Welcome to the bed. We'll go ahead and give you
the story. This is all going to happen super
fast. Welcome to the emergency room. Welcome
back to The Deep Dive. Today we are shifting
gears a little bit. A lot, I'd say. Yeah, a lot.
Usually we take a really broad topic, history,
tech... you know, whatever, and we explore the
edges of it, we kind of meander. Right. But today
we are focusing, we're drilling down, we are
doing a dedicated cram session. That's right.
We are putting on our nursing educator hats today.
Okay. We have a very specific mission. Exactly.
I mean, we know we have a ton of listeners who
are in nurse bagel, or maybe you're prepping
for the NCLE -X, or even seasoned nurses who
are just about to start a rotation on a PEDS
unit and feel a little... Rusty. And the feedback
we get is always the same. I am drowning in information.
Help me figure out what actually matters. It
is the classic problem in medical education,
isn't it? You've got a textbook that's like three
inches thick. You have slides from your professor.
You have hospital protocols. And an exam with
50 questions. Right. And you cannot memorize
everything. In fact, if you try to memorize everything,
you'll probably fail. Yeah. Because you won't
understand the core principles. The Pareto principle.
Exactly. The 80 -20 rule. We want to focus on
the 20 % of the material on adolescents that
is going to show up on 80 % of your exam questions.
And I think more importantly, in 80 % of the
critical clinical situations you're going to
face. So today, our patient is the adolescent.
We're talking ages, what, 11 to 20? the transition
years. And looking at the stack of research and
textbook excerpts we have here from Wolters Kluwer,
from the CDC vaccine schedules, it feels like
this is the era of the shift. That is the perfect
way to describe it. Yeah. It's this shift from,
you know, the total dependency of childhood to
the independence of adulthood. And as a nurse,
your role shifts, too. How so? You aren't just
talking to the parents anymore. I mean, you are,
but you're also building a partnership with the
patient themselves. But it's a dangerous time.
It's a very dangerous time. The body is changing,
the brain is rewiring, and the wrists change
from, I fell off the monkey bars to, I drove
my car too fast. OK, so here is our roadmap for
this deep dive. We are going to strip away the
fluff. We're going to hit the physiology of puberty,
why they look so awkward, and what hormones are
driving the bus. We are going to talk about the
invincible mindset and why it is a safety nightmare.
A huge one. We're going to nail down the tween
trio, the vaccines you have to know, and we are
going to cover the safety assessments that actually
save lives. Just a quick disclaimer before we
jump in. The source material we're using, especially
the growth charts and physiological data, often
categorizes physical development. by males and
females based on biological sex traits, you know,
ovarian or testicular function. However, as nurses,
we know that adolescence is also the prime time
for identity formation. Our job is to provide
safe, inclusive care for all adolescents, regardless
of how they identify, while still understanding
the underlying biology. Well said. OK, let's
get into the nitty gritty, part one. the foundation.
We're talking vitals and pain assessment. These
seem so basic, but I feel like this is where
students lose easy points. It absolutely is.
Because there's a temptation to treat them like
big children, or on the flip side, just treat
them exactly like adult. They're in this gray
zone. So if I walk into a room to assess a 16
-year -old, what should I be expecting? You're
expecting near adult numbers. And this is a common
trap for students who have just come off a toddler
rotation. Right. If you see a heart rate of 110
in a toddler, you're happy. It's totally normal.
If you see our rate of 110 in a 17 -year -old
who's just sitting in a chair, that's tachycardia.
That is a red flag. Let's break down the why
behind that, because understanding the mechanism
helps it stick, right? Sure. Let's look at the
heart. The normal range for an adolescent is
roughly 50 to 100 beats per minute. 50? That
sounds incredibly low compared to a kid. It is.
And here's the physiology. During adolescence,
the heart is physically growing in size and strength.
the actual muscle mass of the heart increases.
Okay. That means the stroke volume increases,
the heart pumps more blood with every single
beat. So it's more efficient. Way more efficient.
