WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:47.069 fast. Welcome to the emergency room. Welcome 00:00:47.069 --> 00:00:50.509 back to The Deep Dive. Today we are shifting 00:00:50.509 --> 00:00:52.750 gears a little bit. A lot, I'd say. Yeah, a lot. 00:00:52.789 --> 00:00:55.409 Usually we take a really broad topic, history, 00:00:55.630 --> 00:00:57.600 tech... you know, whatever, and we explore the 00:00:57.600 --> 00:01:00.420 edges of it, we kind of meander. Right. But today 00:01:00.420 --> 00:01:04.079 we are focusing, we're drilling down, we are 00:01:04.079 --> 00:01:06.620 doing a dedicated cram session. That's right. 00:01:06.620 --> 00:01:09.799 We are putting on our nursing educator hats today. 00:01:09.819 --> 00:01:12.319 Okay. We have a very specific mission. Exactly. 00:01:12.439 --> 00:01:14.760 I mean, we know we have a ton of listeners who 00:01:14.760 --> 00:01:16.959 are in nurse bagel, or maybe you're prepping 00:01:16.959 --> 00:01:20.120 for the NCLE -X, or even seasoned nurses who 00:01:20.120 --> 00:01:22.840 are just about to start a rotation on a PEDS 00:01:22.840 --> 00:01:26.390 unit and feel a little... Rusty. And the feedback 00:01:26.390 --> 00:01:28.989 we get is always the same. I am drowning in information. 00:01:29.370 --> 00:01:31.209 Help me figure out what actually matters. It 00:01:31.209 --> 00:01:33.090 is the classic problem in medical education, 00:01:33.230 --> 00:01:35.409 isn't it? You've got a textbook that's like three 00:01:35.409 --> 00:01:37.269 inches thick. You have slides from your professor. 00:01:37.329 --> 00:01:39.650 You have hospital protocols. And an exam with 00:01:39.650 --> 00:01:42.629 50 questions. Right. And you cannot memorize 00:01:42.629 --> 00:01:44.890 everything. In fact, if you try to memorize everything, 00:01:45.310 --> 00:01:47.310 you'll probably fail. Yeah. Because you won't 00:01:47.310 --> 00:01:49.590 understand the core principles. The Pareto principle. 00:01:49.969 --> 00:01:53.079 Exactly. The 80 -20 rule. We want to focus on 00:01:53.079 --> 00:01:55.719 the 20 % of the material on adolescents that 00:01:55.719 --> 00:01:58.060 is going to show up on 80 % of your exam questions. 00:01:58.079 --> 00:02:01.459 And I think more importantly, in 80 % of the 00:02:01.459 --> 00:02:03.140 critical clinical situations you're going to 00:02:03.140 --> 00:02:06.500 face. So today, our patient is the adolescent. 00:02:06.640 --> 00:02:10.000 We're talking ages, what, 11 to 20? the transition 00:02:10.000 --> 00:02:13.620 years. And looking at the stack of research and 00:02:13.620 --> 00:02:16.379 textbook excerpts we have here from Wolters Kluwer, 00:02:16.479 --> 00:02:18.979 from the CDC vaccine schedules, it feels like 00:02:18.979 --> 00:02:21.719 this is the era of the shift. That is the perfect 00:02:21.719 --> 00:02:23.719 way to describe it. Yeah. It's this shift from, 00:02:23.719 --> 00:02:25.800 you know, the total dependency of childhood to 00:02:25.800 --> 00:02:28.379 the independence of adulthood. And as a nurse, 00:02:28.599 --> 00:02:30.659 your role shifts, too. How so? You aren't just 00:02:30.659 --> 00:02:32.259 talking to the parents anymore. I mean, you are, 00:02:32.280 --> 00:02:34.280 but you're also building a partnership with the 00:02:34.280 --> 00:02:36.199 patient themselves. But it's a dangerous time. 00:02:36.259 --> 00:02:38.379 It's a very dangerous time. The body is changing, 00:02:38.520 --> 00:02:41.000 the brain is rewiring, and the wrists change 00:02:41.000 --> 00:02:43.840 from, I fell off the monkey bars to, I drove 00:02:43.840 --> 00:02:47.800 my car too fast. OK, so here is our roadmap for 00:02:47.800 --> 00:02:50.860 this deep dive. We are going to strip away the 00:02:50.860 --> 00:02:53.180 fluff. We're going to hit the physiology of puberty, 00:02:53.300 --> 00:02:55.620 why they look so awkward, and what hormones are 00:02:55.620 --> 00:02:57.939 driving the bus. We are going to talk about the 00:02:57.939 --> 00:03:01.180 invincible mindset and why it is a safety nightmare. 00:03:01.240 --> 00:03:03.759 A huge one. We're going to nail down the tween 00:03:03.759 --> 00:03:06.259 trio, the vaccines you have to know, and we are 00:03:06.259 --> 00:03:08.379 going to cover the safety assessments that actually 00:03:08.379 --> 00:03:10.759 save lives. Just a quick disclaimer before we 00:03:10.759 --> 00:03:13.400 jump in. The source material we're using, especially 00:03:13.400 --> 00:03:16.400 the growth charts and physiological data, often 00:03:16.400 --> 00:03:19.280 categorizes physical development. by males and 00:03:19.280 --> 00:03:23.000 females based on biological sex traits, you know, 00:03:23.139 --> 00:03:26.639 ovarian or testicular function. However, as nurses, 00:03:27.280 --> 00:03:29.620 we know that adolescence is also the prime time 00:03:29.620 --> 00:03:32.599 for identity formation. Our job is to provide 00:03:32.599 --> 00:03:35.740 safe, inclusive care for all adolescents, regardless 00:03:35.740 --> 00:03:38.360 of how they identify, while still understanding 00:03:38.360 --> 00:03:41.360 the underlying biology. Well said. OK, let's 00:03:41.360 --> 00:03:44.199 get into the nitty gritty, part one. the foundation. 