INTRODUCTION

Postoperative care commences as the child leaves the operating theatre and ends when discharged from the ward. However, in today’s ever-changing national health service environment, hospital in-patient stays are reducing and more children are having surgery undertaken on a day-case basis. Consequently, postoperative care may continue into the home care setting and be supported in part by community children’s nurses (Scottish Office 1994, O’Connor-Von 2000, Pfeil et al 2004).

THE IMMEDIATE RECOVERY PERIOD

Immediate recovery from anaesthesia should be in a fully equipped recovery unit with a one-to-one ratio of nursing personnel trained in children’s nursing (Association of Anaesthetists of Great Britain and Ireland 2002). Recovery units may be known by a different name in some areas, such as reception or post-anaesthetic care units (PACU). The recovery unit is usually situated near the operating theatres. This enables easy access to the patients by the surgical and anaesthetic staff should an emergency arise.

While the child has been in theatre and recovery, the bed/cot area should have been prepared for return to the ward. In some areas, the bed may have been transferred to the recovery unit perioperatively to minimise pain and distress for the child postoperatively. All beds must have a tilt facility and must be able to be raised up and down. (The tilt facility is important if children are experiencing postoperative shock or vomiting as it allows the child’s head to be lowered or raised according to need.)

It is imperative that the bed space has access to working oxygen and suction. It may also be necessary for the child to be moved nearer the nursing station for closer observation. Neonates may need to be transferred in an incubator or Baby Therm and the same principles apply to them. Equipment that may be required postoperatively such as infusion pumps and monitoring equipment should be tested and ready when the child is transferred back to the ward. During the perioperative phase of nursing, the theatre nurse is responsible for the child while under anaesthetic and serves as the patient’s advocate.

Once the theatre nurse has handed the child over to the recovery unit, immediate postoperative management is the responsibility of the anaesthetist involved in the surgery and the unit staff (Andersen et al 2000). Handover should incorporate the condition of the child while under anaesthetic, any problems which may have occurred and any analgesia which has been administered.

Serious complications can occur during the initial stage after surgery; hence the child receives short-term intensive care nursing while in the recovery unit. The duration of a child’s stay in the unit depends on the type of surgery undertaken and the child’s reaction to anaesthesia. If the child’s condition indicates further intensive nursing intervention, the child will be transferred to the high-dependency unit (HDU) or the intensive care unit (ICU) (Tazbir & Cronin 1999, Andersen et al 2000). In the recovery unit the child is attached to a multifunctional monitor which tracks the following: heart rate, ECG, respiratory rate, oxygen saturation, non-invasive blood pressure and skin temperature. This kind of monitoring reduces disturbance to the child yet provides more detailed information for the nurse. Not all children will need all these facilities, as this depends on their condition and the type of surgery undertaken.

All vital signs, e.g. temperature, pulse, blood pressure, respirations and conscious level, are affected by surgery and the anaesthetic. On recovery from anaesthesia initially, the child will be supine with their head tilted; this ensures that the jaw is kept forward, positioning the tongue so that it does not obstruct the airway. Airway management is one of the most important areas of recovering a child from anaesthesia and should only be undertaken by appropriately trained staff. The airway requires support and this usually entails the administration of oxygen via a facemask and continuous monitoring of oxygen saturation. If the child has an airway in situ, the nurse waits for signs of returning consciousness before it is removed.

Anaesthesia-induced unconsciousness will mean normal reflexes are absent and respiration must be supported. During semi-consciousness the reflexes, e.g. breathing, coughing, swallowing and blinking, begin to return and finally the patient should be awake and orientated with the return of all normal reflexes. The airway is usually removed when the patient coughs it out or tries to remove it.

It should be stressed that monitoring is only an aid to continuous nursing observation. One of the most common surgical complications is haemorrhage, which can lead to shock. Any deterioration in condition is usually rapid and demands urgent attention. When shocked, the child will be pale, tachycardic and not responding as normal. In children, and especially neonates, it only takes a small amount of blood loss to make transfusion or rapid fluid replacement essential.

It is imperative that each bed/trolley space has working oxygen and suction, an emergency buzzer and easy access to the resuscitation trolley. The nurse should observe the colour of the child, and whether it is good for that particular patient. This type of information is often gained during the preoperative visit or from the ward’s nursing documentation. Many children with special needs or those with cardiac/pulmonary problems can be pale or even cyanosed. Their oxygen saturations may also be lower than is normal. The promotion of safety and comfort is paramount and the use of cot sides is universal.

Although the child may feel alert and capable of moving, the remaining effects of the anaesthesia and sedation may mean that movements are uncoordinated. Special consideration should be given to children who have had spinal and epidural anaesthesia. Frequent assessment of the lower extremities should be made to determine the return of function. Temperature, colour and range of sensation and movement should be observed. In recovery, the relief of pain and encouragement to rest are also of high priority. The inclusion of parents in the recovery unit is a relatively new idea. The child has to be sufficiently recovered, e.g. fully conscious and maintaining their own airway, for the inclusion of the parent.

The presence of the parent affords reassurance and comfort and is effective in reducing postoperative distress and anxiety (Smith & Dearmum 2006). However, the presence of parents who are themselves visibly distressed, or anxious, can have an adverse effect on the child’s emotional condition. It must also be stressed that not all hospitals allow a parent into the recovery unit, although this is becoming more common.

Before the child is transferred back to the ward certain criteria must be fulfilled:

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