And because the pump is more efficient, it doesn't
need to cycle as fast to maintain cardiac output.
So the engine got an upgrade. Exactly. It's like
switching from a four -cylinder to a V8. It can
idle lower. Now, if you have a teen athlete,
say a cross -country runner, their resting heart
rate might be in the 40s or low 50s. And that's
fine for them. That can be totally normal for
them. Yeah. But if you have a sedentary teen
with a rate of 110, you need to investigate.
Are they anxious? Are they dehydrated? Are they
on some kind of stimulant? And what about the
lungs? Same idea. Same efficiency principle.
The respiratory rate drops to about 16 to 20
breaths per minute. The lungs are increasing
in diameter and length. The vital capacity you
know, the amount of air you can move, it increases
significantly. And blood pressure. We're looking
for a systolic generally less than 120 and a
diastolic less than 80. But here's the high yield
nuance. Hypertension screening becomes very,
very real in this age group. Why is that? I always
thought high blood pressure was an old person
problem. Not anymore. I mean, with the rising
rates of childhood obesity, we are seeing primary
hypertension in 14, 15 and 16 year olds. Wow.
So we need to be checking BP at every well -chilled
visit. If it's elevated, we don't just ignore
it. We recheck, and we start looking at lifestyle.
OK. So vitals are basically approaching adult
norms. What about pain? In pediatrics, we're
always taught about the FLACC scale or the FACES
scale. Does that apply here? For the vast majority
of adolescents, no. and this is a high -yield
exam point and honestly a massive clinical rapport
issue. The gold standard for pain assessment
in anyone over the age of roughly five to seven
and certainly for a teenager is the numeric scale.
0 to 10. Self -report is king. Self -report is
king. An adolescent can verbalize. They can quantify.
They can describe their pain. They can tell you
it's a throbbing pain versus a stabbing pain.
They can localize it. I can just imagine walking
into a room with a 15 -year -old football player
and holding up a card with a cartoon crying face.
You have lost him immediately. You've just signaled,
I see you as a baby. And in adolescent nursing,
rapport is the currency of the realm. If you
insult their intelligence or their maturity,
they will shut down. And if they shut down, they
won't tell you the important stuff later. So
you use the numeric scale unless there is a significant
developmental delay or some kind of communication
barrier. OK, let's move to part two, the biological
shift. We're talking about puberty and physical
growth. The leggy face. I remember this face
so vividly. Just tripping over nothing. Arms
feel too long for your sleeves. Why does that
happen? Is it just random? It is not random at
all. It's a very specific growth pattern. In
infancy, we grow cephalocautal head to toe. That's
why babies have such huge heads. Right. But in
adolescence, the growth reverses. It's distal
to proximal. Distal to proximal. Okay, let's
unpack that. It means your hands and feet grow
first. Really? Yes. Then your arms and legs lengthen.
And the torso grows last. So you literally have
a 13 year old boy whose feet have shot up to
size 11 his legs have lengthened But his torso
hasn't caught up yet. So his center of gravity
is just shifting constantly week by week He is
piloting a vehicle that keeps changing its dimensions.
That's a great way to put it So when he knocks
over the sterile field or trips coming into the
exam room, it's not just carelessness. It's his
physiology That is actually a really helpful
thing to tell parents, too. He's not just being
clumsy on purpose. Absolutely. It's anticipatory
guidance. You tell them, this is normal. He will
grow into his feet. Now, exams love to ask about
the timing of puberty. Who starts first? Females
usually beat the males by about two years. Puberty
for biological females typically begins around
ages 9 to 10. OK. The peak height velocity, that's
the absolute fastest period of growth, that hits
early around age 12. For males. Everything is
shifted back. Puberty starts around 10 to 11,
but that peak growth spurt isn't until maybe
age 14. And here's the big difference. Males
continue growing for much longer. Their growth
plates, the epiphyseal plates, don't close until
they're late teens, maybe 18 to 20. Females typically
stop growing much earlier. Is there... Is there
a marker for when females stop growing? I feel
like I've seen that on practice questions. Yes,
this is a massive need to know. For females,
linear growth usually stops about 2 to 2 .5 years
after menare. After their first period. Right.
