exam 1 Flashcards
Erikson’s stages of development
Infant- Birth-1yr
Trust vs. Mistrust
Toddler- 1-3yrs
Autonomy vs. Shame and Doubt
Preschool- 3-6 yrs
Initiative vs. Guilt
School-age- 6-10yrs
Industry vs. Inferiority
Adolescent- 10-18yrs
Identity vs. Role Confusion
appropriate nursing care for: infant
NURSING CONSIDERATIONS:
knowing how to appropriately play
PSYCHOSOCIAL DEVELOPMENT Stranger Anxiety Separation Anxiety Temperament Object permanence
Most infants double their weight by 4 months and triple weight by one year of age.
Height is increased by 50 percent at 1year of age
GROSS MOTOR DEVELOPMENT 1 month: Lift and turns head 2-3 months: Raises head/chest, slight head lag pulling to sitting 4-5 months: Roll-over 6-8 months: Sitting 9 months: Crawling 10 months: Pull to stand, cruising 12 months: Sit from standing position, walking
FINE MOTOR DEVELOPMENT
1 month: Fist clenched, involuntary
5 months: Grasps rattle
6 months: Releases object in hand to take another
8 months: Gross pincher grasp
10 months: Fine pincher grasp
12 months: Feeds self with cup and spoon, pokes with index finger
appropriate nursing care for: toddler
NURSING CONSIDERATIONS Toddlers may rely on a security item. Giving toddlers choices Allowing some control Potty training Separation Anxiety Parallel play Safety issues
PSYCHOSOCIAL DEVELOPMENT
Language- 12 months of age when a toddler begins to understand common words, but may still use pointing fingers to indicate their wants.
By 36 months- understands most sentences and speech is usually understood by those who know the child (half understood by outside of family)
Temper tantrums
PHYSICAL GROWTH
12-15 months
Walks independently, uses index finger to point, feed self finger foods
18 months
Climbs stairs, pulls toys while walking, stacks blocks, turns pages, removes shoes and socks
24 months
Runs, kicks balls carries several toys, climbs on furniture, stacks 6 cubes, turns knobs, scribbles, R or L handed
36 months
Pedals tricycle, walks up and down stairs alternating feet, undresses self, copies circle, hold pencil in writing position, stacks 9 cubes
appropriate nursing care for: preschool
NURSING CONSIDERATIONS
Magical thinking may be a “good” or “bad” thing
Play is important (ie, medical play, therapeutic art, transitional objects)
Safety issues with strangers, water safety, car seats
Establishing a routine is important
Sometimes view medical treatment as a punishment
PHYSICAL
Much better coordination with walking, running, jumping, climbing
Able to draw shapes, eventually print letters (5y)
Learns to be more independent with self care, at 5years begins to tie shoes
PSYCHOSOCIAL DEVELOPMENT Likes to please parents Initiates activities with other children Acts out roles (domestic mimicry) Develops a conscience Magical thinking
appropriate nursing care for: school aged
NURSING CONSIDERATIONS
Less fearful of harm to their body, but worried about surgery and being kidnapped.
Praise and sense of accomplishment is important to this age group
Consider teaching self injections and encourage child to perform treatments independently
Rewards/punishment/positive reinforcement
PHYSICAL
Early school years vs. later school years
All 20 teeth are lost
Some secondary sex characteristics start to show
Gross motor and fine motor skills improve (sports, playing instruments)
PSYCHOSOCIAL Principle of Conservation- same amount of fluid in both glasses Self esteem develops Group play, team sports high reward
appropriate nursing care for: adolescent
NURSING CONSIDERATIONS Develop trust. Involve peer interaction when warranted. Be aware of body image focus. Speak to them as equal. Consider Tanner’s stages. Provide opportunities to maintain independence. Allow child to participate in decisions.
PSYCHOSOCIAL DEVELOPMENT
Focuses on bodily changes and outward appearance.
Frequent mood changes.
Importance placed on conformity to peer norms and acceptance from peers.
Defines boundaries with parents and authority.
Identifies with same-sex peers.
Egocentric thinking.
