Chapter 22 Preoperative care
INTRODUCTION
Effective preparation of children who are to undergo anaesthesia and surgical intervention is an important factor in reducing the anxiety experienced by the child and their family during hospital admission (RCN 2004). Children provide a unique challenge in that the education and preparation that they require must not only meet their needs, but also the needs of their parents/primary carers (Kelly & Adkins 2003).
RATIONALE
Children, regardless of age, need to be appropriately prepared for theatre. This involves both physical and psychological aspects of care. Children who are familiar with their surroundings, and who are informed of events associated with surgical procedures, are more likely to cope with the overall experience (Newman & Scott 1990, O’Connor-Von 2000).
Parents who are fully informed and involved are confident and capable partners in the hospitalisation and recovery process of their child and on discharge (Darbyshire 2003). Children who are informed will have a reduction in anxiety related to the procedure and also to the hospital environment (LeRoy et al 2003).
FACTORS TO NOTE
Planned surgery
• Planned, or elective, surgery lends itself very well to good preparation prior to the day of surgery (O’Connor-Von 2000, Sexton & Redfearn 2003, Smith & Dearmum 2006, Bray & Sanders 2006). There is time to involve other disciplines who can make a contribution to the overall readiness of both the child and family for forthcoming surgery.
• Psychological preparation can begin at home well before the planned date of admission. There is a wide range of books and other visual aids available from libraries and bookshops, which offer the opportunity to talk through the need for hospitalisation and what to expect. Schools and nurseries will often facilitate role-play which involves dressing up and acting out the nurse/doctor roles. These are all recognised as ways of allaying the fears and anxieties of children and can help those parents who have little experience of hospitals themselves (LeRoy et al 2003). Preparation should include information on what will happen postoperatively including relevant information on wound care (Bray & Sanders 2006).
• The development of pre-admission programmes, such as Saturday morning clubs, facilitates interaction between hospital staff, children and parents and provides the opportunity to discuss pain control and the admission procedure. Efforts made at this stage of contact promote a feeling of well-being and aid in the speedy recovery of the child (LeRoy et al 2003, Sutherland 2003, Bray & Sanders 2006).
• On admission, there is the opportunity to involve play specialists and theatre staff. Thornes (1991), Hogg (1994) and Bray & Sanders 2006 highlight the value of play in hospital and this role has been further developed in paediatric areas. The benefit of the involvement of play specialists in overcoming operation anxiety, the use of photograph albums and visits made by recovery staff, all give a broader view of what the child will experience and the parents’ role in the process (see Ch. 10).
Emergency surgery
• Unplanned surgery often means that there is little time for the psychological preparation of the parent or child. Some children go to theatre directly from the A&E department, and so there may be limited time for explanations or time for premedications. Sudden loss of contact with parents and siblings can cause additional stress to the child. The nurse should be aware of these factors and deal with them sensitively.
• When the child has been transferred to theatre, it is usual for the parents to be taken to the admitting ward to wait for the surgery to be completed. It is during this time that additional information and emotional/psychological support are given.
• When a child is transferred to the ward only a short time prior to surgery, emphasis is mainly on physical preparation, with medical staff completing tasks such as obtaining consent and examination of the child. There may be an opportunity for the parents to speak with the anaesthetist or surgeon, but this is not always possible. Fuller explanations of procedures and planned care usually take place while the child is in theatre and upon return to the ward.
Day-care surgery
• Day surgery has many advantages for both the child and family. Caring for Children in the Health Service is a consortium that was established by the Action for Sick Children charity. They have produced a number of reports concerning the preparation of children for surgery. Thornes (1991) on behalf of Caring for Children in the Health Service, explored the benefits of paediatric day care from an economic viewpoint, and from the child’s needs with regard to avoiding the necessity for overnight admission. This was reinforced by the Audit Commission report, Children First (1993), which encouraged the development of such facilities.
• Morton and Raine (1994) defined some of the benefits as absence of parental separation, less disruption to the family and an increase in the amount of parental involvement. All of these should be supported by care being available in the community for children following attendance at a day-care facility.
• To shorten the admission time, it is preferable that routine preoperative investigations are completed during outpatient visits so that all necessary results are available on the day of admission. LeRoy et al (2003) suggest that younger children (age 3–5 years) should have the preparation as close to the day of surgery as possible, whereas older children (age 6–12 years) benefit more from earlier preparation, i.e. up to 1 week before.
• Written instructions for preoperative fasting should be given to the parents along with information about giving routine medications, e.g. inhalers. Parents should be encouraged to bring any medications with them on the day of admission.
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