A nurse's role in preparing children for surgery

A nurse’s role in preparing children for surgery Sue J Robison, RN

Megan listens to Nurse Sue.

When the family of a pediatric patient comes to the surgeon’s office, the par- ents rarely absorb much beyond the word surgery. Repetition, caring, and concern must be continuous to give the parents the understanding they need to assist their children through the ex- perience. For the child, too, thorough preparation and continuous love and at- tention will ensure tha t he faces surgery calmly and cooperatively.

Some years ago, I became concerned that patients enter the hospital know- ing relatively little about what is going to happen to them. As an operating room nurse, I believed there must be a role for me in educating patients about their care. This interest developed into

an association with David Trump, MD, a pediatric surgeon in Phoenix, Ariz. My role is preparing the child and his parents for surgery and supporting them throughout the experience. To the children, I am Nurse Sue.

We conduct a thorough, detailed preoperative teaching program for each of our patients, regardless of age, and their parents. A valuable feature of our program is that I stay with the child during the entire experience. This one- to-one, trusting relationship, estab- lished early, is comforting both to child and family during a time of stress. I have no other responsibilities during surgery than to be with child and fam- ily.

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The child feels he can remain in control.

The program starts with children who are about age 2%. If the child is too young to participate, the parents are still involved. The parents of babies have as many anxieties as parents of older children, and they need education and reinforcement, too. When newborns are transported to a medical center for surgery, I often visit the mothers in the original hospital to let them know what is happening to their babies and why.

The family as a whole must be consid- ered in treatment of the surgical pa- tient. People are becoming more knowl- edgeable about medical costs, medical care, and procedures. They read magazines and books; they talk to others and watch television. They have many questions. It is my responsibility to assess each situation, finding out what the family knows and whether there are errors in their knowledge, and to provide correct information.

Commenting on our practice, Dr Trump said, “I think the educational program is truly the cornerstone of my practice. Nurse Sue is the one who pre- pares the children and calms their anxieties. She has the parents ready for surgery and communicates effectively with them what to expect.”

Education of a child and family be- gins with the initial office visit. The one-to-one relationship they establish with the surgeon and nurse is developed at each contact. This first meeting must be based on an honest prediction of the

surgical experience. During the initial history and as-

sessment, I get a feeling for the family relationships and attitudes toward the child’s problem. It is important to keep in mind each family’s background, edu- cation, culture, beliefs, and past experi- ences. I t is important to know how brothers and sisters feel about what is happening to their sibling. The child must not feel he is responsible for his problem.

I help the parents organize their thoughts to better use Dr Trump’s time during his physical assessment. He can then devote his consultation to explain- ing and informing the child and parents about the surgical procedure. Finally, I give the parents an overview of the planned surgery. Each education ses- sion lasts from ten minutes to over an hour, depending on the child’s age and background. A return visit is scheduled for the entire family a few days prior to surgery for more indepth education.

Play is the work of children, and effec- tive learning takes place through play. Our office is a child-centered environ- ment with bright colors, child-sized chairs, and pictures of characters famil- iar to all children. This sets the tone for the program. Our education room is fill- ed with hospital equipment for the child to try out, clothes worn by hospital personnel for the child to try on, and a display board showing scenes of differ- ent rooms where the child will be during

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his own hospital stay. There are dolls for giving blood tests and x-rays and taking temperatures.

One of our most effective teaching tools is a colorful booklet entitled Sur- gi’s Friend Has an Operation, which we wrote when the education program was developed. The book includes colorful pictures. Printed and individualized by computer for each child, the text has the child’s name, address, where his opera- tion will be, the names of his friends, pets, and relatives. This invaluable teaching aid, used during the preopera- tive session, is given to the child for parents to use at home to reinforce what has been covered.

The goal is for each child to feel im- portant and that this experience be- longs to him. The child is the center of attention. All events of the actual surgery day are included in the teach- ing. Every effort is made to ensure the experience is an exciting adventure, not one to dread.

Emphasis is placed on physically painful events, such as the blood test, and emotionally painful experiences, such as separation from family and an- esthesia induction. We offer the child choices whenever possible. He is al- lowed to decide which finger blood will be drawn from, whether to walk or ride to the operating room, and whether to sit up or lie down for the induction. They frequently choose walking over riding in a wheelchair or on a cart. When the child reaches the hospital or the preoperative holding area, all the ef- fects of thorough preparation become obvious. The child is calm and coopera- tive, and the family is relaxed.

Preoperative sedation has been rare in our practice since our education pro- gram began four years ago. The cooper- ation of hospital staff and anesthesiolo- gists has gradually increased. Now the anesthesiologist frequently asks how the child wishes to be anesthetized.

An anesthesiologist who operates Surgicenter in Phoenix, where many of our patients have surgery, comments on the education program. “We have quite a few children among our patients,” Wallace Reed, MD, said. “When they have not been prepared by a doctor, nurse, or parent for what to expect, they can present quite a problem for our per- sonnel, especially the anesthesiologist.

“We don’t find this to be the case with Dr Trump’s and Nurse Sue’s patients,” he continued. “The patients from their office are exceptionally well-prepared, and there are rarely any surprises. With the cooperation from a well-prepared child and family, preoperative sedation seldom is necessary and saves the child from the physical and emotional trauma of an injection.