Oh, wow. So if a girl starts her period at 12,
she's pretty much done getting taller by 14 or
15. Exactly. The estrogen surge that causes the
period also works to close those growth plates
in the long bones. So if you have a 14 -year
-old female patient who's worried about being
short and she started her period at 11, Well,
biologically, that window has mostly closed.
It's a hard conversation. It's a hard conversation,
but it's really important physiology for you
to understand. So what are the hormonal drivers
here? We know the names, but what do they actually
do? It all starts in the brain. The hypothalamus
releases GnRH, gonadotropin -releasing hormone.
GnRH, okay. That kicks the pituitary gland to
release FSH and LH. In females, this stimulates
estrogen production. And estrogen is responsible
for breast tissue development, the widening of
the hips, pelvic remodeling for potential childbearing,
and increased fat deposits. And for males. It
triggers testosterone. And here is a specific
exam detail that catches people off guard. The
first sign of puberty in males is testicular
enlargement. Not the voice, not the hair. Nope.
Testicular enlargement is step one. Then comes
the muscle mass increase, the voice deepening,
because the larynx is growing, and the widening
of the shoulders. You mentioned the voice deepening.
That's the larynx growing. Yes. The laryngeal
cartilage grows, and the vocal cords lengthen
and thicken. That's why you get the voice cracks.
It's basically an instrument that is being retuned
while it's being played. That is a great analogy.
Before we leave biology, let's talk about the
brain. Because the body is looking like an adult,
but the decision making... Although the brain
is under massive construction. The myelin sheath,
as the insulation around the nerves, it's growing
rapidly. This speeds up processing power. They
can actually think faster. But the prefrontal
cortex, the CEO of the brain, the part that controls
impulse and judgment, is the last part to mature.
Doesn't finish until the mid -20s. So you have
a Ferrari engine with bicycle brakes. Precisely.
High drive, low control. And that leads us perfectly
into part three. The mindset. psychosocial development.
We have to talk about Erickson. If you're in
nursing school, you live and breathe Erickson.
What's the stage for adolescence? Identity versus
role confusion. This is the who am I phase. And
how does that actually manifest in real life?
They are trying on different hats. I mean, one
month they're into sports, the next month they're
goth, the next month they're activists. They're
trying to separate their identity from their
parents. Right. This is why the peer group becomes
God. Right. Parents often see this as rebellion.
They only care what their friends think. But
as nurses, we need to educate parents that this
isn't really rebellion. It's a developmental
necessity. The peer group. provides a safe base
for them to try out these identities. They can
discuss things with peers they wouldn't dare
tell their parents. So if a teen wants their
friend in the exam room but not their mom, that's
developmentally normal. Very normal. And, you
know, barring any safety issues, we often accommodate
that, or we try to split the visit part with
the parent, part alone with the patient. Which
brings us to Piaget. We're moving from concrete
thinking to what? To formal operations. Abstract
thinking. This is a huge shift. A younger child
thinks, if I touch the scov I burn my hand. It's
very concrete. Right. Cause and effect. Exactly.
An adolescent can think, if I engage in risky
behavior, it might have consequences for my future
career. They can hypothesize. They can think
about the future. But there is a glitch. Because
if they can think about the future, why do they
do such dangerous things? There is a major glitch.
It's called adolescent egocentrism. Even though
they can think abstractly, they're obsessed with
themselves and how others perceive them. And
this shows up in two main ways that exams absolutely
love to test on. Lay them on us. First, the imaginary
audience. The teenager walks into the cafeteria
and believes genuinely believes that every single
person is looking at the pimple on their chin.
They feel constantly watched and judged. I think
some of us never grow out of that one. Probably
not. And the second one. What is it? The personal
fable. This is the belief that I am unique and
the rules of probability don't apply to me. The
it won't happen to me syndrome. That's it. I
can text and drive because I'm a good driver.
