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Perioperative Care of the
Pediatric Patient With DownSyndrome
www.aorn.org/CE
1.9ANDREA TONGE, BSN, RN, CPN, CSRN
T
he care of children with special needs in
the perioperative environment poses many
challenges for health care workers. Chil-drens unique physical, physiological, and psycho-
logical needs require that the patient care team
members possess extensive knowledge of growth
and developmental milestones and the physiology
of various body systems. This article addresses
perioperative implications for pediatric patients
with Down syndrome. Down syndrome is the
most commonly occurring genetic disorder, and,
because of its association with a high incidence of
congenital abnormalities, many children with thisdisorder will require surgical procedures for cor-
rection and repair that will be performed with the
patient under general anesthesia.1 Technological
advances in the medical field also will likely re-
sult in an increase in the number of surgical inter-
ventions for these patients.2 It is essential that peri-
operative staff members acquire a comprehensive
knowledge base regarding coexisting conditions to
properly manage care of this patient population.
HISTORY
Down syndrome, also known as trisomy 21, is an
autosomal genetic disorder named for J. Langdon
Down, a British physician, in 1866.3 Dr Down
sought to describe common characteristics of
individuals affected by the disorder to distinguish
these individuals from other individuals withcognitive delays. In 1959, a geneticist, Jerome
LeJeune, established one of the causes of Down
syndrome as an abnormality of structure (ie, tri-
somy) in the 21st chromosome.4 The two other
causes of the disorder, translocation and mosa-
icism, were determined within the following
three years.4
PATHOPHYSIOLOGY
Human cells normally have 23 pairs of chromo-
somes, for a total of 46. These cells divide by the
process of meiosis to produce gametes (ie, sperm
and egg cells), which contain one copy of each
pair of chromosomes. In Down syndrome, one of
three different types of alterations in chromosomal
structure occur during the process of gamete
formationnondysjunction, translocation, or mo-
saicism.5 Nondysjunction results when, before
conception, a gamete is produced with an extra
copy of chromosome 21. When this gamete unites
with a normal gamete from the other parent, the
embryo develops with all cells having 47 chromo-
somes (instead of the normal of 46), each with
three copies of chromosome 21hence the term
indicates that continuing education contact hours are available for this activity. Earn the contact hours by
reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and
Learner Evaluation at http://www.aorn.org/CE . The contact hours for this article expire December 31, 2014.
SPECIAL NEEDS POPULATIONS
doi: 10.1016/j.aorn.2011.09.005
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trisomy (Figure 1). The maternal gamete is
implicated in 88% of these cases.5 In transloca-
tion, which accounts for 3% to 5% of Down syn-
drome cases, all or part of chromosome 21 is fused
to another chromosome. This form of Down syn-
drome is usually hereditary and is not linked with
an increase in parental age, whereas trisomy and
mosaicism are linked with increased maternal age.
Mosaicism refers to trisomy that occurs in only a
minority of cells (Figure 2). With the majority of
cells remaining normal in chromosomal structure,
affected individuals present with less severe symp-
toms, with the degree of disability relative to the
number of abnormal chromosomes.6
ETIOLOGY
Down syndrome occurs in one in 800 live births,
spanning all ethnicities and economic levels.7
One factor that increases the risk of having a
child with Down syndrome is increased maternal
chronologic age (ie, 35 years or older).8 Most
people believe that maternal age is the primary
predictor of Down syndrome and do not realize
that 80% of children with Down syndrome are
born to women who are younger than age 35. In
addition to maternal age, other theories regarding
the etiology of Down syndrome include environ-
mental factors such as exposure to electromag-
netic radiation and x-rays, toxic effects of
pesticides, smoking, and drinking.7 However,
according to the National Down Syndrome So-
ciety,8 there has been no conclusive research
that links Down syndrome with environmental
factors or parental behavior before conception.
