectiveness of nursing interventions. Table 21-4, which shows the physical changes of the middle-aged adult, can be used with other standard assessment techniques as a guide for physical assessment (see Chapter 27).
FORMING POSITIVE HEALTH HABITS
A habit is a person’s usual practice or manner of behaviour. This behaviour pattern is reinforced by frequent repetition until it becomes the individual’s customary way of behaving. Some habits support health, such as healthy eating, exercise and brushing and flossing the teeth each day. Other habits involve risk factors to health, such as smoking or eating foods with little or no nutritional value.
During assessment, the nurse often obtains data indicating positive and negative health behaviours by the client. Examples of positive health behaviours include regular exercise, adherence to good dietary habits, avoidance of excess consumption of alcohol, participation in routine screening and diagnostic tests (laboratory work for serum cholesterol, mammography) for disease prevention and health promotion, and lifestyle changes to reduce stress. In the planning, implementation and evaluation phases, the nurse helps the client maintain habits that protect health and offers alternatives to promote health in daily life.
Health teaching and health counselling are often directed at improving health habits (Box 21-2). The more fully the nurse understands the dynamics of behaviour and habits, the more likely it is that interventions will help the client to achieve or reinforce health-promoting behaviours.
BOX 21-2 CLIENT TEACHING ABOUT POSITIVE HEALTH HABITS
TEACHING STRATEGIES
• Review with client the daily work schedule and identify potential times for exercise.
• Inform client about the effect of exercise on weight control and improved cardiac function.
• Demonstrate how to calculate target heart rate and assess pulse correctly.
• Provide warm-up and cool-down exercises and demonstrate how to do them.
• Instruct client about support shoes for walking exercises.
To help clients form positive health habits, the nurse becomes a teacher and facilitator. By listening to the client’s interests, imperatives, likes and dislikes and negotiating activities and outcomes, supported by accurate, evidence-based and useful information, the nurse engages in consciousness-raising with the client. Only the client is able to change behaviours and integrate new habits or activities into daily life. Ultimately, however, the client decides which behaviours will become habits of daily living.
Barriers to change do exist (Box 21-3). Some barriers are more amenable to change than others; some can be built into the nurse–client relationship, and others require community, health service and political action.
PSYCHOSOCIAL CONCERNS
ANXIETY
Anxiety is a critical maturational phenomenon related to change, conflict and perceived control of the environment (Haber and others, 1997). Adults often experience anxiety in response to the physiological and psychosocial changes of middle age. Such anxiety can motivate the adult to rethink life goals and stimulate productivity. For some adults, however, this anxiety precipitates psychosomatic illness and preoccupation with death. In this case the middle-aged adult views life as being half or more over and thinks in terms of the time left to live.
Clearly, a life-threatening illness, relationship transition or job stressor increases the anxiety of the client and family. The nurse may need to use crisis intervention or stress management techniques to help the client adapt to the changes of the middle adult years (see Chapter 42).
DEPRESSION
Depression is a mood disorder that manifests itself in many ways. Although the most common age of onset is between 25 and 44 years, it is common among adults in the middle years and may have many causes (Haber and others, 1997). The risk factors for depression include being female; disappointments or losses at work, school or in family relationships; departure of the last child from the home; and family history. In fact, the incidence of depression in women is more than twice that of men.
People experiencing mild depression describe themselves as feeling sad, blue, downcast, down in the dumps and tearful. Other symptoms include alterations in sleep patterns such as difficulty in sleeping (insomnia) or sleeping too much (hypersomnia), irritability, feelings of social disinterest, and decreased alertness. Physical changes such as weight loss or weight gain, headaches or feelings of fatigue regardless of the amount of rest may also be depressive symptoms. Depression that occurs during the middle years is commonly characterised by moderate-to-high anxiety and physical complaints. Mood changes and depression are common phenomena during menopause. Depression may be worsened by the abuse of alcohol or other substances.
Nursing assessment of the depressed middle-aged adult includes focused data collection regarding individual and family history of depression, mood changes, cognitive changes, behavioural and social changes, and physical changes. Assessment data should be collected from both the client and the client’s family, since family data may be particularly important, depending on the level of depression being experienced by the middle-aged adult.
COMMUNITY HEALTH PROGRAMS
Community health programs for middle-aged adults are designed to prevent illness, promote health and detect disease in the early stages. Nurses can make valuable contributions to the community’s health by taking an active part in the planning of screening and teaching programs, as well as supporting community development initiatives. Liaison with other health services, community organisations and businesses is integral to a community nursing role. The skill base required is broad, complex and multidisciplinary.
Greg is a 49-year-old man. He is married with two young children and works in a plant nursery as a horticulturist. Apart from his work he gets little exercise, mainly because of the demands of his family. He is moderately overweight, and his blood cholesterol and blood pressure are both on the high side of normal.
What issues should be considered when devising a plan for Greg to develop a healthier lifestyle?
