Pre and post operative care in pediatrics requires a child-centered, family-inclusive approach that addresses both physical and emotional needs. Surgery either planned or unplanned, is a potentially stressful experience for children.
Hence, the children and their caregivers need adequate information about the child’s condition, surgical procedure, and various phases of care. Facilities should be provided to make children and their family to be comfortable during the hospital stay.
The care of child undergoing surgery involves mainly three phases:
- Preoperative care
- Intraoperative care
- Postoperative care
Preoperative and postoperative care are discussed in the following sections.
Principles of Pre and post operative care
- To care and treat children in a safe manner, as close to home as possible, in an environment that is suitable to their needs
- To Involve parents in decision-making relevant to the child care
- To deliver quality of care through adequate training and providing essential support
Preoperative Care
Equipment needed:
- Identification (ID) band
- Surgical clothing
- Vital signs tray
- Pulse oximeter (if needed)
- Weighing scale
- Preoperative check list
- Razor (if needed)
- Premedications (as prescribed)
Preparation of child and family
It involves three kinds of preparation:
- Psychological preparation:
- Discuss surgical procedure with parents and child and evaluate their level of understanding.
- Discuss limitations on diet if appropriate, depending on the orders of anesthesiologist.
- Explain what nil per os (NPO) sign is; stress that child will be fed again as soon as fluid and food can be tolerated.
- Discuss preoperative injections honestly; the injections do cause discomfort. Explain that medications will make the child drowsy.
- Discuss means of transportation to operating room; and appearance of operating room personnel (colored caps and clothing, masks, gloves, etc.)
- Encourage the child to play with caps, gowns, masks, gloves, and with appropriately dressed dolls.
- Discuss anesthesia as a different kind of sleep or a special sleep.
- Demonstrate postoperative procedures (deep breathing, coughing, and use of blow bottles, turning) and have return demonstrations.
- Demonstrate the equipment to be used postoperatively; e.g., arm boards, tubes, bandages, restraints, oxygen tent, or mask
- Discuss postoperative discomfort and the relief available with medicines.
- Explain about the childcare in the recovery room until awake or in the intensive care unit until well enough to return to the pediatric unit.
- Secure a favorite blanket, toy, or other objects to the bed or stretches when the child is taken to the operating room.
- Assure child that parents will be hereby waiting for him or her after the operation
- is over. Tell the parents where to wait during surgery.
- Physical preparation:
- Monitor vital signs, if any abnormality report to surgeon and record it in chart.
- Give NPO for the period prescribed prior to the surgery.
Note: Traditionally, solid foods and semi-liquids were withheld from midnight before surgery, with clear liquids withheld from 4 to 8 hours before the procedure, depending on the child’s age.
However, research indicates that clear liquids given up to 2 hours before elective surgery for children of any age do not present any additional risk for pulmonary aspiration.
New guidelines can be summarized as 8-6-4-2 (i.e., 8 hours-solid, 6 hours-formula, 4 hours-breast milk, and 2 hours-clear liquids). This results in children who are less anxious are better hydrated and fewer headaches and less nausea postoperatively.
- If the child is ambulatory, take the child away from the area while other children eating breakfast.
- Ensure that good hydration is essential before period of NPO.
- Make certain that all other prescribed preoperative procedures have been completed (enema, insertion of nasogastric tube, etc.).
- Prepare operative site as per institutional policy. Shaving may not be necessary for children.
- Bathe the child; give mouth care the evening before or the morning of the
surgery. - Remind the child not to swallow the rinse water.
- Check the child’s body for rashes, scratches, bruises, or other skin lesions.
These should be noted in the child’s chart preoperatively. - Dress the child in clean hospital gown or other attire according to institutional procedures.
- If the child’s underpants or other clothing are permitted to wear, label them so they are not lost.
- Observe for loosened teeth, dental appliances such as partial plates or braces and report if present.
- Dental appliances are removed if possible and given to the parents.
Presence of loose teeth is reported to the anesthetist. - Remove makeup and nail polish.
Adolescents especially should be told not to apply makeup and nail polish preoperatively. - Urge child to urinate immediately before medication is given preoperatively.
