CHAPTER 8 Adolescent and Gender-Specific Issues
Providing comprehensive care to adolescents with an emphasis on preventive and proactive health care services is a strategic and challenging role for school nurses. Adolescents are an at-risk population for accidents, illness, and inconsistent health care, and they have a challenging lifestyle, often with inadequate nutrition, sleep deprivation, and poor physical fitness habits. Because they live for the moment, adolescents take their health for granted, unaware of the long-term implications of poor health habits. Subject to peer pressure that promotes experimentation with technology, toxic substances, and sexuality, they often become victims of accidents, illness, and addictions. Brain research adds a new reference to understanding adolescent behavior (seeChapter 1, Growth and Development Characteristics).
• Adolescence is a time of change, experimentation, and risk taking.
• Adolescents should be encouraged to pursue a positive, proactive lifestyle based on healthy choices regarding self-care and personal health.
• School nurses should affirm the decision-making and problem-solving capacities of the adolescent for self-determination in the context of confidential delivery of service.
• Adolescents have a great capacity for individual responsibility and can be supported and strengthened by personal grievance and treatment contracts with school nurses, teachers, and parents.
• Health care providers (HCPs) should assess risk factors to maximize the resiliency of the vulnerable adolescent.
• Given the effect of peer orientation on the adolescent, preventive health care efforts should promote a positive peer culture, whereby teenagers assume responsibility for the well-being of one another.
• Every effort should be made to strengthen the adolescent’s resources within the family and the support they receive from parents or parent surrogates, such as foster parents and group home staff.
• The stage of adolescence is fundamental to the formation of attitudes and personal habits regarding health that have long-range effects on quality of life and the onset of diseases and disabilities.
• Be skilled at using health history and high-risk inventories.
• Provide anticipatory guidance in social, sexual, peer pressure, nutrition, exercise, substance abuse, and risk-taking behavioral issues.
• Be aware of important mental health issues.
• Be able to say “I don’t know, but I can find out and get back to you.”
GENERAL CONDITIONS
ACNE VULGARIS
A. Chronic skin condition of the pilosebaceous units, well-developed sebaceous glands with miniature hairs, usually located on the face, neck, upper chest, shoulders, and upper back. Acne is the result of an interaction between keratin, sebum, and sometimes bacteria. When the opening of the follicle is tight, it appears to be white and is referred to as a whitehead (closed comedo); when the pore is open to the air, it appears black and is referred to as a blackhead (open comedo). The black color probably is due to the melanin pigment in the skin and does not represent dirt.
A. The causes of acne include a strong genetic predisposition; increased secretion of hormones, specifically androgens, which trigger production of oil (sebum) on the skin; and plugged oil ducts that allow bacteria on the skin to multiply and produce redness and swelling. The exact mechanisms of acne are unknown.
B. Many adolescents (80%) develop some degree of acne (Darmstadt and Sidbury, 2004). No scientific link has been identified between diet and acne, but some individuals have acne breakouts after eating certain foods.
A. Usually observed between the ages of 12 and 17, but it can begin as early as age 8 and can last for 10 to 15 years.
B. Boys have more severe acne that lasts a shorter time, and girls have milder acne that lasts a longer time.
D. Inflammation, redness, and swelling can occur and may result in pustules, papules, nodules, and cysts, some of which may cause scars.
E. Inflammation, slow healing, and possible scar formation may occur as a result of trauma (e.g., picking, wearing athletic gear).
F. Hormonal triggers, such as premenstrual flares, occur in about 25% to 50% of females with acne (Darmstadt and Sidbury, 2004).
H. Oil-based cosmetics may increase the likelihood of comedones; adolescents should avoid occlusive products, such as cocoa butter and vitamin E oil.
I. Acne is exacerbated by certain medications, such as androgenic oral contraceptives (e.g., Lo-Ovral, Nordette), barbiturates, hydantoin (Dilantin), corticotropin (Acthar), and oral and topical steroids.
