Objectives
Upon completion of this 3 unit course, the learner will be able to:

1. Incorporate physical, psychosocial, developmental and cognitive age-related needs and characteristics into your roles and responsibilities for the following age groups:

• Infant
• Toddler
• Preschool child
• School age child
• Adolescent
• Young adult
• Middle aged adult
• Old adult

2. Incorporate safety, pharmacological, nutritional and other age-related characteristics and needs into your roles and responsibilities for the following age groups:

• Infant
• Toddler
• Preschool child
• School age child
• Adolescent
• Young adult
• Middle aged adult
• Old adult

3. Articulate and integrate JCAHO age-related expectations into the planning, implementation, continuation and evaluation of care.

JCAHO and Age Specific Competency

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires that all members of a health care facility who have patient contact be competent in age specific characteristics and needs. In other words, pharmacists, physical therapists, social workers, laboratory technicians, clinical dietitians, radiology technicians, registered nurses, licensed practical nurses, nursing assistants, care technicians and others are required to meet all of the Joint Commission's requirements related to age specific characteristics and needs, as dictated by the individual's particular job.

JCAHO requires, among other things, that all individuals with patient contact receive education and training related to the characteristics and needs of the age groups they come in contact with. If a nurse is employed in pediatrics and is responsible for the care of children from infancy to the age of twelve, the nurse must receive education and training for that age-range of children. However, if a nurse is employed at a medical center that cares for all age groups and is expected to float to all areas of the facility based on need, then the nurse must receive education and training for all age groups. The training must include characteristics and needs throughout the life span.

If a laboratory technician works in a pediatric hospital, she or he is required to receive education and training related to the ages of the children in that hospital. The rationale underlying the JCAHO requirements for age specific competency is related to the need to modify all aspects of care according to the characteristics and needs of the client. This is in accordance with modifications made with regards to any other of the client's needs, characteristics and preferences. Once the education and training are provided, JCAHO requires that this be documented on the employee's education record.

In addition to the initial training for age specific characteristics and needs, the Joint Commission on Accreditation of Healthcare Organizations requires that anyone with patient contact be continuously assessed for age specific competency. Every employee must be evaluated by her supervisor on how well she has modified various aspects of care for each age group.

Although JCAHO does not require Competency Checklists, it does require that all employees be assessed for competency with measurable, specific criteria. In order to accomplish this goal most organizations develop lists of competencies for evaluation - including those related to age specific characteristics and needs. A few organizations have been able to successfully compress job descriptions and competency criteria into one document.

Age Groups Defined

It is not always clear when one age category ends and another begins. Traditional adult age categories include young adult, middle age adult and older adult with only minor variations found in the literature. According to researcher and writer Gail Sheehy, there has seen a shifting of age group stages because children are growing up faster and adults are taking longer to grow old. Sheehy has redefined the traditional adult age groups as Provisional Adulthood (18-30), First Adulthood (30-45) and Second Adulthood (after the age of 45).1

Although the literature varies to some extent regarding the ages at which each group begins and ends, for the purpose of this course the age groups throughout the life span are defined as follows:

Age Group	Age Span
Infant	Birth to one year
Toddler	One to three years
Preschool child	Three to five years
School age child	Five to twelve years
Adolescent	Twelve to eighteen years
Young Adult	Eighteen to forty four years
Middle Age Adult	Forty five to 65 years
Old Adult	Over 65

As with all human characteristics, there is no clear-cut beginning or end to age groupings. Additionally, although the characteristics and needs may be typical for the specific age group this does not necessarily mean that all individuals in the age group have the same characteristics and needs. For example, a 68 year old man may not have any evidence of sensory impairment and may in fact be an exception to the rule about sensory deficits for the Old Adult. Age specific characteristics are not considered hard and fast rules but instead reliable guidelines that should be considered when providing care to clients of all different ages.

Developmental Needs of the Age Groups
The work of Erik Erikson,a developmental psychologist and author of Childhood and Society ² has been accepted as the framework for exploring the developmental characteristics and needs of age groups throughout the life span. Erikson has identified and defined eight major stages with accompanying tasks that must be met and resolved in order for the individual to progress through the life span in a complete and fulfilling manner. If for any reason an individual is unable to resolve the tasks associated with her age, she can suffer from incomplete and unresolved issues relating to personal development.2

Health care providers must take into consideration the major developmental challenges facing the patients they are caring for and adjust the care accordingly. For example, adolescents are often coping with the challenges associated with identity formation. Not only can hospitalization and serious illness affect an adolescent's sense of self it can also separate her from her peer group, a major force at this stage of life for defining who she is and how she acts and reacts.

