The initial patient assessment provides information necessary to develop a plan of care specific to the needs of each pediatric patient related to age, developmental level, and diagnosis. The unique aspects of care of the pediatric surgical patient revolve around the fact that the child is constantly growing and changing. The perioperative nurse must have a good understanding of the normal physical and psychologic parameters for pediatric patients and be able to recognize and act on deviations from these parameters. Table 26-2 presents normal vital sign ranges for infants and children.

In addition, the perioperative nurse must be familiar with normal growth and developmental factors for each age group. During any given day, the perioperative nurse may care for a variety of pediatric patients ranging from neonates through adolescents. In some instances, children undergoing an ambulatory surgical procedure may visit the OR complex and ambulatory surgery area with their families 1 to 2 weeks before surgery, depending on the child’s developmental level and the availability of a preoperative pediatric education program. If the child has a complex medical history or an extensive surgical procedure is planned, the child and family members will meet with a member of the anesthesia team during this advance visit. A tour may be provided by a child life specialist (Patient and Family Education), along with pictures and age-appropriate explanations of what the child will see and experience. Visiting before the day of surgery can help decrease the anxiety related to the novelty of the experience.

Occasionally the child’s history and physical, surgical consent, and any necessary tests or lab work are done in advance in the surgeon’s office setting, and the child and family have no introduction to the surgical experience until the day of surgery. Information related to the child’s scheduled procedure is either sent home with the family from the surgeon’s office or mailed to the family the week before the surgery is scheduled. The surgical facility contacts the family the day before surgery to inform them when the child should arrive at the facility and to review preoperative eating and drinking instructions. In these instances, the initial interview performed by the perioperative nurse is especially crucial to provide a thorough, documented assessment of the child’s growth (height and weight), current physical status (vital signs, heart and breath sounds, skin integrity), current medication history, allergies, nothing by mouth (NPO) status, recent illnesses, current medical concerns, and behavioral responses to the interview process. The perioperative nurse confirms the intended surgical procedure with the child and family as it is written on the surgical consent as well as their understanding of the operation. This information is critical to the intraoperative nursing team’s plan of care during the surgical procedure.

Children may undergo surgery at ambulatory surgery facilities or in a hospital setting. Certain criteria must be met for children to qualify for surgery at an ambulatory facility (Ambulatory Surgery Considerations). Children who are inpatients may be visited by a perioperative nurse in the hospital on the day before surgery. The nurse reviews the patient’s chart, giving particular attention to the patient’s age, developmental level, diagnosis, and intended surgical procedure. Current nursing diagnoses and the ongoing plan of care are examined. A discussion with the primary nurse can facilitate data collection, assist in providing continuity of care, and provide the perioperative nurse with information regarding preoperative education previously provided. The perioperative nurse can meet the child and any family members present at the time of the visit. The interview can be used to gather information helpful to developing the intraoperative plan of care and to decreasing the anxiety related to the child’s impending surgery by providing a familiar face on the day of the procedure. The focus of this visit is to discuss the perioperative process, not always to provide preoperative education regarding the surgery. In pediatric centers in the inpatient setting, preoperative education may be provided by the primary nurse, child life therapist, or clinical nurse specialist. During the preoperative visit the perioperative nurse can explain, at a developmentally appropriate level, what the child will experience in the preoperative, intraoperative, and postoperative phases of care. The perioperative nurse may briefly describe the roles of various staff members who will be a part of the team responsible for the child’s care in the OR. Common concerns that families express are the length of time that they will be separated from their child and their child’s pain management. Explanations to children should be provided within a developmental framework, taking into account each child’s cognitive and psychosocial abilities. Medical play items, audiovisual aids, puppets, and photographs are all helpful in the education process.

