Home Study Program - POEMS For Children | POEMS for children · demonstrated that music therapists’ skills can alter the effect that a particular music therapy has on a patient.

© AORN, Inc, 2006 NOVEMBER 2006, VOL 84, NO 5 • AORN JOURNAL • 777

Management of preoperative anxiety in children

he article “Management of preoperative anxiety in children” is thebasis for this AORN Journal independent study. The behavioral objec-tives and examination for this program were prepared by RebeccaHolm, RN, MSN, CNOR, clinical editor, with consultation from SusanBakewell, RN, MS, BC, education program professional, Center for

Perioperative Education.Participants receive feedback on incorrect answers. Each applicant who suc-

cessfully completes this study will receive a certificate of completion. The deadlinefor submitting this study is Nov 30, 2009.

Complete the examination answer sheet and learner evaluation found on pages807-808 and mail with appropriate fee to

AORN Customer Servicec/o Home Study Program

2170 S Parker Rd, Suite 300Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

You also may access this Home Study online at http://www.aornjournal.org.

BEHAVIORAL OBJECTIVESAfter reading and studying the article on managing preoperative anxiety in chil-

dren, nurses will be able to

1. discuss factors associated with increased levels of anxiety in children,

2. describe opportunities for interdisciplinary collaboration in relieving preop-erative anxiety in children,

3. explain use of a family-centered approach to relieving preoperative anxiety, and

4. identify interventions to prevent preoperative anxiety according to a child’sdevelopmental stage.

Home Study Program

Thisprogrammeets criteriafor CNORand CRNFArecertifica-tion, as wellas other continuingeducationrequirements.

A minimumscore of 70%on the multiple-choiceexaminationis necessaryto earn 5.6contact hoursfor thisindependentstudy.

One contacthour is equalto 50 minutes.

Purpose/Goal:To educateperioperativenurses abouthow to managepreoperativeanxiety inchildren.

T

© AORN, Inc, 2006778 • AORN JOURNAL • NOVEMBER 2006, VOL 84, NO 5

Victoria A. Dreger, RN; Thomas F. Tremback, MD

In 1996, children in the United Statesunderwent 4.3 million ambulatoryor inpatient procedures.1 In 2004,

children younger than 15 years of ageunderwent 2.3 million inpatient proce-dures.2 One estimate suggests that 60%of these children experience significantanxiety before anesthesia inductionand surgery.3

Anesthesia during the surgical pro-cedure prevents children from recall-ing actual surgical events. They are,however, subjected to stressful eventswhile preparing for surgery, such asthe admission process, having blooddrawn, receiving injections, or havingother medications administered. Chil-dren who cling to their parents pose achallenge for perioperative nurses try-ing to transport them to the OR, and

the children’s stress continues whilethey are being transported, duringinduction, and when they awakenbefore their parents arrive in thepostanesthesia care unit (PACU).4

According to the Watson and Visram5

review, studies dating back 50 yearshave identified an association betweenunsatisfactory anesthetic inductions andnegative personality changes. Thesestudies led to further studies linkingpreoperative anxiety and postopera-tive behavior.5 Literature from aroundthe world indicates that preoperativeanxiety is a global concern.4,6-23 Anes-thesia care providers from the UnitedKingdom refer to the importance ofreducing children’s anxiety for humani-tarian reasons.5 Nursing researchers inHong Kong not only deem it crucial thatinterventions be geared toward mini-mizing anxiety both in children and par-ents, they conclude that there still areopportunities for improvement.14

Health care team members addresspreoperative anxiety in children fromvarious perspectives. The challenge thatnurses face is to change traditionalprocesses so that preoperative anxietycan be managed better in today’s fast-paced ORs. To achieve this goal, preop-erative anxiety should be reviewedfrom the perspective of various disci-plines so that successful strategies canbe identified and applied to typical situ-ations and adapted to atypical ones.

To ensure use of evidence-basedpractice, nurses need to critically evalu-ate the evidence that is currently avail-able to determine what is relevant andvaluable24,25 to achieve the best out-comes. This article highlights a multi-disciplinary approach that supportsperioperative nurses caring for childrenand their family members during the

Home Study ProgramManagement of preoperative

anxiety in children

• ALTHOUGH ANESTHESIA during surgeryprevents children from recalling actual surgicalevents, they are subjected to stressful eventswhile preparing for surgery.

• ONE ESTIMATE SUGGESTS that 60% of chil-dren experience significant anxiety before anes-thesia induction and surgery, and literature fromaround the world indicates that preoperative anx-iety is a global concern for health care providers.

• THE CHALLENGE THAT NURSES FACE is tobetter manage children’s anxiety in today’s fast-paced ORs. This article uses case studies to shownursing strategies that can be used to help allaythe fears of children at different psychosocialstages of development. AORN J 84 (November2006) 778-804. © AORN, Inc, 2006.

ABSTRACT

AORN JOURNAL • 779

Dreger — Tremback NOVEMBER 2006, VOL 84, NO 5

anxiety-filled perioperative period. Byproviding practical application of stud-ied techniques for use in everyday sce-narios, this review can help nurses min-imize preoperative distress for pediatricsurgical patients.

INTERDISCIPLINARY COLLABORATIONPerioperative nurses work closely

with other essential members of theOR team—surgeons; anesthesia careproviders; surgical technologists; andwhen available, child life specialistsand music therapists. A truly collabo-rative approach is possible when sepa-rate and specialized but related knowl-edge is shared between disciplines.This approach adheres to the Nurses’Code of Ethics, which states,

Nurses should actively promote thecollaborative multi-disciplinary plan-ning required to ensure the availabili-ty and accessibility of quality healthservices to all persons who have needsfor health care.26

THE CHILD LIFE SPECIALIST ROLE. The role ofthe child life specialist has become morevisible in recent years. Child life spe-cialists use preparation to help reduceanxiety in children. This health carespecialist supports children and advo-cates for them but also can support andadvocate for the parents.27 For example,when a parent has concerns about beingseparated from his or her child andfears the risks of anesthesia, the childlife specialist educates and supportshim or her.

In a recent study conducted byresearchers from both disciplines (ie,nurses and child life specialists), theresearchers described child life special-ists as professionals trained in childdevelopment who strive to “alleviatethe stress and anxiety that accompanyillness or hospitalization.”28(p16) Overall,the study demonstrated that children

undergoing elective surgery with whoma child life specialist interacted hadless postoperative anxiety than chil-dren without this support. In the dis-cussion of clinical implications, the re-searchers emphasized the importanceof collaboration between nurses andchild life specialists.

. . . when children are prepared for sur-gery, their coping ability increases andanxiety is relieved. By understandingchildren’s misconceptionsand fears regarding sur-gery, child life specialistsare uniquely qualified toaddress pediatric prepa-ration. Child life special-ists support the nursingrole by addressing a child’sanxiety level, which mayaffect compliance withnursing staff during ini-tial admission visits, anes-thesia induction, andrecovery time. . . . Childlife specialists also play animportant role in reducingparental anxiety. Prepar-ing families for the surgi-cal experience not onlyreassures parents but alsoprovides them with theknowledge to supporttheir child through thesurgical process. A collab-orative approach betweennursing and child lifeshould improve overall patient out-comes by lessening anxiety in the daysurgery pediatric patient.28(p21)

ALTERNATIVE OR ADJUNCT APPROACHES. Alter-native approaches, such as music ther-apy, may provide options for childrenand their family members.29 “The use ofmusic therapy interventions for pedi-atric surgical patients is steadilyexpanding in medical facilities.”30(p147)

Child life specialists

are professionalstrained in childdevelopment who strive

“to alleviate thestress and anxietythat accompany

illness or hospitalization.”

780 • AORN JOURNAL

NOVEMBER 2006, VOL 84, NO 5 Dreger — Tremback

Use of music before surgery can in-clude writing songs to express feelingsor concerns about the procedure.Improvisation using various rhythminstruments also can provide the sameopportunity for nonverbal children.Use of music preoperatively also canfacilitate the sedation process, andmusic can be used after surgery to lessen

pain. Studies have shownthat music therapy canaid sleep and lessen theneed for pain medicationin patients recoveringfrom surgery.31-34

A study of interactivemusic therapy32 highlightsthe effect of these indi-vidual skills on patientresponse. Kain et al,32

demonstrated that musictherapists’ skills can alterthe effect that a particularmusic therapy has on apatient. Even if two thera-pists use the same tech-niques or therapeutic style,the effect can vary greatlybetween the two thera-pists. Overall, these re-searchers determined thatmusic therapy may behelpful for the child uponseparation from the par-ent and upon entering theOR, depending on thetherapist and as the result

of significant therapist-specific effects.A recent article described using auric-

ular acupuncture to significantly decreasematernal anxiety during the preoperativeperiod.33 The lessened anxiety in themothers benefited their children duringthe induction phase of anesthesia. Usingcomputer games20,34 and clown doctors35

(ie, health care providers, not necessarilylicensed physicians, who dress as doctorsin clown attire and are present duringinduction of anesthesia) as methods for

preoperative teaching or to facilitate cop-ing have been studied as distractionmethods for treating preoperative anxietyin children.