Age Group	Task	Lack of Resolution
Infant	Development of trust	Mistrust Failure to thrive
Toddler	Autonomy Self control & will power	Shame & doubt Low tolerance to frustration
Preschool	Initiative Confident Has purpose & direction	Guilt Fear of punishment
School Age Child	Industry Self confidence Competency	Inferiority Fears about meeting expectations
Adolescent	Identity formation Devotion & fidelity Sense of self	Role confusion Poor self concept
Young Adult	Intimacy Affiliation & love	Isolation Avoidance of relationships
Middle Age Adult	Generativity Production Concern about others	Stagnation Self absorption Lack of concern about others
Old Adult	Ego integrity Wisdom Views life with satisfaction	Despair Life is meaningless

Cognitive/Learning Development of the Age Groups

Jean Piaget, a developmental psychologist, is considered by many to be the primary source on how humans from birth until age twelve develop in terms of cognitive or learning abilities. Piaget developed his theories after hundreds of hours directly observing children of all ages. His research suggests that children are able to process information and learn according to their age. Cognitive development, according to Piaget, is nearly complete by the age of fifteen when the child is able to think in an abstract manner. Piaget defined several stages of cognitive development - pre-operations, concrete operations and formal operations.

Pre-Operations. During the preoperational stage, the young child is not yet able to use abstract thinking or perform concrete operations like adding and subtracting using marbles or other concrete objects.

Concrete Operations. During the stage of concrete operations the child is still unable to use abstract thinking. For example, he or she is able to add simple numbers using marbles or other concrete objects without a thorough understanding of exactly what the numbers represent and what the meaning of addition is. The number five, for example means that there are five concrete objects that the child is able to hold and manipulate concretely.

Formal Operations. During the stage of formal operations the child has fully developed, complex, logical abstract thought and is able to manipulate abstract concept.

For members of the healthcare team, cognitive and learning development have many implications. Most obvious is the area of patient and family teaching. There are also implications in terms of diversion and entertainment, including the selection of games and television programs. The following age-related cognitive concepts should be considered:

Age	Stage	Features
Up to 2 years	Sensorimotor thought	6 substages Physical manipulation of objects
2 to 7 years	Preoperational symbolic functioning	Language development
7 to 11 years	Concrete operations	Logical reasoning Can solve concrete problems
11 to 15 years	Formal operations	Fully developed, complex, logical abstract thought Manipulation of abstract concepts

From birth until about the age of 2, young children learn how to separate themselves from the environment. They begin to manipulate concrete objects and to understand some of the meaning behind symbols. During the Preoperational Stage starting around age 2, preschool children begin to use and develop language and vocabulary and are better able to converse with others. They learn to count and begin to understand the concepts underlying numbers. They test and try things with trial and error. They learn well with discovery, trial and error. They ask a lot of "why" questions and are very inquisitive. They also begin to be able to draw conclusions, particularly when they are given materials and aids such as concrete objects to manipulate and use.

Young preschool children also think about the results of their actions and begin to manipulate objects. After this stage, about age 7, children move into the Concrete Operation Stage and begin to perform mental operations and logical reasoning. Intellectual development is usually completed between the ages of 12 and 15, a time period referred to by Piaget as the Abstraction Stage. During this time the child learns to think in an abstract way and no longer needs concrete items to manipulate. At this point, Piaget believes that children have completed the development of their cognitive processes.3

Safety Throughout the Life Span
The need for safety, one of our most basic of human needs, is of paramount importance to health care providers for all age groups of patients. During all phases of growth and development for the child and during the late years, safety needs are the greatest. For example, because infants are in the oral phase of development they tend to place small and inappropriate objects in their mouths. Within the home and within the health care facility attention to safety is important in order to prevent choking and accidental poisoning.

Other childhood characteristics that makes safety a primary concern include lack of impulse control, lack of good judgment, intense curiosity, inability to recognize dangers and the need to develop autonomy. For the aging adult sensory loss and cognitive impairment are among the degenerative losses that place older adults in danger of accidents. Confusion, loss of hearing and vision, poor judgment and the inability to recognize dangers are some of the reasons why healthcare providers must maintain a safe environment for the elderly.

Pharmacology Throughout the Life Span

Pharmacology dosage and route considerations vary according to the characteristics of virtually all age groups except for the young and middle-aged adult. For the infant, toddler, preschool and school age child dosage is determined according to the weight of the child in kilograms. By the time the child reaches adolescence most adult dosages are appropriate. As is the case with all medication administration, nurses must be knowledgeable about the medications they are administering and should question or clarify any medication orders that are unclear or possibly inappropriate.