Acute care
Acute illnesses and conditions experienced in middle adulthood are similar to those of young adulthood. Injuries and acute illnesses in middle adulthood, however, may take a longer recovery period because of the slowing of recuperative processes. As well, acute illnesses and injuries experienced in middle adulthood are more likely to become chronic conditions. For those middle-aged adults who are in the sandwich generation, stress levels may also increase as they try to balance responsibilities related to employment, family life, care of children and care of ageing parents while recovering from an injury or acute illness.
Restorative and continuing care
Chronic illnesses such as diabetes mellitus, hypertension, rheumatoid arthritis, chronic obstructive pulmonary disease or multiple sclerosis may affect the roles and responsibilities assumed by the middle-aged adult. Strained family relationships, modifications in family activities, increased healthcare tasks, increased financial stress, the need for housing adaptation, social isolation, medical concerns and grieving may all result from chronic illness. The degree of disability and the client’s perception of both the illness and the disability determine the extent to which lifestyle changes will occur. A few examples of the problems experienced by clients who develop debilitating chronic illness during adulthood include role reversal, changes in sexual behaviour and alterations in self-image.
Along with the current health status of the chronically ill middle-aged adult, the nurse must assess the knowledge base of both the client and the family. This assessment should include the medical course of the illness and the prognosis for the client, the coping mechanisms of the client and family, adherence to treatment and rehabilitation regimens and the need for community and social services, along with appropriate referrals.
KEY CONCEPTS
• Developmental changes in adult years are based on earlier characteristics that help shape subsequent behaviour and characteristics.
• Many changes experienced by the young adult are related to the natural process of maturation and socialisation.
• Maturity is reached when the young adult attains a balance of growth in the physiological, psychosocial and cognitive areas.
• Cognitive development continues throughout the young and middle adult years.
• Emotional health of young adults is correlated with the ability to resolve personal and social problems.
• Young adult life involves many choices in career, relationships, material resources and lifestyle.
• Pregnant women can respond to changes in their health status if they have a good understanding of the biophysical changes that occur throughout pregnancy.
• The woman, partner and other family members experience a range of psychosocial challenges and transitions as a result of pregnancy and childbirth.
• Midlife transition begins when a person becomes aware that physiological and psychosocial changes signify passage to another stage in life.
• Two significant physiological changes of the middle years are menopause in women and the climacteric in men.
• Cognitive changes are rare in middle age except in cases of illness or physical trauma.
• Psychosocial changes for middle-aged adults may be related to career transition, chronic illness, sexuality, life-partner changes, family transition and care of ageing parents.
• Health concerns of middle-aged adults commonly involve stress-related illnesses, health assessment and adoption of positive health habits.
ONLINE RESOURCES
Sites useful for information about breast cancer and its prevention in Australia and New Zealand are:
Sites that address New Zealand and Australian government health strategies can be found at:
www.health.govt.nz/publications/implementing-new-zealand-health-strategy-2008
www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/national-preventative-health-strategy-1lp
The Australian Institute of Health and Welfare has many publications on health and welfare. Its site is www.aihw.gov.au
Australian Bureau of Statistics (ABS). Marriages, Australia, Cat. no. 3306.0.55.001. Canberra: ABS, 2007. Online Available at www.abs.gov.au/ausstats/abs@.nsf/mf/3306.0.55.001 5 Dec 2011.
Australian Bureau of Statistics (ABS). Lifetime marriage and divorce trends, Cat. no. 4102.0. Canberra: ABS, 2007. Online. Available at www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/0B6F42BBA4622404CA25732F001C93F1/$File/41020_Lifetime%20marriage%20and%20divorce%20trends_2007.pdf 13 Dec 2011.
Australian Bureau of Statistics (ABS). Australian social trends, 2007, Cat. no. 4102.0. Canberra: ABS, 2007. Online Available at www.abs.gov.au/AUSSTATS/abs@.nsf/allprimarymainfeatures/3550D34DA999401ECA25748E00126282?opendocument 5 Dec 2011.
Australian Bureau of Statistics (ABS). Population by age and sex, Australian states and territories, Cat no 3201.0. Canberra: ABS, 2010. Online Available at www.abs.gov.au/ausstats/abs@.nsf/mf/3201.0) 5 Dec 2011.
Australian Bureau of Statistics (ABS). Family, community and social cohesion, Cat. no. 1370.0—Measures of Australian progress, 2010. Canberra: ABS, 2010. Online Available at www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/1370.0~2010~Chapter~Suicide%20(4.5.4) 23 Apr 2012.
Australian Institute of Health and Welfare (AIHW). Female SAAP clients and children escaping domestic and family violence 2003–04, Cat. no. AUS 64. Canberra: AIHW, 2005. Online Available at www.aihw.gov.au/publication-detail/?id=6442467758 5 Dec 2011.
Australian Institute of Health and Welfare (AIHW). Mortality FAQs. Canberra: AIHW, 2006. Online Available at www.aihw.gov.au/deaths-faq 23 Apr 2012.
Australian Institute of Health and Welfare (AIHW). Australia’s welfare, Cat. no. ABS 93. Canberra: AIHW, 2007.