Each nurse is unique and has indi-vidual strengths, one of which is his orher interpersonal communication skillsset. In addition to careful training in theobservation of and adherence topatient-focused interventions, nursesneed to be aware of how patients per-ceive them. Nurses can use the timeduring interdisciplinary collaborationto learn from their expert colleaguessuch as specialty- or fellowship-trainednurses, pediatric surgeons, anesthesiacare providers, child life specialists,and music therapists. Nurses can emu-late their colleagues’ skills and receivefeedback on how they are perceivedby patients.

TRENDS IN ANESTHESIA CARENonpharmacogical management of

pain and anxiety is important.

Coping with this preoperative stressrequires consistent communicationbetween the child, the parents, andall health care providers involved inthe perioperative period. . . . bothbehavioral and pharmacological in-terventions can be used to addressthe issue of preoperative anxiety inchildren and their parents.36(p1206)

Although anesthesia care providersuse nonpharmacological interventionsin their care of patients, medicationsare the mainstay of their practice.

DECIDING WHETHER TO PREMEDICATE. Anes-thesia researchers in South Australia17

indicate that preoperative identifica-tion of children who are at high risk ofexcessive anxiety could more effective-ly target the use of pharmacological orother interventions. Using a modifiedversion of the Yale PreoperativeAnxiety Scale,17 they identified factors

Use of music preoperativelycan facilitatethe sedationprocess, can

aid sleep, andcan be used

after surgery tolessen pain and

the need forpain medicationafter surgery.



associated with increased levels of anx-iety in children, such as• an increased number of people in the

room at induction of anesthesia,• a longer waiting time between ad-

mission at the hospital and inductionof anesthesia,

• negative memories of previous hos-pital experiences, and

• having a mother who does not prac-tice a religion.A common-sense approach points to

individual evaluation of each patientand administration of pre-medication when appro-priate, especially when thechild’s parents suggest theneed to do so, becauseparents know their childbest.37 Coexisting healthconditions and individu-alized risks must be con-sidered in deciding on theuse of anxiolytics.36 Acaveat for decision mak-ing is to determine if phys-iological alterations, suchas hypoxemia, hypercap-nia, low cardiac output,and resultant cerebral hy-poperfusion, may be caus-ing anxiety or agitation.38

One author asserts that

if the parents are calmand can effectively man-age the physical transferto a warm and playfulanesthesia care provider

or nurse, premedication is not neces-sary. Semisedation may be awkwardand recovery after premedication maybe prolonged.39(p1220)

Similarly, “psychological preparationmay be as effective as premedica-tion.”17(p69) Another review article says that

good anaesthetic practice, as well as

attention to pharmacological andphysiological issues, should addressthe psychological aspects of the periop-erative care of children.5(p188)

Finally, Swedish researchers report thatin their work,

42% of the children showed noncom-pliant behavior when given premed-ication. . . . although only 14% of the children were anxious or upsetafter premedication, the questionmust be raised about the benefitobtained from using midazolam aspremedication.11(p232)

Recommendations regarding thevalue of administering preoperativeanxiolytics are conflicting. The practicephilosophy of each anesthesia care pro-vider regarding premedication is at leastas important as patient selection criteria.Researchers from Yale University Schoolof Medicine surveyed American anes-thesia care providers in 2004 and deter-mined that 50% of the pediatric patientsthey cared for were administered pre-operative anxiolytics before surgery.40

This was an increase from a previousstudy performed by the same re-searchers in 1995, which showed that30% of children had received sedativepremedication.41 The anesthesia careproviders who premedicate their pedi-atric patients were younger in age. Thismay be explained by the fact thatyounger anesthesia care providerstrained after the advent of oral mida-zolam may be more comfortable withthe safety and efficacy of oral sedation.Before the introduction of oral midazo-lam, most premedications were admin-istered intramuscularly, a major draw-back with pediatric patients because ofthe pain of the injection itself. Althoughthe reasons for the changes in trends inadministration of preoperative anxi-olytics are not known entirely, the

Health careproviders shouldevaluate eachpatient andadminister

premedicationwhen appropriate,especially when

the child’s parentssuggest the need

to do so.



researchers believe that increasedawareness of the cause of children’sand parents’ preoperative anxiety havecontributed to the majority of thechange in practice.

ADVANTAGES OF ADMINISTERING PREOPERATIVEANXIOLYTICS. Anxiolytic medications pro-duce a calm state and allay anxiety andfear38 while promoting hemodynamicstability but still allow patients to re-spond to verbal commands. Benefitsinclude easier separation from parents,improved cooperation and manageabili-ty of pediatric patients for staff members,and avoiding a hemodynamic surge (ie,release of catecholamines manifested asincreased pulse and respiratory rate)from a screaming child. Despite in-creased awareness and acknowledge-ment of preoperative anxiety, variationsin practice remain. For example, accord-ing to one study, only 1.9% of anesthesiacare providers who practiced at a chil-dren’s hospital never premedicated theirpatients as compared with 25.3% ofanesthesia care providers who practicedat a free-standing surgical center.40

DISADVANTAGES OF ADMINISTERING PREOPERATIVEANXIOLYTICS. Although Kain et al assertthat “there is clear rationale for the useof preoperative interventions such assedative premedication,”40(p1258) there aredrawbacks to the use of anxiolytics.Anecdotal considerations and docu-mented concerns suggest that anxioly-sis is not a be-all and end-all interven-tion. First and foremost, timing is criti-cal. Medications administered orallytake 15 to 30 minutes to achieveeffect.36,39 Attempting to separate a childfrom his or her parents too early actual-ly can become a dissatisfier for the par-ents, who find the “miracle drugs” inef-fective or disconcerting. Unanticipateddelays in separating the child from hisor her parents can be just as frustratingbecause a medication like midazolampeaks and wanes after 45 to 60 min-utes.36 Oral premedications, which 93%

of respondents reported as the route ofchoice for use in pediatric patients,40

may delay discharge to home,39 particu-larly for short procedures like bilateralmyringotomy and insertion of pneu-matic equalization tubes. Delayed dis-charge is unfavorable for busy outpa-tient facilities or for families who findrapid postoperative discharge a signifi-cant satisfier. The priceof the medication itself,along with the extendedtime in the surgical facili-ty, can add measurableexpense40 in this era ofcost-consciousness.

A separate and criticaldrawback to anxiolyticpremedication is that theprocess of administeringthe medication (ie, IV, in-tramuscular, rectal, intra-nasal, oral) may actuallyincrease anxiety. Pre-existing IV access rarely isavailable in the pediatricpopulation, particularlythose arriving for outpa-tient surgical procedures,although some pediatricpatients may arrive foroutpatient surgery with acentral line in place. In-tramuscular injections arepainful and often consid-ered unacceptable to already fright-ened children. According to one study,intramuscular injection of medicationswas identified by the vast majority ofchildren queried as the most unpleas-ant preoperative event.42 Rectal admin-istration also has drawbacks because• psychosocially, the route of admin-

istration can be considered less thanideal, especially for older children;

• the medication can be expelled toorapidly; and

• absorption can be variable.36

Intranasal administration results in, at

Anxiolyticmedications

produce a calmstate and allay

anxiety and fearwhile promotinghemodynamic

stability but stillallow patients torespond to verbal

commands.



in the enclosed crib or bed. When trans-porting a pediatric patient, nursesshould be alert for attempts to sit orstand and the potential for injury as aresult of impaired coordination.

Anesthesia practice guidelines thatserve as a reference to minimize therisks associated with medication admin-istration highlight the benefits of seda-tion when it is administered by quali-fied providers.47 Safety considerationswarrant periodic evaluation of thepatient to screen for idiosyncratic reac-tions and excessive sedation with respi-ratory depression and to reinforce to theparents that the alterations in theirchild’s temperament, activity, and dis-position are the desired effects of themedication and are not cause for alarm.

DEVELOPMENTAL FACTORS—ASSESSMENT AND INTERVENTIONS

Nurses should take a family-focusedapproach when helping children andtheir parents deal with the stress of sur-gery. Basic principles of caring for chil-dren and their parents apply to the peri-operative period just as they apply to anyhealth care situation involving children.Performing age-specific preoperativeassessments helps nurses develop andimplement individualized care plans tohelp children and their parents bettercope with preoperative stress. Manyresources are available to help nursesensure that children and their parentsreceive the care necessary to minimizepreoperative stress (Table 1).

TAKE A FAMILY-FOCUSED APPROACH. Oftenparents feel guilty and anxious aboutsubjecting their child to even a minimal-ly invasive surgical procedure, and theirown anxiety may transfer to the child.Subsequently, the child’s perception ofpain may be heightened. Basic concepts,such as talking to the child in age-appropriate terms and using therapeuticplay are intended to keep anxiety at amanageable level so that the ultimate

the least, a bitter, burning irritation thatcauses most children to cry.36 Even oralmedication mixed with flavored syrupcan be unpalatable or poorly accepted.If a resistive child spits out the medica-tion, a power struggle ensues anddiminishes the reliability of the desiredtherapeutic dose or effect.