For children, the oral route of administration is preferred. Obviously, young infants unable to swallow solids must be given liquid forms of a medication by mouth. Pharmacological implications for the infant, toddler and sometimes even the preschool child involve close monitoring of the effects of medication. In these age groups absorption and metabolic rates may be unpredictable.

For the aging adult there are special pharmacological considerations based on some of the distinguishing characteristics of this age group. Muscle atrophy, decreased bone density, diminished blood flow, decreased tissue elasticity, decreased peristalsis, and slowing of the basal metabolic rate leads to changes in physical functioning. As with young children, aging adults may have unpredictable absorption of medications and require close monitoring. A general rule to follow with the elderly is the start low (dose) and go slow.

If a swallowing disorder is present the method of delivery of medications must be modified. There are two common practices for patients with a swallowing disorder - crushing the medication and the use of a liquid form of the medication. There are, however, some medications that cannot be crushed. Time release or extended release capsules, enteric-coated tablets, sublingual medications, effervescent tablets and foul tasting medications should not be crushed. If crushing a tablet or capsule is contraindicated it is a good idea to consult with a pharmacist to determine whether an oral, liquid form is available.

Nutrition and Hydration Throughout the Life Span
Nutritional needs and considerations vary somewhat throughout the life span. Caloric requirements are greatest during infancy and adolescence and for young adults or adolescents who are pregnant or lactating. Infants require iron supplements and fat from whole milk. Infants should be introduced to solid foods at about 4 to 6 months of age starting with cereal. New foods should be added slowly so that any intolerance can be determined.

Toddlers enjoy finger foods and will begin to use utensils and cups instead of bottles or caregiver feeding. Preschool children will begin to develop food preferences and will also begin to develop the manual dexterity and skill necessary to use utensils. School age children prefer fast foods and dining with friends. Adolescents, despite their increased need for calories, protein, calcium, iron, iodine and B complex vitamins, demonstrate irregular eating patterns, a preference for fast food and snacks. It is also during adolescent years that eating disorders (bulimia and anorexia nervosa) and trendy diets may emerge.

In the absence of pregnancy or lactation, the nutritional needs of the young and middle aged adult are relatively constant except for a diminishing need for calories due to the slowing of the metabolic rate seen in the later portion of the middle years. For the aging adult, fewer calories are required as appetite and digestive processes diminish. Other factors that must be considered for this age group include the financial ability to maintain adequate nutrition, dentition, physical limitations and the ability to get to and from the grocery store. "Meals on Wheels" may be a resource for the home bound elderly patient.

Age Related Implications for Health Care Providers
There are many other aspects of care that must be modified based on age characteristics including patient/family education, discharge planning, motivational techniques, ability to participate with care, communication techniques and the impact of illness or hospitalization on the patient. For example, an infant is cognitively unable to learn or question, therefore, the focus of family teaching is the caregiver. Toddlers, on the other hand, have an ability to learn and ask questions. Since they have a short attention span and are concrete thinkers, any teaching with the toddler should consist of short, concrete explanations at their level of understanding. Very often dolls and puppets are useful teaching aides for the toddler.

Discharge planning is also impacted by age specific characteristics and needs. Community resources are often age related. For example, resources such as Alcoholics Anonymous have different groups for teens and adults. Reporting mechanisms and agencies for age related abuse also vary. Elder abuse/neglect and child abuse/neglect are assessed and addressed by different agencies.

As we attempt to motivate our patients for a learning activity our choice of technique should also be appropriate for the age of the client. For example, a school age child may enjoy reading a book at the appropriate reading level while an adolescent may enjoy group learning with peers, particularly if they have a common illness or health care concern. A patient's level of involvement and participation in care is also influenced by age. For example, although the school age and preschool child may have an opinion, decision making is legally placed with the caregiver. At the other end of the continuum of life, the aging adult may be limited physically and/or cognitively and unable to be involved in any physical and/or decision making aspects of their care.

The meaning of illness and the impact of hospitalization upon the patient varies according to the age of the patient. For the infant, illness and hospitalization means separation from the primary caregiver. For the school age child it means missing school. For the adolescent it means separation from the peer group. For the young adult an illness may jeopardize a job. For the older adult, illness may bring up issues relating to mortality and physical decline.

Age Specific Competencies

The following sections will review specific age related competencies and characteristics for each of the age categories previously discussed.