The perioperative nurse who will be participating in the intraoperative care of the child will review the patient’s information and meet with the patient and the family before the child is transferred to the OR. In addition to reviewing the documentation, the nurse validates the patient’s identification using two patient identifiers, confirms that the surgeon has marked the child’s surgical site per institutional protocol, and seeks verbal verification from the patient, parent, or legal guardian about the scheduled procedure, making sure that it matches what is written on the surgical consent (Figure 26-1). If implants are to be used, availability must be confirmed before the patient’s transport to the surgical suite. Frequently children will be given a premedication 20 to 45 minutes before their transportation to the OR. A premedication such as midazolam can greatly decrease a child’s anxiety, minimizing the stress of separation for both child and family. The surgeon and anesthesia provider will each meet with the child and family, usually while the OR is being prepared for the patient. The perioperative nurse will assess the child’s psychologic state, review the intended surgical procedure with the child and family, and ensure that they have no additional questions or concerns. A final communication among the anesthesia provider, surgeon, and nursing staff for the room confirms the team’s state of readiness for the delivery of care before the nurse transports the child to the OR.

Nursing diagnoses related to the care of pediatric patients undergoing surgery might include the following:

Outcomes identified for the selected nursing diagnoses for the pediatric patient could be stated as follows:

Assessment data, combined with information about the planned surgical procedure, enable perioperative nurses to anticipate requirements for surgical positioning, instrumentation, equipment and supplies, medications, and activities necessary for the provision of safe, competent care for the pediatric patient. Knowledge of the child’s developmental level allows the nurse to plan her or his approach and interactions with the child and family (Figure 26-2). The perioperative nurse identifies criteria appropriate to the child and surgical setting for each of the desired outcomes (Sample Plan of Care). A Sample Plan of Care is shown for the pediatric patient on pages 1014-1015.

The perioperative nurse must also develop a trusting relationship with the child and his or her parents, family, or legal guardians. The nurse must explain the events of surgery in a way that allows the child and accompanying adults to better understand what to expect on transfer to the OR (Patient-Centered Care).

Age-appropriate communication is important in implementing the pediatric nursing plan of care. Implementation begins during the perioperative nursing assessment and continues through discharge to the postanesthesia care unit (PACU) or other area. The presence of a parent during much of the preoperative period, including during anesthesia induction in the OR and after anesthesia emergence in the PACU, can help decrease anxiety for both young children and their families and facilitates family-centered care (Evidence for Practice).

Infants, reliant on family to meet their basic needs, are difficult to pacify when NPO for surgery. The facility should provide rocking chairs, pacifiers, warm blankets, and simple distractions such as music or toys. Preoperative teaching should include telling the family to provide fluids for the infant until the deadline for NPO status. Unnecessary delays should be avoided at all costs. Parents may need reassurance and support during the period immediately before surgery.

The toddler or preschooler fears parental separation and abandonment. Toddlers fear, among other things, strangers, the dark, and machines. They attribute lifelike qualities to inanimate objects, believing that the objects, like them, have feelings. Thus a blood pressure cuff that squeezes the child’s arm may be perceived to be doing so because it is angry with the toddler. Toddlers may also believe that their body is held together by their skin; anything that violates the skin integrity is feared. For this reason, bandages are very important. Toddlers and preschoolers interact with the environment using their senses. To integrate this into the patient’s care, the perioperative nurse should give the toddler the opportunity to touch and play with objects that he or she will encounter. An example is to give the child a small anesthesia mask to put on his or her teddy bear. Sensory information should be provided in a soft, gentle voice (i.e., what the toddler will see, feel, touch, and hear). A security object is extremely comforting. The OR should be quiet; background noise should be controlled. Instruments that are frightening should be kept from view. To allow quick induction of anesthesia the toddler should be transferred into the surgical suite when the room and staff are completely prepared.