J. Acne can be exacerbated by environmental factors where adolescents work (e.g., exposure to cooking oils in fast-food facilities, grease in auto repair shops).
IV. Health Concerns/Emergencies
A. Excoriée des filles, or picker’s acne, is a superficial type of acne caused by compulsive picking of trivial facial lesions, which causes secondary damage and often leads to scarring. Picking is also seen in teens who abuse methamphetamines.
B. Acne fulminans is rare but occurs in adolescent boys and manifests with inflammatory nodules and plaques, which lead to severe pustules that leave large ulcerations. Onset is abrupt with fever, weight loss, anemia, and polyarthritis.
2. Rosacea, milia, folliculitis, and cosmetic, environmental, mechanical, or drug-induced acne. Acne clears with removal of causative factors.
1. Wash face with a mild soap, such as Neutrogena; harsh and frequent scrubbing may irritate the skin.
5. Encourage compliance with treatment regimen, because it takes months to clear acne; some teenagers believe particular foods are related to a flare-up, so recommend avoidance of those foods.
6. Discuss lack of documentation that cola, chocolate, nuts, or french fries cause acne, but emphasize the importance of a well-balanced diet for healthy skin.
7. Avoid sun when using tretinoin (Retin-A) or antibiotics (e.g., tetracycline [Achromycin], minocycline [Dynacin, Minocin]).
D. Medications include topical agents (e.g., tretinoin, adapalene, acetylinic retinoid, benzoyl peroxide); systemic therapy to clear eruptions and prevent recurrence (e.g., tetracycline, clindamycin, minocycline, doxycycline, erythromycin); acne surgery, extraction of comedones, or incision and drainage; and peeling treatments, or cryotherapy with liquid nitrogen to remove superficial skin. Usually 6 to 8 weeks are required before significant improvement is noted with antibiotic treatment.
E. Isotretinoin (Accutane) is an important prescription antiacne treatment for severe nodulocystic acne that does not respond to antibiotic therapy. It is a major teratogenic drug and must not be taken during pregnancy or lactation. A pregnancy test must be performed before use, and parents of minors must sign a patient consent form regarding birth defects and Accutane. Girls who cannot take Accutane may be given a trial of hormonal therapy, which may include oral contraceptives.
1. When systemic antibiotics are prescribed, girls taking oral contraceptives should use a back-up method of contraception for the first 2 weeks.
2. Effective contraception must be used 1 month before, during, and 1 month after therapy with isotretinoin for sexually active adolescents.
COSMETIC-RELATED SKIN CARE CONCERNS
A. The regular use of products—specifically by teenage girls—to cleanse, enhance, beautify, or alter appearance may contribute to irritation, infection, and physical health problems.
A. Cosmetic-related skin care concerns may be associated with the integrity of the skin or nails, predisposition, or family genetics. The type of product, amount used, frequency, and lack of adherence to recommended use also may contribute to skin care concerns. Product ingredients, such as fragrances and preservatives, may cause contact dermatitis and allergic reactions. Using outdated cosmetics or the sharing of products may cause adverse reactions. Table 8-1 lists potential risks of cosmetic products.
A. Health concerns usually develop within the first few applications of a cosmetic or skin care product but may develop after continual use.
IV. Health Concerns/Emergencies
A. Irritant contact dermatitis may be caused by many products, including antiperspirants, soaps, detergents, cosmetics, moisturizers, shampoos, and permanent wave solutions.
B. Allergic contact dermatitis may be caused by cosmetic ingredients, such as fragrances and preservatives.
1. More than 5000 known additive fragrances are used in skin care products; hypoallergenic fragrances are available. By law, hypoallergenic products must be labeled, so users should check the label for indications that a product is fragrance-free. Unscented does not mean fragrance-free, because an additive may be used to disguise the chemical odor. Users must also check labels of products advertising natural ingredients to avoid plant or animal allergens.