Infant (birth to one year)

Physical gains	Weight doubles by 6 months
	Poor temperature control
	Sensitive to fluid losses
	Immature immune system
	Nasal breather
Senses early weeks	Response to light and sounds
Senses later	Response to familiar faces and voices
Mid year	Can raise head, roll over and bring hand to mouth
End of year	Reflexes diminish and intentional actions begin Can crawl, stand and even walk alone or with help
Pulse	100 -160/min
Respiration	30 -60/min
BP	50 -100/25 -70

Psychosocial and Developmental Tasks

The infant is dependent on others for total care and will quickly begin to develop feelings of trust for the caregiver and the environment. The infant will begin to communicate with and have emotional relationships with others. The infant who has trouble with trust may demonstrate this mistrust by a failure to thrive.

Infants enjoys cuddling and touching, finger sucking and exploring the environment through taste and touch. Sleep/wake periods become established during infancy. Caregivers, siblings and other family members are the most significant people in the infant's life and his or her greatest fear is separation from the primary caregiver. The infant will begin to differentiate the primary caregiver from others.

Cognitive/Learning

The infant has a limited ability to communicate needs and will cry due to hunger and pain. He or she begins to follow simple commands, manipulate and move objects and learn by imitation. Towards the end of the year the infant may speak a few words and mimic sounds.

Safety Needs

Infants are unable to recognize dangers and should not be left unattended unless in a crib with the rails up. Avoid the use of pillows and keep medications, small objects and other unsafe items out of reach. Prevent heat loss with the use of blankets and be aware that the infant may choke on objects placed in the mouth. An appropriate infant car seat must be used.

Nutrition

Breastfeeding or iron fortified formula is recommended. Avoid nonfat or low fat milks. Caloric balance must be maintained and iron and fluoride supplements may be needed. Monitor food tolerance - strained foods begin at 4-6 months with 1 new food added each week. Infant cereal is usually the first food given - remember that aspiration is a risk at this age. Dental caries may result from the prolonged contact of milk, formula and juice on dental surfaces.

Patient Education

All teaching should be directed to the primary caregiver with emphasis on preventive care, immunizations, nutrition, bonding and safety. Allow caregivers time to ask questions and return demonstrate procedures. Encourage caregivers to participate in care to decrease separation anxiety. Provide emotional support to the family. Provide tactile stimulation and motor skill development with age appropriate and safe toys of large size and without small pieces.

Pharmacology

Monitor the infant closely for effects, since absorption and metabolism are not predictable. Remember that oral routes of administration are preferred and dosages are based on kilograms of body weight. Make sure medications are kept out of reach of the infant.

Other Considerations

It is important to promptly meet the needs of the infant by promoting close contact and allowing the infant to bond with the caregiver. Always use infant-sized objects for care such as BP cuffs, electrodes, catheters and other routine and emergency equipment and supplies. Be careful to support the neck when holding and handling. Provide a safe and "baby proof" environment and protect the infant from infections. Remember that suspected child abuse or neglect must be reported.

Toddler (one to three years)

Physical Gains	4-6 lbs/year
	Has 4-16 teeth
	Eats 3 meals a day
	Teething may continue
Stools	1-2 times a day
Voids	4-6 times a day
	Toilet training
Physical skills	Walks, runs and climbs, initially with an awkward, wide stance
	Throws and drops toys
	Able to stack blocks, scribble and enjoy age appropriate toys
	Moves from gross to fine motor coordination
	Parallel play with others
Senses	Responds to verbal stimuli

Psychosocial and Developmental Tasks

The toddler will struggle with autonomy, shame and doubt. Shame and doubt may manifest as a low tolerance for frustrations and a lack of confidence in self. During this phase of childhood, the toddler will begin to establish a core general identity and will tolerate brief separation from caregiver. There will begin to be less dependence on the caregiver.

The toddler will show emotions such as frustration, anger, jealousy, affection and the aggression and negativism of the "terrible twos". At this age the child is impulsive with little control and the caregiver will have to establish limits and controls. Language and communication abilities will increase and control of bowel and bladder function will develop. The caregivers are the most significant people in the toddler's life and the greatest fear is separation from the caregiver.

Cognitive/Learning (Preoperational)

The toddler is better able to verbally communicate needs than the infant. Vocabulary begins to develop as well as symbolic functions. A toddler can differentiate familiar people from others but is still unable to recognize dangers.

The toddler learns through exploration, discovery and imitation but has a short attention span. The child's concept of distance is only what can be seen and his or her concept of time is immediate and now.

A toddler seeks positive reinforcement and approval from the caregiver and is able to follow simple commands and understands concrete explanations. He or she begins to develop knowledge and skills with toys and storybooks and will demonstrate "magical thinking".

