Nursing 109

N109: Foundations in Nursing Practice Study Guide 2nd Edition 11/6/2018

This study guide is subject to copyright.

Acknowledgements We would like to thank the authors for their patience, support, and expertise in contributing to this study guide; and Christina Wulff for her invaluable efforts in reading and editing the text. We would also like to thank those at Achieve whose hard work and dedication to fulfilling this project did not go unnoticed. Lastly, we would like to thank the Achieve students who have contributed to the growth of these materials over the years.

Copyright © 2018 by Achieve All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review. Printed in the United States of America First Printing, 2012 Achieve PO Box 10188 #29831 Newark, NJ 07101-3188 Tel: 888.900.8380 Visit the Achieve website at http://www.achievetestprep.com/student

N109: Foundations in Nursing Practice Study Guide

Table of Contents Chapter One: Functional Assessment ........................................................................................................6 1.1 Growth and Development Across the Lifespan ............................................................................6 1.2 Neonates and Infants: Birth to 1 Year .............................................................................................7 1.3 Toddler: 1 to 3 Years............................................................................................................................9 1.4 Preschooler: 4 to 5 Years................................................................................................................. 11 1.5 School-Age: 6 to 12 Years................................................................................................................. 12 1.6 Adolescent: 12 to 18 Years.............................................................................................................. 13 1.7 Young Adulthood: 18 to 40 Years.................................................................................................. 15 1.8 Middle Adulthood: 40 to 65 Years................................................................................................. 16 1.9 Older Adults: Over 65 Years............................................................................................................ 18 1.10 Factors Influencing Growth, Development, Functional Ability, and Health.................... 20 1.11 The Key Components of the Patient’s Bill of Rights ............................................................... 22 1.12 The Nursing Process....................................................................................................................... 23 Chapter One Practice Exam.................................................................................................................... 29 Chapter Two: Pain and Discomfort.......................................................................................................... 31 2.1 Types of Discomfort and Pain ........................................................................................................ 31 2.2 Characteristics of Pain...................................................................................................................... 32 2.3 Physiology of Pain.............................................................................................................................. 33 2.4 Myths about Pain ............................................................................................................................... 34 2.5 Comfort Needs and Responses ....................................................................................................... 35 2.6 Communication and Comfort.......................................................................................................... 37 2.7 Factors Influencing Comfort and Communication.................................................................... 39 2.8 Non-Pharmacological Treatment Modalities............................................................................. 41 2.9 Pharmacological Treatment Modalities ...................................................................................... 42 2.10 The Nursing Process....................................................................................................................... 43 Chapter Two Practice Exam................................................................................................................... 46 Chapter Three: Chronic Illness ................................................................................................................. 48 3.1 Acute vs. Chronic Illness .................................................................................................................. 48 3.2 Trajectory Model of Chronic Illness ............................................................................................. 48 3.3 Chronic Care Model ........................................................................................................................... 49 3.4 Adjustment Patterns......................................................................................................................... 49 3.5 Problems Associated with Chronic Illness.................................................................................. 49 3.6 Factors Influencing Chronic Illness .............................................................................................. 50 3.7 Alternative/Complementary Treatments................................................................................... 52 3.8 The Nursing Process ......................................................................................................................... 53 Chapter Three Practice Exam................................................................................................................ 55