CLINICAL PRESENTATION
Children with Down syndrome commonly present
with abnormalities in physical features, congenital
malformations of various organ systems, and im-
pairment in physical and cognitive abilities.9 They
appear smaller in size than their average counter-
parts and develop at a slower rate both mentally
and physically.10 Fifty percent of affected chil-
dren have congenital heart disease, and they are
at increased risk for thyroid dysfunction; gastroin-
testinal, hematologic, and endocrine disorders;
respiratory problems; sensory impairment; and
mental disabilities.9
Physical features characteris-tic of the disorder include a flat occiput; flat facial
features; slanted eyes with skin folds between the
inner corner of the eyes and upper eyelids; speck-
ling of the iris; small nose and ears; small mouth
with a large, protruding tongue; short neck; and
sparse hair. Other manifestations include in-
creased flexibility of certain joints, hypotonia,
flabbiness of abdominal muscles, a single palmar
TRISOMY
Chromosome 21
MONOSOMYNormal
gamete
Normal
gamete
Meiosis I
Nondysjuncon
Meiosis II
Ferlizaon
Ferlizaon
Figure 1. In Down syndrome, nondysjunction of chromosome 21 occurs when it fails to divide properly,
resulting in monosomy (which is lethal) or trisomy.
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crease in the hands, and short fingers, as well as
small penis and undescended testicles in males.6
All children with Down syndrome have some
measure of developmental delay, including
language and motor skills.1 These become appar-
ent during the first year of life. Cognitive impair-
ment is manifested more in verbal short-term
memory than in visual processing.6 One study
demonstrated that short-term memory and com-
prehension could be improved through visual im-agery and cues.11 Social skills are usually not
impaired in children with Down syndrome. Men-
tal capabilities vary from mild to moderate, with
an IQ ranging from 50 to 70 and 35 to 50, re-
spectively.9 Some individuals will require exten-
sive supervision to lead a life of optimal poten-
tial, whereas others can maintain a level of
independence with fewer support systems.
TREATMENT
Clinical specialists gear the treatment of children
with Down syndrome toward managing any com-
promise in physical, physiological, or cognitive
function. The goal is to use early interventions
and therapies to help affected individuals lead
productive lives.12 Management includes assess-
ing all physiological systems at birth; educating
the childs parents and family members about
diagnostic procedures, the potential for impaireddevelopment, and treatments and medications that
are indicated for medical conditions commonly
associated with Down syndrome; and making ap-
propriate referrals. It is also important for health
care providers to assist parents with their coping
ability; to provide the childs caregivers with the
necessary resources for short-term and long-term
care involving physical, occupational, and speech
Figure 2. In Mosaicism, trisomy occurs in only a minority of cells. Reprinted with permission from the National
Genetics Education and Development Centre (www.geneticseducation.nhs.uk).
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therapies; to discuss diagnostic procedures and
therapeutic regimens; and to emphasize the im-
portance of follow-up care for managing medical
conditions.12 These interventions will help children
with Down syndrome maintain a healthy lifestyle
and promote their physical and psychological
well-being during the entire lifespan.
PERIOPERATIVE IMPLICATIONS
According to Zuckerberg and Maxwell,13 8% to
10% of patients diagnosed with Down syndrome
develop perioperative complications during non-
cardiac surgical procedures. These include ob-
struction of the airway, bronchospasm, and diffi-
culty with intubation. Cardiac anomalies with
pulmonary hypertension also place these patients
at risk from the use of anesthetic agents.1 Because
of the significance of these and other associated
problems, a thorough preoperative evaluation with
careful planning is essential to ensure the best out-
comes for these patients. The preoperative evalua-
tion should include assessment of the patients
cardiac, pulmonary and respiratory, musculosk-
eletal, gastrointestinal, endocrine, hematologic,
developmental/psychosocial, and neurological
systems. The preoperative nurse must develop
an individualized plan of care to guide the
management of the patient during the entire
perioperative period, based on comprehensive
assessment data that addresses all commonly coex-
isting conditions (Table 1).
Cardiac
Approximately 40% to 50% of children with
Down syndrome have congenital cardiac anoma-
lies that will require corrective surgical repair.1
An echocardiogram with cardiology consult is
indicated preoperatively for patients with a car-
diac history because of the effects of anesthetics
and the stress of surgery on the heart.14 Nurses in
the presurgical clinic can play an important role
in ensuring that the patient with Down syndrome
is screened preoperatively by educating the pa-
tients parents on the importance of keeping pre-
operative medical appointments. Nurses can also
assist the anesthesia professionals in obtaining
laboratory, radiology, and other diagnostic re-
ports. On the day of surgery, the perioperative
nurse should obtain baseline vital signs, including
oxygen saturation level. To prevent endocarditis,
patients may need antibiotics prophylactically
30 to 60 minutes before some surgical proce-
dures. The nurse should screen for a history of
allergies and perform a reconciliation of all of
the patients medications to prevent possible
adverse medication interactions.