00:03:44.439 --> 00:03:46.180 We're talking vitals and pain assessment. These 00:03:46.180 --> 00:03:47.900 seem so basic, but I feel like this is where 00:03:47.900 --> 00:03:50.340 students lose easy points. It absolutely is. 00:03:50.580 --> 00:03:52.879 Because there's a temptation to treat them like 00:03:52.879 --> 00:03:55.439 big children, or on the flip side, just treat 00:03:55.439 --> 00:03:58.259 them exactly like adult. They're in this gray 00:03:58.259 --> 00:04:01.400 zone. So if I walk into a room to assess a 16 00:04:01.400 --> 00:04:03.620 -year -old, what should I be expecting? You're 00:04:03.620 --> 00:04:06.219 expecting near adult numbers. And this is a common 00:04:06.219 --> 00:04:08.500 trap for students who have just come off a toddler 00:04:08.500 --> 00:04:11.120 rotation. Right. If you see a heart rate of 110 00:04:11.120 --> 00:04:14.030 in a toddler, you're happy. It's totally normal. 00:04:14.490 --> 00:04:16.930 If you see our rate of 110 in a 17 -year -old 00:04:16.930 --> 00:04:20.149 who's just sitting in a chair, that's tachycardia. 00:04:20.430 --> 00:04:22.790 That is a red flag. Let's break down the why 00:04:22.790 --> 00:04:24.689 behind that, because understanding the mechanism 00:04:24.689 --> 00:04:27.069 helps it stick, right? Sure. Let's look at the 00:04:27.069 --> 00:04:29.769 heart. The normal range for an adolescent is 00:04:29.769 --> 00:04:33.009 roughly 50 to 100 beats per minute. 50? That 00:04:33.009 --> 00:04:35.709 sounds incredibly low compared to a kid. It is. 00:04:35.769 --> 00:04:38.449 And here's the physiology. During adolescence, 00:04:38.810 --> 00:04:41.649 the heart is physically growing in size and strength. 00:04:41.870 --> 00:04:44.769 the actual muscle mass of the heart increases. 00:04:44.990 --> 00:04:47.089 Okay. That means the stroke volume increases, 00:04:47.470 --> 00:04:49.389 the heart pumps more blood with every single 00:04:49.389 --> 00:04:51.649 beat. So it's more efficient. Way more efficient. 00:04:51.730 --> 00:04:54.149 And because the pump is more efficient, it doesn't 00:04:54.149 --> 00:04:56.850 need to cycle as fast to maintain cardiac output. 00:04:56.970 --> 00:05:00.230 So the engine got an upgrade. Exactly. It's like 00:05:00.230 --> 00:05:02.509 switching from a four -cylinder to a V8. It can 00:05:02.509 --> 00:05:05.610 idle lower. Now, if you have a teen athlete, 00:05:05.709 --> 00:05:08.920 say a cross -country runner, their resting heart 00:05:08.920 --> 00:05:11.540 rate might be in the 40s or low 50s. And that's 00:05:11.540 --> 00:05:13.519 fine for them. That can be totally normal for 00:05:13.519 --> 00:05:15.420 them. Yeah. But if you have a sedentary teen 00:05:15.420 --> 00:05:18.060 with a rate of 110, you need to investigate. 00:05:18.680 --> 00:05:21.480 Are they anxious? Are they dehydrated? Are they 00:05:21.480 --> 00:05:23.100 on some kind of stimulant? And what about the 00:05:23.100 --> 00:05:25.540 lungs? Same idea. Same efficiency principle. 00:05:26.019 --> 00:05:28.379 The respiratory rate drops to about 16 to 20 00:05:28.379 --> 00:05:30.819 breaths per minute. The lungs are increasing 00:05:30.819 --> 00:05:33.750 in diameter and length. The vital capacity you 00:05:33.750 --> 00:05:35.850 know, the amount of air you can move, it increases 00:05:35.850 --> 00:05:38.329 significantly. And blood pressure. We're looking 00:05:38.329 --> 00:05:42.430 for a systolic generally less than 120 and a 00:05:42.430 --> 00:05:45.889 diastolic less than 80. But here's the high yield 00:05:45.889 --> 00:05:48.529 nuance. Hypertension screening becomes very, 00:05:48.589 --> 00:05:51.370 very real in this age group. Why is that? I always 00:05:51.370 --> 00:05:53.129 thought high blood pressure was an old person 00:05:53.129 --> 00:05:55.269 problem. Not anymore. I mean, with the rising 00:05:55.269 --> 00:05:57.870 rates of childhood obesity, we are seeing primary 00:05:57.870 --> 00:06:01.329 hypertension in 14, 15 and 16 year olds. Wow. 00:06:01.600 --> 00:06:04.220 So we need to be checking BP at every well -chilled 00:06:04.220 --> 00:06:06.180 visit. If it's elevated, we don't just ignore 00:06:06.180 --> 00:06:08.600 it. We recheck, and we start looking at lifestyle. 00:06:08.899 --> 00:06:11.420 OK. So vitals are basically approaching adult 00:06:11.420 --> 00:06:14.439 norms. What about pain? In pediatrics, we're 00:06:14.439 --> 00:06:18.019 always taught about the FLACC scale or the FACES 00:06:18.019 --> 00:06:21.060 scale. Does that apply here? For the vast majority 00:06:21.060 --> 00:06:23.699 of adolescents, no. and this is a high -yield 00:06:23.699 --> 00:06:26.600 exam point and honestly a massive clinical rapport 00:06:26.600 --> 00:06:29.860 issue. The gold standard for pain assessment 00:06:29.860 --> 00:06:32.680 in anyone over the age of roughly five to seven 00:06:32.680 --> 00:06:35.459 and certainly for a teenager is the numeric scale. 00:06:35.990 --> 00:06:38.750 0 to 10. Self -report is king. Self -report is 00:06:38.750 --> 00:06:41.430 king. An adolescent can verbalize. They can quantify. 