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Chapter Four: End of Life Care .................................................................................................................. 57 4.1 Types of Loss ....................................................................................................................................... 57 4.2 Types of Grief Responses................................................................................................................. 57 4.3 Theories of Loss and Grieving ........................................................................................................ 58 4.4 Factors Influencing End of Life Care and the Grief Response................................................ 60 4.5 Death and Dying................................................................................................................................. 63 4.6 Hospice and Palliative Care ............................................................................................................ 65 4.7 Post-Mortem Care.............................................................................................................................. 65 4.8 The Nursing Process ......................................................................................................................... 66 Chapter Four Practice Exam.................................................................................................................. 69 Chapter Five: Sensory Impairments........................................................................................................ 71 5.1 Sensory Impairment ......................................................................................................................... 71 5.2 Structure and Function of the Eye................................................................................................. 71 5.3 Problems Causing Visual Impairment.......................................................................................... 72 5.4 Structure and Function of the Ear ................................................................................................. 75 5.5 Problems Causing Hearing Impairment ...................................................................................... 77 5.6 Clinical Manifestations of Sensory Impairment ........................................................................ 78 5.7 Factors Influencing Sensory Ability and Impairment.............................................................. 79 5.8 The Nursing Process ......................................................................................................................... 81 Chapter Five Practice Exam................................................................................................................... 85 Chapter Six: Culture and Diversity .......................................................................................................... 87 6.1 Definition of Concepts ...................................................................................................................... 87 6.2 Health and Culture ............................................................................................................................ 88 6.3 Theory of Transcultural Care ......................................................................................................... 89 6.4 Factors Influencing Culture and Diversity.................................................................................. 90 6.5 Spiritual Concepts and Practices................................................................................................... 91 6.6 Complementary and Alternative Therapies............................................................................... 92 6.7 The Nursing Process ......................................................................................................................... 92 Chapter Six Practice Exam...................................................................................................................... 95 Chapter Seven: Community-Based Nursing Care................................................................................. 97 7.1 Historical Perspectives .................................................................................................................... 97 7.2 Healthy People 2020......................................................................................................................... 97 7.3 Prevention ........................................................................................................................................... 99 7.4 Practice Roles and Settings ...........................................................................................................100 7.5 Community Health Systems ..........................................................................................................100 7.6 Epidemiology and Communicable Disease ...............................................................................101 7.7 Factors Influencing Health in the Community .........................................................................101

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7.8 The Nursing Process .......................................................................................................................103 Chapter Seven Practice Exam..............................................................................................................105

Appendix A: Key Terms and Concepts ..................................................................................................107 Appendix B: Nursing Code of Ethics ......................................................................................................114 Appendix C: Practice Exam ......................................................................................................................116 Appendix D: Answer Keys ........................................................................................................................147 Chapter 1 ............................................................................................................................................................................. 147 Chapter 2 ............................................................................................................................................................................. 148 Chapter 3 ............................................................................................................................................................................. 149 Chapter 4 ............................................................................................................................................................................. 150 Chapter 5 ............................................................................................................................................................................. 151 Chapter 6 ............................................................................................................................................................................. 152 Chapter 7 ............................................................................................................................................................................. 153 Practice Exam Answer Key ......................................................................................................................................... 154

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Chapter One: Functional Assessment Learning Objectives 1. Discuss theories of growth and development and what impact they haveon functional abilities. 2. Discuss factors that influence functional abilities. 3. Discuss how the concepts of health promotion and disease prevention relate to functional ability. 4. Describe tools the nurse can use to assess functional ability. 5. Develop a plan of care related to functional ability using the nursing process. 1.1 Growth and Development Across the Lifespan When thinking about functional ability, the nurse must have a firm grasp on growth and development. Growth refers to an increase in size over time and can be measured. Development refers to ongoing changes with an increase in complexity of skill and function. Characteristics of growth and development include: • Predictability • Orderly • Sequential but unevenly paced • Occurring from head to foot (cephalocaudal) and center to outer (proximodistal) • Developing from simple to complex • Helped or hindered by learning • Each stage has specific characteristics Although age might help predict normal growth and development, individuals can be delayed or stopped at any stage due to physiological, psychosocial, cognitive, moral, or spiritual factors. Theories of Growth and Development The nurse must have a good understanding of normal developmental stages (physical, psychosocial, cognitive, moral, and spiritual) in order to knowwhen an individual is at risk. Although the stages are typically associated with age ranges, the astute nurse will use these stages to identify the developmental stage of any patient regardless of age. For example, a patient may be 20 years old but, because of some disability, may only function at a school-age level. Nursing care and intervention must be aimed at the patient’s developmental stage, rather than age. Several theorists have contributed to growth and development literature and can provide guideposts for the nurse when evaluating functional abilities: • Robert Havighurst recognized certain developmental tasks that occur over the course of a person’s lifetime. • Sigmund Freud and Erik Erikson did work in the area of psychosocial development. • Jean Piaget did definitive work in cognitive development.