SAFETY ISSUES IN PREMEDICATION. Monitoringand safety considerations must be inplace to ensure that premedicated chil-dren remain safe.43,44 Three of the JointCommission on Accreditation of Health-care Organizations’ (JCAHO’s) PatientSafety Goals for 2007 specific to the peri-operative arena are

• goal 9—reduce therisk of patient harmresulting from falls,

• goal 13—encouragepatients’ active in-volvement in theirown care as a patientsafety strategy, and

• goal 13A—define andcommunicate the meansfor patients and theirfamilies to report con-cerns about safetyand encourage themto do so.45

Thus, nurses must informparents of the potentialfor impaired coordina-tion of a child who hasbeen premedicated andthe necessity of guardingthe child against fallsfrom a bed or whileambulating. A clinicaltrial using nitrous oxide

or midazolam for laceration repair pro-cedures in children demonstrated thatataxia, dizziness, difficulty walking,and crying were much more prevalentafter the procedure in the midazolamtreatment group.46 Caregivers must bevigilant, either securely holding thechild or ensuring that the child remains

In one study,ataxia, dizziness, difficulty walking,

and crying were much

more prevalent postoperatively inchildren to whommidazolam wasadministered.



outcome—progressing more quickly tobeing discharged—can be achieved.48

Acknowledging and reassuring parentalanxiety is key.

APPLY BASIC PRINCIPLES WHEN CARING FOR CHIL-DREN. Surgery disrupts a child’s routine.Nurses should explain to the parents thatanxiety and regression, such as bedwet-ting, is normal for a child during this

time. To minimize the fear of theunknown, nurses can provide hospitaltours where children and their parentsvisit the OR and are allowed to see, touch,and play with OR equipment. Nursesalso can provide age-appropriate toysand games or allow a child to bring his orher favorite toy or stuffed animal to theOR for reassurance.48

TABLE 1Helpful Web Sites for Pediatric Nursing, Surgery, and Anesthesia

Web site Web Address Content of web siteAORN http://www.aorn.org Links to various pediatric sites from the

/patient/peds.htm AORN web site

AORN Communities of http://communities.aorn Pediatric Specialty Assembly web portal Practice .org/COP (requires Pediatric Speciality Assembly

membership and an AORN member user name and password login)

American Society of http://www.asahq.org Includes sections on patient safety; when Anesthesiologists /patientEducation.htm your child needs anesthesia; “My Trip to

the Hospital Coloring Book” in printableportable document file format; and a videotape news release “Preparing Your Child for Surgery” with suggestions for effective preparation of a child for sur-gery and anesthesia

Society for Pediatric http://www.pedsanesthesia Includes explanations of pediatric Anesthesia .org/patiented/faq.iphtml anesthesiologist services, risks of

anesthesia, and fasting before surgery

National Association of http://www.napnap.org Features discussion forum and clinical Pediatric Nurse Practitioners practice guidelines information

Child Life Council http://www.childlife.org Provides overviews of the association for child life professionals and other mem-bers, certification, and program services

American Academy of http://www.aap.org Provides information on a variety of child-Pediatrics ren’s health topics for parents and health

care practitioners, including behavioral andmental health; diseases and conditions; healthy development; populations with unique health care needs; and individualtopics such as breastfeeding, immunization,literacy, nutrition, and physical activity

National Dissemination http://www.nichcy.org Provides information on disabilities Center for Children with in children and youths and programs Disabilities and services for those children; other

sections discuss educational rights, early intervention, and research

American Academy of http://www.familydoctor.org Features sections on healthy living, Family Physicians parents and kids, and talking to

your physician; includes informa-tion in Spanish



BOLSTER COPING ABILITIES. Performing pre-operative assessments and providingindividualized care is especially impor-tant for pediatric patients. Nurses mustbe alert to subtle and overt signs, suchas when a patient grimaces or contractshis or her body parts; or when thepatient specifically asks for comfortmeasures. An astute nurse needs to beaware that even if these behaviors arenot observed, that does not mean thepatient is not in distress. Overall, theprerequisite for complete assessment isassessing each child individually.49

In her early work, nursing professorLaMontagne50 emphasized the impor-tance of interview skills for accurate

and complete nursingassessments. Assessmentshould go beyond overtbehaviors because subtlesigns of distress can beoverlooked.

It is imperative to assessfor preoperative anxiety.The complexity of preop-erative fear warrants morecomprehensive assess-ment before surgery. Tofind out if previous hos-pital experiences mighthave frightened or mightbe causing a patient’s con-cern during this visit, thenurse must ask aboutthose experiences. Someof the concerns affecting

this admission may be valid. During thehectic preoperative preparation period,it is easy to overlook subtle cues orstatements that convey these concerns;therefore, perioperative nurses need tohave highly developed interview skills.During preoperative assessments, thenurse should pay full attention to ques-tions and assess coping strategies.Armed with this information, the nursecan then work to enhance the copingstrategies the patient is using and to

suggest alternatives. By creating anenvironment in which patients feel freeto identify and acknowledge fears thatthey may have tried to hide from others,nurses provide the best in perioperativecare. Nurses can then help to convertthe anticipated and actual stressfulexperience into a tolerable, and evenpleasant, experience.51

The nurse should ask the child await-ing surgery what he or she knows andwants to know about the upcoming sur-gery.50 This allows the nurse to clarify mis-understandings and provide additionalinformation and suggestions on how thechild can better manage fear or worry.For example, simply explaining his orher nursing functions (eg, offeringmedication for pain relief postoperative-ly) to the child may help some childreneffectively cope with the stressful de-mands of surgery and anticipated pain.50

When asked, some children (ie, clas-sified as vigilant copers) reveal that theylike to know all the details of the sur-gery.50 Other children (ie, classified asavoidant copers) may prefer less infor-mation and may benefit more from sup-portive discussions of the positiveaspects of surgery (eg, less pain, betterhealth).50 Understanding which strategya child uses to cope and determining hisor her appraisal of the surgery providesthe only way of knowing which inter-vention is most appropriate.50 For in-stance, distraction can be of benefit par-ticularly for avoidant copers. Distraction,however, requires creativity and vivacityfrom staff members.49

In another study, LaMontagne et al(2003)52 expanded on the concept ofmanaging preoperative anxiety whenidentifying the interactive effects of anx-iety in both parent and child. They dis-covered that although significant de-creases in parental anxiety occurredfrom the preoperative to postoperativeperiods, parental anxiety levels re-mained high, indicating that parents

Assessmentshould look

beyond overtbehaviors so

that subtle signsof distress do

not go unnoticed.



remain emotionally distressed through-out their child’s recovery. Managingpreoperative anxiety requires the nurseto identify the interactive effects of anxi-ety in both parent and child becauseanxiety in the parent transfers to thechild. The researchers suggested direct-ing nursing interventions according tothe child’s individual coping style andother interventions aimed at helpingparents deal with their anxiety to helpalleviate the child’s anxiety and distress.This commonly used, emotion-focusedapproach entails positive reappraisal (ie,

pointing out the positiveaspects of a situation). Bypresenting the positiveaspects of the surgical in-tervention and outcomes,nurses may help parentsto display a more opti-mistic attitude, which thechild senses. Parents andchildren who expect posi-tive outcomes tend to beless anxious and may bemore effective in copingwith their circumstances.

Seeking social support(eg, attending supportgroups, asking for refer-rals) has been shown to bethe problem-focused cop-ing strategy used mostoften.52 Nurses shouldcontinually reassess par-ents’ need for reassuranceand positive emotionalsupport during the entire

perioperative experience. Ultimately,focusing on the benefits of surgery andurging parents to participate actively intheir child’s care and progress bolstersthe parents’ ability to cope.52

Although interview techniques andskills are important, simply being avail-able and broaching the subject of copingalso is therapeutic. LaMontagne et al(1997)53 emphasized that by asking par-

ents about their fears, nurses give the par-ents permission to focus on their ownconcerns. That openness in discussionsencourages parents to consider theirchild’s perceptions, thoughts, and feel-ings and encourages the child to expressand process those emotions, therebyenhancing parental effectiveness in deal-ing with their child. Other sources showthe dynamic interplay between patient,family, and professional.54,55 Health carepractitioners may speed up the psycho-logical recovery of the patient most effec-tively by focusing on the needs of thefamily unit as a whole.54

Steelman and Wilt, in reviewingLaMontagne’s previous work, reportedthat the findings show

the value of using theoretical frame-works to guide our practice. Researchis not always available to identify bestinterventions to address a patient careproblem. . . . It is important to developinterventions to help parents reducepreoperative anxiety. . . . Perioperativeresearchers should evaluate the effec-tiveness of the different alternatives todetermine the best practice.56(p245)

Brewer et al concur, stating that,

Research examining the use of anxi-olytics versus preparation for alleviat-ing pediatric anxiety would be valu-able. Comparing the effectiveness ofanxiolysis versus preparation wouldenable health care professionals todetermine which type of interventionwould be most beneficial.28(p21)

What can the individual nurse dowhen such gaps in research comparisonsexist? Decisions are made via clinicalexpertise, and ultimately are blendedwith “patient preferences and withavailable good evidence.”57 When anurse is deciding whether the informa-tion and results apply to his or her

Health care practitionersmay speed up

the psychologicalrecovery of thepatient mosteffectively by

focusing on theneeds of the

family unit as awhole.



iety levels. The nurse can use this infor-mation to tailor an approach to the childand parents on the day of surgery.49 Thenurse should thoroughly document theinformation gleaned from the preopera-tive interview and relay this informationto other health care team members. Apreoperative telephone call provides thenurse with an opportunity to instruct theparents and establish thefirst contact for creating re-lationships with the childand parents after theyarrive in the preoperativesetting.