Safety Needs

The toddler must be closely monitored due to an exploratory, uninhibited and energetic nature. Medications, small objects and other unsafe items, such as chemicals and cleansers must be kept out of reach. Choking on objects is a threat and accidents and injuries may occur as autonomy increases. Car seats must be used.

Nutrition

The toddler has increased tolerance for a wider variety of foods and enjoys finger foods. He or she may continue to use a bottle or be breastfed but can begin to use a cup and spoon or fork for eating. The toddler requires less calories and more protein and is at increased risk for dental caries. Whole milk should be used until after 2 years of age.

Requirements:
2 servings of milk
1-3 oz of protein (24 gms)
4 servings of grains
4 servings of fruits/veg
1-2 tbs. of butter/margarine
Calcium, iron and vitamins A and C are important

Patient Education

Most teaching is directed to the primary caregivers with emphasis on preventative care, immunizations, nutrition, parenting and safety. Allow the caregiver time to ask questions and return demonstrate procedures.
Encourage the caregiver to participate in the toddler's care to decrease separation anxiety. Provide emotional support to the family and the toddler.

Toddlers benefit from simple, short and concrete explanations and instruction consistent with their vocabulary. The use of puppets, dolls and storybooks can facilitate learning and decrease anxiety.

Pharmacology

Monitor medications closely for effects, since absorption and metabolism are unpredictable in toddlers. Oral routes of administration of medications are preferred and dosages are usually based on kilogram of body weight.

Keep medications out of reach of the toddler.

Other Considerations

Promote close contact between the caregiver and toddler and encourage the caregiver to participate in the care of the toddler. Use appropriate sized objects for care such as BP cuffs, electrodes, catheters and other routine and emergency equipment and supplies. A pediatric pain assessment scale may remain useful if the toddler is in pain. Provide a safe and "baby proof " environment. Remember that suspected child abuse or neglect must be reported

Preschool Child (three to five years)

Physical Gains	Gains 5-6 lbs/year
	Has full set of 20 teeth
	Eats 3 meals a day
Stools	1-2 times a day
Voids	4-6 times a day
	Bowel and bladder training complete
Physical Skills	Fine motor function and coordination increased
	Can walk on tip toes, stand on one foot and hop
	Able to feed and dress self

Psychosocial and Developmental Tasks

The preschool child will be concerned with issues of initiative vs. guilt. Guilt may manifest with a fear of punishment and the lack of purposeful direction. The preschool child demonstrates curiosity about sexual differences - exploration and masturbation may occur. At this stage, the child increasingly tolerates brief separation from caregiver and begins to socialize and play with groups and peers. There is an increased awareness of self vs. others.

Language and communication abilities increase and there is less dependence on the caregiver. The preschool child begins to develop better impulse control but limits must still be maintained. The most significant people in the life of the preschool child is the child's family. The greatest fears are the unknown, the dark, being alone, nightmares, mutilation and fear of bodily injury.

Cognitive/Learning (Pre-Operational)

During the preschool years speech becomes more intelligible and the child will begin to speak in 4-6 word sentences. Vocabulary will increase by about 1,000 words. At this stage the child begins to reason logically, use abstract thought and differentiating right from wrong. Attention span increases.

The preschool child will learn his or her name, address and phone number and begin to differentiate familiar people from others. The child remains somewhat egocentric and unable to recognize dangers. He or she learns from and tells stories but also learns through exploration, discovery and seeking answers to questions - the "Why Phase". At this stage imagination increases.

Safety Needs

The preschool child still needs constant supervision and accidents and injuries remain as threats. Car seats must still be used.

Nutrition

The preschool child will begin to develop food preferences and dislikes. He or she will begin to use utensils with a higher degree of skill. Whole milk or low fat milk can be used.

Requirements:
16 oz of milk
1-3 oz of protein (24 gms)
4 servings of grains
4 servings of fruits/veg
1-2 tbs. of butter/margarine
Calcium, Iron & Vitamins A and C remain important

Patient Education

A sense of independence and control can be enhanced with increasingly more detailed information, as level of cognition increases. The preschool child is capable of most self care and ADLs but caregiver education remains important.

Emphasis continues on preventative care, immunizations, nutrition, parenting and safety. The use of puppets, dolls and storybooks can remain useful educational resources. Allow caregivers and the child time to ask questions and return demonstrate procedures. Provide emotional support to the family and the child, particularly in addressing fears about mutilation and pain.