Pulmonary and Respiratory
The presence of a small buccal cavity, large
tongue, and small nasal passages predispose chil-dren with Down syndrome to an increased risk
for airway obstruction and complications related
to anesthetic agents and sedatives.1,15 Airway ob-
struction can occur while these patients are awake
or asleep, which is of special consideration in
patients who receive procedural sedation without
an artificial airway in place. Children with Down
syndrome also have a higher incidence of subglot-
tic stenosis and may require intubation with
smaller-than-expected endotracheal tubes.
7
Physi-cians and nurses must assess for a history of ob-
structive sleep apnea, stridor, barky cough, snor-
ing, or unusual sleeping positions because of the
possibility of subglottic stenosis. Nurses assisting
with procedural sedation must anticipate the need
for smaller airway adjuncts and have them
available if necessary. Obesity, hypotonia, and
cardiac disease also have been associated with
both lower and upper airway problems in this
population.
7
When performing a preoperativeassessment, the perioperative nurse also must
consider these other factors.
Musculoskeletal
Approximately 20% of children with Down syn-
drome have atlantoaxial instability (AAI), a con-
dition in which there is increased mobility be-
tween the two cervical bones at the top of the
neck. This causes instability of the cervical spine
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and predisposes these children to spinal cord
compression.1,16 The American Academy of Pedi-
atrics recommends cervical spine radiographs of
children with Down syndrome who are three to
five years old to detect possible AAI. Because the
majority of children with Down syndrome are
asymptomatic for AAI, it is important that the
perioperative nurse obtain a pertinent history
regarding neck pain, changes in gait, muscle
weakness, or changes in bowel and bladder func-
tion before surgery.13 A history of increased flex-
ibility of joints in the fingers and elbows is asso-
ciated with AAI.7 Because of the prevalence of
hypotonia and delay in motor development in these
patients,1 the perioperative nurse should obtain base-
line data about any impairment in motor skills
TABLE 1. Perioperative Nursing Implications: Children With Down Syndrome
Preoperative care
Schedule procedures for children with diabetes early in the day to decrease fasting time.
Encourage parents to comply with preoperative screening of patients.
Obtain a relevant history, including information about cardiac disease, obstructive sleep apnea, stridor, diabetes,
hypothyroidism, gastroesophageal reflux disease, vomiting, obesity, hypotonia, neck pain, changes in gait, muscle weakness,
and changes in bowel and bladder function.
Obtain baseline data regarding the childs developmental age and impairment in motor skills.
Assist in obtaining relevant laboratory and diagnostic reports (eg, echocardiogram, cervical spine radiograph, blood glucose
level, thyroid function tests).
Obtain baseline vital signs on the day of surgery.
Perform a medication reconciliation and obtain the patients history of allergies.
Administer antibiotics prophylactically to prevent endocarditis.
For procedural sedation cases, have a large selection of airway adjuncts available.
Enforce practice guidelines governing infection control and prevention.
Encourage family members to participate in all procedures by giving the child his or her medications, encouraging the child to
communicate with staff members, providing comforting measures during invasive procedures, and incorporating the childs
routine in the plan of care.
Use visual aids and gestures when communicating with the child.
Prepare the patients family members for a longer-than-usual observation period postoperatively.
Intraoperative care
Limit neck manipulation.
Prepare to assist with cricoid pressure before anesthesia induction.
Observe for adverse effects from anesthetics, sedatives, or analgesics.
Assess for adequate cardiopulmonary function by monitoring vital signs and ventilation status as well as level of
consciousness in sedation cases.
Protect the patient from heat loss and hypothermia.
Maintain proper body alignment and support of extremities during patient positioning and transfer.
Monitor intake and output.
Postoperative care
Continue to monitor cardiopulmonary status.
Observe for signs and symptoms of airway obstruction.
Monitor for postoperative bleeding and drainage.
Assess for adverse effects of muscle relaxants.