After surgery, the nurseshould ensure that theparents are allowed toparticipate in postopera-tive care as much as possi-ble and coach the parentsand child regarding homecare needs. After assess-ing the parents’ literacylevels, the nurse shouldpresent all postoperativeinstructions to the parentsorally and provide themwith written copies of allinformation. Written in-structions are particularlyimportant because thestress of the perioperativeexperience may makeremembering oral instruc-tions difficult. The nurseshould provide the par-ents with a telephonenumber to call if ques-tions arise and then should perform afollow-up telephone call to check on thechild and parents the next day.

INFANTS/TODDLERS—BIRTH TO THREE YEARS. Inthis sensorimotor stage, infants displaynatural curiosity as they explore theirenvironment and their own bodies. Inearly infancy, sources of anxietyinclude sudden loud noises and loss ofpostural support. Stranger anxiety

patient, the nurse should have a discus-sion with the patient. Although success-ful pediatric preoperative care processesencourage health care practitioners togear teaching to the appropriate devel-opmental age of the child,55 research rec-ommendations may not be explicit orsuited specifically to every child, whichcan lead to feelings of ineptitude or sim-ple frustration for nurses.

One group of authors provide apractical, how-to manual in which theyexplain that

. . . the child and family have differentagendas at different ages; so shouldthe clinician. . . . This changing agen-da instills a freshness into the practiceof pediatrics that in our experienceadds to professionalism and enjoy-ment.58(xv) . . . each encounter [withchildren and families] is an opportu-nity for learning and growth.58(xvii) . . .some of the most effective . . . teachingoccurs individually with students . . .as we discuss or examine a specificpatient.58(xv)

INTERVENTIONS FOCUSED ONDEVELOPMENTAL STAGE

Pediatric patients can be grouped intoage categories according to the agegroup’s salient characteristics. Inter-ventions for children and their parentscan be geared to those characteristicsusing a team approach.59-61

ALL AGES. Performing a preoperativetelephone call gives a perioperative nursethe opportunity to assess a child viainformation obtained from the child’sparents over the telephone. The nurseshould gather information about thechild’s temperament, health, and previ-ous OR experiences and answer all ques-tions from the parents or child. Whilegathering this information, the nurse alsohas the opportunity to assess both thechild’s and parents’ knowledge and anx-

Pediatric patientscan be grouped

into age categories

according to theage group’s

salientcharacteristics;

interventions forchildren and their

parents can begeared to thosecharacteristics.



develops between five months to two-and-a-half years, peaking between sixand 12 months. At one year, childrenfeel uncertain and fearful aroundstrangers, as well as in unfamiliar situ-ations or with unfamiliar objects.Although onset and duration vary de-pending on the child, separation anxi-ety starts around seven months, peaksbetween 18 and 36 months, and lastsuntil about four years of age.62 Photo-graphs of the parents placed where thechild can see them during the parents’

absence may reassure chil-dren in this age group.63

Toddlers believe thatbecause they cannot seetheir mother, she has“gone away.” A toddler,who does not quite graspthe concept of time, cannotbe sure if or when his orher mother might return,which is why children inthis age group cling totheir mothers so fiercely.

By establishing a consis-tent pattern of attentivegood-byes and happyreunions, [parents] canbuild the child’s confi-dence in [them] and[their] relationship.64

In addition, practicingcan help a child becomeaccustomed to separation.The nurse should en-courage the parents to saygood-bye the same way

every time and to make a ceremony ofthe good-bye process. The nurse shouldemphasize the importance of sayinggood-bye lovingly but firmly, explainingin terms their child can understandwhen they will return (ie, at breakfasttime). The nurse should encourage theparents to stick to this ceremony consis-

tently and not to give in and come backif their child begins to cry. Giving in onlyencourages the child to try the cryingbehavior the next time.64

The nurse should explain to the par-ents that it is critical for the parents tocome back at the time they promised.Keeping promises to children helpsthem learn to trust and have confidencein themselves. The nurse should explainthat when parents show confidence inthe caregiver to care for the child in theparents’ absence, the child will pick upon these feelings and have confidencetoo. Furthermore, the nurse shouldexplain to the parents that a

child’s unwillingness to leave you isa good sign that healthy attachmentshave developed between the two ofyou. Eventually your child will beable to remember that you alwaysreturn after you leave, and thesememories will be enough to comforthim or her while you are gone. Thisalso gives your child a chance todevelop his or her own coping skillsand a little independence.64

This age encompasses the psychoso-cial stages of trust versus mistrust (ie,birth to 12 months) and autonomy ver-sus shame and doubt (ie, one to threeyears). To provide for both physical andemotional security, the nurse should per-suade the parents to be actively involvedby encouraging their child and answer-ing the child’s questions. The nurseshould ask the parents about the child’slikes and dislikes. The nurse then canincorporate this information into thecustomized care plan. To reduce separa-tion anxiety, if at all possible, the nurseshould• not separate the parents and child;• allow the child to keep a transitional

object (eg, teddy bear);• allow parents to remain with their

child during induction or at least

Nurses shouldemphasize the

importance of parents

saying good-bye lovingly but

firmly and thenexplaining whenthey will returnin terms their

child can understand.



minimize the time between separa-tion and induction;

• not perform or administer anythingpainful until the child is anes-thetized;

• allow parents to come into the PACUas soon as possible.

INFANT/TODDLER PATIENT EXAMPLE. Mrs Wbrought 16-month-old Joseph to the hos-pital for an outpatient repair of bilateralinguinal hernias. Mrs W wanted to bewith Joey in the OR. The preoperativenurse, Nurse Q, explained that parentalpresence during induction was not

Parental Presence During Induction of Anesthesia

The literature shows varying viewpoints about parental presence during induction of anesthesia (PPIA). Forexample, in one study of anesthesia practices, 50% of US respondents reported that parents were never

present during anesthesia induction of their children, 26% of hospitals did not allow parents to be present,and trends varied depending on where in the country they practiced.1 Some reports encourage PPIA for select-ed children. In Australia, the practice is common;2 however, other areas, while advocating parental presence,still acknowledge the need for further studies of its efficacy.3

Another report focuses on parents’ desire to assist their child during induction and acknowledges theneed for administrative support, through staff focus groups and inservice programs about research evi-dence.4 They predict the standard in perioperative services will become family-centered care. Ultimately,parental preparation is required to accomplish this, which the authors explain is a responsibility of nurs-es who have the opportunity to influence family satisfaction with PPIA.4 Another writer goes beyond sug-gestions to stronger admonishments.

Despite the concerns of some staff, we would argue that there is compelling evidence that parentalexclusion from anaesthetic rooms is harmful to the child. [Barriers to PPIA] need to be challenged andrealistic strategies to overcome them developed. We therefore recommend an early reappraisal of prac-tice in children’s units to ensure that parents are given a chance of accompanying their child to theanaesthetic room.5(p17)

One author, however, speaks of the disadvantages or lack of adequate evidence of the efficacy of parentalpresence during induction, explaining that “. . . if decreasing parental anxiety is considered the outcome,parental presence during induction cannot achieve this purpose.”6(S190) Another author details the drawback ofparental presence during induction and the need for increased preparations, saying that

Potential disadvantages of PPIA include parental anxiety resulting in possible adverse reactions of theparents. . . . Since it has not been definitively proven that PPIA decreases a child’s anxiety before sur-gery, the question arises as to whether or not an additional risk to the child is created by allowing par-ents into the operating room for what might only result in increased parental satisfaction. . . . toreduce possible negative consequences, the parents must be provided with adequate preoperative edu-cation and information.7(p108)

SIDEBAR

1. Z N Kain et al, “Trends in the practice of parental pres-ence during induction of anesthesia and the use of preop-erative sedative premedication in the United States, 1995-2002: Results of a follow-up national survey,” Anesthesiaand Analgesia 98 (May 2004) 1252-1259.2. S R Wollin et al, “Predictors of preoperative anxietyin children,” Anaesthesia and Intensive Care 31(February 2003) 69-74.3. A T Watson, A Visram, “Children’s preoperative anxi-ety and postoperative behavior,” Paediatric Anaesthesia13 (March 2003) 188-204.4. S L Romino et al, “Parental presence during anesthesia induction in children,” AORN Journal

81 (April 2005) 780-792.5. A Glasper, C Powell, “First do no harm: Parentalexclusion from anaesthetic rooms,” Paediatric Nursing12 (2000) 14-18. 6. R Leelanukrom, W Somboonviboon, P Sriprachittichai,“Parental presence during induction of anesthesia inchildren: A study on parental attitudes and children’scooperation,” Journal of the Medical Association ofThailand 85 no 1 suppl (June 2002) S186-S192.7. H Koinig, “Preparing parents for their child’s sur-gery: Preoperative parental information and educa-tion,” (Editorial) Paediatric Anaesthesia 12 (February2002) 107-109.



allowed at this hospital. Nurse Q took aninstamatic photograph of mother andchild, which she sent with Joey to the OR.The circulating nurse, Nurse C, remindedthe mother that, as the anesthesia careprovider had explained earlier, the anes-thetic gases that Joey would breathewould allow him to fall asleep quickly,right after entering the OR. The next thingJoey would know, he would be wakingup in the PACU, which is where shewould rejoin and hold him. Nurse C dis-tracted Joey with his favorite colorfulstuffed animal as she wheeled him downthe hall in his enclosed crib. Mrs W wassurprised at how smoothly the separationwent. The family liaison nurse, Nurse H,also updated Mrs W about progress dur-ing surgery, and Mrs W wrote on her sur-vey questionnaire that she was satisfiedand relieved by the care she and her childhad received.