2. Preservatives added to skin products are the second most common cause of contact dermatitis. These agents are added to preserve the products from light and oxygen damage and to prevent bacterial and fungal growth that causes skin reactions. Preservatives must be added if a cosmetic contains water. Not all students will react to every preservative, and a reaction to one preservative does not imply that a reaction will occur to all preservatives.
C. Acne cosmetica may be caused by the use of heavy, oil-based products. Check the product label for the term noncomedogenic or nonacnegenic; this means the product will not clog pores or cause acne.
B. Washing hands before applying cosmetics or performing skin care decreases contamination of skin and products. Bacteria in the products can contribute to skin irritation and decrease the effectiveness of the product.
C. Use of products developed to maintain healthy skin—such as astringents, moisturizers, and sunscreens—may minimize potential concerns but also poses risks:
3. Containers should be stored away from sunlight and tightly closed to maintain active preservatives.
Table 8-1 Potential Risks of Cosmetic Products
| Products | Risks | Comments |
|---|---|---|
| Artificial nails | ||
| Nail polish | May cause rash on other parts of body that have been exposed before drying (face, eyelids, neck, fingers). | Avoid touching body, or try hypoallergenic polish. |
| Hair dye | Semipermanent and permanent dyes may cause contact dermatitis or immediate reactions that include hives and wheezing. | |
| Hair shampoo | May irritate and dry skin or scalp. | Change product brand. |
| Hair permanents | Can damage hair and cause brittle, dry hair and scalp irritation. | |
| Aerosol sprays | ||
| Powders | Inhalation may cause lung damage. | Avoid when possible or apply gently to decrease airborne inhalation. |
HOMOSEXUALITY
A. Homosexuality is the persistent attraction to a member of the same sex. Same-sex attractions may have their onset in late elementary and early adolescence and may involve some homosexual experimentation.
A. The etiology of homosexuality is unknown. Several theories are associated with the cause of homosexuality: genetic (gene and twin studies), hormonal (prenatal effects of sex hormones on the brain), psychosocial circumstances (learned behavior, lack of heterosexual exposure), neurological (prenatal development of brain structures and genitalia), and combinations (complex interplay of many theories).
A. Sexual identity is formed gradually over time and becomes more dominant in late adolescence and young adulthood.
IV. Health Concerns/Emergencies
A. At risk for sexually transmitted infections (STIs); traumatic injuries related to intercourse should be assessed based on sexual behavior, not sexual orientation.
E. Health care may not be adequate; some health care professionals lack understanding of special health issues and concerns involved with same-sex attraction and fear of HIV.
F. Documentation could jeopardize confidentiality and compromise a student’s ability to obtain insurance or certain types of employment.
A. Listen to adolescents and encourage them to articulate concerns and fears about sexual orientation.
C. Recommend yearly testing for gonorrhea, syphilis, and chlamydia; encourage periodic HIV testing for students who are sexually active or substance abusers; discuss safe-sex practices.
D. Listen to and support parents; provide contact for support groups, such as the local chapter of Parents, Family, and Friends of Lesbians and Gays (PFLAG).
A. Some heterosexual teens will engage in homosexual activity in certain environments (e.g., incarceration facilities, summer camps, military or boarding schools) but revert to heterosexual activities when environment changes. These experiences may lead to confusion and panic, especially when the teenager enjoys the activity.
B. Decisions made for a child with ambiguous genitalia may have been incorrect. Genitalia, genes, internal gender structures, and feelings may not match sexual assignment, causing inner confusion, guilt, and discontent (see Ambiguous Genitalia inChapter 4).
DENTAL CARIES
A. Dental caries is the term used for progressive loss of tooth mineral caused by a bacterial infection, particularly Streptococcus mutans. It is the most common health problem for the school-age child.