00:06:41.610 --> 00:06:43.230 They can describe their pain. They can tell you 00:06:43.230 --> 00:06:45.769 it's a throbbing pain versus a stabbing pain. 00:06:45.930 --> 00:06:48.430 They can localize it. I can just imagine walking 00:06:48.430 --> 00:06:50.670 into a room with a 15 -year -old football player 00:06:50.670 --> 00:06:53.490 and holding up a card with a cartoon crying face. 00:06:53.850 --> 00:06:56.689 You have lost him immediately. You've just signaled, 00:06:56.689 --> 00:06:59.910 I see you as a baby. And in adolescent nursing, 00:07:00.490 --> 00:07:03.920 rapport is the currency of the realm. If you 00:07:03.920 --> 00:07:05.639 insult their intelligence or their maturity, 00:07:06.199 --> 00:07:08.420 they will shut down. And if they shut down, they 00:07:08.420 --> 00:07:10.660 won't tell you the important stuff later. So 00:07:10.660 --> 00:07:14.160 you use the numeric scale unless there is a significant 00:07:14.160 --> 00:07:17.019 developmental delay or some kind of communication 00:07:17.019 --> 00:07:19.699 barrier. OK, let's move to part two, the biological 00:07:19.699 --> 00:07:21.800 shift. We're talking about puberty and physical 00:07:21.800 --> 00:07:24.399 growth. The leggy face. I remember this face 00:07:24.399 --> 00:07:27.819 so vividly. Just tripping over nothing. Arms 00:07:27.819 --> 00:07:30.060 feel too long for your sleeves. Why does that 00:07:30.060 --> 00:07:32.459 happen? Is it just random? It is not random at 00:07:32.459 --> 00:07:34.680 all. It's a very specific growth pattern. In 00:07:34.680 --> 00:07:37.579 infancy, we grow cephalocautal head to toe. That's 00:07:37.579 --> 00:07:40.399 why babies have such huge heads. Right. But in 00:07:40.399 --> 00:07:43.100 adolescence, the growth reverses. It's distal 00:07:43.100 --> 00:07:45.199 to proximal. Distal to proximal. Okay, let's 00:07:45.199 --> 00:07:47.120 unpack that. It means your hands and feet grow 00:07:47.120 --> 00:07:51.339 first. Really? Yes. Then your arms and legs lengthen. 00:07:51.560 --> 00:07:55.040 And the torso grows last. So you literally have 00:07:55.040 --> 00:07:57.279 a 13 year old boy whose feet have shot up to 00:07:57.279 --> 00:08:00.620 size 11 his legs have lengthened But his torso 00:08:00.620 --> 00:08:02.660 hasn't caught up yet. So his center of gravity 00:08:02.660 --> 00:08:06.319 is just shifting constantly week by week He is 00:08:06.319 --> 00:08:08.959 piloting a vehicle that keeps changing its dimensions. 00:08:09.120 --> 00:08:11.100 That's a great way to put it So when he knocks 00:08:11.100 --> 00:08:13.420 over the sterile field or trips coming into the 00:08:13.420 --> 00:08:16.060 exam room, it's not just carelessness. It's his 00:08:16.060 --> 00:08:18.360 physiology That is actually a really helpful 00:08:18.360 --> 00:08:20.699 thing to tell parents, too. He's not just being 00:08:20.699 --> 00:08:23.300 clumsy on purpose. Absolutely. It's anticipatory 00:08:23.300 --> 00:08:25.860 guidance. You tell them, this is normal. He will 00:08:25.860 --> 00:08:28.500 grow into his feet. Now, exams love to ask about 00:08:28.500 --> 00:08:31.600 the timing of puberty. Who starts first? Females 00:08:31.600 --> 00:08:34.840 usually beat the males by about two years. Puberty 00:08:34.840 --> 00:08:37.120 for biological females typically begins around 00:08:37.120 --> 00:08:40.820 ages 9 to 10. OK. The peak height velocity, that's 00:08:40.820 --> 00:08:43.299 the absolute fastest period of growth, that hits 00:08:43.299 --> 00:08:45.919 early around age 12. For males. Everything is 00:08:45.919 --> 00:08:48.379 shifted back. Puberty starts around 10 to 11, 00:08:48.720 --> 00:08:51.200 but that peak growth spurt isn't until maybe 00:08:51.200 --> 00:08:54.659 age 14. And here's the big difference. Males 00:08:54.659 --> 00:08:57.500 continue growing for much longer. Their growth 00:08:57.500 --> 00:09:00.259 plates, the epiphyseal plates, don't close until 00:09:00.259 --> 00:09:03.940 they're late teens, maybe 18 to 20. Females typically 00:09:03.940 --> 00:09:05.899 stop growing much earlier. Is there... Is there 00:09:05.899 --> 00:09:08.019 a marker for when females stop growing? I feel 00:09:08.019 --> 00:09:09.919 like I've seen that on practice questions. Yes, 00:09:09.919 --> 00:09:12.659 this is a massive need to know. For females, 00:09:13.059 --> 00:09:16.120 linear growth usually stops about 2 to 2 .5 years 00:09:16.120 --> 00:09:18.179 after menare. After their first period. Right. 00:09:18.419 --> 00:09:20.519 Oh, wow. So if a girl starts her period at 12, 00:09:20.539 --> 00:09:22.980 she's pretty much done getting taller by 14 or 00:09:22.980 --> 00:09:25.820 15. Exactly. The estrogen surge that causes the 00:09:25.820 --> 00:09:28.600 period also works to close those growth plates 00:09:28.600 --> 00:09:31.200 in the long bones. So if you have a 14 -year 00:09:31.200 --> 00:09:33.100 -old female patient who's worried about being 00:09:33.100 --> 00:09:36.519 short and she started her period at 11, Well, 00:09:36.980 --> 00:09:39.000 biologically, that window has mostly closed. 00:09:39.179 --> 00:09:40.940 It's a hard conversation. It's a hard conversation, 00:09:40.980 --> 00:09:42.700 but it's really important physiology for you 00:09:42.700 --> 00:09:44.980 to understand. So what are the hormonal drivers 00:09:44.980 --> 00:09:47.159 here? We know the names, but what do they actually 00:09:47.159 --> 00:09:49.600 do? It all starts in the brain. The hypothalamus 00:09:49.600 --> 00:09:52.860 releases GnRH, gonadotropin -releasing hormone. 00:09:53.620 --> 00:09:56.440 GnRH, okay. That kicks the pituitary gland to 00:09:56.440 --> 00:10:00.299 release FSH and LH. In females, this stimulates 00:10:00.299 --> 00:10:03.269 estrogen production. And estrogen is responsible 00:10:03.269 --> 00:10:05.429 for breast tissue development, the widening of 00:10:05.429 --> 00:10:08.830 the hips, pelvic remodeling for potential childbearing, 00:10:09.309 --> 00:10:11.730 and increased fat deposits. And for males. It 00:10:11.730 --> 00:10:14.710 triggers testosterone. And here is a specific 00:10:14.710 --> 00:10:18.149 exam detail that catches people off guard. The 00:10:18.149 --> 00:10:21.429 first sign of puberty in males is testicular 00:10:21.429 --> 00:10:24.029 enlargement. Not the voice, not the hair. Nope. 00:10:24.159 --> 00:10:27.100 Testicular enlargement is step one. Then comes 00:10:27.100 --> 00:10:29.720 the muscle mass increase, the voice deepening, 00:10:29.840 --> 00:10:31.980 because the larynx is growing, and the widening 00:10:31.980 --> 00:10:34.059 of the shoulders. You mentioned the voice deepening. 