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N109: Foundations in Nursing Practice Study Guide • Lawrence Kohlberg and Carol Gilligan contributed to the field of moral development. • James Fowler developed theories around the individual’s spiritual and faith-based development. Normal development and the work of these theorists are detailed below by the patient’s chronological age. As the nurse works with each age group, it is helpful to know typical developmental expectations for the age while understanding that delays or acceleration may occur. Each stage of development also has specific health problems that may be identified in that age group. The astute nurse will be alert to the problems typically seen in each group. 1.2 Neonates and Infants: Birth to 1 Year Physical Development Size: Weight at birth averages 6-8.5 pounds. It doubles by six months, and triples by one year of age. Length at birth averages 20 inches and increases by about eight inches by one year old. Head circumference at birth averages 14 inches, and chest circumference is about one inch less. The anterior fontanel (soft spot) closes by about 18 months. Vision: Vision is poorly developed at birth but by four months of age, the infant is able to recognize familiar objects and follow moving ones. At six months, the infant can perceive colors and by nine months, can recognize faces. Depth perception does not develop until approximately one year of age. Hearing: Hearing in infants can be checked by making a loud noise; the infant with intact hearing will exhibit a startle reflex (Moro). By nine months, the infant should recognize familiar sounds and by 12 months, should begin to respond to simple commands. Reflexes: • Rooting reflex: The rooting reflex begins when the corner of the baby's mouth is stroked or touched. The baby will turn his head and open his mouth to follow and “root” in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding. • Sucking reflex: Rooting helps the baby become ready to suck. When the area around the baby’s mouth is touched, the baby will begin to suck. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability because of this. The sucking reflex lasts approximately 10 months. Babies also have a hand-to-mouth reflex that goes with rooting and sucking, which may be seen in the form of sucking on fingers or hands. • Moro reflex: The Moro reflex is often called a startle reflex because it usually occurs when a baby is startled by a loud sound, quick movement, or feels like she is falling. In response, the baby quickly extends out the arms with the fingers fanning out then pulls the arms back in. A baby’s own cry can startle her and begin this reflex. This reflex lasts about four months. • Tonic neck reflex: This happens when a baby’s head is turned to one side while lying supine. The arm and leg on that side stretch out and the opposite arm and leg bend up. This is often called the “fencing” position. The tonic neck reflex lasts about six months.

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N109: Foundations in Nursing Practice Study Guide • Palmar grasp reflex: Stroking the palm of a baby’s hand causes the baby to close her fingers in a grasp. The palmar grasp reflex disappears by six months and is stronger in premature babies. • Babinski reflex: When the sole of the foot is firmly stroked upward starting at the heel, the big toe bends back toward the top of the foot and the other toes fan out. This is a normal reflex up to about two years of age. • Stepping reflex: This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his feet touching a solid surface. The stepping reflex will disappear at three months. Motor Development At one month, the infant should be able to lift his head when lying on his abdomen. By six months, most children can sit without support. At nine months, children are grasping objects and are at risk for putting small objects in their mouths. By 12months, most children will exhibit an interest in books and will be able to turn pages. Common Health Problems Identified in thisStage During infancy, the child is totally dependent on the caregiver for health and safety needs. Some of the common problems in infancy include: • Cradle cap: The thick, yellow scale or flaky, dry skin that accompanies cradle cap is usually more distressing to parents than to the child and will typically go away without treatment. • Umbilical hernia: When an infant has an umbilical hernia, his belly button will protrude out at times. It often becomes worse when he strains or cries. Umbilical hernias almost always go away without treatment. • Colic: This is uncontrollable, extended crying in a healthy, well-taken care of infant. • Shaken baby syndrome: This occurs when a baby is shaken violently, causing whiplash that can result in brain damage or death. • Failure to thrive (FTT): This is defined as the point at which an infant’s height and weight on a standard growth chart fall below the fifth percentile. • Sudden Infant Death Syndrome (SIDS): This is defined as the sudden, unexpected death in a child less than one year old. SIDS continues to be poorly understood. • Child abuse: Child abuse can be seen during any phase of childhood and canbe physical, sexual, or emotional abuse, as well as physical or emotional neglect. Havighurst’s Developmental Tasks During this period, the developmental tasks include learning to crawl, walk, and take solid food. Freud’s Psychosocial Development Oral stage: During the oral stage, the child is focused on oral pleasures (sucking). According to Freud, too much or too little gratification can result in an oral fixation or oral personality, which is evidenced by a preoccupation with oral activities. Erikson’s Psychosocial Development