Pharmacology

An oral route of administration is preferred. Dosages are usually based on kilogram of body weight. Keep medications and medical equipment out of reach of the child.

Other Considerations

Promote close contact between the caregiver and the child and also promote participation in care with caregiver. Use appropriate sized objects for care such as BP cuffs, electrodes, catheters and other routine and emergency equipment & supplies. A pediatric pain assessment scale may remain useful. Provide a safe environment and allow for rituals and routines. Suspected child abuse or neglect must be reported.

School Age Child (five to twelve years)

Physical Gains	5-6 lbs/year
	Baby teeth are replaced with permanent teeth
	Bowel and bladder patterns established
Physical Skills	Neuromuscular skills refined
	Balance improved
	Greater muscular strength
Pubescence	Despite wide variations, early signs may appear
	Females gain about 20-25 lbs. and grow 6 inches
	Males gain 15-20 lbs. and grow 5 inches
	Some clumsiness may occur as a result of growth spurts

Psychosocial and Developmental Tasks

During the school age years, a child must deal with issues of industry and inferiority. Inferiority manifests with feelings of inadequacy and fears about not meeting the expectations of others while industry is marked by competency, achievement and confidence in self. The school aged child will begin to assume responsibilities for household chores and school work and begin to develop moral and ethical behavior.

During this stage of development children seek independence from parental omniscience and authority and begin to depend on themselves. He or she learns gender appropriate behavior, attitudes and roles, forms lasting relationships with peers and strives to be accepted by the peer group. Peer groups are preferred over the family by the school aged child and there is a fear of loss of control and failure to meet expectations.

Cognitive/Learning

The school aged child is preoperational in early school age years and then moves to operational, logical thought. Logic and deductive reasoning replace concrete, literal and specific thinking. The child begins to move from attention to the present to an understanding of the meaning of the past and the future.

School aged children learn about a large variety of subjects from school teachers but may be reluctant to ask questions. They are able to articulate discomforts to some degree and have an increasing understanding of death and its finality. Finally, the school aged child begins to develop a limited understanding of anatomy, bodily functions and illness.

Safety Needs

Peer pressure may drive the scool aged child to act with poor judgment and as a result accidents remain a threat. Seat belts replace car seats

Nutrition

Prefers fast food and dining with friends.

Requirements:
Same as for the preschool child.

Patient Education

The school aged child has a sense of greater control and independence that can be enhanced with increasingly more detailed information as the level of cognition increases. The healthcare professional should provide the child with opportunities for decision making and self care and encourage questions and verbalization of feelings.

Pharmacology

Oral routes of administration are preferred. Dosages based on kilogram of weight are replaced with adult dosage based on body weight. Keep medications and medical equipment out of reach of the child.

Other Considerations

Provide for schooling, particularly with long periods of hospitalization and encourage peer contact. Promote self care and decision making but recognize that rebellious feelings may affect compliance with the medical regimen.

Support the family unit but recognize the child's need for privacy. Remember that peer pressure may surpass good judgment. Suspected child abuse or neglect must be reported.

Adolescent (twelve to eighteen years)

Physical Gains	Adult weight acheived
	Eruption of permanent teeth
	Greater muscular strength
Physical Changes	Rapid and marked changes particularly in terms of height and primary/secondary sexual characteristics
	Body hair and facial blemishes develop
	Vital signs approximate those of the adult
Dietary patterns	Variable appetite, food fads frequent
Lab values reached except:	Hematocrit level are higher in males
	Platelet and sedimentation rates are increased in girls
	White blood cells are lower in both sexes

Psychosocial and Developmental Tasks

The adolescent will struggle with identity formation vs. role confusion.

Identity is demonstrated by devotion, fidelity and sense of self while role confusion may manifest with a poor sexual and/or self concept. Hospitalization may threaten self identity. Wide mood swings, anger and outbursts may occur. Separation from peers causes concerns.

The adolescent is often critical and confused about appearance and body changes and concerned about self image and being accepted. Relationships with the opposite sex take on new meaning. There may be conflicts with authority and rules and a longing for independence but also a desire for dependence.

The most significant people in the world of the adolescent are peers and the greatest fear is appearance, acceptance and school performance.

Cognitive/Learning (Operational)

The adolescent has fully developed cognitive abilities with logical thought and an ability for abstract, deductive and analytical reasoning. Adolescents are able to understand hypothetical situations and form independent opinions. There is the beginning of occupational identity and learning, " I want to be ...". The adolescent may be reluctant to admit that he or she does not understand something and has a limited understanding of body structures and functions.