00:10:34.059 --> 00:10:36.360 That's the larynx growing. Yes. The laryngeal 00:10:36.360 --> 00:10:39.059 cartilage grows, and the vocal cords lengthen 00:10:39.059 --> 00:10:40.779 and thicken. That's why you get the voice cracks. 00:10:41.000 --> 00:10:43.440 It's basically an instrument that is being retuned 00:10:43.440 --> 00:10:45.559 while it's being played. That is a great analogy. 00:10:46.080 --> 00:10:47.759 Before we leave biology, let's talk about the 00:10:47.759 --> 00:10:50.019 brain. Because the body is looking like an adult, 00:10:50.019 --> 00:10:52.179 but the decision making... Although the brain 00:10:52.179 --> 00:10:55.169 is under massive construction. The myelin sheath, 00:10:55.330 --> 00:10:57.370 as the insulation around the nerves, it's growing 00:10:57.370 --> 00:10:59.929 rapidly. This speeds up processing power. They 00:10:59.929 --> 00:11:02.950 can actually think faster. But the prefrontal 00:11:02.950 --> 00:11:05.789 cortex, the CEO of the brain, the part that controls 00:11:05.789 --> 00:11:08.870 impulse and judgment, is the last part to mature. 00:11:09.250 --> 00:11:11.830 Doesn't finish until the mid -20s. So you have 00:11:11.830 --> 00:11:14.870 a Ferrari engine with bicycle brakes. Precisely. 00:11:15.169 --> 00:11:18.789 High drive, low control. And that leads us perfectly 00:11:18.789 --> 00:11:24.250 into part three. The mindset. psychosocial development. 00:11:24.490 --> 00:11:26.230 We have to talk about Erickson. If you're in 00:11:26.230 --> 00:11:28.830 nursing school, you live and breathe Erickson. 00:11:28.990 --> 00:11:31.960 What's the stage for adolescence? Identity versus 00:11:31.960 --> 00:11:34.960 role confusion. This is the who am I phase. And 00:11:34.960 --> 00:11:37.059 how does that actually manifest in real life? 00:11:37.159 --> 00:11:39.500 They are trying on different hats. I mean, one 00:11:39.500 --> 00:11:41.200 month they're into sports, the next month they're 00:11:41.200 --> 00:11:43.200 goth, the next month they're activists. They're 00:11:43.200 --> 00:11:44.919 trying to separate their identity from their 00:11:44.919 --> 00:11:47.059 parents. Right. This is why the peer group becomes 00:11:47.059 --> 00:11:49.159 God. Right. Parents often see this as rebellion. 00:11:49.320 --> 00:11:51.100 They only care what their friends think. But 00:11:51.100 --> 00:11:53.820 as nurses, we need to educate parents that this 00:11:53.820 --> 00:11:55.919 isn't really rebellion. It's a developmental 00:11:55.919 --> 00:11:59.850 necessity. The peer group. provides a safe base 00:11:59.850 --> 00:12:02.190 for them to try out these identities. They can 00:12:02.190 --> 00:12:04.169 discuss things with peers they wouldn't dare 00:12:04.169 --> 00:12:06.289 tell their parents. So if a teen wants their 00:12:06.289 --> 00:12:09.129 friend in the exam room but not their mom, that's 00:12:09.129 --> 00:12:10.980 developmentally normal. Very normal. And, you 00:12:10.980 --> 00:12:14.000 know, barring any safety issues, we often accommodate 00:12:14.000 --> 00:12:16.500 that, or we try to split the visit part with 00:12:16.500 --> 00:12:18.460 the parent, part alone with the patient. Which 00:12:18.460 --> 00:12:20.779 brings us to Piaget. We're moving from concrete 00:12:20.779 --> 00:12:24.559 thinking to what? To formal operations. Abstract 00:12:24.559 --> 00:12:26.879 thinking. This is a huge shift. A younger child 00:12:26.879 --> 00:12:30.000 thinks, if I touch the scov I burn my hand. It's 00:12:30.000 --> 00:12:32.799 very concrete. Right. Cause and effect. Exactly. 00:12:33.440 --> 00:12:35.639 An adolescent can think, if I engage in risky 00:12:35.639 --> 00:12:37.919 behavior, it might have consequences for my future 00:12:37.919 --> 00:12:39.950 career. They can hypothesize. They can think 00:12:39.950 --> 00:12:43.210 about the future. But there is a glitch. Because 00:12:43.210 --> 00:12:45.029 if they can think about the future, why do they 00:12:45.029 --> 00:12:48.210 do such dangerous things? There is a major glitch. 00:12:48.230 --> 00:12:51.669 It's called adolescent egocentrism. Even though 00:12:51.669 --> 00:12:54.169 they can think abstractly, they're obsessed with 00:12:54.169 --> 00:12:57.110 themselves and how others perceive them. And 00:12:57.110 --> 00:12:59.990 this shows up in two main ways that exams absolutely 00:12:59.990 --> 00:13:03.710 love to test on. Lay them on us. First, the imaginary 00:13:03.710 --> 00:13:06.950 audience. The teenager walks into the cafeteria 00:13:06.950 --> 00:13:10.840 and believes genuinely believes that every single 00:13:10.840 --> 00:13:12.779 person is looking at the pimple on their chin. 00:13:12.879 --> 00:13:15.840 They feel constantly watched and judged. I think 00:13:15.840 --> 00:13:18.120 some of us never grow out of that one. Probably 00:13:18.120 --> 00:13:20.740 not. And the second one. What is it? The personal 00:13:20.740 --> 00:13:24.120 fable. This is the belief that I am unique and 00:13:24.120 --> 00:13:26.980 the rules of probability don't apply to me. The 00:13:26.980 --> 00:13:29.720 it won't happen to me syndrome. That's it. I 00:13:29.720 --> 00:13:31.360 can text and drive because I'm a good driver. 