Caring for pediatric, adolescent, obstetric, and older adult patients in the perianesthesia setting can be challenging. Pregnancy and age—either young or old—challenge the perianesthesia nurse to look closely at the specific needs of these populations. The anatomic and physiologic changes in these populations profoundly influence the way patients recover from the stress of surgery and anesthesia. As you prepare for the certification examinations, much valuable information about the anesthesia and perianesthesia care these patient populations require can be found close to home. The Core Curriculum has several excellent chapters about these specialty populations. The Journal of PeriAnesthesia Nursing has provided some outstanding articles addressing the needs of these patients.
| ESSENTIAL CORE CONCEPTS | AFFILIATED CORE CURRICULUM CHAPTERS |
|---|---|
| Nursing Process | Chapters 3, 13, 14, 15, 16, 26 |
| Assessment | |
| Planning and Implementation | |
| Evaluation | |
| The Pediatric/Adolescent Patient | Chapters 13, 14 |
| Anatomy: Child vs. Adult | |
| Developmental Concepts | |
| Education | |
| Family Dynamics | |
| Psychosocial | |
| Perianesthesia Issues | |
| Airway Compromises | |
| Anesthetic Specifics for Children | |
| Operative Specifics for Children | |
| Specific Patient Care Concerns | |
| Awakening, Restlessness, and Emesis | |
| Pain Management: Drugs and Alternatives | |
| Thermal Balance | |
| Parent Education | |
| The Obstetric Patient | Chapter 46 |
| Physiology of Pregnancy | |
| Expected Organ Systemic Changes | |
| Managing Organ Pathophysiology | |
| Pregnancy-associated Disorders | |
| Assessing Preterm Labor | |
| Hemorrhagic Emergencies | |
| Hypertension: Eclampsia and Seizures | |
| Postpartum/Postcesarean Observation | |
| Perianesthesia Specifics | |
| Anesthetic Options | |
| Pharmacologic Interventions | |
| Observation of Mother and Fetus After Surgery | |
| The Geriatric Patient | Chapter 16 |
| Physiology of Aging | |
| Age-related Organ Dysfunction | |
| Pharmacologic Responses | |
| Anesthetic Options | |
| Prescribed Medications | |
| Perianesthesia Specifics | |
| Barriers: Special Needs | |
| Education Considerations | |
| Risk Factors and Disease | |
| Ventilation, Temperature, Fluids, and Comfort |
ITEMS 3.1-3.30
3.1. A 4-year-old boy is admitted to the PACU after a biopsy of a mass of the tibia under general anesthesia. He is incoherent, crying, thrashing, and kicking. His behavior is non-purposeful. The nurse should immediately assess the patient for signs and symptoms of:
a. hypoxemia and hypercarbia.
b. hemodynamic instability.
c. inadequate reversal.
d. fever and sepsis.
NOTE: Consider the scenario and items 3.2-3.3 together.
A 3 year-old girl is admitted to the preoperative unit for an elective tonsillectomy and adenoidectomy. She has a history of recurrent upper respiratory infections (URI) and currently has a runny nose with a slight, nonproductive cough.
3.2. A thorough preanesthesia assessment for this child will include assessing for these signs and symptoms.
a. Sore throat and tachycardia
b. Fever and congestion
c. Sneezing and clear secretions
d. Anxiety and history of asthma
3.3. Careful preoperative assessment of the pediatric airway is essential because postanesthesia pediatric patients are at great risk for:
a. emergence delirium.
b. airway hyperreactivity.
c. prolonged recovery.
d. pulmonary emboli.
3.4. The anesthesiologist has ordered midazolam to be given by mouth (PO) to a 15-kilogram 3-year-old child for preoperative sedation. What dosage of midazolam should the nurse administer?
a. 2.5 mg
b. 3 mg
c. 5 mg
d. 7.5 mg
3.5. A 9-month-old infant is admitted to the PACU after a Nissen fundoplication. His heart rate is 175 beats per minute (bpm), blood pressure is 50/38, and axillary temperature is 36.6° C (97.9° F). Admission assessment also reveals periorbital edema, grunting respirations, and adventitious lung sounds. The PACU nurse is most concerned about:
a. hyperthermia.
b. pain.
c. respiratory distress.
d. hypervolemia.
NOTE: Consider the scenario and items 3.6-3.8 together.
A 22-year-old woman who is 7 months pregnant is admitted to the PACU after a cholecystectomy under general anesthesia. The patient is placed on supplemental oxygen.
3.6. This patient has an increased potential for pulmonary aspiration because:
a. general anesthesia increases lower esophageal sphincter tone.
b. gastric acidity increases and varies widely during pregnancy.
c. gastric motility and emptying time are decreased in pregnancy.
d. uterine contractions stimulate the chemoreceptor zone.
3.7. A priority of care for the pregnant patient in the PACU is:
a. providing emotional support.
b. assessing and treating pain.
c. monitoring vital signs.
d. meeting oxygen demand.