PRESCHOOL/EARLY CHILDHOOD—THREE TO SIXYEARS. This preoperational stage is charac-terized by concrete and literal thinking. Inthe psychosocial stage of initiative versusguilt, children become egocentric, andthus believe that they caused their ownillness and that it is a form of punishment.Besides fearing needles, they fear bodilyinjury, mutilation, and torture.37,65 Stillcurious, their active imagination andmagical thinking feeds into the fears,such as phobias of the dark and mon-sters.62,65 This is an especially importanttime for a nurse to forge alliances with theparents and child. By providing detailedinformation in clear, simple, brief lan-guage, the nurse prevents misinterpreta-tions. Knowing that children tend toblame themselves, the nurse should reas-sure the child that the condition is not thechild’s fault. Stimulation of the sensesremains important, along with therapeu-tic play using dolls or puppets. The nurseshould convey dignity by respecting thechild’s privacy; for instance, the nurseshould not ask the child to disrobe withthe door or curtains open.66 The nurse

should use parental input about theirchild’s likes and dislikes, strengths andweaknesses. By encouraging questionsfrom both the child and parents, the nursecan determine the child’s perceptions andfeelings. By this time, children havedeveloped motor skills, such as for draw-ing, that can express their feelings in non-verbal ways.

The therapeutic rela-tionship that a nursingstudent established witha three-year-old duringthe perioperative periodwas analyzed in one casestudy.8 The nursing stu-dent performed a thoroughdevelopmental assess-ment, provided a preop-erative tour, and usedtherapeutic play tech-niques. This successfullyreduced the child’s fearsand anxiety related tothe hospitalization andsurgery, ensuring thatthe surgical experiencebecame a constructiveencounter for the childand parents.

PRESCHOOL/EARLY CHILDHOODPATIENT EXAMPLE. DespiteNurse R’s gentle reassur-ances and coaxing and afirm tone, four-year-oldTanisha sat in her moth-er’s lap, clinging to her,crying, and refusing toremove her clothing or put on the hos-pital gown. Mrs P was embarrassedabout Tanisha’s behavior and becameabrupt and scolding, which only agi-tated Tanisha and made her cry louder.Nurse R called the anesthesia careprovider who ordered midazolam.Given that Tanisha was resistivealready, Nurse R used a syringe toplace the medication in the back ofTanisha’s mouth to encourage her to

The preschool/early childhood

stage is characterized by

concrete and literal thinking;children becomeegocentric, and

thus believe thatthey caused theirown illness andthat it is a formof punishment.



swallow the “red-juice medicine” butwithout causing Tanisha to gag. Stillscreaming, Tanisha swallowed somebut spit the rest out.

With the environment quieted behindclosed curtains, Tanisha, still held by hermother, began to doze off after 20 min-utes. She then allowed her mother tochange her into a colorful pediatric hos-pital gown in the privacy of her room.The circulating nurse, Nurse G, andanesthesia care provider arrived with alitter with padded side rails. Nurse Gintroduced herself to Tanisha’s mother

and then helped hermake Tanisha comfort-able with warm blanketson the litter.

While they were en-route to the OR, Tanishanoticed that her motherwas missing and tried tosit up, but she was toouncoordinated to do so.Nurse G helped steadyher and talked quietly toTanisha to distract heruntil Tanisha again closedher eyes in fatigue. Atthat point, Nurse G andthe anesthesia care pro-vider ensured that con-versations were avoidedto prevent further agita-tion. While Tanisha wasbeing transferred to theOR bed, she started re-peating, “I want mymommy!” and tried to situp and jump off the ORbed. Nurse G and theanesthesia care provider

kept a calm and pleasant demeanor,using information Tanisha’s motherhad provided about the family pet andan art project at preschool. Nurse Gstayed with Tanisha throughout anes-thesia induction by mask, which pro-ceeded without incident.

SCHOOL-AGED/MIDDLE CHILDHOOD—SIX TO12 YEARS. This cognitive stage is charac-terized by concrete operations. Thesechildren can reason both inductivelyand deductively and can understandcause and effect. Subsequently, theycan grasp the seriousness of situationsand the consequences of their actions.Although body privacy and dignity areconcerns for most age groups, they areparticularly so for children in the mid-dle childhood age group;66 and likeyounger children, they fear bodilyinjury and physical danger.62 One studyshowed that children between the agesof eight and 11 years may experiencemore anxiety without preparation (eg,from a child life specialist) because oftheir increased ability to process infor-mation.28 For example, their baselineanxiety levels may be adversely affect-ed because these children may haveencountered medical situations amongfamily members or on television andproject it onto themselves.28 As childrenmature, their increasing mental aware-ness can lead to increased reports ofpostoperative pain.

This heightened preoperative perceptionof pain can affect postoperative painrelief needs; therefore, the use of preop-erative antianxiolytics can be critical toa pain management protocol.67(p713)

To address their psychosocial stage ofindustry versus inferiority, nursesshould encourage these children to par-ticipate actively and to show independ-ence. For instance, the nurse shouldallow the child to choose a scented mask(eg, cherry, orange, bubble gum), and ifhe or she is not premedicated, allow thechild to walk to the OR from the preop-erative area accompanied by the anes-thesia care provider or circulating nurseinstead of being transported on a litter.The nurse should speak directly to thechild rather than through his of her

The school aged/middle childhood

stage is characterized by

concrete operations so

these children canreason both

inductively anddeductively andcan understand

cause and effect.



parents. Furthermore, the nurse shouldinform the child about what he or she canexpect during surgery (eg, duration,recovery time, return to the nursing unit);the location of the incision; and how thedressings will look. These options help

meet the child’s devel-opmental needs at thisstage, such as gainingself-control and develop-ing competence.68 Thenurse should use simplewords to explain the pur-pose of items seen in theOR, such as the strap onthe OR bed for safety andpreventing accidental falls(ie, not to be used to tiechildren down, but to actlike a seat belt in the car).68

Distraction techniques areeffective for this agegroup as well. The nurseshould engage the childby asking open-endedquestions about schoolactivities, sports events,friends, and hobbies.68

SCHOOL-AGED/MIDDLE CHILD-HOOD PATIENT EXAMPLE. Janie, anine-year-old patient withsevere scoliosis, arrivedwith her parents, Mr andMrs F for spinal surgery.To determine if Janie was

a vigilant or avoidant coper, the pedi-atric nurse practitioner, Nurse L, askedJanie whether she would prefer to knowa lot about what was going to happen insurgery or if she would rather not knowmuch. At first, Janie said “I guess I don’twant to know very much.” While NurseL was speaking quietly with Janie’s par-ents, Janie spontaneously asked, “If youcut me open, won’t I die?” Up until thispoint, Janie had been calm, cooperative,and charming, not displaying any stressor fear. Nurse L answered the questiondirectly by explaining that the purpose

of the surgery was to fix her back andeveryone would take excellent care ofher. Janie said, “I guess maybe I dowant to know what’s going to happenafter all.”

Nurse L calmly explained the role ofthe anesthesia care provider who wouldmake sure Janie was okay while the sur-geon worked on her back and thenbriefly explained how the surgery wasperformed. Janie’s relief at Nurse L’sreassuring response was obvious, afterwhich Janie announced in a matter-of-fact tone, “Then I’ll be okay.” A simpleclarification corrected her mispercep-tions. If she had not been asked, herfears could have gone undetected.

ADOLESCENCE. Some sources label adoles-cence as a period between the ages of 11and 21 years.69 There is a vast difference inthe physical, cognitive, and psychologicalmaturity of adolescents; therefore, preop-erative preparation is challenging fornurses who care for pediatric patients inthis wide age range.