Make clinical judgments regarding pain control based on cues and information from the patients family members.
Communicate with patients who have sensory impairment to prevent feelings of isolation.
Provide a favorite toy or other objects of comfort.
Ensure patient safety to prevent physical injury.
Provide discharge instructions to the patients family members based on the interdisciplinary plan of care.
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preoperatively to properly assess for adverse events
related to the administration of muscle relaxants.
Gastrointestinal
Abnormalities in the gastrointestinal system, in-
cluding tracheoesophageal fistula, pyloric stenosis,and Hirschsprung disease, occur in about 12% of
children with Down syndrome, and many will
need surgical repair in the neonatal period.1 Be-
cause gastroesophageal reflux disease frequently
occurs in individuals with Down syndrome, the
preoperative nurse should assess for a history of
vomiting because of the implication for possible
aspiration during anesthesia induction.
Endocrine
There is an increased risk for diabetes and a preva-
lence of hypothyroidism in individuals with Down
syndrome.1 Therefore, it is important for the preop-
erative nurse to collaborate with the anesthesia team
in obtaining and reviewing relevant history and cur-
rent laboratory values before the surgical procedure.
Nurses must be knowledgeable about the signs and
symptoms of these disorders to identify and report
significant findings to the physician. An infant with
hypothyroidism may present with a large tongue and
an umbilical hernia. Older children with hypothy-
roidism might be noted with slow heart rate and
intolerance to cold.15 Some perioperative implica-
tions for hypothyroidism include decreased cardiac
output and delayed gastric
emptying. Children with dia-
betes should be scheduled for
surgery early in the day to
decrease their hours of
fasting.
Hematology
Patients with Down syn-
drome have some measure
of immune system deficiency
that renders them prone to a
higher incidence of infection
relative to the general popu-
lation and dramatically in-
creases their likelihood of developing acute leuke-
mia.1 It has been documented in the literature
that, although there is a high success rate in sur-
gical procedures performed to repair cardiac
anomalies in patients with Down syndrome, there
is also an increase in postoperative complications
and deaths that are possibly associated with recur-
rent infections.7 The nurse has an essential role
in managing the perioperative environment to
ensure that all members of the perioperative
team comply with practice guidelines for infec-
tion control and prevention.
Developmental and Psychosocial
Compared with adults, young children in general
have unique psychological responses to hospital-
ization in terms of feelings of separation anxiety,
fear, and punishment.3 The perioperative nurse
caring for the child with Down syndrome is faced
with the added challenges of cognitive and sen-
sory delays in these patients. Because these chil-
dren vary in their degree of cognitive delay and
may have vision and hearing deficits, nurses need
to know the level of impairment to communicate
effectively with them. One way that nurses can
do this is to collaborate with parents and family
members to properly assess and determine the
childs developmental age. These children also
may have some difficulty expressing their feelings
verbally, which can result in added anxiety and
Online Resources
National Human Genome Research Institute
http://www.genome.gov/19517824National Down Syndrome Congress
http://www.ndsccenter.org/
National Down Syndrome Society
http://www.ndss.org
National Dissemination Center for Children with Disabilities
http://nichcy.org/disability/specific/downsyndrome
Web site access verified August 16, 2011.
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frustration.8 Adolescent patients with Down syn-
drome might present with a history of emotional
and behavioral problems such as aggression and
exaggerated anger.17 The administration of anx-
iolytics or sedatives might be beneficial. The
nurse should communicate with the patient on the
patients cognitive level by using simple instruc-
tions, preferably with visual aids and gestures. The
nurse also can observe the childs social interac-
tion with family members to identify cues that
might decrease anxiety and fear. Nurses should
explore their own feelings and attitudes about
caring for these children to reveal possible
biases and barriers that could affect their
nursing care.6
According to Hayes,16 many children with
Down syndrome resist changes in their routine.
Nurses should try to incorporate the childs rou-
tine into the plan of care to decrease anxiety
and promote cooperation. Parents can identify
activities that the child can do independently
(eg, changing clothes to don hospital attire, self-
administering oral medications with supervision).