3.8. After 10 minutes in the PACU, this patient states “All of a sudden I feel nauseated and faint.” The patient’s blood pressure has dropped from 130/70 to 110/60. An initial nursing intervention would be:
a. turning the patient to a left lateral position.
b. increasing the oxygen liter flow.
c. medicating the patient for nausea.
d. administering an IV fluid bolus.
3.9. Hypothermia in a small child can lead to:
a. hypoxemia, hypoglycemia, and metabolic acidosis.
b. hypercarbia, hypoglycemia, and metabolic alkalosis.
c. hypoxemia, hyperglycemia, and metabolic acidosis.
d. hypercarbia, hyperglycemia, and metabolic acidosis.
NOTE: Consider the scenario and items 3.10-3.11 together.
A 16-year-old male patient under general anesthesia is admitted to the PACU after an anterior cruciate ligament (ACL) reconstruction. On admission to the PACU, he is alert and oriented. Blood pressure is 100/50, heart rate is 120, and respiratory rate is 28 breaths per minute. Oxygen saturation is 88% with oxygen in use at 4 liters per nasal cannula. When the patient speaks, he becomes dyspneic after three or four words and his oxygen saturation drops to 82%. Auscultation of breath sounds reveals scattered rales heard throughout all lung fields.
3.10. Understanding postanesthesia complications, what does the nurse suspect?
a. Anaphylactic reaction
b. Noncardiogenic pulmonary edema
c. Cardiogenic shock
d. Inadequate reversal
3.11. What mechanism of injury would cause this to occur?
a. Exposure to latex
b. Inadequate reversal
c. Breathing against a closed glottis
d. Mitral valve dysfunction
3.12. Vagal stimulation during anesthesia and surgery place pediatric patients at risk for:
a. tachycardia and normotension.
b. tachycardia and hypoxia.
c. bradycardia and hypotension.
d. bradycardia and hypoxia.
3.13. Postanesthesia shivering increases an older adult patient’s risk of:
a. delayed awakening, acidosis, and decreased renal perfusion.
b. delayed awakening, alkalosis, and cardiopulmonary compromise.
c. hypoxia, alkalosis, and delayed drug metabolism.
d. hypoxia, acidosis, and cardiopulmonary compromise.
3.14. In the pediatric postanesthesia population, the majority of cardiac dysrhythmias and arrests are related to:
a. medication error.
b. respiratory failure.
c. cardiac anomaly.
d. hypothermia.
3.15. In completing a preanesthesia history of a 79-year-old patient, the nurse is well aware that one of the leading issues contributing to anesthesia-related mortality and morbidity in the older population is:
a. concurrent diseases.
b. sedentary lifestyle.
c. heredity.
d. physiologic changes.
3.16. Children are at increased risk for hypoxia secondary to:
a. decreased functional residual capacity and greater oxygen consumption.
b. increased functional residual capacity and slower glomerular filtration rate.
c. increased tidal volume and proportionally larger tongue than head.
d. smaller nares, narrower airways, and increased cardiac output.
3.17. The normal infant response to hypoxia is:
a. tachycardia.
b. cardiac arrest.
c. respiratory arrest.
d. bradycardia.
3.18. A 28-year-old woman has been admitted to the PACU after a cesarean section under spinal anesthesia. A magnesium sulfate infusion to treat preeclampsia was initiated 24 hours earlier. One indication for the use of magnesium sulfate in the preeclamptic patient is for:
a. preventing clotting alterations.
b. improving fetal oxygenation.
c. preventing seizure activity.
d. improving uterine contractions.
3.19. While assessing a 79-year-old patient in the PACU, the nurse is aware that elderly patients are at an increased risk for intraoperative myocardial infarction because general anesthesia:
a. impairs gas exchange.
b. depresses the myocardium.
c. alters drug metabolism.
d. affects cardiac reserve.
3.20. What age-group may believe postoperative pain is “punishment” for their thoughts or deeds?
a. Adolescent
b. School age
c. Pre-school
d. Toddler
3.21. Polypharmacy is common in many older adult patients because older patients:
a. need multiple medications to manage symptoms from many concurrent diseases.
b. often misunderstand medication administration directions and may not discontinue medications as ordered.
c. add over-the-counter medications, vitamins, minerals and supplements, and folk remedies.
d. seek treatment from a variety of health care providers and receive multiple prescriptions.
3.22. PACU assessment after cesarean section includes assessment for full bladder. A full bladder after delivery can cause:
a. boggy uterus and increased lochia.
b. boggy uterus and decreased lochia.
c. uterine displacement and atony.
d. uterine displacement and decreased lochia.
NOTE: Consider the scenario and items 3.23-3.26 together.
An 86-year-old female was found on the floor of her apartment by a neighbor. It is estimated that she fell 2 days earlier and fractured her hip. She was sent directly to the preoperative department from the emergency room.