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Expected outcome: Trust vs. mistr st In infancy, the major emphasis is on the primary caregiver’s positive and loving care for the child, with a major emphasis on visual contact and touch. The individual who successfully completes this period of life will learn to trust that life is basically good and predictable, and will have basic confidence in the future. If the child fails to experience trust and is constantly frustrated because his needs are not met, he may end up with a deep-seated feeling of worthlessness and a mistrust of the world in general. The most significant relationship is with the primary caregiver as the most significant and constant caregiver. Health teaching should be conducted in collaboration with the parent or caregiver. Piaget’s Cognitive Development Sensorimotor phase: During this stage, the child learns about himself and his environment through motor and reflex actions. Thought derives from sensation and movement. The child learns that she is separate from her environment and that aspects of her environment continue to exist even though they may be outside the reach of her senses. Teaching for a child in this stage should be geared to the sensorimotor system. Behavior can be modified by using the senses (for example, a frown, a stern voice, or soothing voice). Fowler’s Spiritual Development Undifferentiated faith: In this stage, the infant develops basic trust and mutuality with the ones providing care. The quality of interactions in this phase underlies all future faith development for the individual. 1.3 Toddler: 1 to 3 Years Physical Development Toddlers still have heads disproportionately large for their bodies. They typically have short legs and chubby extremities. The toddler’s abdomen is typically rounded, and they have pronounced lumbar lordosis. Gross and fine motor skills continue to develop. Most toddlers will be climbing stairs with assistance by 18 months, putting them at increased risk for falls and injury. By the age of two, most children have quadrupled their birth weight and their brain is 70% of the final adult size. Most toddlers are highly mobile, able to run, and can ride a tricycle. By the age of three, hearing is fully developed and most children are toilet trained, although accidents are not uncommon. Common Health Problems Identified in thisStage During the toddler stage, the child is still totally dependent on the caregiver for health and safety needs. Some of the common problems in this stage include: • Accidents: Because the toddler is becoming more mobile, accidents are the most common problem in this stage. Car seats can help prevent injury from automobile accidents, but drowning, burns, and poisoning are also threats. • Lead poisoning: Children who live in older houses with lead-based paint on the walls are at risk. Toys produced outside of the United States may be painted with lead-based paint.

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N109: Foundations in Nursing Practice Study Guide • Ear infections: Due to the structure of the toddler's ear and Eustachian tubes, ear infections are common in this age group. • Upper respiratory infections: Toddlers often experience the common cold, which can affect the child’s ears, nose, throat, and sinuses. • Dental cavities: Dental cavities are often caused by putting a toddler to bed with a bottle, or from eating excessive sweets. The child should begin a regular routine of teeth brushing. Havighurst’s Developmental Tasks During this period, the developmental tasks include learning to walk and talk, bowel and bladder control, and learning language. Freud’s Psychosocial Development Anal stage: The child’s focus of pleasure in this stage is on eliminating and retaining feces. According to Freud, through society’s pressure, mainly via parents, the child has to learn to control anal stimulation. Erikson’s Psychosocial Development Expected outcome: Autonomy vs. shame/doubt During early childhood, the individual learns to master skills. She will learn to walk, talk, and feed herself, and will develop finer motor skills and toilet training. During this stage, the individual has the opportunity to build self-esteem and autonomy as she gains more control over her body and acquires new skills, learning right from wrong. It is also during this stage, however, that the child can be very vulnerable. If she is shamed in the process of learning important skills, the child may feel great shame and doubt of her capabilities, suffering low self-esteem as a result. The most significant relationships are with parents or primary caregivers. People at this developmental stage can learn simple skills through imitation and repetition, but teaching must still include the parent or caregiver. Piaget’s Cognitive Development Pre-conceptual or pre-operational phase: As the child learns to talk and communicate with others, he begins to use symbols to represent objects. Early in this stage, he also personifies objects. He takes in information and then changes it in his mind to fit his ideas. Teaching must take into account the child’s vivid fantasies and undeveloped sense of time. To achild this age, everything is about “me.” Using neutral words, body outlines, and equipment a child can touch gives him an active role in learning. Kohlberg’s Moral Development Pre-conventional level (to 9 years old): Morality is defined as obeying rules and avoiding negative consequences. Children in this stage see rules set, typically by parents, as defining moral law. Whatever satisfies the child’s needs is seen as good and moral. Fowler’s Spiritual Development Intuitive-projective faith: Here, the child is egocentric. In this stage, the child’s imagination is formed. The child imitates the faith of his parents without understanding the meaning. Prayers are learned when parents praise the child for learning them.