00:13:31.559 --> 00:13:33.720 Other people crash, but I won't. I can have unprotected 00:13:33.720 --> 00:13:36.879 sex just as once I woke it pregnant. This personal 00:13:36.879 --> 00:13:39.000 fable is the driving force behind the high rates 00:13:39.000 --> 00:13:41.340 of injury and death in this age group. So it's 00:13:41.340 --> 00:13:43.179 not that they don't know the risks. Oh, they 00:13:43.179 --> 00:13:45.220 know them. They can recite the risks to you. 00:13:45.580 --> 00:13:48.080 It's they don't believe the risks apply to them. 00:13:48.320 --> 00:13:51.059 So as a nurse, how do you talk to someone who 00:13:51.059 --> 00:13:53.460 thinks they are invincible? You can't just lecture 00:13:53.460 --> 00:13:57.299 them. No, lecturing fails every time. You have 00:13:57.299 --> 00:13:59.240 to treat them like a partner or a colleague. 00:13:59.899 --> 00:14:04.259 No baby talk. And the most critical tip, confidentiality. 00:14:04.320 --> 00:14:06.580 How much confidentiality? You need to establish 00:14:06.580 --> 00:14:09.539 it early. You say, what we discuss here is private 00:14:09.539 --> 00:14:12.139 between you and me. Unless. There's always an 00:14:12.139 --> 00:14:15.519 unless. Unless you tell me you are going to hurt 00:14:15.519 --> 00:14:17.779 yourself, hurt someone else or someone is hurting 00:14:17.779 --> 00:14:22.259 you. You have to set that boundary. But beyond 00:14:22.259 --> 00:14:24.919 those safety issues, you need them to trust you 00:14:24.919 --> 00:14:27.320 enough to tell you about the drugs, the sex, 00:14:27.500 --> 00:14:29.600 the depression. Right. If they think you're just 00:14:29.600 --> 00:14:31.720 going to run and tell their mom that they vape, 00:14:31.879 --> 00:14:34.220 they will clam up. And use open -ended questions, 00:14:34.379 --> 00:14:37.559 right? Not yes, no. Always. Never ask, do you 00:14:37.559 --> 00:14:39.620 understand? They will just nod to get you to 00:14:39.620 --> 00:14:41.720 shut up. Right. You say, tell me what you know 00:14:41.720 --> 00:14:43.960 about, or how do you plan to handle it if your 00:14:43.960 --> 00:14:45.980 friends are drinking at the party? Make them 00:14:45.980 --> 00:14:48.220 walk you through their thought process. It forces 00:14:48.220 --> 00:14:50.519 them to use that new abstract thinking ability. 00:14:50.879 --> 00:14:53.559 OK, let's pivot to the scary stuff. Part four, 00:14:54.059 --> 00:14:58.519 the danger zone. We mentioned the personal fable 00:14:58.519 --> 00:15:01.419 drives risk. What is actually killing adolescents? 00:15:02.139 --> 00:15:03.779 If you remember nothing else from the safety 00:15:03.779 --> 00:15:06.759 section, remember this order. The number one 00:15:06.759 --> 00:15:09.940 cause of death is unintentional injuries and 00:15:09.940 --> 00:15:14.200 specifically motor vehicle crashes. MVCs. The 00:15:14.200 --> 00:15:16.279 car is the most dangerous weapon they handle. 00:15:16.580 --> 00:15:19.320 Absolutely. It's inexperience, plus that personal 00:15:19.320 --> 00:15:22.340 fable, plus distractions like texting or having 00:15:22.340 --> 00:15:25.259 other teens in the car. It is a lethal combination. 00:15:25.480 --> 00:15:28.000 So the nursing guidance is strict. Very strict. 00:15:28.340 --> 00:15:31.019 Seatbelts, no texting, limit night driving, and 00:15:31.019 --> 00:15:33.360 limit the number of passengers. Why limit passengers? 00:15:33.600 --> 00:15:35.820 The data shows that for every additional teen 00:15:35.820 --> 00:15:38.279 passenger in the car, the risk of a fatal crash 00:15:38.279 --> 00:15:40.659 goes up exponentially. It's the distraction factor. 00:15:40.779 --> 00:15:43.110 What's number two? Homicide. often involving 00:15:43.110 --> 00:15:45.210 firearms and often related to gang violence or 00:15:45.210 --> 00:15:47.429 sometimes domestic situations. And number three. 00:15:47.570 --> 00:15:50.230 Suicide. And this is a major, major focus for 00:15:50.230 --> 00:15:52.590 mental health screening. Suicide is the third 00:15:52.590 --> 00:15:54.750 leading cause of death in this age group. OK, 00:15:54.750 --> 00:15:57.710 we need to deep dive on suicide assessment. What 00:15:57.710 --> 00:15:59.870 are the red flags? What are we looking for? Well, 00:15:59.909 --> 00:16:02.210 depression is an obvious one, but look for regression. 00:16:03.090 --> 00:16:05.190 Withdrawal from friends is a huge one. So they're 00:16:05.190 --> 00:16:08.429 isolating themselves. Yes. Or giving away prized 00:16:08.429 --> 00:16:12.129 possessions. A sudden unexplained drop in grades. 00:16:12.870 --> 00:16:16.929 Also, pay attention to high -risk groups. LGBTQ 00:16:16.929 --> 00:16:20.210 plus youth are at a significantly higher risk, 00:16:20.549 --> 00:16:23.129 not because of their identity itself, but because 00:16:23.129 --> 00:16:25.629 of the marginalization and bullying they so often 00:16:25.629 --> 00:16:28.210 face. If we suspect something, what's the nursing 00:16:28.210 --> 00:16:31.429 action? Do we beat around the bush? Never. You 00:16:31.429 --> 00:16:33.370 ask directly, have you thought about hurting 00:16:33.370 --> 00:16:36.129 yourself? Do you have a plan? I know some people 00:16:36.129 --> 00:16:39.049 worry that asking plants the idea in their head. 00:16:39.320 --> 00:16:42.019 That is a complete myth. Research shows that 00:16:42.019 --> 00:16:44.879 asking does not plant the idea. It actually provides 00:16:44.879 --> 00:16:47.419 relief that someone noticed. And if they have 00:16:47.419 --> 00:16:49.779 a plan, you do not leave them alone. You ensure 00:16:49.779 --> 00:16:53.019 safety. You remove lethal means, pills, firearms. 