3.23. The patient is oriented to person only and is alone. What is one of the initial interventions the preoperative nurse should consider as part of the preanesthesia assessment of an elderly patient?
a. Start an IV
b. Locate family
c. Assess pain
d. Check blood glucose
3.24. Considering physiologic changes associated with aging, what other diagnostic information will the preoperative nurse be certain to include in the preanesthesia assessment?
a. Electrocardiogram (ECG) and blood urea nitrogen (BUN)
b. Chest X-ray
c. Liver enzymes
d. Blood gases
3.25. After undergoing a hip pinning under spinal anesthesia, the patient is in the PACU. Her blood pressure is 130/86, heart rate is 48 bpm, and oxygen saturation is 96% on oxygen at 2 liters per nasal cannula. Estimated blood loss (EBL) was 900 mL. She remains oriented to person only and is not moving her lower extremities. Considering the physiologic changes that occur with aging, which of the following choices will the PACU nurse utilize to improve this patient’s neurologic status?
a. Increase oxygen delivery
b. Administer a fluid bolus
c. Administer atropine
d. Assess patient’s ability to hear
3.26. The patient’s blood pressure is now 150/90. Her rhythm is normal sinus bradycardia with frequent premature ventricular contractions (PVCs) at a rate of 48 bpm. She is still not moving her lower extremities. What intervention, if any, is needed?
a. No intervention at all
b. Medicate for pain
c. Consider hypovolemia
d. Consider atropine
3.27. Oxytocin infused faster than 500 mL per hour can cause:
a. severe cramping and respiratory distress.
b. severe cramping and uterine atony.
c. hypertension and cardiac dysrhythmias.
d. hypotension and cardiac dysrhythmias.
3.28. When assessing a patient after delivery in the PACU, the PACU nurse understands that lochia is considered normal when:
a. two pads or more are saturated per hour.
b. it is brown in color with no clots.
c. it is red to dark red with no clots.
d. it is red to dark red with clots.
3.29. Nasal airways are generally not used in children younger than 6 years because at this age children have:
a. adenoidal hypertrophy.
b. smaller nares.
c. shorter necks.
d. wider tongues.
3.30. What is the IV fluid of choice when replacing volume in the geriatric patient?
a. 0.9% normal saline
b. D5 0.45% normal saline
c. Lactated Ringer’s
d. D5 0.2% normal saline
ITEMS 3.31–3.60
3.31. A 76-year-old man has been admitted to the PACU after a rotator cuff repair. His blood pressure is 160/90, and heart rate is 92 bpm with normal sinus rhythm. Oxygen saturation is 98% on oxygen at 2 liters per nasal cannula. He was given 2 mg of morphine sulfate approximately 5 minutes ago before leaving the OR. On a scale of 1 to 10, he now reports his pain as a “20.” Which of the following interventions is now most appropriate?
a. Administer 1 mg of morphine sulfate
b. Administer a nonsteroidal antiinflammatory drug (NSAID)
c. Assess for another 5 minutes
d. Administer a different opioid
3.32. Uncuffed endotracheal tubes are generally used in children up to what age?
a. 3 years
b. 6 years
c. 9 years
d. 10 years
3.33. In the immediate postanesthesia period, what is the staffing guideline recommended by the ASPAN 2006-2008 Standards of Perianesthesia Nursing Practice for a 6-year-old intubated and unconscious child?
a. One nurse to two patients
b. One nurse to one patient
c. Two nurses to one patient
d. One nurse and one aide/tech to one patient
3.34. A 34-year-old woman is admitted to the PACU after cesarean section under general anesthesia. A magnesium sulfate infusion, started 10 hours earlier during labor, continues. The PACU nurse will monitor this patient for the development of:
a. uterine atony.
b. coagulopathy.
c. hypertension.
d. respiratory depression.
3.35. An 18-month-old child is admitted to the PACU after a hernia repair. On admission to the PACU, his oxygen saturation is 100% on 4 liters of oxygen delivered by blow-by. As the pulse oximeter begins to indicate a decreasing saturation, the nurse:
a. continues to monitor the patient.
b. assesses the monitor for problems.
c. stimulates the child to breath.
d. assesses heart rate for bradycardia.
NOTE: Consider the scenario and items 3.36-3.37 together.
A 42-year-old woman is admitted to the PACU after delivery of a healthy baby boy. EBL for the delivery was 1500 mL. Admission assessment revealed blood pressure 130/90, normal sinus rhythm with heart rate of 89 bpm, oxygen saturation of 98% on oxygen at 2 liters per nasal cannula, and profuse bright-red lochia. One IV is patent and infusing well with 10 units of Pitocin added to the solution in the bag.
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3.36. The immediate nursing intervention is to:
a. draw a complete blood count (CBC).
b. assess for pain.
c. change perineal (peri) pad.
d. assess for full bladder.
3.37. Which of the following next interventions is most appropriate?
a. Setting up patient-controlled analgesia (PCA) as per order
b. Starting a second large-bore IV
c. Assessing that Foley catheter is draining
d. Bringing the baby to his mother
3.38. Which of the following is most consistent with Standard II (Environment of Care) in ASPAN’s 2006-2008 Standards of Perianesthesia Nursing Practice?
b. Arranging for walls of pediatric areas to be painted in bright, friendly colors
c. Stocking “kid-friendly” snacks such as pizza and ice cream in Phase II
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