Preoperative preparation of adoles-cents . . . will differ considerably incontent and context depending on theage and developmental level of the ado-lescent. . . . Developmentally appropri-ate preparation before surgery will helpperioperative nurses and surgical teammembers establish rapport and effec-tively communicate with [the patients]to reduce their anxiety and enlist theircooperation.69(p337)

All of the following ages comprise thecognitive stage of formal operations, dur-ing which adolescents develop a capacityfor abstract, scientific thinking. Identityversus role confusion is the hallmarkchallenge of this psychosocial stage.

EARLY ADOLESCENCE—10 TO 13 YEARS.Preteen children in this age group arebeginning to break away from their par-ents, which is demonstrated by their pref-erence for friends over family members.70

Preoperativepreparation of

adolescents, whorange from 11 to21 years of age,is challenging

because there is avast difference in

adolescentphysical,

cognitive, andpsychological

maturity.



Preteen children need to adjust as theirbodies undergo rapid changes. Althoughpreteen children start to develop abstractthought, they primarily retain concretethinking. They can build on past learning,so the nurse should determine what thepreteen patient already knows, such aswhat the surgeon has explained to him orher thus far. To ensure privacy, the nurseshould consider talking to a preteenpatient without his or her parents presentbut should inform the patient that thebasic content covered in the teaching ses-sions will be relayed to the parents.60

EARLY ADOLESCENT PATIENT EXAMPLE. Alyssa,an extremely shy and anxious 12-year-old, presented in the emergency depart-ment (ED) with her parents with symp-toms of an ovarian cyst. Mr and Mrs Nasked the physician about a hospitalwhere child life specialist serviceswould be available. The physicianreferred them to a surgeon who prac-ticed at a nearby children’s hospitalwhere child life specialist services wereavailable. This children’s hospital alsoallowed parental presence during in-duction of anesthesia. The child life spe-cialist, Ms J, met with Alyssa and herparents to discuss and reinforce theteaching about Alyssa’s ovarian cystand expected follow-up visits. Duringthis assessment, Alyssa admitted beingvery anxious about having the IV start-ed, so Ms J explained how Alyssa’s handwould be numbed with topical anesthet-ic spray before the IV was started, andshe would hardly feel the IV beinginserted. Alyssa was greatly relievedand began to open up to Ms J, alsoadmitting that she was very worriedabout having a big scar on her stomachthat would show when she wore herbathing suit. Ms J explained that the sur-geon would be making the incision justunderneath her bikini/hair line and thatafter it healed and her pubic hair grewback, no one would be able to see it. Thepreoperative nurse, Nurse D, then met

with Alyssa privately to review Alyssa’sgynecological history, after which NurseD invited the parents back into the roomand began to set up for starting Alyssa’sIV. Alyssa explained to her parents howthe IV would not hurt because of the localanesthetic, and the preoperative nursecompleted the IV insertion without prob-lems. Before leaving for the OR, Alyssatelephoned her best friend, excitedlyexplaining to her about the location ofthe incision. Alyssa’s father accompaniedAlyssa to the OR. The circulating nurse,Nurse Q, tucked warm blankets aroundAlyssa and held Alyssa’sright hand while Mr Nheld Alyssa’s left hand asAlyssa fell asleep with theanesthesia. Nurse Q thenescorted Mr N to the wait-ing room.

Figure 1 is Alyssa’spreoperative depiction ofwhat she believed the sur-gery would be like. Alyssaexplained that “Before mysurgery, I was nervousthat the IV would hurt. Ialso was scared that I’dhave a huge, ugly scar so Icould never wear a bikinibathing suit.” Alyssa’s pri-mary concerns were aboutbody image and painmanagement. Figure 2 isAlyssa’s depiction of heractual surgical experience.Alyssa explained that

Everyone at the hospitalwas very nice and help-ful. Having the spray onmy hand before the nurseput in the IV was real cold but then Icouldn’t feel hardly anything whenshe put in the IV. It didn’t hurt and Ijust felt her wiggling my skin around.I was nervous when we went into theOR but the nurse got me a warm

Preteen childrenstart to developabstract thought

but primarilyretain concretethinking. They

can build on pastlearning, so

nurses shoulddetermine whatpreteen patients

already knowabout the surgery.



blanket, and she and Dad stayed withme until I went to sleep. It’s only beena couple months since my surgeryand you can’t see my scar. I can evenwear a bikini!

Although Alyssa received a local anes-thetic before the IV start, she still wasnot pain-free, but she felt in control.Several comments show how thenurse’s presence and attentiveness com-forted her. The drawings and explana-tion emphasize the therapeutic value ofthe nurse’s presence and the impor-tance of the nurse’s caring, friendlyapproach.

MIDDLE ADOLESCENCE—14 TO 16 YEARS. Stillgrowing, teenage children are ambiva-lent about separation from their parents.They are in the process of testing differ-ent images and trying new styles ofclothing and personal appearance inalliance with their peer group in anattempt to fit in. They are fascinated bytheir increasing abilities to reason anduse logic, and they like to argue anddebate their points. They may try toassert their independence through rebel-lious behaviors, albeit minor infractions.Their peer group provides support.60,70

MIDDLE ADOLESCENT PATIENT EXAMPLE.Sixteen-year-old Daniel’s eyelid wasscratched and torn while he was playingbasketball. Daniel’s guardian, Aunt M,

brought him to the surgery center. Theinjury occurred during the summer sohis two friends, Sarah and Javier, cameto the surgery center with him. As thecirculating nurse, Nurse V, arrived,Aunt M mentioned that the night before,Daniel had announced that he was aman and did not need anesthesia. Sarahgiggled. Daniel quickly said to Nurse V,“Yes, tell the gas man not to come inhere. I don’t need that stuff.” Nurse Vasked Daniel to explain why. Danielsaid, “This just isn’t that big a deal. I’mnot a kid. I don’t need it.” Nurse Vexplained that he, himself, was injuredrecently when he was playing flag foot-ball and that he was really glad to haveanesthesia when the injury was re-paired. Nurse V explained to Danielthat most people who have surgeryuse some kind of anesthesia. Danielseemed to relax and agreed that hav-ing anesthesia might be okay.

The surgeon had met with Danieland Aunt M earlier to discuss thedetails of surgery. When Nurse V askedDaniel what type of additional informa-tion he would want to know about thesurgery, Daniel asked how long the sur-gery would take and whether it wouldseem that long while he was asleep.Nurse V told Daniel the anticipated sur-gical timeframe, allowing for extra timein case Daniel’s tear duct also was

Figure 1 •Preoperativedrawing by a12-year-old

girl depictingwhat shethought

wouldhappen

during andafter surgery.(Illustration

by MollyBorman,

based on aconcept by

AmberDreger)



involved. Nurse V also told Daniel that,like a nap, it would seem as though hehad just fallen asleep and then wokenup. Daniel was content with that infor-mation and then was transferred to theOR bed and cooperated with induction.

LATE ADOLESCENCE—17 TO 21 YEARS.Increasingly independent, these youngadults become more comfortable withtheir body image, which more closelymatches their personality. They developcaring relationships, and individualrelationships become more importantthan the entire peer group. Theirabstract thinking ability is more refinedand they identify steps to accomplishtheir goals. Their values are idealistic,and they hold rigid beliefs of right andwrong. Their self-centered values shiftto attention to others.70

LATE ADOLESCENT PATIENT EXAMPLE. At age 20,Betsy, who was on a college cheerlead-ing squad, arrived in the ED with hercoach. During practice, another girl fellfrom a cheerleading pyramid onto Betsyand fractured Betsy’s nose. Although at20, Betsy still is classified as a pediatricpatient, legally, she can make her owndecisions about health care; so the ear,nose, and throat surgeon obtained in-formed consent directly from Betsy.After determining that Betsy did notneed general anesthesia, the surgeonordered benzodiazepine as a premedica-

tion and a local anesthetic during therepair procedure. Nurse K helped Betsychange her upper body clothing into ahospital gown and helped Betsy getcomfortable on the minor procedureroom bed. After tucking Betsy in withwarm blankets, Nurse K injected a localanesthetic subcutaneously into Betsy’sleft hand and then inserted an IV. Betsyimmediately expressed her relief andgratitude that the IV insertion was sopainless. With additional monitoring,Nurse K then administered the sedativeaccording to the facility protocol, andthe surgeon started the surgical repair.Nurse K remained with Betsy through-out the procedure, talking quietly withher and offering comfort while monitor-ing Betsy’s vital signs. The surgeon com-pleted the procedure without incidentand applied an external nasal splint.During a follow-up appointment, Betsyexplained to Nurse K that friends atschool had teased her a lot about theexternal nasal splint, but Betsy wascapable of understanding that in thelong run her appearance and functionwould be restored. Betsy said that shewas pleased with her overall results.