“Children can handle just about any type of surgical intervention if they are prepared for it in a loving way,” Dr Reed said. “The child feels he can remain in control of the potentially threatening environment of the surgical suite.”

The well-prepared pediatric patient ambulates and voids sooner, requires less pain medication, has less nausea and vomiting, and is able to return home sooner with parents who are con- fident in their ability to care for him.

Many facilities we use now allow par- ents to be in the recovery room with their children. The children emerge from anesthesia more calmly, and the parents feel involved in their children’s care. After outpatient surgery, we call the family later in the day of surgery to reassure them and intercept any ques- tions or problems.

From our experience with this pro- gram, we have made some observations

Sue J Robison, RN, BSN, is a pediatric surgi- cal nurse practitioner. She has a Bachelor of Science degree from Arizona State University. This article is based on her presentation at the 1979 AORN Congress.

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I get a feeling for the family relations hips.

that may be helpful to operating room nurses who work with pediatric pa- tients.

Some problem areas for children in the hospital are:

0 admission x-rays, laboratory tests, injections,

0 transportation 0 separation from family 0 waiting 0 induction of anesthesia 0 postoperative care (equipment,

bandages, and special care and routines)

A child can be assisted through all these areas emotionally and physically by someone who cares and who estab- lishes a relationship with him. How can an operating room nurse assist a child with these problems?

The OR nurse can help by making preoperative visits and assessments of the child and family. This should be ar- ranged in the schedule every day. If pos- sible, the nurse who will be in the OR with the child should make the preoperative assessment to become acquainted with him.

The nurse should become familiar with young patients-what size they are and what their problems are. She should wear the clothes the child will see in the OR suite and show him she can still talk through that funny mask. She should arrange a preoperative tour if none is available.

Establishing a realtionship with the

child will be comforting. The OR nurse should know what procedures the anes- thesiologist uses and give the child a truthful prediction of what will happen. It is essential to be honest with children to establish trust. If a procedure will be painful, the nurse should tell them it will hurt. Children can handle just about anything if they are prepared. Fear of the unknown is more disturbing.

A child must be allowed to maintain his control and integrity at all times. The nurse should know the personnel who will transport the child and care for him in the operating room suite. Do they know children and care about them? Transportation to the OR is anxiety-producing. The child is sepa- rated from his family and taken to a strange area. Usually, he is strapped flat on his back not long after receiving an injection.

The child should not be taken to the operating room any earlier than neces- sary. We cannot expect a child to handle what he is likely to see there, and his anxiety level goes higher the longer he has to wait. If the child must be trans- ported early, an area should be provided separate from adults in a quiet, child- centered environment. He should be al- lowed to have a favorite toy or blanket for security.

The security a child gets from his fam- ily cannot be replaced by any other in- dividual. He should know where his family will be waiting. Waiting is dif-

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ficult for parents. I am in constant communication with waiting parents to keep them informed of their child’s progress. Someone should notify wait- ing parents of any surgical delays.

Anesthesia induction and the operat- ing room itself can be terrifying. The operating room nurse can help a child through this particularly difficult time by letting him know she cares, by talk- ing to him and asking him to help. She should explain side rails and belts and be future-oriented, as many children fear dying.

The operating room should be quiet. Too much auditory stimulation is dis- turbing. Conversation should be kept to a minimum and directed only to the child. Other persons in the room should remain quiet, and instruments should be kept quiet until the child is asleep. The nurse should be careful what she says in front of the child because he may take what he hears literally. They don’t understand what it means when the nurse says, “DO you have any bulldogs?’ or “DO you need any armies?” What could it mean to a five-year-old when someone says, “We are going to put you to sleep,” and he remembers the dog that went to the veterinarian and never returned?

Think as a child. How does a child view what is going on?

What does he hear and what does he see? Psychologist Carl Jung said that anything we wish to have changed in children we should first change in our- selves. Children have emotional needs that most adults have long forgotten. They need to know we are thinking and caring adults.

Children need to know it is okay for them to be a little afraid-that everyone feels a little afraid in a new experience. They also need to know it is okay to cry. I have frequently brought children to the operating room after the separation from their family to have them shed a

few tears but quickly recover with this short release of tension. Children shouldn’t be made to feel that they have to be too brave or too good. That may be an unrealistic goal for a child to achieve, and he may feel he has failed. Bravery goes out the window in the face of stress. Children need to be reassured that their feelings are normal and that they can act out their feelings to relieve tension without being ridiculed or belittled.

Love can be communicated through touch. The nurse can hold their hands, talk to them, smile, and never leave them alone. She can be there to help them through the uncomfortable ex- perience they will have to tolerate. Love and attention can make the experience more pleasant, and they will not forget it.

Our goal is to bring a well-prepared child to the operating room anticipating the experience, walking or riding, whatever he chooses, holding his own anesthesia mask, and putting himself to sleep. Because of our efforts, the child will have a better attitude toward health care for the rest of his life.

Editor’s note: Information about obtaining the book Surgi’s Friend Has an Operation is avail- able by writing Sue J Robison, RN, Pediatric Surgical Nurse Practitioner, Affiliated Pediatric Surgeons, Ltd, 101 0 E McDowell Rd, Phoenix, Ariz 85006.

The term Surgicenter is a registered trademark.

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