00:16:53.320 --> 00:16:55.580 Let's talk substances. Alcohol and drugs are 00:16:55.580 --> 00:16:57.740 classics. But what's the new challenger on the 00:16:57.740 --> 00:17:01.539 block? Vaping. E -cigarettes. This is huge right 00:17:01.539 --> 00:17:03.919 now. A lot of teens think it's just safe water 00:17:03.919 --> 00:17:07.279 vapor. It's not. It's highly concentrated nicotine. 00:17:07.440 --> 00:17:09.680 which is terrible for that developing brain we 00:17:09.680 --> 00:17:11.940 talked about, plus heavy metals and other chemicals. 00:17:12.259 --> 00:17:14.720 So the education is it's not a safe alternative. 00:17:15.180 --> 00:17:18.180 Correct. And for alcohol, the big risk is binge 00:17:18.180 --> 00:17:21.130 drinking. because of their physiology, high liver 00:17:21.130 --> 00:17:24.130 efficiency, high energy, they can often metabolize 00:17:24.130 --> 00:17:26.170 alcohol efficiently enough to stay awake longer 00:17:26.170 --> 00:17:29.190 than an adult might, leading to dangerously high 00:17:29.190 --> 00:17:31.589 blood alcohol levels before they pass out. So 00:17:31.589 --> 00:17:33.910 they don't have the stop switch that adults might 00:17:33.910 --> 00:17:36.029 have. Exactly. Okay, that is heavy, but it's 00:17:36.029 --> 00:17:38.930 the reality of the ER. Let's switch gears to 00:17:38.930 --> 00:17:41.970 prevention. Part five. Immunizations and nutrition. 00:17:42.190 --> 00:17:44.410 We're in the clinic. The 11 or 12 -year -old 00:17:44.410 --> 00:17:46.980 comes in. What are we sticking them with? This 00:17:46.980 --> 00:17:49.339 is a classic exam question in a critical public 00:17:49.339 --> 00:17:51.220 health moment. We call it the tween trio. At 00:17:51.220 --> 00:17:53.660 age 11 to 12, there are three routine vaccines 00:17:53.660 --> 00:17:56.519 due. Three needles at 11. I like that mnemonic. 00:17:56.799 --> 00:18:00.940 OK, what are they? Needle one. Tdap. That's tetanus, 00:18:01.180 --> 00:18:04.640 diphtheria, and a cellular pertussis. Note the 00:18:04.640 --> 00:18:07.099 P is pertussis whooping cough. This is a booster 00:18:07.099 --> 00:18:10.440 to the D -tap they got as babies. Immunity wanes. 00:18:10.559 --> 00:18:14.740 So we boost it here. OK. Needle two. Meningococcal. 00:18:15.319 --> 00:18:19.250 ACWY. often called Menacwy or Menveo. This protects 00:18:19.250 --> 00:18:21.730 against meningitis, which is absolutely devastating 00:18:21.730 --> 00:18:23.849 in this age group. Now, there is a catch with 00:18:23.849 --> 00:18:25.450 meningococcal, right? It's not one and done. 00:18:25.609 --> 00:18:27.970 Correct. This is the exam trap. You get the first 00:18:27.970 --> 00:18:31.390 dose at 11 -12. But you must get a booster at 00:18:31.390 --> 00:18:34.789 age 16. By 16, why not? Like, 18. Think about 00:18:34.789 --> 00:18:37.549 what happens around 18. They go to college dorms, 00:18:37.849 --> 00:18:40.529 military barracks, crowded housing. Meningitis 00:18:40.529 --> 00:18:43.609 spreads in close quarters. We want that antibody 00:18:43.609 --> 00:18:45.730 peak to be fresh right before they enter that 00:18:45.730 --> 00:18:47.650 high -risk environment. If you give the booster 00:18:47.650 --> 00:18:49.750 too early, it might wear off by the time they 00:18:49.750 --> 00:18:52.549 get to college. So dose one at 11, booster at 00:18:52.549 --> 00:18:55.690 16. Got it. And the third needle? HPV, human 00:18:55.690 --> 00:18:58.569 papillomavirus. This is the cancer prevention 00:18:58.569 --> 00:19:01.190 vaccine, protects against cervical cancer, throat 00:19:01.190 --> 00:19:04.029 cancer, anal cancer, penile cancer. And the dosing 00:19:04.029 --> 00:19:05.910 schedule here is tricky. It depends on when you 00:19:05.910 --> 00:19:08.430 start. Yes. Applying the Pareto principle. This 00:19:08.430 --> 00:19:10.369 is the complex detail you really need to memorize. 00:19:10.630 --> 00:19:13.029 If the child starts the series before their 15th 00:19:13.029 --> 00:19:15.789 birthday, they only need two doses. Just two. 00:19:15.990 --> 00:19:19.829 Just two. One today, and one in six to 12 months. 00:19:20.230 --> 00:19:23.089 So two doses, it started before 15. Correct. 00:19:23.230 --> 00:19:25.150 Their immune system is so robust at that age 00:19:25.150 --> 00:19:28.309 that two doses gives them full protection. But 00:19:28.309 --> 00:19:30.950 if they start on or after their 15th birthday, 00:19:31.250 --> 00:19:33.210 or if they're immunocompromised for some reason, 00:19:33.369 --> 00:19:36.029 They need three doses, usually at zero, one, 00:19:36.029 --> 00:19:38.289 two months, and six months. So starting early 00:19:38.289 --> 00:19:40.569 saves a shot. That's a good selling point for 00:19:40.569 --> 00:19:43.509 parents. It is. It's better immunity with fewer 00:19:43.509 --> 00:19:46.470 needles. And remember, HPV is not just for females. 