Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.


Eleven- to Thirteen-Year Visit (Preadolescent)

Mary J. Alvarado and Beth Richardson

Acne, 706.1

HIV, 042


Coronary artery disease, 414

Peripheral vascular disease, 443.9


Depression, 311

Physical abuse, 995.54


Emotional abuse, 995.51

Scoliosis, 737.3


Goiter, 240.9

Sexual abuse, 995.53



A. Preadolescence is time of rapid change and emotional turbulence.

B. Need support, understanding, caring from adults in particular, which is not usually what they receive.


A. Nutritional requirements.

1.  Increased energy and protein requirement due to rapid growth.

2.  Require 2200-3000 calories/day.

3.  To meet increased need, increase milk and dairy products to 4 servings/ day, bread group servings to 9 servings/day.

4.  One-fourth of daily calories is typically consumed in snacks; encourage fruit, cheese, milk beverages, raw vegetables, nuts.

5.  Diet should consist of 10-15% protein, 25-30% fat, 50-60% carbohydrates.

6.  Needs 8-15 mg of iron/day; iron is most commonly deficient nutrient.

7.  A well-balanced diet does not require supplementation; irregular eating patterns and/or high-calorie/low-nutrient snacking may lead to deficiencies requiring multivitamin.

B. Nutritional assessment.

1.  Calculate and plot body mass index (BMI) (see Appendix D).

2.  Evaluate 24-hour recall.

3.  Examine intake, eating patterns; ask about special diets or supplements.

4.  Assess for eating disorders.

5.  Monitor athletes' increased need for calories; advise on appropriate dietary changes.

6.  Provide guidance about nutrition annually.

7.  Refer to nutritionist if indicated.


A. Expect consistent pattern of elimination.

B. Changes may occur with irregular eating patterns, illness, diets, stress, eating disorders.

C. Check understanding of normal elimination and methods employed to deal with problems.


A. Question about amount of sleep; at least 8 hours/night.

B. Age and activity level.

C. Monitor for any difficulties, ability to cope.

D. Advise on sleep hygiene if necessary.


A. Physical.

1.  Early adolescence is marked by rapid physical change. Tempo of adolescent development is variable and may be influenced by gender, health, socioeconomic status, genetics. Predictable sequence of events occurs over 2-6 years from onset, which on average is age 9-11 for girls and age 10-12 for boys. The preadolescent may prefer to be examined with parent out of the room.

2.  Perform complete physical exam with attention to the following:

a. Document height, weight, and BMI annually (see Appendix D).

b. Assess and document Tanner stage of pubertal development annually.

c. Monitor blood pressure annually.

d. Screen cholesterol once in this age group if following risk factors exist:

• Parent with serum cholesterol > 240.

• Family history unknown.

• Parent/grandparent with stroke, peripheral vascular disease, coronary artery disease, sudden cardiac death younger than 55 years.

e. Palpate thyroid gland; goiter may present in this age group.

f. Examine spine for development/progression of scoliosis during rapid growth.

g. Assess for presence/severity of acne.

h. Ask about sexual activity; screen sexually active teens for sexually transmitted infections (STIs), evaluate risk for acquiring HIV.

B. Emotional.

1.  Rapid physical changes of early adolescence lead to increased self consciousness and focus on external characteristics.

2.  Adolescent feels everyone is looking at him/her and questions if he/she is normal.

3.  Reassure about normal findings in the physical exam.

4.  Explain that each individual progresses through physical changes of adolescence in same sequence but at his/her own pace.

5.  Ask about friends, family, school. Is there a best friend? A supportive adult? Monitor self-esteem.

6.  Ask about moods. Emotional lability is normal. Assess for excessive stress or depression.

7.  Ask about physical, emotional, or sexual abuse.

8.  Discuss safe use of Internet and online social networks. Remind to use caution when sharing personal information, photos, and videos by Internet and phone.

C. Intellectual.

1.  Adolescent begins to transition from concrete to abstract thinking; timing is variable. Some develop higher level thinking in early adolescence, some later or not at all. Individual may be able to think abstractly about algebra but not about decision making regarding risky behaviors. Abstract thinking gives adolescent better ability to reason and see other points of view.

2.  How is school performance? Ask about academic, athletic, personal goals. May still have impractical/unrealistic ideas.

3.  What are responsibilities at home? Early adolescents should be encouraged to take on new responsibilities with supervision.

4.  Ask about extracurricular activities. Encourage involvement in groups that interest him/her. Increasing communication skills help with problem solving. Group discussions help adolescents learn to express themselves.

