Providing Perianesthia Care and Education Presented by: Danyel Dorn RN, MSN, CPN Clinical Nurse Educator-Pediatric Service Line

Purpose Demonstrate understanding of the developmental age of children utilizing age appropriate actions and words. Identify psychosocial needs of the patient and family as well as their readiness for the hospital experience. Provide preoperative education to increase knowledge and decrease anxiety with language and play therapy.

Competency Statement Demonstrate skills in helping prepare the pediatric patient and family for surgery, keeping in mind the developmental age of the child.

Infants (1-12 months) Minimize separation from parents Utilize parental suggestions to keep routines Encourage stimulation such as holding and sucking (pacifier) Swaddle and use rolled blankets as “boundaries” to contain the infants environment and increase feelings of security

Toddlers (1-3 yrs old) Provide choices, whenever possible (which arm to check how big their muscles are: BP) Utilize transitional objects (favorite blanket or toy) Comfort measure awareness (i.e., if child is sucking on their left thumb, place IV in their right hand

Toddlers (cont.) Explain how things will sound, feel, taste, look and smell Encourage touching/playing with safe hospital objects, like a face mask or stethoscope Minimize separation anxiety Encourage parents at the time of separation that they are leaving, but will return soon and to leave a personal item with the child if possible

Toddlers (cont.) Provide care in a gentle and soothing manner Recognize toddlers with use “no” excessively Help parents understand normal regressive behavior when toddlers are frustrated or seeking immediate gratification

Preschool (3-5 yrs old) Dispel misconceptions and encourage expressions of feelings Maintain routine when possible and allow active participation in care Acknowledge fear about body integrity (i.e., provide a band- aid because of fear of “losing blood” Avoid any and all questions that would result in a “no” answer (i.e., “Do you want your medicine?”

Preschool (cont.) Practice awareness of terminology used to describe the hospital experience (don’t say: removing this, cutting out that, putting someone to sleep) Allow appropriate choices and options to develop trust and control (i.e., would you like me to give you your medicine or do you want mommy to give you your medicine)

School Age (5-13 yrs) Provide for socialization and age appropriate activities for coping (i.e., coloring books) Promote the developing sense of cooperation and compromise Recognize that school age children can listen and follow directions

School Age (cont.) Provide opportunities for preparation and involvement in procedures/care (e.g., preop tour of procedural area, conducting online searches) Provide privacy and discuss fears Encourage verbalization of feelings and needs

Adolescents (13-18 yrs) Encourage participation in all care issues Provide privacy, ask open-ended questions Elect time away from parents to ask about drug/alcohol use/sexual activity (this could be asked when you check height/weight) Allow decision making (who can visit and when)

Adolescents (13-18 yrs) Allow phone use: communication with peers and social networking Respect modesty issues (allow them to go to the OR with underwear on Use verbal and written communication They will use logic and can have meaningful conversations about their care needs

Activities to Promote Comfort Utilize books, movies, play medical kits and dolls Teaching moments (toys and videos about doctor visits and hospitals stays) Play with equipment like face masks, thermometers and blood pressure cuffs Allow security objects into the OR like special toy or blanket

Relaxation and Pain Mgmt Skills Deep breathing Visualization Progressive muscle relaxation Educate on need to have medication to control pain Many adolescents have never experienced significant pain, so they also have a hard time describing what type of pain and the intensity they may be feeling

Expression through Play Games Drawings Physical activity Pictures Puppet play Continued involvement on social media sites

Preop Tour Offer a tour prior to undergoing surgery An extensive lit review showed that most children prepared for procedures, experience significantly lower levels of fear and anxiety as compared to children who are not prepared. Preparation also promotes long term coping and adjustment to future medical challenges. Key elements of effective preparation include the provision of clear and accurate information about the medical procedure and potential coping strategies, the encouragement of emotional expression and the establishment of trust with a health professional.

Child Life Specialist Make a referral to a child life specialist, which can help the pediatric patient prior to undergoing surgery They will be able to help address the psychosocial needs of the child and their families and improve the overall surgical experience

Child Life (Cont.) Child life with communicate how effective the intervention was and can make recommendations to help make the surgery process smoother for pediatric patients Child life creates unique goals for every patient and family for whom they work with.

Child Life (Cont.) Goals for the patient and family often include: Increased familiarity with the environment, process, and sensory information Decreased distress related to procedure Identification of coping strategies Recognition of the role to help decrease anxiety and increase coping

Child Life (Cont.) Things assessed include: Patient’s developmental level Coping style Past medical experiences Family structure Cultural background Personality type and learning style

Child Life (Cont.) They explain medical terms like surgery and anesthesia Assesses the patient’s understanding of surgery and clarifies any misconceptions (kids sometimes thinks they were at the hospital because they were bad) If a concern is identified a coping strategy is then created (stress ball, or pin wheel for deep breathing) The child life specialist attempt to normalize the patient’s surgery experience

Child Life & Hospital Tour Happens prior to surgery Patient’s and family may “practice” the steps of the surgery process including check in, vital signs assessment, entering an operating room, choosing a scent for induction mask, manipulating medical equipment, tour of pacu and/or inpatient room

Education Plan Anesthesia Induction: Parental Presence?? Up to the discretion of the Anesthesia Provider. Identify cases not appropriate for parent presence: children under the age of one year, difficult airway issues, previous family history of MH, parental inability to cooperate (increase in anxiety) Utilize child life

PACU Visitation Varies from one institution to another Strongly recommended that parents are brought to the bedside as soon as possible Educate families: explain to parents that it may not be time yet to touch, hold or speak to the child Tell parents to remain calm since their child will take cues from them

PACU Visitation Explain it is acceptable to leave the bedside if they are having trouble with the situation Reassure parents that behavior in the Phase I is frequently challenging to manage and it is often related to the anesthesia and surgical situation

Pacu Visitation Many parents have a hard time and will state “this is not like my child” Nurses may need to assist parents with this sometimes difficult behavior of the child, educate them about the effects of anesthesia and various pain medications and reassure them their child will return to normal shortly.

Pacu Visitation Work with parents to determine if they think the behavior is related to fear or pain Many parents can assist with how to manage their child and when it is the best time to administer pain medication This is a good time to start postoperative teaching about pain management and post-surgical care.

Reference ASPAN (2016). A Competency Based Orientation and Credentialing Program for the Registered Nurse Caring for the Pediatric Patient in the Perianesthesia Setting. Smith, P., Cowie, H., Blades, M. (2011). Understanding Children’s Development. 5th ed Chichester, West Sussex, United Kingdom

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