Other people crash, but I won't. I can have unprotected
sex just as once I woke it pregnant. This personal
fable is the driving force behind the high rates
of injury and death in this age group. So it's
not that they don't know the risks. Oh, they
know them. They can recite the risks to you.
It's they don't believe the risks apply to them.
So as a nurse, how do you talk to someone who
thinks they are invincible? You can't just lecture
them. No, lecturing fails every time. You have
to treat them like a partner or a colleague.
No baby talk. And the most critical tip, confidentiality.
How much confidentiality? You need to establish
it early. You say, what we discuss here is private
between you and me. Unless. There's always an
unless. Unless you tell me you are going to hurt
yourself, hurt someone else or someone is hurting
you. You have to set that boundary. But beyond
those safety issues, you need them to trust you
enough to tell you about the drugs, the sex,
the depression. Right. If they think you're just
going to run and tell their mom that they vape,
they will clam up. And use open -ended questions,
right? Not yes, no. Always. Never ask, do you
understand? They will just nod to get you to
shut up. Right. You say, tell me what you know
about, or how do you plan to handle it if your
friends are drinking at the party? Make them
walk you through their thought process. It forces
them to use that new abstract thinking ability.
OK, let's pivot to the scary stuff. Part four,
the danger zone. We mentioned the personal fable
drives risk. What is actually killing adolescents?
If you remember nothing else from the safety
section, remember this order. The number one
cause of death is unintentional injuries and
specifically motor vehicle crashes. MVCs. The
car is the most dangerous weapon they handle.
Absolutely. It's inexperience, plus that personal
fable, plus distractions like texting or having
other teens in the car. It is a lethal combination.
So the nursing guidance is strict. Very strict.
Seatbelts, no texting, limit night driving, and
limit the number of passengers. Why limit passengers?
The data shows that for every additional teen
passenger in the car, the risk of a fatal crash
goes up exponentially. It's the distraction factor.
What's number two? Homicide. often involving
firearms and often related to gang violence or
sometimes domestic situations. And number three.
Suicide. And this is a major, major focus for
mental health screening. Suicide is the third
leading cause of death in this age group. OK,
we need to deep dive on suicide assessment. What
are the red flags? What are we looking for? Well,
depression is an obvious one, but look for regression.
Withdrawal from friends is a huge one. So they're
isolating themselves. Yes. Or giving away prized
possessions. A sudden unexplained drop in grades.
Also, pay attention to high -risk groups. LGBTQ
plus youth are at a significantly higher risk,
not because of their identity itself, but because
of the marginalization and bullying they so often
face. If we suspect something, what's the nursing
action? Do we beat around the bush? Never. You
ask directly, have you thought about hurting
yourself? Do you have a plan? I know some people
worry that asking plants the idea in their head.
That is a complete myth. Research shows that
asking does not plant the idea. It actually provides
relief that someone noticed. And if they have
a plan, you do not leave them alone. You ensure
safety. You remove lethal means, pills, firearms.
Let's talk substances. Alcohol and drugs are
classics. But what's the new challenger on the
block? Vaping. E -cigarettes. This is huge right
now. A lot of teens think it's just safe water
vapor. It's not. It's highly concentrated nicotine.
which is terrible for that developing brain we
talked about, plus heavy metals and other chemicals.
So the education is it's not a safe alternative.
Correct. And for alcohol, the big risk is binge
drinking. because of their physiology, high liver
efficiency, high energy, they can often metabolize
alcohol efficiently enough to stay awake longer
than an adult might, leading to dangerously high
blood alcohol levels before they pass out. So
they don't have the stop switch that adults might
have. Exactly. Okay, that is heavy, but it's
the reality of the ER. Let's switch gears to
prevention. Part five. Immunizations and nutrition.
We're in the clinic. The 11 or 12 -year -old
comes in. What are we sticking them with? This
is a classic exam question in a critical public
health moment. We call it the tween trio. At
age 11 to 12, there are three routine vaccines
due. Three needles at 11. I like that mnemonic.