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1.4 Preschooler: 4 to 5 Years Physical Development During this period, the child will begin to grow more in height than weight and will begin to take on a slimmer, more erect appearance. By age five, the child has typically doubled her birth length and her brain has reached approximately adult size. Vision is still not fully developed and it is normal for a preschooler to be slightly farsighted. Preschoolers are able to do simple activities of daily living (brushing hair and teeth, dressing themselves, and washing hands and face) but will probably require reminders and some assistance to do these activities. Balance is improving. Common Health Problems Identified in this Stage During the preschool stage, the child is still totally dependent on the caregiver for health and safety needs, but is beginning to venture away from the primary caregiver for short periods of time. Accidents and abuse continue to be sources of health problems. Dental cavities are still an area of concern. It is during this stage when vision, hearing, and developmental tasks may be measured. Immunizationstatus must also be assessed. Havighurst’s Developmental Tasks During this period, the developmental tasks include learning sex differences and sexual modesty, refining language, and getting ready to read. Preschoolers also learn to relate to others emotionally and distinguish right from wrong. Freud’s Psychosocial Development Phallic stage: The pleasure zone switches to the genitals. Freud believed that during this stage boys develop unconscious sexual desires for theirmother. Because of this, he becomes rivals with his father and sees him as competition for his mother’s affection. During this time boys also develop a fear that their father will punish them for these feelings, such as by castrating them. The boy develops masculine characteristics and identifies himself as a male, and represses his sexual feelings toward his mother. Erikson’s Psychosocial Development Expected outcome: Initiative vs. guilt During the preschool years children are learning to master the world around them using basic skills. They begin to develop courage, independence, and judgment. At this time, parents should encourage independence and not dismiss new ideas or creativity, or children may feel guilt regarding their own needs and desires. Piaget’s Cognitive Development Intuitive thought phase: The child is now better able to think about things and events that are not immediately present. However, oriented to the present, the child has difficulty conceptualizing time. His thinking is influenced by fantasy, the way he would like things to be, and he assumes that others see situations from his viewpoint. The individual begins to think about the idea of death.

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Kohlberg’s Moral Development Pre-conventional level: Morality is defined as obeying rules and avoiding negative consequences. Children in this stage see rules set, typically by parents, as defining moral law. Whatever satisfies the child’s needs is seen as good andmoral. Fowler’s Spiritual Development Intuitive-projective faith: Here, the child is egocentric. In this stage, the child’s imagination is formed. The child imitates the faith of his parents without understanding the meaning. 1.5 School-Age: 6 to 12 Years Physical Development Deciduous (baby) teeth are shed during the school-age years. Weight gain is more rapid during these years and girls may outweigh boys at this age. Both sexes will typically experience a growth spurt immediately before puberty during which the extremities grow faster than the trunk, often resulting in awkwardness. Stereognosis, or the ability to identify objects by touch, is fully developed during this stage. By age 11, vision is fully developed and visual screening becomes critical. Hearing is fully developed during this stage and the child with normal hearing will be able to differentiate fine distinctions in sounds. As puberty approaches, and the endocrine glands begin to increase in function, perspiration and body odor increase. Coordination and physical skills develop rapidly during this period and fine motor skills are being perfected. Common Health Problems Identified in thisStage During the school-age stage, motor vehicle accidents are the leading cause of death. Drowning and bicycle accidents are also common. Safety precautions (for example, the use of seatbelts, bicycle helmets, and swimming with other people) must be stressed with the school-age child. During this stage, the child may become more prone to being overweight as eating habits and lack of exercise begin to be more common. Immunization status must continue to be assessed. Havighurst’s Developmental Tasks During this period, developmental tasks include developing physical skills to play games, learning to get along with other children, developing a positive attitude toward self, learning acceptable social roles, and gaining basic reading, writing, and math skills. Children also begin to develop a sense of morality as well as independence. Freud’s Psychosocial Development Latency stage: During this stage, sexual urges remain repressed and children interact and play mostly with same sex peers.