ACHIEVING BEST OUTCOMESSeveral aspects of managing preop-

erative anxiety in children, such as useof premedications23,36-40,42,47 and parental

Figure 2 •Postoperativedrawing by a12-year-oldgirl depictingher feelingsabout whatactuallyoccurred during andafter surgery.(Illustrationby MollyBorman,based on aconcept byAmberDreger)



presence during induction,21,22,33,40,71 re-main controversial. Despite the recenttrend in increased use of sedation, it isnot a panacea and has its drawbacks.Depending on the source of informationregarding preoperative anxiety in pedi-atric patients, benefits may outweighthe drawbacks or vice versa and thusclinical judgment is required for eachindividual patient.

Health care practitioners’ comfortlevel with children, their ability toemploy speed, use distraction tech-niques, and develop rapport can beinstrumental in decreasing the distressexperienced by pediatric patients,whether by pharmacological, interper-sonal, educational, or alternative means.Managing the typical fears and anxietiesduring the preoperative phase preventsescalation of this stressful period to atraumatic event.

Principles that remain constant andare supported by the literature are thevalue of therapeutic communicationand rapport;12,37,72,73 importance of age-appropriate interventions tailored to thepatient’s developmental level;33-35,58-60,63

and interdisciplinary collaboration,sharing expert experiences amongteam members.28,30,32,61 Nurses can useevidence-based information to workwith anesthesia colleagues, child lifespecialists, and music therapists toconvert children’s distressed anticipa-tion of surgery to a tolerable, if notpleasant, experience. ❖

Victoria A. Dreger, RN, MA, CNOR,is a staff nurse at Advocate ChristMedical Center, Oak Lawn, Ill.

Thomas F. Tremback, MD, is a pedi-atric anesthesiologist on sabbaticalfrom private clinical practice.

This article is dedicated in memory of PaulE. Miller, MD, a superb clinician who wasloved and respected by staff members,

patients, and their family members. Theauthors thank Sara Blair, RN, MSN, assis-tant professor at Deicke Center forNursing Education, Elmhurst College,Elmhurst, Ill, and Kelly Evans, MS,CCLS, certified child life specialist atAdvocate Christ Medical Center, OakLawn, Ill, for their input in revising thisarticle; and the library staff members atboth Elmhurst College and AdvocateChrist Medical Center for their assistance.

NOTES1. “Ambulatory and inpatient procedures,”National Center for Health Statistics, http://www.cdc.gov/nchs/pressroom/99facts/ambinpat.htm (accessed 9 Aug 2006).2. C J DeFrances, M N Podogornik, “2004national hospital discharge survey. Ad-vance data from vital and health statistics,”National Center for Health Statistics,http://www.cdc.gov/nchs/data/ad/ad371.pdf(accessed 9 Aug 2006).3. Z N Kain et al, “Preoperative anxietyin children: Predictors and outcomes,”Archives of Pediatrics and Adolescent Medicine(December 1996) 1238-1245.4. D L Wong, M J Hockenberry, “Pediatricvariations of nursing interventions,” inWong's Nursing Care of Infants and Children,seventh ed (St Louis: Mosby, 2003) 1110.5. A T Watson, A Visram, “Children’s pre-operative anxiety and postoperative be-havior,” Paediatric Anaesthesia 13 (March2003) 188-204.6. M Ruzafa Martinez, M J Ruiz Garcia, CGomez Garcia, “Cirugia en el niño y el ado-lescente,” Revista de enfermeria 26 (Septem-ber 2003) 8-16.7. C Silvente, J Moix, A Sanz, “Reducciónde la ansiedad en la antesala del quirófanoen pacientes pediátricos,” Cirugia Pediatrica13 (January 2000) 30-34.8. F Faleiros, M L Sadala, E M Rocha,“Relacionamento terapéutico com crianca noperíodo perioperatório: Utilizaçáo do brin-quedo e da dramatizaçáo,” Revista da Escolade Enfermagem da USP 36 (March 2002) 58-65.9. J Thomas, “Brute force or gentle persua-sion?” (Editorial) Paediatric Anaesthesia 15(May 2005) 355-357.10. E Christiansen, N Chambers, “Casereport: Induction of anesthesia in a combat-ive child; Management and issues,” Paedia-tric Anaesthesia 15 (May 2005) 421-425.11. M Proczkowska-Bjorklund, C G Svedin,“Child related background factors affecting



compliance with induction of anaesthesia,”Paediatric Anaesthesia 14 (March 2004) 225-234.12. H Koinig, “Preparing parents for theirchild’s surgery: Preoperative parental infor-mation and education,” (Editorial) PaediatricAnaesthesia 12 (February 2002) 107-109.13. M Richardson-Tench, A Pearson, MBirks, “The changing face of surgery: Usingsystematic reviews,” British Journal of Peri-operative Nursing 15 (June 2005) 240-246. 14. H C Li, H Y Lam, “Paediatric day sur-gery: Impact on Hong Kong Chinese chil-dren and their parents,” Journal of ClinicalNursing 12 (November 2003) 882-886.15. M Edwinson Mannson, A K Dykes,“Practices for preparing children for clinicalexaminations and procedures in Swedishpediatric wards,” Pediatric Nursing 30 (May-June 2004) 182.16. S Woodward, L Franck, D Wilcox,“Consent for paediatric surgery: What arethe risks?” Clinical Governance 9 no 4 (2004)216-221.17. S R Wollin et al, “Predictors of preoper-ative anxiety in children,” Anaesthesia andIntensive Care 31 (February 2003) 69-74.18. T Iacobucci et al, “Evaluation and satis-faction level by parents and children fol-lowing pediatric anesthesia,” PaediatricAnaesthesia 15 (April 2005) 314-320.19. P Callery, “Preparing children for sur-gery,” Paediatric Nursing 17 (April 2005) 12.20. C Campbell, M T Hosey, S McHugh,“Facilitating coping behavior in childrenprior to dental general anesthesia: A ran-domized controlled trial,” PaediatricAnaesthesia 15 (October 2005) 831-838.21. A Glasper, C Powell, “First do no harm:parental exclusion from anaesthetic rooms,”Paediatric Nursing 12 (2000) 14-18. 22. R Leelanukrom, W Somboonviboon, PSriprachittichai, “Parental presence duringinduction of anesthesia in children: A studyon parental attitudes and children’s coopera-tion,” Journal of the Medical Association ofThailand 85 no 1 suppl (June 2002) S186-S192.23. M Duggan et al, “Benzodiazepine pre-medication may attenuate the stressresponse in daycase anesthesia: A pilotstudy,” Canadian Journal of Anesthesia 49(November 2002) 932-935.24. P Benner, V W Leonard, “Patient con-cerns, choices, and clinical judgment in evi-dence-based practice,” in Evidence-BasedPractice in Nursing and Healthcare, B M Mel-nyk, E Fineout-Overholt, eds (Philadelphia:Lippincott Williams & Wilkins, 2005) 164.25. T Porter-O’Grady, K Malloch, “Thrivingin complexity: Ten principles for leaders in

the coming age,” in Quantum Leadership: ATextbook of New Leadership (Boston: Jonesand Bartlett Publishers, 2003) 42.26. “Code of ethics for nurses with inter-pretive statements,” The American NursesAssociation, The Center for Ethics andHuman Rights, http://nursingworld.org/ethics/code/protected_nwcoe303.htm(accessed 9 Aug 2006).27. M T Stein el al, “Preparing a 3 year oldand his parents for an elective surgery, Part3,” Pediatrics 114 (November 2004) 1414-1419.28. S Brewer et al, “Pediatric anxiety: Childlife intervention in day surgery,” Journal ofPediatric Nursing 21 (February 2006) 13-22.29. B A Daveson, J Kennelly, “Music thera-py in palliative care for hospitalized chil-dren and adolescents,” Journal of PalliativeCare 16 (Spring 2000) 35-39.30. J Jarred, “Music assisted surgery: Pre-operative and postoperative interventions,”in Music Therapy in Pediatric Healthcare:Research and Evidence-Based Practice, S LRobb, ed (Silver Spring, Md: The AmericanMusic Therapy Association, Inc, 2003) 147.31. J Przelicke, personal communication withthe author, Oak Lawn, Ill, 15 April 2006.32. Z N Kain et al, “Interactive music ther-apy as a treatment for preoperative anxietyin children: A randomized controlled trial,”Anesthesia and Analgesia 98 (May 2004) 1260-1266.33. S M Wang et al, “Parental auricularacupuncture as an adjunct for parentalpresence during induction of anesthesia,”Anesthesiology 100 (June 2004) 1399-1404.34. M Rassin, Y Gutman, D Silner, “De-veloping a computer game to prepare children for surgery,” AORN Journal 80(December 2004) 1095-1102.35. L Vagnoli et al, “Clown doctors as atreatment for preoperative anxiety in chil-dren: A randomized, prospective study,”Pediatrics 116 (October 2005) 1013-1014.36. J P Cravero, Z N Kain, “Pediatricanesthesia,” in Clinical Anesthesia, fifth ed,P G Barash, B F Cullen, R K Stoelting, eds(Philadelphia: Lippincott Williams &Wilkins, 2006) 1205-1209.37. J Pérez Fontán, G Lister, “The acutely illinfant and child,” in Rudolph’s Pediatrics, 21sted, C D Rudolph, A M Rudolph, eds (NewYork: McGraw Companies, Inc, 2003) 336. 38. T Carpenter et al, “Critical care,” inCurrent Pediatric Diagnosis and Treatment, 17thed, W W Hay et al, eds (New York: McGraw-Hill [International Edition], 2005) 396.39. J L Lichtor, “Anesthesia for ambulatorysurgery,” in Clinical Anesthesia, fourth ed, P G