Safety Needs

Peer pressure may drive the adolescent to act with less than good judgment, therefore accidents remain a threat. Suicide rates and depression among adolescents are high. There may be experimentation and use of cigarettes, drugs and/or alcohol.

Nutrition

The adolescent prefers fast foods and dining with friends. Eating patterns are irregular and snacks comprise about 25% of a teenager's diet.

Requirements:
Caloric needs increase because of increased metabolic demands
Girls: 2200 cal/day
Boys: 2500- 3000 cal/day
Need for more:
Protein
Calcium
Iron
Iodine
B Complex Vitamins
Pregnant teens have increased metabolic demands
Nutritional status may be compromised due to fast food, weight loss diets, skipped meals, etc.

Patient Education

A sense of greater control independence can be enhanced with increasingly more detailed information. The healthcare professional should provide opportunities for decision making and self care. Encourage questions and verbalization of feelings.

Pharmacology

Usually adult dosages/routes.

Other Considerations

Encourage peer contact but recognize that peer pressure may surpass good judgment. Promote self care and decision making and recognize the need for privacy. Rebellious feelings may affect compliance with the medical regimen.

Provide for schooling, particularly with long periods of hospitalization.

Assess for depression and encourage the use of stress reduction techniques. Refer to appropriate youth support groups

Young Adult (eighteen to forty four)

Physical gains and changes	All areas of physical and motor development complete
	Adult lab values are reached
	Gradual slowing of physiological functions
	Tissues have less capacity to regenerate
	Degenerative changes such as arthritis
	Loss of skin elasticity
	Atrophy of reproductive systems begins

Psychosocial and Developmental Tasks

The young adult is concerned with the issues of intimacy vs. isolation. Intimacy is demonstrated by the capacity to develop and maintain intimate friendships and an intimate love relationship while isolation may manifest with poor self esteem and withdrawal. The young adult will begin to establish a personal identity and an acceptance of self.

Major stressors include finding a career, establishing a family, balancing numerous roles and responsibilities at home, work, school and in the community and child rearing. The most significant people in the young adult's life are the spouse, children and co-workers. The greatest fear is the loss of work or social relationships.

Cognitive/Learning

The young adult forms his or her own opinion and makes independent decisions.
Life experiences provide learning.


Safety Needs

Major causes of death result from stressors of this age group and the impact of unhealthy lifestyles adopted in earlier years.

Nutrition

Requirements:

Dairy: 2 or more servings
Protein: 2 or more servings
Grain: 4 or more servings
Fruits/Veg: 4 or more servings
1-2 tbs. margarine/butter
Obesity may occur

Needs of the pregnant mother:
Pregnancy weight gain: 22 to 35 lbs
Protein: 60 gms
Iron: 30 mg/day
Calcium: 1200 mg/day
Iodine: 25 ug
Vitamin A, B, folic acid, vitamins C and D needs increase
Avoidance of ETOH

Needs of the lactating mother:
Protein needs: 65 gms
Iron: 30 mg/day
Calcium: 1200 mg/day
Iodine: 25 ug
Vitamin A, B, folic acid, vitamins C and D needs increase
Avoidance of ETOH

Patient Education

Include significant other in education and provide opportunities for decision making and self care. Allow the young adult to verbalize fears and concerns and emphasize the importance of regular physicals and health care screenings.

Pharmacology

Adult dosages/routes

Other Considerations

Promote self care and decision making. Use stress reduction techniques and encourage exercise.

Middle Aged Adult (forty five to sixty five)

Physical	Continued slowing of physiological functions
	Continued inability for tissues to regenerate
	Lower Basal Metabolic Rate (BMR)
	Degenerative changes continue
	Loss of skin elasticity and moisture continues
	Decalcification and reabsorption of bone, diminished bone density and osteoporosis, especially in women
	Farsightedness
	Beginning of loss of hearing, taste, balance and coordination
	Atrophy of reproductive systems continue
	Menopause which may be associated with depression

Psychosocial and Developmental Tasks

The middle aged adult is concerned with generativity vs. stagnation.

Generativity is demonstrated by tasks that nourish and nurture such as managing a household, rearing children and caring about the next generation.

Stagnation can be demonstrated by self absorption. Stressors include career, family, balancing roles and responsibilities at home, work, school and in the community. Midlife crisis and empty nest syndrome may add additional stress.

The middle aged adult may have to sandwich responsibilities between aging parents and children. Challenges include financial and emotional security and letting go of parental authority. The most significant people in the middle aged person's life are the spouse, children and co-workers. Greatest fears include loss of youth, work and social status and disenchantment with work.