The school-age child may still perceive hospitalization or surgery as a punishment but can evaluate painful intrusive actions in terms of logical function (e.g., getting an IV line hurts, but then I can get medicine in it to make me feel better). Feelings of inadequacy may be associated with something the child thinks he or she should be expected to do or know. Fear of body injury or mutilation, loss of control, and fear of the unknown characterize this developmental stage. These children benefit from simple, concrete explanations in familiar terms; a book or other teaching aid can be helpful. The concepts of time and unseen body functions can now be incorporated in the explanations. The child should be allowed to make choices when possible (e.g., letting the child decide in which hand to place the IV line or which flavor to add to the anesthetic mask).

Adolescents may fear altered body image, peer rejection, disability, and loss of control or status. The fear of death is more prevalent in this age-group than any other, and adolescents may find explanations of monitoring and safety measures reassuring. They need as much privacy as possible, and their attempts to be independent should be respected (e.g., walking into the OR instead of being wheeled in on a stretcher if the patient has not been sedated). The adolescent may not wish to show any fear; questions might not be asked while the parents are present. Information and explanations should be provided as reasonably and truthfully as possible. If appropriate, some choices should be allowed, such as wearing underwear to the OR. Patient care procedures that violate privacy, such as hair removal, skin preparation, or insertion of an indwelling urinary catheter, should be conducted after the patient is anesthetized.

Key points in providing perioperative care to pediatric patients include remaining alongside the child until the child is anesthetized, keeping the room quiet during induction, accepting a child’s need to express fear and fearful behaviors (e.g., crying), and using simple words without double meanings to explain care. Security objects should remain with the child until induction has been completed. A child’s behavior during induction is likely to be the same during emergence; thus all attempts should be made to provide calm, reassuring care. Parents should be alerted to delays in the surgery schedule; in some instances, the child may be allowed to have fluids if the surgery is delayed by several hours.

Implementing the nursing plan of care includes continual reassessment of the patient’s needs as well as the efficient execution of activities that facilitate the surgical intervention. Remaining with the child during induction, positioning, and prepping the surgical site; creating and maintaining a sterile field; collecting, documenting, and disposing specimens; and administering medications are all part of helping to provide a safe environment for the pediatric surgical patient. Making sure that the pediatric patient’s family receives regular updates of the child’s status is also a part of the perioperative nurse’s responsibilities and will decrease their anxiety and help foster a sense of trust in the healthcare professionals caring for their child.

The perioperative nurse provides a hand-off report to the PACU nurse, focusing on the condition of the child, the response to surgery and anesthesia, the presence of catheters and drains, the quality and amount of wound drainage, a description of the dressings applied, and any special needs. Part of this report should focus on the outcomes established in the perioperative plan of care. For the plan of care presented in this chapter, they might be as follows:

Patient and family teaching varies significantly based on the type of surgery performed. Some hospitals provide special preoperative teaching and hospital tours for pediatric patients and their parents to help them prepare for the surgical experience. Sometimes information is discussed with the child and family at the time of the office visit, when the surgery is scheduled. For same-day procedures, the day-surgery nursing staff might teach postoperative care immediately before patient discharge. Basics of postoperative care are reviewed with the parents at this time. In some cases, written material may be provided (Box 26-2). Parents should be advised to be alert for certain signs and symptoms during the postoperative recovery period that could indicate an infectious process, such as fever, pain, nausea, redness around the incision area, drainage from the wound, or difficulty breathing. These signs and symptoms may develop days or even weeks after surgery. It is important that parents understand the necessity of not ignoring any of these signs and symptoms and of reporting them to the surgeon promptly so that an early diagnosis can be made and treatment prescribed. Although discharge information depends on the type of surgery performed, it typically includes recommendations about activity restrictions, return to school or daycare, wound care, bathing or showering, diet, and follow-up appointments. The printed discharge instructions are reviewed with the parents, and their understanding is verified. This time should provide the family with an opportunity to ask questions or seek clarification of the instructions. Phone numbers for the surgeon and the main hospital are provided in case the family has concerns or questions during the child’s recovery period at home. An appointment for the child’s follow-up visit may be made before discharge, or the parents are instructed to call the physician’s office to schedule an appointment.