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Erikson’s Psychosocial Developmen Expected outcome: Industry vs. inferiority During this stage, the child will begin to learn new knowledge and skills, thus developing a sense of industry. This is also a very social stage of development and if the individual experiences unresolved feelings of inadequacy and inferiority among peers, he can have serious problems in terms of competence and self-esteem. As the world expands a bit, the most significant relationship is with the school and neighborhood. Parents are no longer the complete authorities they once were, although they are still important. A person at this developmental stage understands cause and effect and has some reasoning skills. While this age can learn healthcare skills, the school-age child will need reminders to maintain a regimen of treatment. Piaget’s Cognitive Development Concrete operations phase: During this stage, accommodation increases and the child begins to move from egocentrism to cooperation. The child develops an ability to think abstractly and to make rational judgments about concrete or observable phenomena, which in the past he needed to manipulate physically to understand. In giving instructions to this child, giving him the opportunity to ask questions and to explain things back to you allows him to mentally manipulate information. Kohlberg’s Moral Development Pre-conventional level: Morality is defined as obeying rules and avoiding negative consequences. Children in this stage see rules set, typically by parents, as defining moral law. They try to live up to these expectations. Whatever satisfies the child’s needs is seen as good andmoral. Conventional level: Older school-age children begin to understand what is expected of them by their parents, teacher, and other authority figures. Morality is seen as achieving these expectations. Fulfilling obligations as well as following expectations are seen as moral law during this stage. Fowler’s Spiritual Development Mythic-literal faith: In this stage, the individual will start sorting out the real from the make-believe. Beliefs, moral rules, and attitudes are held as literal truth. The individual is also more able to take the perspective of another person, but his view of reciprocity is also literal. 1.6 Adolescent: 12 to 18 Years Physical Development During puberty, growth accelerates and physical appearance may change dramatically. This typically happens by the age of 14 for girls, and by the age of 16 for boys. Because growth is so rapid, the adolescent is often uncoordinated and awkward. As the production of sex hormones increases, primary and secondary sexual characteristics begin to develop. For girls, this is usually seen first as the breasts begin to develop, followed by pubic hair. The onset of menarche is approximately two years after the breast buds begin to develop. Female reproductive organs are usually adult size by 20 years old. For boys, pubic hair and the enlargement of the scrotum and testes are usually the first signs of sexual development. A boy’s first ejaculation usually occurs around age 14 and full sexual maturity occurs by about 18 years.

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Common Health Problems Identified i thisStage During adolescence, the child is beginning to identify more with outside influences and less with the family. Some of the common problems in this stage include: • Motor vehicle accidents • Suicide and homicide • Falls, drowning, and poisoning • Drug and alcohol use and abuse • Sexually transmitted diseases • Unwanted/unplanned pregnancies Havighurst’s Developmental Tasks During this period, the developmental tasks include beginning to develop more mature relationships with peers, further development of appropriate social roles, accepting one’s own body, further development of independence from family, development of a solid ethical system, achievement of responsible behavior, and preparation for an occupation and starting one’s own family. Freud’s Psychosocial Development Genital stage: This stage begins at the start of puberty when sexual urges are once again awakened. Through the lessons learned during the previous stages, adolescents direct their sexual urges onto opposite sex peers. The primary focus of pleasure is the genitals . Erikson’s Psychosocial Development Expected outcome: Identity vs. role confusion Beginning in adolescence, development depends primarily upon what the individual does rather than what is done to her. Life becomes more complex as she attempts to find herown identity, struggle with social interactions, and grapple with moral issues. The task in this stage is to discover who she is as an individual apart from her family of origin and as a member of a wider society. If the individual is unsuccessful in navigating this stage, she will experience role confusion and upheaval. A significant task is to establish a philosophy of life, and in this process, the individual will tend to think in terms of ideals, which are conflict-free, rather than reality, which is not. During this stage, the individual will develop strong devotion to friends and causes. The most significant relationships during adolescence are typically with peer groups. Further, the adolescent is able to reason and understand teaching; however, peer pressure and a fear of being different may prevent the adolescent from following a regimen. Piaget’s Cognitive Development Formal operations phase: During this stage, the child has finally developed cognition to its final form. The individual no longer requires concrete objects to make rational judgments. At this stage, the adolescent is capable of hypothetical and deductive reasoning. Teaching for the adolescent may be much more diverse since she will be able to consider many possibilities from different perspectives. Kohlberg’s Moral Development Conventional level: Children begin to understand what is expected of them by their parents, teacher, and other authority figures. Morality is seen as achieving these expectations. Fulfilling obligations, as well as following expectations, are seen as moral law during this stage.