00:19:46.789 --> 00:19:49.390 It is for everyone. Is there anything else? What 00:19:49.390 --> 00:19:51.789 about meningitis B? That's separate from the 00:19:51.789 --> 00:19:55.380 ACWY. MenB is usually a shared clinical decision 00:19:55.380 --> 00:19:58.319 given between ages 16 and 23, with the preferred 00:19:58.319 --> 00:20:01.420 timing being 16 to 18. It's not strictly mandatory 00:20:01.420 --> 00:20:03.680 on every schedule, like the Trio, but it's highly 00:20:03.680 --> 00:20:05.740 recommended, especially for college -bound kids. 00:20:05.819 --> 00:20:09.039 And obviously, flu and COVID annually. Standard 00:20:09.039 --> 00:20:11.299 maintenance, yeah. Let's talk fuel, nutrition. 00:20:11.339 --> 00:20:12.980 They are growing so fast, they must be eating 00:20:12.980 --> 00:20:16.019 a ton. The caloric needs skyrocket. I mean, a 00:20:16.019 --> 00:20:18.180 teenage boy during his peak growth spurt can 00:20:18.180 --> 00:20:20.880 easily need 2 ,800 to 3 ,000 calories a day. 00:20:21.019 --> 00:20:23.910 Wow, that's more than most adults. It is, but 00:20:23.910 --> 00:20:26.450 it can't just be junk. So what are the key nutrients 00:20:26.450 --> 00:20:28.329 we're worried about? We call them the big three 00:20:28.329 --> 00:20:31.799 for teens. Calcium, iron, and zinc. Why those 00:20:31.799 --> 00:20:34.779 three? Calcium is critical for the bones. They 00:20:34.779 --> 00:20:37.460 need 1300 milligrams a day. Remember, nearly 00:20:37.460 --> 00:20:40.019 half of your adult bone mass is accumulated during 00:20:40.019 --> 00:20:42.839 adolescence. If you don't bank the calcium now, 00:20:43.079 --> 00:20:45.960 you get osteoporosis in your 60s. So you're preventing 00:20:45.960 --> 00:20:48.960 fractures decades in the future. Exactly. And 00:20:48.960 --> 00:20:51.319 iron. For females, it's obviously to replace 00:20:51.319 --> 00:20:54.619 losses from menstruation. For males, it's needed 00:20:54.619 --> 00:20:56.640 for the expansion of their muscle mass and blood 00:20:56.640 --> 00:21:00.210 volume. Everyone needs more iron. And zinc. Essential 00:21:00.210 --> 00:21:02.809 for growth and for sexual maturation. We have 00:21:02.809 --> 00:21:05.210 to touch on the flip side of nutrition obesity. 00:21:05.569 --> 00:21:08.529 Yes. Roughly 20 % of adolescents classify as 00:21:08.529 --> 00:21:11.349 obese. You need to be screening BMI. But the 00:21:11.349 --> 00:21:14.349 advice isn't go on a diet. Right. Diets in teens 00:21:14.349 --> 00:21:17.549 often trigger eating disorders. The advice is 00:21:17.549 --> 00:21:20.589 my plate. make half the plate fruits and veggies, 00:21:21.150 --> 00:21:23.829 and focus on activity. 60 minutes a day, right? 00:21:24.069 --> 00:21:27.130 Moderate to vigorous physical activity, 60 minutes 00:21:27.130 --> 00:21:29.769 daily. Sports are great, but you have to watch 00:21:29.769 --> 00:21:32.529 out for overuse, injuries, and concussions. And 00:21:32.529 --> 00:21:34.990 if they aren't into sports, just getting them 00:21:34.990 --> 00:21:37.509 moving, walking, dancing, even active gaming 00:21:37.509 --> 00:21:40.890 is the goal. Part six, common issues. These are 00:21:40.890 --> 00:21:42.470 the things they actually complain about in the 00:21:42.470 --> 00:21:45.650 office. Let's start with the zombie mode, sleep. 00:21:46.089 --> 00:21:48.829 Adolescents are chronically sleep deprived. They 00:21:48.829 --> 00:21:52.410 need about 9 to 9 .5 hours of sleep. They rarely, 00:21:52.410 --> 00:21:54.109 rarely get it. Is it just that they want to stay 00:21:54.109 --> 00:21:56.089 up playing video games? Well, that's part of 00:21:56.089 --> 00:21:58.230 it. But there's also a biological shift called 00:21:58.230 --> 00:22:01.809 a circadian delay. Their bodies physically don't 00:22:01.809 --> 00:22:03.869 start producing melatonin until later at night. 00:22:04.069 --> 00:22:06.390 Oh, really? Yeah. So they aren't tired until 00:22:06.390 --> 00:22:09.910 11 PM or midnight. But school starts at 730 AM. 00:22:10.309 --> 00:22:12.650 It's a complete mismatch between their biology 00:22:12.650 --> 00:22:14.710 and society. So what's the nursing advice for 00:22:14.710 --> 00:22:17.329 that? Sleep hygiene. New screens in the bedroom. 00:22:17.609 --> 00:22:20.349 The blue light suppresses melatonin even further. 00:22:20.670 --> 00:22:23.369 Consistent bedtimes, even on weekends, to avoid 00:22:23.369 --> 00:22:26.190 social jet lag. What's social jet lag? If they 00:22:26.190 --> 00:22:28.910 sleep until 2 p .m. on Saturday, they won't be 00:22:28.910 --> 00:22:30.890 able to sleep Sunday night and Monday morning 00:22:30.890 --> 00:22:35.970 is a total disaster. Got it. Next up. Skin. Acne. 00:22:36.170 --> 00:22:38.430 It's a rite of passage, but it really hurts their 00:22:38.430 --> 00:22:41.150 self -esteem. It does. The sebaceous glands go 00:22:41.150 --> 00:22:44.049 into overdrive because of androgens. The advice 00:22:44.049 --> 00:22:47.150 is simple. Wash the face two to three times a 00:22:47.150 --> 00:22:50.369 day with plain unscented soap or a mild cleanser. 