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Course: Pediatric Nursing

Topic: Perioperative Care

The Nurses International Community

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Module Goals

Learners will be able to:

Describe the purpose of perioperative nursing care.
Apply the nursing process to the perioperative care of the child.
Discuss the importance of preoperative client education.
Describe the importance of ROM, turning, cough/deep breathing exercises in postoperative care.

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What is Perioperative Care?

CPOC, n.d.

‘Perioperative care, also referred to as perioperative medicine, is the practice of patient-centered, multidisciplinary, and integrated medical care of patients from the moment of contemplation of surgery until full recovery.’

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Perioperative Care

Care given before, throughout and after surgery
Aims at making the child physically and mentally stable

For the operating procedure
After the surgical treatment

Duration of care depends on the child’s needs
Includes three stages:

Preoperative
Intraoperative
Postoperative

Journal of Perioperative and Critical Intensive Care Nursing, n,d.

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Preoperative Care

Preoperative care begins when those authorized to make decisions for the child makes the informed decision to have the surgery.
Child is physically and psychologically prepared for surgery.
Required laboratory tests are performed.
Required preoperative medications, if any, are administered.
Preoperative assessments and interviews are conducted to gather the child’s information for plan of care.

Goodman & Spry, 2017

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Preoperative Assessment and Management

Nutritional status

Assessment and treatment of malnourishment

Cardiopulmonary considerations

Assessment of cardiac or pulmonary disorders that pose peri/post-operative risks

General screening for medical issues

Serum blood urea nitrogen (BUN)
Serum creatinine, sodium, calcium and full blood count
Prescription medications should be reviewed

Cancer Australia, 2018a

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Preoperative Assessment and Management

Cancer Australia, 2018a

Coluzzi, 2017

Garimella & Cellini, 2013

Pain Management

Preoperative evaluation and planning is vital to successful postoperative pain management
Special consideration for opioid-tolerant child

Psychological impact of surgery

Psychological preparation linked to shortened hospital stay and decreased need of analgesia
Provide child and family with opportunity to verbalize fears/concerns
Multidisciplinary team shares the responsibility of pre-operative teaching

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Preoperative Education

Positively influences child’s post-operative outcomes
Empowers family and child’s self-management, which facilitates recovery
Comprehensive information vital for informed consent
Key principles of pre-operative education include:

Developmentally appropriate education provided to the child
Consideration of the child and family’s coping style
Tailored information which suits general level of comprehension, education and cultural background
Communication of the risks involved in the surgery
Consideration of the timing of education to avoid times of elevated anxiety, such as immediately preceding surgery

Cancer Australia, 2018a

Aranha & Dsouza, 2019

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Preoperative Education by Nurse

Restrictions on certain medications as ordered by doctor prior to surgery
‘Nothing by mouth’ (NPO) status before surgery (when, how, why)
Bathing/shower, oral hygiene required before surgery
What parts of the process family can be present for and where to meet up with the child after surgery
Postoperative care and activities child and family can expect:

Frequent vital signs monitoring
Physical activity/diet requirements and restrictions
Breathing exercises for children that are old enough
Pain control measures

University of IOWA Health Care, 2017

Aranha & Dsouza, 2019

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Pediatric Considerations

Infant - 2 years

Parents should prepare themselves emotionally for surgery.
Infants as young as 6 months watch parents for emotional cues, so if parents are relaxed and comfortable, infant is more likely to be the same.
Encourage parents to bring comfort item from home (pacifier, blanket etc).
Will most likely have stranger and separation anxiety.
May experience significant emotional upset and behavioral regression post surgery.

Ahmed & Rufo, 2022

Beaumont Hospital, n.d.

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Pediatric Considerations

2-5 years old

Use simple language to talk to the child about the surgery.
Still concerned about separation.
Children at upper range of this age group may be concerned about body integrity.
Child may see the surgery as punishment, so offer reassurance that they have done nothing wrong and the purpose of the surgery is to make them feel better.
Can help child relax and become familiar with surroundings through medical play such as playing with medical kits and exploring surgical area prior to surgery.
Give child jobs to promote cooperation.

Ahmed & Rufo, 2022

Beaumont Hospital, n.d.

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Pediatric Considerations

6-11 years

Children of this age can understand basic information about body systems and how the surgery will help them.
Explain what type of surgery is being done and where on the body it will be performed.
Often fearful about their bodies being hurt and confused about anesthesia; clear up misconceptions.
Give truthful information.
Gaining independence at this age so allow opportunities to participate in their own care.