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Gilligan's Moral Development Pre-conventional level: In this level, the focus is on women caring for their own needs. They do not feel connected to others. Fowler’s Spiritual Development Synthetic-conventional faith: In this stage, authority is located outside the self and is enforced more in the church leaders, in the government, or in the social group. The person is not fully conscious of having chosen to believe something and beliefs are not the result of analysis. Most people in this stage see themselves as believing what “everybody else” believes. Many adults stop their spiritual development in this stage. 1.7 Young Adulthood: 18 to 40 Years Physical Development During this period, all systems function well in a healthy individual. Physical performance and strength peak during this period. Common Health Problems Identified in thisStage Young adults are typically healthy with most health problems related to: • Accidents • Suicide • Drug and alcohol abuse • Sexually transmitted diseases • Violence • Beginning to see some incidence of chronic diseases, such as hypertension and cancer Havighurst’s Developmental Tasks During this period, the developmental tasks include selecting and learning to live with a partner, starting a family, raising children, becoming established in an occupation, managing a home, and being involved in social and civic groups. Erikson’s Psychosocial Development Expected outcome: Intimacy vs. isolation In the initial stage of being an adult, the individual seeks one or more companions and love. As one tries to find mutually satisfying relationships, primarily through marriage and friends, they may also begin to start a family. If negotiation of this stage is successful, one can experience intimacy on a deep level. If they are not successful, isolation and distance from others mayoccur. In this stage, significant relationships are with life partners and friends. Since individuals at this age usually have little exposure to poor health, they may be unwilling to accept the fact of illness in themselves. This denial might block the individual’s willingness to participate in learning activities.

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Piaget’s Cognitive Development Piaget assumed that cognitive development was complete with mastery of the formal operations phase. However, other theorists posit that there may be a post-formal phase during which the individual develops the ability to problem solve, taking into consideration the relativity of knowledge. Kohlberg’s Moral Development Post-conventional level: As adults, individuals begin to understand that people have different opinions about morality and that rules and laws vary from group to group and culture to culture. Morality is seen as upholding the values of one’s group or culture. Understanding personal beliefs allows the adult to judge themselves and others based upon higher levels of morality. In this stage, what is right and wrong is based upon the circumstances surrounding an action. Basics of morality are the foundation with independent thought playing an important role. Gilligan’s Moral Development Conventional level: In this level, the focus is on women caring for others and not hurting others. They understand the value and need for caring relationships. Fowler’s Spiritual Development Individuating-reflexive faith: This stage requires that the person be willing to interrupt his reliance on external authority and relocate the source of authority within. The person is more able to govern him/herself without the need for rules from the outside. The person gains the ability to make comparisons and whatever meanings they retain are explicitly held and are more authentic. 1.8 Middle Adulthood: 40 to 65 Years Physical Development As hormones begin to decrease, men and women experience many changes during this period. When menstruation stops in women (usually by the age of 55), menopause ensues. During this time, women may experience hot flashes, insomnia, weight gain, and headaches. Although men go through a similar “change of life” called the climacteric, androgen levels decrease slowly and the changes are subtle. During this period, hair begins to thin and gray and the skin begins to lose turgor and fat, resulting in wrinkles. By age 60, both sexes will notice a decrease in muscle mass and an increase in abdominal fat. Vision and hearing (particularly high-pitched sounds) will begin to diminish. A slowing metabolic rate may lead to weight gain and bouts of constipation. Common Health Problems Identified in thisStage During the middle adulthood stage the individual continues to be relatively healthy, however the incidence of chronic illness begins to increase during this stage. Some of the common problems include: • Accidents • Cancer • Hypertension and cardiovascular disease • Pulmonary diseases • Alcoholism • Obesity