OK, what are they? Needle one. Tdap. That's tetanus,
diphtheria, and a cellular pertussis. Note the
P is pertussis whooping cough. This is a booster
to the D -tap they got as babies. Immunity wanes.
So we boost it here. OK. Needle two. Meningococcal.
ACWY. often called Menacwy or Menveo. This protects
against meningitis, which is absolutely devastating
in this age group. Now, there is a catch with
meningococcal, right? It's not one and done.
Correct. This is the exam trap. You get the first
dose at 11 -12. But you must get a booster at
age 16. By 16, why not? Like, 18. Think about
what happens around 18. They go to college dorms,
military barracks, crowded housing. Meningitis
spreads in close quarters. We want that antibody
peak to be fresh right before they enter that
high -risk environment. If you give the booster
too early, it might wear off by the time they
get to college. So dose one at 11, booster at
16. Got it. And the third needle? HPV, human
papillomavirus. This is the cancer prevention
vaccine, protects against cervical cancer, throat
cancer, anal cancer, penile cancer. And the dosing
schedule here is tricky. It depends on when you
start. Yes. Applying the Pareto principle. This
is the complex detail you really need to memorize.
If the child starts the series before their 15th
birthday, they only need two doses. Just two.
Just two. One today, and one in six to 12 months.
So two doses, it started before 15. Correct.
Their immune system is so robust at that age
that two doses gives them full protection. But
if they start on or after their 15th birthday,
or if they're immunocompromised for some reason,
They need three doses, usually at zero, one,
two months, and six months. So starting early
saves a shot. That's a good selling point for
parents. It is. It's better immunity with fewer
needles. And remember, HPV is not just for females.
It is for everyone. Is there anything else? What
about meningitis B? That's separate from the
ACWY. MenB is usually a shared clinical decision
given between ages 16 and 23, with the preferred
timing being 16 to 18. It's not strictly mandatory
on every schedule, like the Trio, but it's highly
recommended, especially for college -bound kids.
And obviously, flu and COVID annually. Standard
maintenance, yeah. Let's talk fuel, nutrition.
They are growing so fast, they must be eating
a ton. The caloric needs skyrocket. I mean, a
teenage boy during his peak growth spurt can
easily need 2 ,800 to 3 ,000 calories a day.
Wow, that's more than most adults. It is, but
it can't just be junk. So what are the key nutrients
we're worried about? We call them the big three
for teens. Calcium, iron, and zinc. Why those
three? Calcium is critical for the bones. They
need 1300 milligrams a day. Remember, nearly
half of your adult bone mass is accumulated during
adolescence. If you don't bank the calcium now,
you get osteoporosis in your 60s. So you're preventing
fractures decades in the future. Exactly. And
iron. For females, it's obviously to replace
losses from menstruation. For males, it's needed
for the expansion of their muscle mass and blood
volume. Everyone needs more iron. And zinc. Essential
for growth and for sexual maturation. We have
to touch on the flip side of nutrition obesity.
Yes. Roughly 20 % of adolescents classify as
obese. You need to be screening BMI. But the
advice isn't go on a diet. Right. Diets in teens
often trigger eating disorders. The advice is
my plate. make half the plate fruits and veggies,
and focus on activity. 60 minutes a day, right?
Moderate to vigorous physical activity, 60 minutes
daily. Sports are great, but you have to watch
out for overuse, injuries, and concussions. And
if they aren't into sports, just getting them
moving, walking, dancing, even active gaming
is the goal. Part six, common issues. These are
the things they actually complain about in the
office. Let's start with the zombie mode, sleep.
Adolescents are chronically sleep deprived. They
need about 9 to 9 .5 hours of sleep. They rarely,
rarely get it. Is it just that they want to stay
up playing video games? Well, that's part of
it. But there's also a biological shift called
a circadian delay. Their bodies physically don't
start producing melatonin until later at night.