5.  Advise to keep TV viewing, computer time, video games to < 2 hours/day. These activities interfere with opportunities to engage in communication with peers, family.


A. Early adolescents begin to develop greater independence from parents, family.

B. Establishment of reliable relationships with peers, other adults is important developmental task.

C. New peer group, which is usually same sex, provides opportunity to test, evaluate values/behaviors. It allows for sense of belonging, self-worth and affords opportunity to build social competence.

D. Recognize that hairstyles, clothing, music preferences, piercing are expressions of individuality; often mirror others in peer group.

E. Preoccupation with own appearance is typical. Help parents anticipate greater privacy need.

F. Encourage variety of school/community activities to allow wider exposure to peers/interests.

G. Testing authority may occur. Encourage families to clearly establish and enforce guidelines for appropriate behavior. Identify consistent caring adult with whom adolescent is comfortable communicating.

H. Question about friends, peer groups, adult role models. Social isolation is not normal.

I. As with other areas of development, individuals progress at variable rates and often oscillate between dependence/independence.


A. Immunizations should be given according to recommended childhood immunization schedule (see Appendix A):

1.  Hepatitis B: complete or initiate series.

2.  MMR: give second dose now if not already administered.

3.  Tetanus toxoid (Tdap): recommended at age 11-12 if at least 5 years since last dose. Subsequent doses every 10 years throughout adulthood.

4.  Varicella: give if not previously immunized or unreliable history of disease. If 13 years or older, give 2 doses 4 weeks apart.

5.  Mennigococcal: (MCV).

6.  HPV: recommend initiating series for males and females.

7.  Influenza: recommend annually at start of flu season.


A. Unintentional injury is main cause of death and disability in this age group.

1.  Counsel about accident prevention: seat belts, helmets, proper sports equipment, water-safety instruction, CPR.

2.  Instruct that firearms should be locked up, ammunition kept separate.

3.  Educate about dangers of drug use, both ingested and inhaled. Provide strategies to resist negative peer pressure.

4.  Discuss date rape prevention.

5.  Assess for depression. Adolescents at high risk for suicide: those with chronic illness or extreme stress (i.e., overachievers), athletes, those who feel unwanted.

6.  Assess for physical, emotional, sexual abuse.


A. Promotion of health.

1.  Review pubertal development of same and opposite sex.

2.  Explain menstruation and its management to females.

3.  Advise to get 8 hours of sleep every night.

4.  Encourage moderate to vigorous exercise for 30-60 minutes at least 3 times a week.

5.  Instruct to eat 3 nutritious meals/day. Snack on healthy foods such as fruits, vegetable, nuts, low-fat dairy. Choose foods rich in calcium, iron.

6.  Encourage maintaining healthy weight through exercise, appropriate eating habits.

7.  Remind to schedule dental exam every 6 months. Brush teeth twice a day. Floss daily.

8.  Educate about acne management.

9.  Provide safety instruction, avoidance of substance abuse and gang involvement.

B. Social development.

1.  Encourage participation in school activities.

2.  Advise to take on new responsibilities in home, school, community.

3.  Clarify parental limits, consequences of unacceptable behavior.

4.  Educate about safe use of the Internet and how to avoid exploitation.

C. Mental health.

1.  Encourage teens to consider their strengths and talents.

2.  Recommend talking with trusted adult/health professional if teen feels sad or helpless often.

3.  Advise against alcohol, drug use. Discuss strategies to resist negative peer pressure.

4.  Evaluate for potential abuse, counsel on avoiding date rape, gang involvement, abusive relationships.

D. Sexuality.

1.  Counsel on sexual abstinence. Encourage to identify supportive adult to provide accurate information. Invite adolescent to call the office for advice/information as needed. Explain confidentiality policy.

2.  If sexually active, discuss contraceptive methods, STI prevention. Counsel on abstinence.

3.  Educate about protection against STIs and pregnancy as indicated.


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Fisher J, Wildey L. Developmental management of adolescents. In: Burns C, et al., eds., Pediatric Primary Care: A Handbook For Nurse Practitioners. 3rd ed. Philadelphia: W.B. Saunders; 2004.

Fox J, ed. Primary Health Care of Infants, Children, and Adolescents. 2nd ed. St. Louis: Mosby; 2002.

Green M, Palfrey J, eds. Bright Futures: Guidelines For Health Supervision Of Infants, Children, and Adolescents. 2nd ed. Arlington, VA: National Center for Education in Maternal and Child Health; 2002.

Neinstein L. Adolescent Health Care: A Practical Guide. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002.

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