These activities should be encouraged to develop
the childs sense of trust in the environment.6 The
patients family members should be prepared with
the knowledge that their child might need to be
observed for a longer period postoperatively than
is typically expected for the procedure, depending
on the childs status after the procedure. Patients
undergoing ambulatory surgery might require an
overnight stay for further observation. It might be
beneficial to have the childs favorite toy, blanket,
or other comforting object on hand in case the
postoperative stay is prolonged.
There is an increased rate of mental illness in
older individuals with Down syndrome. In some
health care institutions, care for the pediatric pop-
ulation extends past 18 years of age. Nurses and
health care providers in these institutions need to
be knowledgeable of state laws and regulations
and of institutional policies that address the issue
of consent for treatment for persons with mental
illness.10
Neurological
Individuals with Down syndrome may have a
higher pain threshold than the general population
and may react to pain more slowly.10 Research
results have shown that these children also differ
in their ability to precisely identify the location of
painful stimuli and are less likely to communicate
their pain verbally.18 Parents can provide the
health care team with information about pain indi-
cator behaviors that their child exhibits (eg, use
of certain words, pointing, expressions of anger,
acting out) to help effectively assess and control
the childs pain.
INTRAOPERATIVE CARE
The goal in the intraoperative period focuses on
patient safety while the patient is anesthetized or
sedated. Precautions should be taken to limit neck
manipulation in all children with Down syndrome
because some patients are asymptomatic for AAI.
The childs neck should be maintained in a neu-
tral position with a soft collar to avoid extreme
neck flexion, extension, or rotation.7 Because of
the incidence of airway abnormalities, it is impor-
tant to have different sizes of airway modalities
available to effectively manage respiratory com-
plications. The intraoperative nurse should be pre-
pared to assist anesthesia professionals with the
application of cricoid pressure in the event of a
rapid sequence induction in a child with a history
of gastroesophageal reflux and vomiting.
Nurses administering or assisting with proce-
dural sedation should have substantial knowledge
of sedatives, analgesics, and reversal medications,
and implications for patients with Down syn-
drome who have coexisting conditions. The seda-
tion nurse should constantly assess for adequate
cardiopulmonary function by monitoring vital
signs, ventilation status, and level of conscious-
ness. Infection control measures should continue
to be instituted by the intraoperative nurse. In the
event of hypothyroidism, coupled with the chal-
lenge of temperature regulation in the pediatric
age group, care should be taken to protect against
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heat loss and hypothermia. Proper body position-
ing and support of extremities are also important
in this population because of possible hypotonia.
Nurses must ensure that extra care is taken to
appropriately support joints and limbs throughout
patient transfer.
POSTOPERATIVE CARE
Postoperative care of the pediatric patient with
Down syndrome focuses on continued monitor-
ing of cardiopulmonary status, with an empha-
sis on observing for signs and symptoms of
airway obstruction, laryngospasm, and postextuba-
tion croup. The patient care team in the postanes-
thesia care unit should determine the critical as-pects of the patients status that could affect his
or her recovery.3 Nurses should monitor for post-
operative bleeding or drainage, which could affect
hemodynamic status. Strict intake and output
should also be observed to prevent possible fluid
overload.3 The patient care team should use base-
line data to assess for adverse effects of muscle
relaxants because of the prevalence of motor de-
lays in these children. Nurses must make clinical
judgments regarding pain control and the adminis-tration of analgesics, because children with Down
syndrome may not show obvious evidence of dis-
comfort.10 The nurse might need to make a deci-
sion based on the type of procedure and the anes-
thetic agents and medications used during the
procedure.3 In patients with a history of hearing
loss or vision impairment, nurses must be espe-
cially sensitive to anticipate the childs needs and
communicate with him or her to prevent feelings
of isolation.6 Patient safety must be considered,and the childs immediate surroundings must be
secured to prevent physical injury. Discharge
plans from the postoperative area should incorpo-
rate an interdisciplinary approach, addressing the
patients physical, physiological, and psychosocial
needs, and should be based on the preoperative
assessment and on intraoperative and postopera-
tive events.