A. Formation of dental caries depends on dietary sucrose or fermentable carbohydrates that are broken down into sugar in the mouth. Bacteria in plaque feed on the sugar-producing organic acids, which demineralize the tooth.
A. Caries may begin in toddlers with bedtime bottle use and frequent intake of sugary drinks and foods.
B. Cavity-causing bacteria, Streptococcus mutans, may be spread from person to person (e.g., a mother or father with cavities may pass the bacteria to the baby through kissing).
C. Children’s early cavities begin as white spots on the four upper front teeth, which is an indicator of demineralization.
IV. Health Concerns/Emergencies
A. Large holes in teeth, pain, inflammation with or without fistulas, or draining abscesses on gums in root area of teeth.
B. Premature loss of primary teeth can affect nutrition, speech, self-esteem, resulting in crowding of permanent teeth.
E. Limit intake of sweet, sticky foods and drinks, especially at snack time; provide fruits and vegetables.
F. Use a pea-sized amount of fluoride toothpaste daily as early as age 1 and a larger amount for adolescents.
MALOCCLUSION, ORTHODONTIA, AND BRACES
A. Orthodontics concern the diagnosis, prevention, and correction of malocclusion and irregularities of the teeth. Most orthodontic appliances exert continuous pressure to modify teeth positions and move or keep teeth aligned for an extended period of time. A variety of appliances are used, including fixed, removable, intraoral, and extraoral devices.
A. A common cause of malocclusion is genetics, but thumb sucking, tongue thrusting, trauma, dental disease, or early loss of primary or permanent teeth may be contributory factors.
2. Braces may be metal, attached with adhesives; clear and attached to outside surfaces; ceramic, appearing like natural teeth; minibraces; or invisible, which are fixed to the inside of the teeth.
3. Head or neck gear is ordered when extra tension outside the mouth is needed; worn during the day, at night, or evening.
IV. Health Concerns/Emergencies
B. Analgesics: ibuprofen (Motrin) or acetaminophen (Tylenol) may be needed to relieve discomfort and pain. Never place medication directly on gums.
C. Encourage wearing of orthodontic devices during lengthy treatment regimen and after treatment, if retainer devices are prescribed.
2. If unable to remove the appliance, cover sharp or protruding points with cotton balls, gauze, wax, or chewing gum.
3. If wire is stuck in the gums, cheek, or tongue, do not remove it; immediately refer student to a dentist or orthodontist.
A. After appliances are removed, the teeth are cleaned thoroughly, and more x-ray films and impressions of the teeth may be taken. Monitor growth of wisdom teeth for possible extraction. Retention treatment may be needed to maintain teeth position and prevent shifting and moving of teeth until gums, bones, and muscles adapt to the change. Retainers may be ordered to be worn on a daily basis for a few months to several years. Retainers prevent shifting of teeth back to their prior position.
PERIODONTAL DISEASE
A. Periodontal disease, often called gum disease, refers to a pathological condition of the tissues surrounding and supporting the teeth.
A. Periodontal disease usually is caused by plaque, a sticky film of bacteria that continuously forms on teeth. When the plaque is not removed, gums become irritated, inflamed, and begin detaching from teeth to form pockets, where bacteria can be harbored. When untreated, this process can destroy bone and other important tooth-supportive tissues, eventually leading to tooth loss.
2. Gums and bone that are supportive structures of the teeth are seriously damaged; pockets form, and gums recede or pull away from teeth.
IV. Health Concerns/Emergencies
C. Bacteria or inflammatory response from gum disease may be associated with systemic problems, such as bacterial pneumonia, cardiovascular disease, or stroke.
A. When plaque hardens, it becomes a porous, rough deposit called tartar or calculus. When hardened, plaque can be removed only by a dentist or dental hygienist. An instrument called a periodontal probe is used to measure the gingival sulcus depth around each tooth, and the space between the gums and teeth, to determine whether pockets are present. The normal depth between healthy gums and teeth is 3 mm or less.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