Barash, B F Cullen, R K Stoelting, eds(Philadelphia: Lippincott Williams &Wilkins, 2001) 1217-1222.40. Z N Kain et al, “Trends in the practiceof parental presence during induction ofanesthesia and the use of preoperativesedative premedication in the UnitedStates, 1995-2002: Results of a follow-upnational survey,” Anesthesia and Analgesia98 (May 2004) 1252-1259.41. Z N Kain et al, “Premedication in theUnited States: A status report,” Anesthesia andAnalgesia 84 (February 1997) 427-432.42. C J Coté, “Sedation for the pediatricpatient: A review,” Pediatric Clinics of NorthAmerica 41 (February 1994) 31-58.43. “Identifying, collecting, and developingclinical and educational resources toimprove patient safety in the surgical set-ting,” AORN: Patient Safety First, http://www.patientsafetyfirst.org/about-us.html(accessed 2 Oct 2007).44. S C Smeltzer, B G Bare, “Intraopera-tive nursing management,” in Brunner &Suddarth’s Textbook of Medical-Surgical Nur-sing 10th ed (Philadelphia: LippincottWilliams & Wilkins, 2004) 432. 45. “2007 Hospital/Critical Access HospitalNational Patient Safety Goals,” Joint Com-mission on Accreditation of HealthcareOrganizations, http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_hap_cah_npsgs.htm (accessed 9 Aug 2006).46. J Lumann et al, “A randomized clinicaltrial of continuous-flow nitrous oxide andmidazolam for sedation of young childrenduring laceration repair,” Annals of Emer-gency Medicine 37 (January 2001) 20-27.47. American Society of AnesthesiologistsTask Force on Sedation and Analgesia byNon-anesthesiologists, “Practice guide-lines for sedation and analgesia by non-anesthesiologists,” Anesthesiology 96(April 2002) 1004-1017.48. B Swoveland et al, “The Nuss proce-dure for pectus excavatum correction,”AORN Journal 74 (December 2001) 828-840.49. J Bentley, “Distress in children attendingA&E,” Emergency Nurse 12 (July 2004) 20-26.50. L L LaMontagne, “Facilitating children’scoping: Preoperative assessment interviews,”AORN Journal 42 (November 1985) 718-723.51. A G Wiens, “Preoperative anxiety inwomen,” AORN Journal 68 (July 1998) 74-85.52. L L LaMontagne et al, “Optimism, anxi-ety, and coping in parents of children hospi-talized for spinal surgery,” Applied NursingResearch 16 (November 2003) 228-235.53. L L LaMontagne et al, “Child and

parent emotional responses during hospi-talization for orthopaedic surgery,” TheAmerican Journal of Maternal Child Nursing22 (November/December 1997) 303.54. K K Scott, “The psychological aspects ofpediatric trauma: Perspectives on patient,family, and provider,” Surgical Clinics of NorthAmerica 82 (April 2002) 419-434.55. M M Kelly, L Adkins, “Ingredients for a successful pediatric preoperative care process,” AORN Journal 77 (May 2003) 1006-1010.56. V M Steelman, W Wilt, “Children’s pre-operative coping and its effects on postop-erative anxiety and return to normal activi-ty,” (Reviews) AORN Journal 71 (January2000) 244-246.57. “What is evidence-based medicine(EBM)?” University of North Carolina,Health Sciences Library, http://www.hsl.unc.edu/Services/Tutorials/ebm/index.htm(accessed 9 Aug 2006).58. S D Dixon, M T Stein, Encounters withChildren: Pediatric Behavior and Development,third ed (St Louis: Mosby, 2000) xv-xvii.59. L E Berk, Infants, Children, and Adolescents,fifth ed (Boston: Allyn & Bacon, 2005).60. S B Bastable, M A Dart, “Developmen-tal stages of the learner,” in Essentials ofPatient Education (Boston: Jones and BartlettPublishers, 2006) 103-144.61. R Justus et al, “Preparing children andfamilies for surgery. Mount Sinai’s multi-disciplinary perspective,” Pediatric Nursing32 (January/February 2006) 35-42.62. J Hagman, D W Bechtold, “Child andadolescent psychiatric disorders & psycho-social aspects of pediatrics,” in CurrentPediatric Diagnosis and Treatment, 17th ed, W W Hay et al, eds (New York: McGraw-Hill [International Edition], Inc, 2005) 176,196-199.63. E Goldson, R J Hagerman, A Reynolds,“Child development and behavior,” inCurrent Pediatric Diagnosis and Treatment,17th ed, W W Hay et al, eds (New York:McGraw-Hill Companies, Inc, 2005) 78. 64. “KidsHealth for parents: Separationanxiety,” Nemours Foundation, http://kidshealth.org/parent/positive/family/separation_anxiety.html (accessed 9 Aug 2006).65. S Dresser, B Melnyk, “The effective-ness of conscious sedation on anxiety,pain, and procedural complications inyoung children,” Pediatric Nursing 29(July/August 2003) 320.66. D M Popovich, “Preserving dignity inthe young hospitalized child,” NursingForum 38 (April-June 2003) 12.



67. A R Tate, G Acs, “Dental postoperativepain management in children,” DentalClinics of North America 46 (October 2002)707-717.68. V Hendricks-Ferguson, M A Nelson,“Treatment of cholelithiasis in children withsickle cell disease,” AORN Journal 77 (June2003) 1170-1182.69. N H Busen, “Perioperative preparationof the adolescent surgical patient,” AORNJournal 73 (February 2001) 337-363.70. M E Felice, J Maehr, “Eleven to thir-teen years: Early adolescence—Age ofrapid changes,” in Encounters with

Children: Pediatric Behavior and Develop-ment, third ed, S D Dixon, M T Stein, eds (St Louis: Mosby, 2000) 429.71. S L Romino et al, “Parental presenceduring anesthesia induction in children,”AORN Journal 81 (April 2005) 780-792.72. T Porter-O’Grady, K Malloch, “The leaderas peacemaker: Managing conflicts of a mul-tifocal workplace,” in Quantum Leadership: ATextbook of New Leadership (Boston: Jones andBartlett Publishers, 2003) 88.73. C R Foy, F Timmins, “Improving commu-nication in day surgery settings,” NursingStandard 19 (Oct 27–Nov 2, 2004) 37-42.

People who suffer from allergic rhinitis are 2.9times more likely to develop Parkinson’s disease

later in life than those without allergic rhinitis,according to an Aug 7, 2006, news release from theMayo Clinic, Rochester, Minn. Researchers theorizethat the immune response that occurs in allergicrhinitis also may occur in the brain, producinginflammation. This inflammation might result inthe death of brain cells, as is seen in patients withParkinson’s disease.

Previous studies have shown that people whoregularly take anti-inflammatory medications are lesslikely to develop Parkinson’s disease. Researchers

therefore investigated a possible link betweenParkinson’s and other common inflammatory dis-eases. No association was found, however, betweenParkinson’s disease and lupus, rheumatoid arthritis,pernicious anemia, vitiligo, or asthma. Althoughallergies do not cause Parkinson’s disease,researchers believe there may be an associationbetween the two.

Mayo Clinic Links Allergies to Parkinson’s Disease(news release, Rochester, Minn: Mayo Clinic, Aug 7,2006) http://www.mayoclinic.org/news2006-rst/3578.html (accessed 8 Sept 2006).

Allergies May Be Linked to Parkinson’s Disease

Anew surgical technique for addressing hip painoffers patients an alternative to total hip

replacement (THR), according to a May 19, 2006,news release from NewYork-Presbyterian Hospital/Columbia University Medical Center, New York. Hipresurfacing is a technique that allows the orthope-dic surgeon to shave and cap several centimeters ofbone within the hip joint, covering the joint’s sur-faces with an all-metal implant that more closelyresembles a tooth cap than a hip implant.

Advantages of the hip resurfacing techniqueover THR include a reduced postoperative risk of• dislocation because the implant for hip resurfac-

ing is larger than the one that is traditionally

used in THR, resulting in increased stability,• inaccurate leg length because the femoral head

and neck are not removed and replaced as inTHR, and

• resurgery to replace a worn-out plastic socketbecause the hip resurfacing implant is all metal.

The procedure is indicated for patients under the ageof 60 who live nonsedentary lifestyles and suffer fromhip pain related to diseases that affect the hip joint.

New Alternative to Hip Replacement Designed forPatients with Active Lifestyles (news release, New York:NewYork-Presbyterian Hospital/Columbia UniversityMedical Center, May 19, 2006).

New Technique Offers Alternative to Total Hip Replacement

Home Study Program - POEMS For Children | POEMS for children · demonstrated that music therapists’ skills can alter the effect that a particular music therapy has on a patient.

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