Ahmed & Rufo, 2022

Beaumont Hospital, n.d.

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Pediatric Considerations

Adolescents

Discuss reason for surgery, type of surgery, and where on the body it will be performed.
Review the fact that staff will be monitoring them to ensure that they do not wake up until the surgery is over.
Discuss importance of not eating or drinking before the surgery.
May have concerns regarding body image, self-esteem, and potential loss of dignity.
Encourage adolescent to ask questions and express how they are feeling.

Ahmed & Rufo, 2022

Beaumont Hospital, n.d.

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Critical Thinking Question:

What are the elements of preoperative care?

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Nurse’s Role in Preoperative Care

Work collaboratively with doctors to assess child’s health care needs for the planned procedure or operation.
Ensure child’s legal guardian(s) are fully informed and signed informed consent.
Ensure child is prepared for surgery, and it is safe to proceed with surgery.
Assess child and ensure all necessary preparations have been made.

Australian College of Perioperative Nurses, n.d.

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Nurse’s Role in Preoperative Care

Substantiate data relevant to the child’s readiness for surgery
Communicate pertinent information to the surgical team
Provide psychological support to the child and family

Allow child and family to voice their concerns and ensure they are addressed
Ensure/facilitate timely provision of information of tests and results to the family to reduce stress/anxiety of uncertainty
Provide information about postoperative destination

Cancer Australia, 2018a

Cancer Australia, 2018b

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Intraoperative Care

Begins when child is transferred to operating room
Ends when child is transferred to post-anaesthesia care unit (PACU) or where post-surgical recovery care is provided
Surgical intervention occurs where child is

Anaesthetized
Monitored
Prepped, draped
Surgical procedure is performed

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Nurse’s Role in Intraoperative Care

Nurse’s responsibilities in intraoperative phase:

Child’s safety
Facilitation of the procedure
Prevention of infection
Satisfactory physiologic response to anaesthesia and surgical intervention

Nurse roles in intraoperative care:

Anaesthetic Nurse
Circulating Nurse
Instrument Nurse

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Nurse’s Role in Intraoperative Care:

Anaesthetic Nurse

Assistant to the anesthetist/anesthesia nurse performs:

Prepare environment and equipment for administering anaesthesia
Receive and identify the correct child in operating room
Address guardian(s) concerns, and get informed consent
Communicate relevant information with intraoperative team
Assist with intraoperative monitoring and ensure the child’s safety, comfort and warmth
Assist anesthetist at the end of the procedure as the child emerges from the effects of anesthesia

Australian College of Perioperative Nurses, n.d.

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Nurse’s Role in Intraoperative Care:

Circulating Nurse

Non-sterile member of the team in operation room who:

Coordinates the activities in the operating room.
Implements the nursing plan of care, supply the sterile team as needed and document all care given.
Advocate for the child and ensure a safe environment.
Undertake and document the count of all accountable items, together with the instrument nurse.
Consistently monitor intraoperative environment and aseptic status of the sterile team using their surgical conscience.

Australian College of Perioperative Nurses, n.d.

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Nurse’s Role in Intraoperative Care: Instrument Nurse

Also referred to as ‘Scrub Nurse’
Scrubs, gowns and gloves for the surgical procedure
Activities:

Responsible for setting up and handing sterile supplies.
Responsible for handing instruments to the surgeon.
Maintain an accurate count of all accountable items throughout the procedure.
Consistently monitor intraoperative environment and the aseptic status of the sterile team using their surgical conscience.

Australian College of Perioperative Nurses, n.d.

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Critical Thinking Question:Discussion

Why is preoperative education important for surgery?

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Post-operative Care

Begins with the transfer of the child to post-anaesthesia care unit (PACU) or post-operative care unit (POCU).
Ends with the resolution of surgical sequelae.
Currently, many surgical interventions are performed on outpatient basis where possible.

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Immediate Post-operative Care in PACU/POCU

Following assessments are undertaken immediately and frequently:

Respiratory rate
Oxygen saturation
Temperature
Systolic blood pressure
Pulse rate
Level of consciousness (consider sedation/opioid analgesia given)
IV Infusions

Child must be monitored and assessed closely for any deterioration in condition.
Relevant postoperative care plan or pathway is implemented.