00:22:50.490 --> 00:22:53.609 And the Gordon rule? Do not squeeze. Do not pop. 00:22:54.170 --> 00:22:57.210 It leads to scarring and infection. If over -the 00:22:57.210 --> 00:22:59.569 -counter benzoyl peroxide isn't working, get 00:22:59.569 --> 00:23:01.430 them to a provider, but don't let them perform 00:23:01.430 --> 00:23:03.609 bathroom surgery on themselves. Finally, sexual 00:23:03.609 --> 00:23:05.950 health. We touched on the risk aspect, but what's 00:23:05.950 --> 00:23:08.329 the standard of care for education? Education 00:23:08.329 --> 00:23:11.029 is the standard of care. Abstinence is the only 00:23:11.029 --> 00:23:13.730 100 % effective method for preventing pregnancy 00:23:13.730 --> 00:23:16.789 and STIs, and we should state that. However, 00:23:17.250 --> 00:23:19.609 we absolutely must provide factual, judgment 00:23:19.609 --> 00:23:21.849 -free information about contraception and barrier 00:23:21.849 --> 00:23:25.160 methods. And consent. Huge. We need to discuss 00:23:25.160 --> 00:23:27.339 what a healthy relationship looks like. One in 00:23:27.339 --> 00:23:29.839 12 teens reports physical violence in a dating 00:23:29.839 --> 00:23:31.980 relationship. We need to talk about consent, 00:23:32.220 --> 00:23:34.589 coercion, and that no means no. We should also 00:23:34.589 --> 00:23:36.809 briefly touch on the concept of developmental 00:23:36.809 --> 00:23:39.769 red flags. We talked about what's normal, but 00:23:39.769 --> 00:23:42.710 what screens delay at this age. Right. At this 00:23:42.710 --> 00:23:45.670 age, you aren't looking for not walking or not 00:23:45.670 --> 00:23:48.789 talking. You are looking for social and cognitive 00:23:48.789 --> 00:23:52.549 delays. A teen who cannot engage in abstract 00:23:52.549 --> 00:23:55.309 thought by late adolescence needs an evaluation. 00:23:55.309 --> 00:23:57.930 OK. Or a teen who has zero interest in peers 00:23:57.930 --> 00:24:01.349 or exhibits no desire for independence that might 00:24:01.349 --> 00:24:03.250 signal a developmental issue or maybe severe 00:24:03.279 --> 00:24:05.920 anxiety. And what about age -appropriate activities? 00:24:05.960 --> 00:24:07.980 If you have a teen in the hospital for a week, 00:24:08.440 --> 00:24:10.640 do you give them a coloring book? Maybe an intricate 00:24:10.640 --> 00:24:13.759 adult coloring book, but generally no. Age -appropriate 00:24:13.759 --> 00:24:16.180 activities for teens involve connection. Let 00:24:16.180 --> 00:24:18.279 them use their phone to FaceTime friends, video 00:24:18.279 --> 00:24:21.039 games are great, journaling, anything that allows 00:24:21.039 --> 00:24:22.980 them to express their identity or connect to 00:24:22.980 --> 00:24:25.140 their peer group. So isolation is the enemy? 00:24:25.480 --> 00:24:27.480 Isolation is the enemy for the hospitalized teen. 00:24:27.609 --> 00:24:29.710 All right, we've covered a massive amount of 00:24:29.710 --> 00:24:32.170 ground. We've gone from hormones to helmets. 00:24:32.369 --> 00:24:34.910 Let's wrap this up with our, if you remember 00:24:34.910 --> 00:24:37.490 nothing else, summary. I want the absolute highest 00:24:37.490 --> 00:24:40.150 yield takeaways. OK, here are my top four takeaways 00:24:40.150 --> 00:24:42.190 for the exam and for the bedside. Number one. 00:24:42.430 --> 00:24:44.849 Safety first. The number one killer is motor 00:24:44.849 --> 00:24:47.690 vehicle accidents. Your assessment has to include 00:24:47.690 --> 00:24:50.009 questions about seatbelts, texting and driving 00:24:50.009 --> 00:24:53.769 habits and always, always ask directly about 00:24:53.769 --> 00:24:56.880 suicide. It's the number three killer. and silence 00:24:56.880 --> 00:25:00.519 can be deadly. Number two. The 11 -12 year vaccine 00:25:00.519 --> 00:25:05.259 checkpoint. Remember the tween trio. Tdap, MinICWY, 00:25:05.500 --> 00:25:08.759 and HPV. And remember that HPV rule. Two doses 00:25:08.759 --> 00:25:11.519 if you start before 15, three doses if you start 00:25:11.519 --> 00:25:14.319 after. Number three. Regression is a red flag. 00:25:14.680 --> 00:25:17.259 It's normal for teens to be moody or want privacy. 00:25:17.740 --> 00:25:19.720 It is not normal for them to completely withdraw 00:25:19.720 --> 00:25:22.200 from friends, stop doing things they love, or 00:25:22.200 --> 00:25:24.529 have a plummeting GPA. That requires a mental 00:25:24.529 --> 00:25:26.910 health intervention. And number four. Privacy 00:25:26.910 --> 00:25:29.809 versus safety. Respect their need for confidentiality 00:25:29.809 --> 00:25:31.910 to get an honest history. You need them to trust 00:25:31.910 --> 00:25:34.390 you, but know your hard line. If there is a risk 00:25:34.390 --> 00:25:37.250 of harm to self or others, safety trumps privacy 00:25:37.250 --> 00:25:39.309 every single time. I love the analogy you used 00:25:39.309 --> 00:25:42.509 earlier about the bridge. Yes. Adolescence is 00:25:42.509 --> 00:25:45.910 a bridge between childhood and adulthood. It's 00:25:45.910 --> 00:25:48.809 a long bridge, it's shaky, and sometimes the 00:25:48.809 --> 00:25:52.049 weather is terrible. Our job as nurses isn't 00:25:52.049 --> 00:25:54.170 to carry them across. All right. It's to make 00:25:54.170 --> 00:25:56.430 sure the bridge is structurally sound through 00:25:56.430 --> 00:25:59.210 vaccines, safety checks, and education so they 00:25:59.210 --> 00:26:01.430 can walk across it themselves. And maybe catch 00:26:01.430 --> 00:26:03.529 them if they trip over their own rapidly growing 00:26:03.529 --> 00:26:06.670 feet. Exactly. That is a wrap on our adolescent 00:26:06.670 --> 00:26:08.990 nursing review. Whether you are cramming for 00:26:08.990 --> 00:26:11.150 tomorrow's exam or prepping for clinicals, we 00:26:11.150 --> 00:26:13.250 hope this deep dive helped you focus on the 20 00:26:13.250 --> 00:26:15.390 % that matters most. Good luck studying. You've 00:26:15.390 --> 00:26:17.329 got this. Thanks for listening to the deep dive. 00:26:17.589 --> 00:26:18.329 We'll see you next time.