Thinks of themselves as invincible
medication administration in hospitalized client
5 R’s
3 checks
check name band and ask parent
choose the least invasive route
different types of play
Medical play: Helps them see what will happen and lessen their fears Or correct misconceptions
Using play/expressive activities to minimize stress
Diversional activities
Toys
Expressive activities
Therapeutic play
Dramatic play
tv, games, songs, videos
normalizing hospital environment: treat it like its home
family’s role in care
family centered care: take care of the parents as well
stressors: Separation from parents and loved ones Fear of the unknown Loss of control and autonomy Bodily injury resulting in discomfort, pain, and mutilation Fear of death
sibling reactions: Loneliness, fear, worry Anger, resentment, jealousy Guilt ENCOURAGE SIBLINGS TO VISIT
STRESSORS AND REACTIONS FROM FAMILY Disbelief, anger, guilt Especially if sudden illness Fear, anxiety Related to child’s pain, seriousness of illness Frustration Especially related to need for information Depression
PHASES OF SEPARATION ANXIETY
Protest phase: crying & clinging
Despair phase: no crying, isolating
Detachment phase: happens after being hospitalized for a long time- start to forget who their parents are d/t so many people coming in and out of the room
Infants’ Needs Trust Toddlers Needs Autonomy Preschoolers Magical thinking, guilt School age Independence Adolescents Independence, peers
calculating maintenance
(100x10)+(50x10)+(20x_)
shock treatment
Shock is circulatory FAILURE- causes may be different, but results are the same
Hypovolemic shock- reduction in circulating blood volume (in this case extracellular fluid loss)
Manifestations- hypotension, poor perfusion, tachycardia, lethargy
Tx- Bolus 20ml/kg of Normal Saline or Lactated Ringers, rapid, until good UOP and VS have returned to normal. Then keep maintenance fluids going until able to take PO
dehydration classifications
Mild <50ml/kg TBW loss in 48hr period-
Up to 5% loss of body weight
Moderate 50-90 ml/kg TBW loss
5-9% loss of body weight
Severe >/or equal to 100ml/kg TBW loss
10% or higher loss of body weight
CLINICAL MANIFESTATIONS MILD Few loose stools Pale Tacky mucous membranes VS unchanged Normal behavior 1.020 Specific gravity of urine
MODERATE Several loose watery stools Decreased urine output Irritable Gray color Dry mucous membranes Slightly depressed anterior fontanel Increased pulse, BP normal or slightly low, Capillary refill 2-3 seconds 1.020-1.030 specific gravity
SEVERE Lethargic Mottled Skin Parched mucous membranes Little to no urine or stool output Sunken anterior fontanel Rapid pulse, lower blood pressure Capillary refill greater than or equal to 3 seconds. 1.030 > specific gravity
assessment and causes of dehydration at all ages and recovery
HEALTH HISTORY Medical history Onset and progression Chief complaint History of vomiting: Contents/character Effort and force Timing History of Diarrhea: Stool description Medical history
PHYSICAL ASSESSMENT Well Appearing Look/Listen/Feel S/S of dehydration Mild/Moderate/Severe Isotonic, hypotonic, and hypertonic dehydration
DIAGNOSTICS Laboratory Stool culture Radiologic Xray, ultrasound, CT scan
RISK FACTORS IN CHILDREN
-Greater amount of total body water (TBW) than adults
Age, sex, body fat content
Extracellular fluid (ECF)
-Immature Kidney function
-Greater vulnerability to severe electrolyte losses
-Higher metabolic rate
rehydration process: oral, IV, calculate caloric requirements
Oral rehydration
Mild to moderate dehydration resulting from vomiting
0.5-2oz oral replacement every 15 minutes
Increase as tolerated
. Wait 1-2 hours after last emesis and then introduce an appropriate rehydration solution: pedialyte for an infant up to 1 year, Gatorade beyond. Do not give carbonated beverages or sugary juices for this process
-IV fluids Used when not tolerating oral rehydration Requires IV access Strict calculations! -Maintenance Therapy
Caloric requirements
Accurate weight and height is necessary
-Can change quickly with growth spurts or illness
-Convert to Kg ( Lb/2.2=Kg)
-Calculate with every growth spurt or drastic change
Assess the child’s intake at home
breastfeeding and formula
Infant formula feedings
Calories/ounce the client consumes in 24 hours is considered
Standard formulas, nonfat cow’s milk-whey/casein base
Enfamil
Similac
Carnation- Good Start
Lactose intolerant-soy based
Prosobee
Isomil
Nusoy
Others
Malabsorption, carb intolerant/protein modified
Specialty Formulas, impaired renal, GI, and CV functions
Standard formula is 20cal/oz, including breast milk
-Older Child
Measure consumption by percentages
Calorie counts will often be ordered in the hospital and done per institutional requirements and policy
BREASTFEEDING
Difficult to quantify unless mom is pumping
Measure in minutes
Discuss with mom the quality of the suck: constant, sleepy, ect.