Cognitive/Learning

The middle aged adult forms his or her own opinions and makes independent decisions. Life experiences provide learning.

Safety Needs

None notable.

Nutrition

Obesity may occur due to the slowing of the BMR (Basal Metabolic Rate).

Patient Education

Include significant other in education and provide opportunities for decision making and self care. Allow the middle aged adult to verbalize fears and concerns and emphasize the importance of regular physicals and health care screenings.

Pharmacology

Adult dosages/routes.

Other Considerations

Promote self care and decision making and encourage the use stress reduction techniques. The most common health problems in this age category are:

Cardiovascular disease
Cancer
Cirrhosis
COPD
Signs and symptoms of menopause

Old Adult (over sixty five)

Physical	Diminished function
Muscular	Muscle atrophy
	Diminished strength
Skeletal	Bones brittle and subject to breaking
	Joints painful and stiff
	Decreased mobility
Cardiovascular	Less cardio force
	Arteries less elastic and narrower
	Less blood flow
	Reduced blood flow to brain
Respiratory	Respiratory muscles weaken
	Lung tissue less elastic
Urinary	Kidney function decreases
	Urine more concentrated
Gastrointestinal	Diminished appetite, peristalsis and digestive juices
Integumentary	Skin less elastic, dry skin
	Graying/thinning of hair, thick and tough nails
Nervous	Decreased hearing, vision, taste, smell, touch, balance
	Forgetful, short term memory, confusion, loss of brain cells

Psychosocial and Developmental Tasks

The old adult is concerned with the issues of ego integrity vs. despair. Integrity manifests with wisdom and feelings of satisfaction with one's life while despair arises from remorse about what could have been. The presence of despair causes life to be viewed as meaningless.

Stressors include loss of friends, spouse, loss of mental and physical health and preparing for one's own death. The old adult may be introspective and spend time reviewing his or her life. Challenges include coping with physical decline and death. Significant people include the spouse, children, grandchildren and friends. The greatest fears include loss of spouse, declining health, changes in economic security and changes in social status.

Cognitive/Learning

The older adult may be faced with diminished memory and learning abilities and a limited ability to communicate.


Safety Needs

There is a significant increase in safety risk due to sensory and cognitive impairments. The older adult may be unable to recognize dangers and may be at increased risk for falls. The healthcare provider should assess for confusion and/or agitation.


Nutrition

The older adult has a decreased metabolic rate and requires less calories than the younger adult. Factors influencing nutritional health:

Income
State of health
Dentition
Physical limitations
Taste acuity changes
Transportation
Isolation

Factors that may improve food intake:

Position patient upright
Offer smaller, more frequent meals
Adjust food intake to activity level
May require pureed foods and nutritional supplements

Patient Education

The older adult may have a limited ability to understand. Include significant other in education and decision making and allow the patient to verbalize fears and concerns. Present material in a slow and understandable manner in short sessions and avoid distractions. Use large print materials and simple pictures or drawings.

Pharmacology

The older adult should receive adult dosages and routes but keep in mind that age affects absorption, metabolism and excretion. There may be idiosyncratic and untoward effects. Use aids such as medication dose calendars, daily pill boxes, etc.

Other Considerations

Promote self care, decision making and as much independence as possible.
Assess fall risk and nutritional status. Initiate advanced directives if desired by patient. Remember that hospitalization may cause confusion. Discharge planning must begin early since many people need continued support and care in the community or alternative placements. Assess for and intervene for the hazards and problems associated with immobilization.4

Conclusion

In order to provide quality care to all of our patients it is necessary to modify aspects of care according to a variety of characteristics and needs specific to the individual patient. Some of these modifications require that we consider such differences among patients as culture, personal preferences, religious affiliation and age specific characteristics. Keep in mind that it is unwise to stereotype and categorize patient needs according to chronological age or any other label, including those characteristics related to the various age groups throughout the life span should be considered and used as guidelines for modifying and individualizing care in order to attain the best possible outcome for the patient.

Copyright © 1999-2000 Alene Burke (reprinted with permission)

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References
Books with links can be bought at Amazon.com

1. Sheehy G. New Passages: Mapping Your Life across Time. New York: Ballantine Books, 1995.

2. Erikson E. Childhood and Society, 2nd Edition. New York: WW Norton, 1963.

3. Schuster C and Ashburn S. The Process of Human Development: A Holistic Life Span Approach. Boston: Lippincott, 1992.

4. Alspach JG. A Framework for Assessing Age Related Competency: Distinguishing Attributes of Various Age Groups. Pensacola, Florida: National Nursing Staff Development Organization, 1996.