Oh, really? Yeah. So they aren't tired until
11 PM or midnight. But school starts at 730 AM.
It's a complete mismatch between their biology
and society. So what's the nursing advice for
that? Sleep hygiene. New screens in the bedroom.
The blue light suppresses melatonin even further.
Consistent bedtimes, even on weekends, to avoid
social jet lag. What's social jet lag? If they
sleep until 2 p .m. on Saturday, they won't be
able to sleep Sunday night and Monday morning
is a total disaster. Got it. Next up. Skin. Acne.
It's a rite of passage, but it really hurts their
self -esteem. It does. The sebaceous glands go
into overdrive because of androgens. The advice
is simple. Wash the face two to three times a
day with plain unscented soap or a mild cleanser.
And the Gordon rule? Do not squeeze. Do not pop.
It leads to scarring and infection. If over -the
-counter benzoyl peroxide isn't working, get
them to a provider, but don't let them perform
bathroom surgery on themselves. Finally, sexual
health. We touched on the risk aspect, but what's
the standard of care for education? Education
is the standard of care. Abstinence is the only
100 % effective method for preventing pregnancy
and STIs, and we should state that. However,
we absolutely must provide factual, judgment
-free information about contraception and barrier
methods. And consent. Huge. We need to discuss
what a healthy relationship looks like. One in
12 teens reports physical violence in a dating
relationship. We need to talk about consent,
coercion, and that no means no. We should also
briefly touch on the concept of developmental
red flags. We talked about what's normal, but
what screens delay at this age. Right. At this
age, you aren't looking for not walking or not
talking. You are looking for social and cognitive
delays. A teen who cannot engage in abstract
thought by late adolescence needs an evaluation.
OK. Or a teen who has zero interest in peers
or exhibits no desire for independence that might
signal a developmental issue or maybe severe
anxiety. And what about age -appropriate activities?
If you have a teen in the hospital for a week,
do you give them a coloring book? Maybe an intricate
adult coloring book, but generally no. Age -appropriate
activities for teens involve connection. Let
them use their phone to FaceTime friends, video
games are great, journaling, anything that allows
them to express their identity or connect to
their peer group. So isolation is the enemy?
Isolation is the enemy for the hospitalized teen.
All right, we've covered a massive amount of
ground. We've gone from hormones to helmets.
Let's wrap this up with our, if you remember
nothing else, summary. I want the absolute highest
yield takeaways. OK, here are my top four takeaways
for the exam and for the bedside. Number one.
Safety first. The number one killer is motor
vehicle accidents. Your assessment has to include
questions about seatbelts, texting and driving
habits and always, always ask directly about
suicide. It's the number three killer. and silence
can be deadly. Number two. The 11 -12 year vaccine
checkpoint. Remember the tween trio. Tdap, MinICWY,
and HPV. And remember that HPV rule. Two doses
if you start before 15, three doses if you start
after. Number three. Regression is a red flag.
It's normal for teens to be moody or want privacy.
It is not normal for them to completely withdraw
from friends, stop doing things they love, or
have a plummeting GPA. That requires a mental
health intervention. And number four. Privacy
versus safety. Respect their need for confidentiality
to get an honest history. You need them to trust
you, but know your hard line. If there is a risk
of harm to self or others, safety trumps privacy
every single time. I love the analogy you used
earlier about the bridge. Yes. Adolescence is
a bridge between childhood and adulthood. It's
a long bridge, it's shaky, and sometimes the
weather is terrible. Our job as nurses isn't
to carry them across. All right. It's to make
sure the bridge is structurally sound through
vaccines, safety checks, and education so they
can walk across it themselves. And maybe catch
them if they trip over their own rapidly growing
feet. Exactly. That is a wrap on our adolescent
nursing review. Whether you are cramming for
tomorrow's exam or prepping for clinicals, we
hope this deep dive helped you focus on the 20
% that matters most. Good luck studying. You've
got this. Thanks for listening to the deep dive.
We'll see you next time.