Can fortify milk with formula if baby isn’t gaining weight
Increases calories of the breastmilk while still allowing mom to pump
Lactation
Always initiate when in the hospital
Can be initiated by the nurse
Clinical manifestations of CF
Vary widely & change as progresses RESPIRATORY Wheezing Nonproductive cough>chronic> becomes paroxysmal Irregular aeration Secondary infection Dyspnea Cyanosis, clubbing fingers, barrel chest
REPRODUCTIVE SYSTEM
Delayed puberty
Infertility
Pregnancy- inc premature birth, LBW
INTEGUMENT
Abnormal high sodium & chloride concentrations
Limited fluid stores- rapid developing dehydration
Diminished protein absorption- inc edema
GASTROINTESTINAL
Meconium ileus: a baby’s first stool is blocking the last part of the baby’s small intestine (ileum)
Constipation>obstruction
Obstruction pancreatic duct
Large, frothy, loose stools with foul odor
FTT: failure to thrive, late puberty
Vitamin deficiencies
Clinical manifestations of Epiglottitis
Febrile- >39 Tripod position Sitting upright and leaning forward with chin thrust out Mouth open Tongue protruding Sudden onset Complete obstruction may occur 6-12 hrs Three cardinal signs: 1. No spontaneous cough 2. Drooling 3. Agitation Cherry-red edematous epiglottis Severe inspiratory stridor No hoarseness
Clinical manifestations of Asthma
General appearance can vary from pink to eventually cyanotic
Work of breathing increased with increased accessory muscles and head bobbing
Audible wheezing present
Wheezing and coarseness on ascultation
Appears anxious or lethargic
Airway can be severely obstructed (no wheezing heard)
Barrel chest in persistent severe cases
Clinical manifestations of Bronchiolitis
URI symptoms for several days Sneezing Clear nasal drainage Difficulty feeding Cough may develop Wheezing, rales, retractions Hospitalized resp >60/min, <6 weeks age, or has other chronic respiratory illnesses
Specific treatment for CF including diet, respiratory, medications, follow-up care, initial diagnostic testing
Primary treatment goal is effective airway clearance
CPT 2-3x/day
Flutter mucus clearance device
High frequency oscillating device
Recombinant human D’Nase 1x/day inhaled
Fat-soluble vitamins
Pancreatic enzymes
Bronchodilators and inhaled corticosteroids, if hx asthma
Well balanced, high-protein, high-caloric, moderate fat
Free water & salt
Antibiotics
Bronchoscopy- NPO until gag reflex returns
Lung transplant- wont cure but will prolong
Take enzymes with every meal and snack so they can absorb nutrients
chest physiotherapy
Respiratory & GI assessment Monitor oxygen administration carefully Cough assist & assist with other therapies (CPT) Nutrition & fluid management Medication administration Skin care Education home care Psychological support child & family
DIAGNOSIS Sweat chloride test (Gold standard) Newborn screening Need 2 positive results of 60 meq/liter of chloride for diagnosis Chromosome testing PFT’s Chest x-ray Stool analysis for fat & enzyme Sputum culture Infant & child- staph aureus & haemophilus influenza Adolescent- pseudamonas aeruginosa
normal pediatric Vital signs (ie. O2 Saturations, HR, RR) and what interventions to take with alterations in these
..
Allergic Rhinitis and Asthma teaching for home care and in hospital setting
Allergic Rhinitis: Some need all the time meds some just for certain seasons AVOID ALLERGEN promedicate medication education
Asthma: Identifying triggers Environmental control measures Recognizing s/s of an episode Importance relaxation & exercise Daily PEFR readings Set an action plan
Appropriate nursing interventions for Epiglotitis
Think arrest- endotracheal intubation or tracheostomy
Antibiotics (cefurozime 100mg/kg/24hrs)
Corticosteroids
Chest x-ray “thumb sign”
Lab work- elevated WBC
Extubated often after 24hrs of antibiotic and corticosteroid therapy
Prevention is key- Hib vaccine
Rifampin 20mg/kg x 1 for all contacts <4years
May occur other bacterial organisms
Prepare intubation No throat examination or throat culture No x-ray or IV before intubation Elevate HOB Keep calm- avoid crying Emotional support parents Care similar any other child with respiratory distress & ventilator support
Peak Flow: purpose? Function? What does it mean?