Australian Institute of Health and Welfare (AIHW). Australia’s health, Australia’s health series, Cat. no. AUS 122. Canberra: AIHW, 2010. Online Available at www.aihw.gov.au/publication-detail/?id=6442468376 5 Dec 2011.
Australian Institute of Health and Welfare (AIHW). Health priority areas. Canberra: AIHW, 2011. Online Available at www.aihw.gov.au/health-priority-areas 23 April 2011.
Baker M. Families, labour and love. Sydney: Allen & Unwin, 2001.
Breast Cancer Australia. Website information. Online. Available at www.breastcanceraustralia.org/home.html, 2011. 12 Dec 2011.
Brooks GR. The crisis of masculinity. In: Brooks GR, ed. Beyond the crisis of masculinity: a transtheoretical model for male-friendly therapy. Washington, DC: American Psychological Association, 2010.
Brown D, Edwards H. Lewis’s Medical–surgical nursing, ed 2. Sydney: Elsevier, 2007.
Cannella BL. Mediators of the relationship between social support and positive health practices in pregnant women. Nurs Res. 2006;55(6):437–445.
Chartier K, et al. Alcohol problems in young adults transitioning from adolescence to adulthood: the association with race and gender. Addict Behav. 2011;36(3):167–174.
Erikson E. Identity: youth and crisis. New York: Norton, 1968.
Erikson E. The life cycle completed: a review. New York: Norton, 1982.
Gabriel Y, et al. Temporary derailment or the end of the line? Managers coping with unemployment at 50. Organ Stud. 2010;31(12):1687–1712.
Gilligan C. In a different voice: psychological theory and women’s development. Cambridge, MA: Harvard University Press, 1992.
Haber J, et al. Comprehensive psychiatric nursing. St Louis: Mosby, 1997.
Hale S, et al. Male GPs’ views on men seeking medical help: a qualitative study. Br J Health Psychol. 2010;15(4):697–713.
Harrison J, et al. Youth suicide and self-injury Australia, suppl to issue 15. Adelaide: Research Centre for Injury Studies, Flinders University, 2010. Online Available at www.nisu.flinders.edu.au/pubs/bulletin15/bulletin15sup.html#Heading2 5 Dec 2011.
Havighurst R. Successful aging. Williams RH, et al, eds. Process of aging, vol 1. New York: Atherton, 1972.
Lowdermilk D, et al. Maternity and women’s health care, ed 10. St Louis: Mosby, 2011.
Masters W, Johnson V. Human sexual response. Boston: Little, Brown, 1970.
McCance K, Huether S. Pathophysiology: the biologic basis for disease in adults and children, ed 3. St Louis: Mosby, 1998.
Miller A, Sassler S. Stability and change in the division of labor among cohabiting couples. Sociol Forum. 2010;25(4):677–702.
Ministry of Health. Suicide facts: deaths and intentional self-harm hospitalisation 2007. Wellington: Ministry of Health, 2009. Online Available at www.health.govt.nz/publication/suicide-facts-deaths-and-intentional-self-harm-hospitalisations-2007 24 May 2011.
Ministry of Health. Health targets. Wellington: Ministry of Health, 2011. Online Available at www.health.govt.nz/new-zealand-health-system/health-targets 5 Dec 2011.
Ministry of Health. Mortality demographic data 2008. Wellington: Ministry of Health, 2011. Online Available at www.health.govt.nz/publication/mortality-and-demographic-data-2008 23 April 2012.
Mitchell M. Nutrition across the life span. Philadelphia: Saunders, 1997.
National Health and Medical Research Council (NHMRC). Dietary guidelines for all Australians. Canberra: NHRMC, 2003. Online Available at www.nhmrc.gov.au/guidelines/publications/n29-n30-n31-n32-n33-n34 5 Dec 2011.
Perrig-Chiello P, Hutchison S. Family caregivers of elderly persons: a differential perspective on stressors, resources, and well-being. J Gerontopsychol Geriatr Psych. 2010;23(4):195–206.
Schaffer M, Lia-Hoagberg B. Effects of social support on prenatal care and health behaviors of low-income women. J Obstet Gynecol Neonatal Nurs. 1997;26(4):433.
Statistics New Zealand. New Zealand life tables 2005–2007. Wellington: Statistics New Zealand, 2009. Online Available at www.stats.govt.nz/browse_for_stats/population/births/new-zealand-life-tables-2005-07.aspx 7 Dec 2011.
Statistics New Zealand. Demographic trends: 2010. Wellington: Statistics New Zealand, 2010. Online Available at www.stats.govt.nz/browse_for_stats/population/estimates_and_projections/demographic-trends-2010.aspx 7 Dec 2011.
Statistics New Zealand. Births and deaths: year ended September 2011. Wellington: Statistics New Zealand, 2011. Online Available at www.stats.govt.nz/~/media/Statistics/Browse%20for%20stats/BirthsAndDeaths/HOTPYeSep11/BirthsAndDeathsYeSep11HOTP.pdf 7 Dec 2011.
Xie R-H, et al. Prenatal social prenatal social support, postnatal social support, and postpartum depression. Ann Epidemiol. 2009;19(9):637–643.