Liddle, 2013a

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Post-operative Care in PACU/POCU

Pain management

Assess for indication of pain
Ensure infusion lines are intact
Assess/evaluate effectiveness in opioid-tolerant children

May need higher doses analgesia compared to other children

Assess for hemorrhage and/or shock:

Excessive bleeding on the surgical wound dressing
Tachycardia, lowered systolic reading, cold/clammy skin, and prolonged capillary refill time, which indicate internal bleeding leading to shock

Liddle, 2013 a

Liddle, 2013 b

Coluzzi et al., 2017

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Post-operative Care: Further Care

Unless contraindicated, encourage and assist the older child to an upright position supported by a pillow
Assist child:

Deep breathing exercises and coughing, turning frequently

Support incision firmly with hands/small pillow during cough
Encourage small children to take deep breaths by blowing bubbles, whistles, pinwheels etc.
Helps clear lungs and lowers the risk of pneumonia

Encourage range of motion through play for younger children and exercises for older children to reduce the risk of embolism

Government of Alberta, 2019

Liddle, 2013b

The Hospital for Sick Children, 2014

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Post-operative Care: Further Care

When possible, assist child to ambulate

Can often be done through play
Improves blood circulation that helps in wound healing
Helps early return of bowel and bladder function

Bladder catheterization is last resort
Introduction of small amounts of fluidinitially, unless contraindicated

Progress to solids as appropriate
Child should be eating full diet by the time they are discharged

American Cancer Society, 2019

Liddle, 2013b

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Nurse’s Role in Post-operative Care

Same perioperative nurse should provide care at postoperative phase where child is expected to return home the same day
Perioperative nurses responsibilities:

Support recovery from surgery and identify potential complications
Keep up-to-date with guidelines, policies and evidence-based practice pertinent to perioperative care
Adhere to best practice guidelines
Skilled at knowing what is normal or abnormal
Effectively communicate/manage emergency situations

Liddle, 2013a

Liddle, 2013b

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Nurse’s Role in Immediate Post-operative Care

Liddle, 2013a

PACU/POCU nurse receives child and provides immediate care:

Ensure child safety from any kind of injury.
Ensuring child is in recovery position with patent airway.
Respiratory, cardiovascular and neurological assessments.
Assess for signs of external/internal bleeding.
If child deteriorates, immediately call for help and carry out management interventions according to the agency protocol.

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Nurse’s Role in Post-operative Care in the Ward/Daycare Units

Monitor vital signs, pain, active bleeding, wound dehiscence
Administer appropriate medications

Antibiotics, IV fluids, pain medications, anticoagulants

Assistchild with:

Deep breathing, coughing exercises, incentive spirometry
Range of motion
Early ambulation
Bowel movements and urination
Wound care

Liddle, 2013b

The Hospital for Sick Children, 2014

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Nurse’s Role in Post-operative Care

Education before discharge provided to caregivers and the child at a developmentally appropriate level:

Physical activities, exercises that can be done safely

To prevent wound dehiscence and promote wound healing

Nutritional diet for wound healing
Hygienic habits to care for wound at home

Signs of infection and when to seek medical care

Date and time for follow-up
Documentation

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Family-Centered Perioperative Care

Respect parent/family role in child’s care
Parent/family involvement in decision making about child’s surgery and care
Provide preoperative counselling:

About surgery, possible complications, prognosis
Waiting time and place
Post-operative management required

Provide choice for parent’s presence during anesthesia induction
Supporting parent’s presence in recovery room
Teach parent how to care for child and involve them in care as much as possible

Chorney & Kain, 2010

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What Would the Nurse Do?

The nurse is caring for a child in the recovery room who has had abdominal surgery.

What assessments should be done by the postoperative nurse in this case?

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Red Flags

Tachycardia
Increased blood or drainage on dressing
Low blood pressure
Prolonged capillary refill
Lower level of consciousness
Fever (may indicate life threatening reaction to anesthesia)
Anxiousness, restlessness, grimacing
Urinary retention
Low Oxygen saturation readings
Decreased respirations

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
Health customs: In some cultures family members play a large role in health care decision-making
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

(AHRQ, 2020)

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

(AHRQ, 2020)

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Cultural Considerations

Tolerance and expression of pain differs across cultures.

Maintenance of privacy in preoperative and recovery areas.