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Havighurst’s Developmental Tasks During this period, the developmental tasks include helping children to become responsible adults, relating to one’s partner, maintaining satisfactory performance in a career, fulfilling social and civic responsibilities, developing meaningful leisure activities, adjusting to the physiological changes of middle adulthood, and managing aging parents. Erikson’s Psychosocial Development Expected outcome: Generativity vs. stagnation During this stage, work is most crucial. Middle-age is when the individual tends to be occupied with creative and meaningful work andwith issues surrounding the family. Also, middle adulthood is when there is an expectation to “be in charge.” The significant task is to perpetuate culture and transmit values of the culture through the family, while working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, often called generativity, so when the individual is in this stage, he may fear inactivity and meaninglessness. As the children leave home, or as relationships or goals change, the individual may be faced with major life changes, also known as the mid-life crisis, and may struggle with finding newmeanings and purposes. If adults do not get through this stage successfully, they can become self-absorbed and stagnate. Significant relationships are within theworkplace, community, and family. The middle-aged adult may be beginning to have more health problems and may be more willing to learn and follow treatment regimens. Kohlberg’s Moral Development Post-conventional level: As adults, individuals begin to understand that people have different opinions about morality and that rules and laws vary from group to group and culture to culture. Morality is seen as upholding the values of one’s group or culture. Understanding personal beliefs allows the adult to judge him/herself and others based upon higher levels of morality. In this stage, what is right and wrong is based upon the circumstances surrounding an action. The basics of morality are the foundation, with independent thought playing an important role. Gilligan's Moral Development Post-conventional level: In this level, the focus is on women caring for self and others. Women see the need for balance and responsibility of caring for self and caring for others. Fowler’s Spiritual Development Conjunctive faith: In this stage, the person begins to expand their world beyond the black and white stance of the prior stage, toward a “shades of gray”orientation where the answers (and the power of the rational mind to figure them out) are not so clear. People in this stage are willing to engage in dialogue with those of other faiths in the belief that they might learn something that will allow them to correct their own truths. Middle-aged adults often find comfort in religion when faced with illness or the death of a loved one.

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1.9 Older Adults: Over 65 Years Physical Development Senescence is the progressive decline in body systems associated with age, and is a natural process. During this stage, it is critical that the nurse understand normal changes that occur in the aging process so that abnormal or disease-related changes can be quickly identified. Neuromuscular: Muscle and bone mass, reaction time, and strength begin to diminish. These changes may result in joint stiffness, loss in height, osteopenia and osteoporosis, and impaired balance. Sensory: All senses begin to decrease and the incidence of cataracts may increase, leading to even further diminishment of visual acuity. Gradual age-related hearing loss (presbycusis) occurs in most individuals. Cardiovascular: Diminished vascular tone and decreased arterial elasticity may result in decreased blood flow to the extremities, causing cool hands and feet and calf pain or tenderness. These changes can also result in orthostatic hypertension (a drop in blood pressure) as the individual stands up from a sitting or lying position. Pulmonary: Respiratory efficiency may be decreased due to diminished lung expansion and vital capacity in the lungs. Dyspnea (difficulty breathing) is often seen with exertion. Gastrointestinal: Indigestion and constipation may become common due to decreased motility in the intestines and decreased digestive enzymes. Urinary: Kidney function may be slowed, causing a slower excretion of wastes. The older adult may experience frequency and urgency as muscle tone diminishes, and they may be unable to completely empty their bladder. Genital: In older men, hypertrophy of the prostate may occur. Older women may notice a decrease in vaginal secretions. Skin: Skin will become less elastic and more fragile. With less subcutaneous fat and muscle tissue, the older adult will experience wrinkling and sagging of the skin and have diminished tolerance for cold temperatures. Common Health Problems Identified in thisStage In the older adult, the individual begins to experience a general decrease in strength, flexibility, and physical reserve. Specific problems might include the following: • Falls are responsible for the majority of fractures in older adults. During this stage, the individual is most at risk for developing and worsening chronic illnesses. Hypertension and heart disease, sensory impairments, arthritis, stroke, pulmonary disease, and cognitive dysfunction may appear or increase during this life stage. • Elder abusemay be an issue during this stage. This abusemay take the formof physical, mental,

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