Test used to see a change in a pulmonary condition, not to diagnose
Procedure
Use the highest of 3 readings
Need to take 2 times per day over a 2 week period during a normal respiratory state to determine a patient’s personal best reading
Exhale forcefully over a short period of time to obtain the highest level on a meter
how fast you can push air out of your lungs when you blow out as hard and as fast as you can- measures how open the airways are
Cardiac cath- post op cares, complications, discharge teaching
POST OP
Post Op Nursing Implications
Typically out patient unless otherwise required
Child must lay as flat as possible 4-8 hours (depending on approach)
Assess for post op complications- bleeding at insertion site!!
Monitor I&O- contrast has a diuretic effect
Discharge teaching
COMPLICATIONS
Signs of infection, streaking, fever, redness, swelling, poor circulation
DISCHARGE TEACHING
Monitor site for redness, irritation, bleeding- report to APRN or MD
Assess temperature, color, sensation and pulses
Resume regular diet after procedure
Check for s/sx of infection via temp daily for 3 days post (100.4F at home, 38.2C in hospital)
No submerging in the tub for 3 days
No strenuous activities x3 days
Watch for changes in appearance such as color, complaints of heart flutter or heart skipping a beat, fever, or difficulty breathing
Give acetaminophen or ibuprofen for pain
Follow up instructions
Heart failure- clinical manifestations, digoxin administration, nursing interventions/teaching parents
CLINICAL MANIFESTATIONS
Edema: face, hands, and lower extremities
Increased work of breathing
nasal flaring
cough that can be productive or not
presence of bloody mucus
Auscultate the heart and lungs for quality of sound and variances of abnormal
abdominal distention indicative of ascites, hepatomegaly or splenomegaly
DIGOXIN ADMINISTRATION
Increases contractility of the heart
MUST be administered accurately
Double check the dose and volume before administration
Check pulse prior to administration
If dose is missed, administer if within 2 hours of missed dose. Otherwise wait until next dose is due
Monitor for toxicity
Nausea, vomiting, abdominal pain, visual changes
Administer on an empty stomach. (1 hour before meal or 2 hours after meal)
dont give if HR >60bpm
NURSING INTERVENTIONS
Oxygenation
Positioning of the infant/child
Suctioning
Chest physiotherapy/IS
Cardiac function Digitalis-Education!! Diuretics Daily weights Nutrition Higher caloric intake Smaller more frequent feedings/meals PO to NG (HR>60) Rest Age/development appropriate activities at rest Home school Cluster cares No crying it out!
Atrial Septal Defect (ASD) Understand where pressure and blood flow have changed and be ready to identify teaching points for parents.
increased pulmonary flow defect
The blood shifts against the normal flow. Blood that is already oxygenated is put back into the right side of the heart and recirculated into the lungs, thus increasing the volume. If untreated, the defect can cause problems such as pulmonary hypertension and heart failure.
hole between right and left atrium
When small, up to 80% of infants may have spontaneous closure by 18 months of age
May be asymptomatic. Large defect will lead to heart failure, shortness of breath, fatigue, or poor growth.
Ventricular Septal Defect (VSD) Understand where pressure and blood flow have changed and be ready to identify teaching points for parents
increased pulmonary flow defect
The left to right shunt happens when the pulmonary resistance is low. There is an increase in blood flow to the right ventricle and then also increased blood flow to the lungs. There is risk for right ventricle hypertrophy in attempts to shunt enough blood to the lungs.
Opening between the right and left ventricular chambers of the heart
Spontaneous closure of small defect occurs in about half of children by 2 years of age.
Surgical repair is recommended by age 2 to decreased pulmonary hypertension.
May not show immediate signs and symptoms at birth because left to right shunting is minimal due to high pulmonary resistance common after birth
Patent Ductus Arteriosus (PDA) Understand where pressure and blood flow have changed and be ready to identify teaching points for parents
increased pulmonary flow defect
Failure of the ductus arteriosus, a fetal circulatory structure, to close within the first weeks of life
Higher incidence in premature infants and infants born at high altitudes
Left to right shunt
Not enough o2 to the organs
Continuous blood flow from the aorta to the pulmonary artery
Altered blood flow pattern increases the workload of the left side of the heart leading to left ventricular hypertrophy
If small, asymptomatic.