- Prepare preoperative medications before surgery as ordered. Inform the child that it is ready to give it immediately.
- Encourage the child to scream if the injection is uncomfortable.
- Chat with older child while giving the injection.
Protective measures:
- Ensure that a consent form for the anesthetic and surgical procedure has been signed correctly and witnessed by child’s parents or legal guardian.
- Adolescents old enough according to law can sign consent forms themselves prior to medication.
- Ensure that all laboratory reports (urine, blood and other, radiological report, and the results of any other tests) are included in chart.
- Administer correct dosage of preoperative medication.
Fasten side rails of crib or bed securely after preoperative medication has been given. - Make certain that child’s ID band is securely attached.
- Record complete notations on nurse’ notes regarding preoperative procedures and child’s emotional and
- physical state before surgery.
- Have a familiar person stay with the child to provide explanations of strange
events and places and to protect him or
her physically while awaiting surgery. - Children should not be left alone.
Postoperative Nursing Care of Child
Equipment needed
- Gloves
- Vital signs tray
- Fluids as prescribed
- Bedpan/urinal
- Blankets
- Warming devices
- Incentive spirometer
- Pillow for splinting
- Emergency drugs
- Resuscitation and intubation equipment
- Oxygen and oxygen delivery system
- Cardiopulmonary monitoring equipment
- Ventilator
Preparation
- Prepare postanesthetic bed prior to shifting from operation theater (OT).
- Assess the child for developmental stage andlevel off cognitivee functioning.
- Assess OT and recovery room records for the type of anesthesia, medicines administered vital signs, blood loss, fluid and blood replacement, and procedural information and complications.
- Determine whether the family members would like to visit the child.
- Respect the child’s feelings.
Care during postoperative period
Activity level
- Assess the child’s activity.
- Constant nursing attention or restraint may be necessary to prevent dislodging intravenous infusion lines, dressings, drains, or chest tubes.
Vital signs and skin color
- Vital signs are taken as often as necessary depending on the child’s condition and the policy of the hospital.
- Generally, they are taken q15 minutes for first 1 hour, 30 minutes for second 1 hour, and every hour until the vital parameters are stabilized.
- Keep the blood pressure cuff on the child’s arm and inflate it only when necessary to prevent disturbing the child.
- Report signs of shock immediately.
- Keep the child warm.
- Place the child in a supine position with legs elevated slightly.
Adequacy of ventilation
- Place 02, resuscitative, and suction equipment near the bed and use as necessary.
- Have the child deep breathe, turn, and cough.
- Splint operative site with pillow or hand before doing these procedures to minimize discomfort.
- Teach older children to learn to splint themselves.
- Administer medications for pain, if necessary.
- If the child cannot breathe deeply, he or she may use equipment, such as Uniflo inspirometer.
Level of consciousness (LOC) and feeding
- Assess LOC.
- Child should be on NPO until completely awake.
- Determine the ability to swallow.
- Begin feedings with bits of chipped ice or sips of water.
Pain management
- Attempt to alleviate pain through nursing measures such as turning the child on the side, repositioning extremities, massaging aching muscles, and talking soothingly to the child.
- If these measures fail, give pain medications as prescribed.
Intake and output
- Rate and kind of fluid being given should be accurate according to prescription.
- Assess for infiltration, and if present notify to physician.
- Apply arm board, reposition, and retape the arm.
- Notify the physician if child has not voided (time depends on surgical procedure and postoperative order).
Dressing
- Assess for evidence of dark blood or bright red blood (new) observed after surgery.
- Report signs of shock, if present.
- Notify physician of bleeding or drainage; change bedlinen if soiled.
Anxiety
- Reunite parents and child as early as possible postoperatively.
- Decrease parental anxiety by answering any questions they may ask.
Complications
Assess for immediate complications and continued nursing assessment is imperative to identify signs and symptoms of possible post operative complications.
Common Postoperative Complications
- Shock
- Hemorrhage from wound
- Nausea and vomiting
- Distention of abdomen
- Hypoxia
- Atelectasis
- Hypostatic pneumonia
- Retention of urine.
- Infection of wound
- Thrombophlebitis
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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