CONCLUSION
Pediatric patients with Down syndrome pose con-
siderable challenges for the entire perioperative
team. A careful preoperative screening and evalu-
ation is crucial to target issues of special concern
relative to this population. Nurses can function as
facilitators to ensure that a multidisciplinary
approach is used in anticipation of perioperative
complications and in the development of a com-
prehensive plan of care. The psychosocial needs
of these children must be given special attention
because of the incidence of cognitive and sensory
impairment, and effective communication with
parents and families must be used to meet these
needs. Extra time must be secured to allow for
the management of possible adverse events re-
lated to coexisting medical conditions. With
the application of the most current knowledge,
evidence-based practice, and careful planning, the
health care team can prevent complications and
ensure a positive perioperative experience for pe-
diatric patients with Down syndrome.
Acknowledgement: The author thanks Michelle
Byrne, PhD, RN, CNE, CNOR, associate profes-
sor and coordinator for the Master of Science in
Nursing Education Program at North Georgia
College and State University, Dahlonega, GA, for
her guidance and support in the preparation of
this manuscript.
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15. Motoyama EK, Davis PJ. Smiths Anesthesia for Infants
and Children. 7th ed. Philadelphia, PA: MosbyElsevier; 2006.
16. Hayes J. Perioperative care planning for a Downs syn-
drome patient. J Perioper Pract. 2010;20(2):70-73.
17. Bawle E. Chapter 258: Down syndrome: managing the
child and family. In: American Academy of Pediatrics.
Textbook of Pediatric Care. Pediatric Care Online.
2008. https://www.pediatriccareonline.org/pco/ub/view/
Point-of-Care-Quick-Reference/397156/3 [subscription
required]. Accessed July 19, 2011.
18. Davies RB. Pain in children with Down syndrome: as-
sessment and intervention by parents. Pain Manag
Nurs. 2010;11(4):259-267.
Andrea Tonge, BSN, RN, CPN, CSRN, is a
resource staff nurse, Childrens Healthcare of
Atlanta, GA. Ms Tonge has no declared affilia-
tion that could be perceived as posing a potential
conflict of interest in the publication of this
article.
December 2011 Vol 94 No 6 TONGE
614 AORN Journal
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Special Needs Population
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CONTINUING EDUCATION PROGRAM
1.9
www.aorn.org/CEPerioperative Care of the PediatricPatient With Down Syndrome
PURPOSE/GOAL
To educate perioperative nurses about caring for the pediatric surgical patient with
Down syndrome.
OBJECTIVES
1. Discuss the pathophysiology of Down syndrome.
2. Identify the etiology of Down syndrome.
3. Describe the clinical presentation of Down syndrome.
4. Describe treatments used for children with Down syndrome.
5. Discuss implications of perioperative care for a patient with Down
syndrome.
The Examination and Learner Evaluation are printed here for your conve-
nience. To receive continuing education credit, you must complete the Exami-
nation and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1. In Down syndrome, the types of alteration in
chromosomal structure that may occur during the
process of gamete formation include
1. mosaicism
2. nondysjunction
3. translocation
4. trisomy
a. 1 and 2 b. 3 and 4
c. 1, 2, and 3 d. 1, 2, 3, and 4
2. Down syndrome occurs in one in _________ live
births.
a. 800 b. 1,000
c. 1,200 d. 1,500
3. Children with Down syndrome commonly present
with
1. abnormalities in physical features.
2. congenital malformations of various organ
systems.
3. heightened cognitive abilities.
4. impaired physical abilities.
a. 1 and 2 b. 3 and 4
c. 1, 2, and 4 d. 1, 2, 3, and 4
4. Children with Down syndrome are at an in-
creased risk of
1. congenital heart disease.
2. gastrointestinal, hematologic, and endocrine
disorders.
3. respiratory problems.
4. sensory impairment.
5. thyroid dysfunction.
a. 1 and 5 b. 2, 3, and 4
c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5
EXAMINATION
AORN, Inc, 2011 December 2011 Vol 94 No 6 AORN Journal 615
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5. Interventions that can help children with Down
syndrome maintain a healthy lifestyle include
1. assessing all physiologic systems at birth.
2. educating the childs parents and family mem-
bers about diagnostic procedures, the potential
for impaired development, and treatments and
medications that may be needed.
3. assisting the parents with their coping abilities.