Many countries have practices that require family to supply food and linens for the patient in the hospital. The nurse should provide teaching in this area to assist the family in providing required diet and linens.

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References:

Aranha, P.R., & Dsouza, S.N. (2019). Preoperative information needs of parents: a descriptive survey. J Res Nurs, 24(5):305-314. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7932424/

American Cancer Society (2019, October 2). Risks of Cancer Surgery. https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/surgery/risks-of-cancer-surgery.html

Ahmed, Z., & Rufo, P.A. (2022, April 30). Pediatric preoperative management. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK559198/

Australian College of Perioperative Nurses. (n.d.). Nurses roles. Retrieved on September 7, 2021 from https://www.acorn.org.au/nursing-roles

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References:

Beaumont Hospital. (n.d.). Pediatric pre-surgery education. Beaumont. https://www.beaumont.org/services/childrens/pre-surgery-education

Cancer Australia. (2018a). EdCaN module: Fundamentals of cancer surgery/Individual Assessment. version 2.1. Retrieved on September 7, 2021 from https://www.edcan.org.au/edcan-learning-resources/supporting-resources/surgery/care-of-person/pre-op-assessment

Cancer Australia. (2018b) EdCaN module: Fundamentals of cancer surgery/Pre-operative education. version 2.1. Retrieved on September 7, 2021 from https://www.edcan.org.au/edcan-learning-resources/supporting-resources/surgery/care-of-person/pre-op-education

Contact info: info@nursesinternational.org

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References:

Children’s Health of Orange County. (n.d.). NPO guidelines. CHOC. https://www.choc.org/programs-services/surgery/npo-guidelines/

Chorney, J.M., & Kain, Z.N. (2010). Family-centered Pediatric Perioperative Care. Anesthesiology, 112, 751–755. https://pubs.asahq.org/anesthesiology/article/112/3/751/10783/Family-centered-Pediatric-Perioperative-Care

CPOC (n.d.). What is perioperative care?. Retrieved on September 7, 2021 from https://cpoc.org.uk/about-cpoc/what-perioperative-care

Contact info: info@nursesinternational.org

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References:

Coluzzi, F., Bifulco, F., Cuomo, A., Dauri, M., Leonardi, C., Melotti, R.M., Natoli, S., Romualdi, P., Savoia, G., & Corcione, A. (2017).The challenge of perioperative pain management in opioid-tolerant patients. Ther Clin Risk Manag, 13,1163-1173. https://doi.org/10.2147/TCRM.S141332

Garimella, V., & Cellini, C. (2013). Postoperative pain control. Clinics in colon and rectal surgery, 26(3), 191–196. https://doi.org/10.1055/s-0033-1351138

Goodman, T., & Spry, C. (2017). Essentials of Perioperative Nursing (6th ed.). Jones & Bartlett Learning.

Contact info: info@nursesinternational.org

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References:

Government of Alberta. (2019, May). Deep Breathing, Coughing, and Moving After Surgery. https://myhealth.alberta.ca/Alberta/Pages/deep-breathing-coughing-after-surgery.aspx

Journal of Perioperative & Critical Intensive Care Nursing (n.d.). Perioperative care. Retrieved on September 7, 2021 from https://www.longdom.org/scholarly/perioperative-care-journals-articles-ppts-list-1504.html

Liddle, C. (2013a). Postoperative care 1: principles of monitoring postoperative patients. Nursing Times, 109 (22): 24-26. https://www.nursingtimes.net/clinical-archive/critical-care/postoperative-care-1-principles-of-monitoring-postoperative-patients-31-05-2013/

Contact info: info@nursesinternational.org

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References:

Liddle, C. (2013b). Postoperative nursing care 2: how to reduce the risk of deterioration after surgery. Nursing Times; 109 (23):16-17. https://www.nursingtimes.net/clinical-archive/perioperative-nursing/postoperative-care-2-how-to-reduce-the-risk-of-deterioration-after-surgery-07-06-2013/

The Hospital for Sick Children. (2014, June 25). Incentive spirometry or bubbles: Encouraging deep breathing to clear the lungs. https://www.aboutkidshealth.ca/article?contentid=981&language=english

University of IOWA Health Care. (2017, July 16 ). Routine preoperative teaching for the adult patient. https://medicine.uiowa.edu/iowaprotocols/routine-preoperative-teaching-adult-patient

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