Some demonstrate signs and symptoms of heart failure
Cardiac surgery- pre, post op: pain, fever, bleeding, education Low grade fever is only normal in the first 24 hours… beyond is concerning! (added FYI)*
PRE-OP
History and physical
Baseline vital signs
Labs: CBC, clotting studies, electrolytes, urinalysis.
Radiology: chest , ECG, or Echo. By this time a cardiac should have been completed but could come up if further complications have arisen.
POST-OP
Frequent assessment>Intervention>Reassessment is crucial
VS q 1hour until stable then as ordered
ABCs are vital!
Incisional assessment
Super accurate I&O and nutrition- will be on the dry side!
Pain and LOC assessment
Daily weight
Support and education
Safety!!
Color of skin and mucus membranes, pulses, rate and rhythm of heart
Chest tube output must be accurately measured
Ventilator or not, oxygenation, deep breathing/cough/IS/Pinwheel when ready
EDUCATION
Heart anatomy and how the defect is affecting the function
Processes of surgery, for example the pre-op bath and scrub down in the OR
Location of post op and what they can expect- ICU, monitors, tubes, dressings
Post-op activity level: this will include IS or deep coughing (RT will direct) also getting out of bed, bathroom privileges vs urinal/bedpan vs catheter. Also visitors and when will they go home! This is something that families need to be given information carefully! Set goals, not expectations in the event there are set backs.
Nutrition instructions- NPO times super important! (solids- 6hrs, liquids- 2hrs)
Medications: Current meds and when to stop is important. Also education on anesthesia and meds to expect post op
Rheumatic Fever vs Kawasaki- know the differences/similarities, rashes, treatment, cardiac involvement
Rheumatic Fever
Delayed sequelae of group A strep
Occurs more often in school age children 5-15 yo
Can happen 2-4 weeks after initial infection (strep)
Antibodies cross-react with antigens in cardiac muscle and neuronal and synovial tissue
Results in carditis, arthritis, and chorea (involuntary random jerking movements)
Attacks last 6-12 weeks and then resolve
May recur with subsequent strep infections
inflammatory disease involving the joint, heart, skin & nervous system
Management/treatment Compliance of antibiotic treatment-10 day course Prophylactic antibiotics Aspirin after diagnosis Frustration outlet
Kawasaki
Acute systemic vasculitis, ages 6 months- 5 years of age
Leading cause of acquired heart disease
Patho
Etiology unknown
Autoimmune response
Generalized systemic vasculitis occurs in the blood vessels due to inflammation and edema and can lead to coronary dilatation and aneurysm
Not everyone develops coronary artery changes
Diffuse erythematous polymorphous rash
Edema of the hands and feet
Erythema and painful induration of the palms and soles
Desquamation/peeling of the perineal region, fingers, toes, palms, and feet
Possible jaundice
Management
Acute phase- High dose aspirin in 4 divided doses daily
Single does of IVIg within first 7-10 days of dx
Monitory cardiac status
Promote comfort-cluster cares, acetaminophen for fever management
Hypertension- primary vs secondary and interventions to treat
Primary Hypertension- post pubertal children, African Americans, and children who are overweight or obese
Secondary hypertension- occurs with an underlying medical problem (heart disease, kidney disease, etc.)
Educate on dietary restrictions
Exercise
Medication compliance
Regular BP checks
Criteria for giving a Flu shot or live virus, contraindications, people who need it
Inactivated—IM
Recommended annually for all children older than 6 months
High risk (long term aspirin, asthma, CHF, diabetes, sickle cell disease)
Live—intranasal
Approved for healthy children and adults from 5 through 49 years of age
Do NOT give to high risk individuals and those younger than 5 or older than 50 years
- if it is the first time getting vaccine they will need 2 doses, must be 6 months of age
contraindications
Illness—moderate to severe
Allergies to certain medications, food or any vaccine
Serious reaction to vaccine in past
Immunocompromised—NO live vaccine
Immunosuppressive therapy—NO live vaccine
Blood products, plasma or immune globulin in past year—NO live vaccine
Pregnancy or chance of pregnancy in next month—NO live vaccine
Need to be properly stored. Understand manufacture directions clearly All doses are 0.5ml. IM vs Subq? Rotate sites 25 mm (7/8 to 1 in) needle Avoid dorsogluteal muscle- use vastus lateralis newborns & young infants. May use Deltoid if over 1 year age.