4. referring patients for physical, occupational,
and speech therapies as appropriate.
a. 1 and 3 b. 2 and 4
c. 1, 2, and 3 d. 1, 2, 3, and 4
6. Research indicates that __________ of patients
with Down syndrome develop perioperative com-
plications during noncardiac surgical procedures.
a. 8% to 10% b. 12% to 15%
c. 20% to 25% d. 33% to 38%
7. Children with Down syndrome have a higher in-
cidence of subglottic stenosis and may require
intubation with smaller-than-expected endotra-
cheal tubes.
a. true
b. false
8. Pediatric patients with Down syndrome who have
endocrine disorders may present with
1. a large tongue.2. an umbilical hernia.
3. decreased cardiac output.
4. delayed gastric emptying.
5. intolerance to heat.
6. increased heart rate.
a. 1, 3, and 5 b. 2, 4, and 6
c. 1, 2, 3, and 4 d. 1, 2, 3, 4, 5, and 6
9. To address the patients unique psychological
responses to hospitalization, the perioperative
nurse should
1. collaborate with the patients parents to deter-
mine the childs developmental age.
2. communicate by using simple instructions with
visual aids, keeping gestures to a minimum.
3. avoid administering anxiolytics or sedatives.
4. incorporate the childs routine into the plan of
care.
5. identify cues that might decrease anxiety and
fear by observing the patients interaction with
his or her family members.a. 2 and 3 b. 1, 4, and 5
c. 1, 3, 4, and 5 d. 1, 2, 3, 4, and 5
10. During the intraoperative period, the perioperative
nurse should
1. be prepared to assist with applying cricoid
pressure in the event of rapid sequence
induction.
2. ensure different sizes of airway modalities are
available to manage respiratory complications.
3. take precautions to limit neck manipulation.
4. take extra care to support joints and limbsthroughout patient transfer.
a. 1 and 4 b. 2 and 3
c. 1, 2, and 3 d. 1, 2, 3, and 4
The behavioral objectives and examination for this program were created by Kimberly Retzlaff, editor, with consultation from
Rebecca Holm, MSN, RN, CNOR, clinical editor, and Susan Bakewell, MS, RN-BC, director, Center for Perioperative Education.
Ms Retzlaff, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of in-
terest in the publication of this article.
December 2011 Vol 94 No 6 CE EXAMINATION
616 AORN Journal
8/3/2019 Special Needs Population
12/13
CONTINUING EDUCATION PROGRAM
1.9
www.aorn.org/CEPerioperative Care of the PediatricPatient With Down Syndrome
This evaluation is used to determine the extent
to which this continuing education program
met your learning needs. Rate the items as
described below.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?1. Discuss the pathophysiology of Down syndrome.
Low 1. 2. 3. 4. 5. High
2. Identify the etiology of Down syndrome.
Low 1. 2. 3. 4. 5. High
3. Describe the clinical presentation of Down syn-
drome. Low 1. 2. 3. 4. 5. High
4. Describe treatments used for children with Down
syndrome. Low 1. 2. 3. 4. 5. High
5. Discuss implications of perioperative care for a
patient with Down syndrome.
Low 1. 2. 3. 4. 5. High
CONTENT
6. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
7. To what extent were your individual objectives
met? Low 1. 2. 3. 4. 5. High
8. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
9. Will you change your practice as a result of
reading this article? (If yes, answer question
#9A. If no, answer question #9B.)
9A. How will you change your practice? (Select all
that apply)
1. I will provide education to my team regard-
ing why change is needed.
2. I will work with management to change/
implement a policy and procedure.
3. I will plan an informational meeting with
physicians to seek their input and acceptance
of the need for change.
4. I will implement change and evaluate the
effect of the change at regular intervals until
the change is incorporated as best practice.
5. Other:
9B. If you will not change your practice as a result
of reading this article, why? (Select all that
apply)
1. The content of the article is not relevant tomy practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make
a change.
4. Other:
10. Our accrediting body requires that we verify the
time you needed to complete the 1.9 continuing
education contact hour (114-minute) program:
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center
approves or endorses products mentioned in the activity.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this
activity for relicensure.
Event: #11525; Session: #0001 Fee: Members $9.50, Nonmembers $19
The deadline for this program is December 31, 2014.
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Eachapplicant who successfully completes this program can immediately print a certificate of completion.
LEARNER EVALUATION
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Reproducedwithpermissionof thecopyrightowner. Further reproductionprohibitedwithoutpermission.