Giving immunizations with epinephrine on hand; adverse reactions, pain control with shots; how to deal with parent refusal
Make sure epinephrine 1:1000 is available
Anaphylactic reaction
Systemic—bronchospasms, laryngeal edema, flushing, nausea, vomiting, anxiety etc
Local– hives edema, warm, and erythema
parents
About 1% of the pediatric population are unvaccinated
Different reasons often fear of side effects
Question need for
Excessive # may weaken immune system
Can have an alternate schedule
Can use medication to help with the pain
EMLA (mix of lidocaine and prilocaine) apply at least 1 hrs before. Also use distraction techniques
Clinical manifestations of infectious dz (ie. Fifth’s Dz, Lyme Dz, Roseola).
fifths- lacelike rash on extremities, rash on face
lyme- bullseye rash
roseola- rash all over
scarlet fever- rash, strawberry tongue, desquamation
Know treatment and teaching for all of the skin disorders
CONTACT DERMATITIS: avoid triggers
URTICARIA/HIVES: Remove cause, provide antihistamines or steroids
SEBORRHEA/CRADLE CAP: head & shoulders
ANIMAL BITES: Administer meds: Vaccine, antibiotic, etc
Irrigate
Prepare for closure
INSECT BITES: Stinger-remove it and apply ice
Antihistamine
Avoidance- clothing
Deet
SCABIES: Treatment- must kill the mites and eggs
Topical- apply for 8 hours
Oral
IMPETIGO: Treat- oral or topic antibiotics
May return to school after 24 hours of treatment
TINEA: Topical Antifungals
Antibiotics for secondary bacterial infections
Eczema characteristics and treatment
Also known as Atopic Dermatitis
Associated with allergies and asthma
Before age of 2 onset
Chronic itch
Itchy, inflamed, red, swollen skin
Response to allergens (foods), environmental triggers (mold, dust, pets, pollen, etc)
Other triggers: extreme temp changes, skin irritants, stress
Assessment
History- disrupted sleep, scratch marks, wiggling or scratching, familial history, asthma, food or environment allergies
Physical findings
Dry, scaly, flakey skin
Lesions… are they infected?
Under 2- face, scalp, wrists and extensior surfaces
Older children- can be anywhere, more common on flexor sites
Erythema or warmth to skin- infection?!
Hyper or hypo pigmentation- prior exacerbation
Respiratory symptoms associated with flare up
Tx
Avoid hot water and any smelly lotion or soaps
Mild soaps to clean only dirty areas
Pat skin dry, no rubbing- leave the child moist!!
Lather them up, the more slippery the better: Eucerin, Aquaphor, Vaseline
Cut fingernails
Burn prevention education
Prevention
Smoke detectors
Water safety- pour/splash injury, Set temp <120 degrees F
Fireworks
Cares at Home
Seek attention if it appears to be worse than first-degree
Steps to treat (extensive)
Remove clothing only if it comes off easily or if still smoldering
ABCs/CPR
Do not apply ice, butter, ointment, or cream
Cover with clean, lint free bandage or sheet
Do not attempt breaking blisters
Identify shock
Steps to treat (superficial)
Run cool water until pain lessens
Do not apply ice, butter, ointment, or cream
Cover lightly with clean, non adhesive, bandage
Tylenol or Ibuprofen for pain
Be seen within 24 hours
TANNER STAGES
pubic hair:
stage 1: preadolescent; no sexual hair
stage 2: sparse, pigmented, long, straight, mainly along labia and at base of penis
stage 3: darker, coarser, curlier
stage 4: adult, but decreased distribution
stage 5: adult in quantity and type with spread to medial thighs
breast: stage 1: preadolescent stage 2: breast budding stage 3: continued enlargement stage 4: areola and papilla form secondary mount stage 5: mature female breasts
male genitalia:
stage 1: preadolescent
stage 2: enlargement, change in texture
stage 3: growth in length and circumference
stage 4: further development of glans penis, darkening of scrotal skin
stage 5: adult genitalia
