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Principles of pre-operative care

Introduction:- a child surgical experience may be elective planned in advance or the result
of an emergency or trauma. How a child respond to the experience depends on the
psychological and physical preparation he or she recieves. We should prepare the child
psychologically & physically for surgery.

GOAL :- to reduce the fear associated with the unknown and decreases stress and anxiety
associated with surgery.

Psychological preparation:- the manner in which children responds to the threat of


anesthesia & surgery.

1. Infants:- they can sense emotionally when their parents and others in environment
are anxious. They may become irritable and fearful but can be soothed with a pacifier
& gentle touching,holding or rocking.
2. Older infants & toddler:- usually most fearful of seperation from their parents.
Therefore parents should remain with them as long as possible. A favourable objects
such as a toy or a blanket should be taken to operating room with the child to
provide additional security.
3. Pre school children:- are egocentric and have difficulty understanding why a surgical
procedure must be done when they cannot understand a rationale for it or do not
want to carried out. It is essential, therefore that procedure should be explained to
them thoroughly that they may be permitted to participate in any way they can and
their parents be with them as much as possible.
4. School age children:- may fear anesthesia because they believe it may become a
perminant form of sleep from which they will not awaken, they also may fear that
they will awaken during operation and experience pain so they need an explanation
about different kinds of sleep or special sleep (anesthesia) required for surgical
procedures and the manner in which it wiil be uncluded. Emphasize that they will
awaken only when the operation is over.
5. Adolescents:- have develop self image as increasingly independent persons may fear
what will happen and what they will say and do while under anaesthesia they must
be reassured about the competency of anesthesiologist and the facts taht only what
is suppose to be done will be done during the period fo unconciousness.

The persons who will give the anesthesia should visit the child
prior to the scheduled surgery to establish rapport with the child and parents.

 Discuss surgical procedures with parents and children and evaluate their
understanding.
 Discuss limitation on diet depending on the orders of anesthesiologist,clear fluids
may be permitted to mid night before the day of surgery,although some physicians
do not want children to eat or drink after bed time-parents aspiration of vomitus
during surgery.
 Emphasis the need for the child to recieve fluids untill the hour designed-parents may
so fear the danger of aspiration of vomitus that they stop giving fluids long before
the designated time and thus cause dehydration of their child.
 Discuss pre-operative infection honestly, the infection does cause discomfort .
explain that the medication will make the child drowsy- it less anxiety.
 Discuss means of transportation to operating room and appearence of operating
room personnel (colored caps and clothing, masks and gloves etc). encourage child
to play with appropriately dressed dolls. It reduces the fear of unknown.
 Discuss anesthesia as a “different kind of sleep” or a “special sleep”, young children
genrally recieve anesthesia by inhalation and are permitted to choose the flavouring
to smell on the mask, such as chery,root beer,strawberry or grape. Older children
recieve anesthesia by IV injection.
 Demostrate post-op procedures (deepbreathing,coughing,use of blow
bottles,turning) & have return demonstration promotes co-op during post-op period.
 Demonstrate list & use of equipments to be used post operatively
armboards,tubes,bandages,restrints,O2 tent or mask children may also get benefit
before surgery from seeing and ET tube,chest tube or urinary catheter being used.
Children become less fearful if a trusted nurse orients them to these procedures.
 Explain about the child’s care in necessary room until awake or int he ICU untill well
enough to return to the pedaitric unit. It reduces the fear of unknown when
awakened in a strange place.
 Tapes of family members talking or reading the child’s favourite stories can be made
in advance and played for the child in recovery room. It increases security.
 Remove external objects such as hair ribbons and jewellary. If jewellary has
sentimental or religious value to the child or family,attach it securely to the IV arm
board or to a part of the child’s body with tape- religious belief provides a sense of
security.
 Secure a favourite blanket,toy or other objects to the bed or stretcher when the child
is taken to the operating room-is decreases fear of seperation,
 Encourage parents to visit with the child prior to surgery. Here parents accompany
the child as far as possible to the operating room. It decreases the child’s level of
anxiety.
 Use tapes,puppets,body out line dolls, drawings, and model to teach the child about
the surgical procedures.
 Playing with stethoscope,gowns,masks,and syringes without needles also help the
child feel more in control.
Physical preparation:-
1. Monitor TPR & BP any abnormal vital signs are reported to the surgeon. Changes
noted since admission are reported. An elevation temperature may be an indication
of infection.
2. Give nothing by mouth(NPO) for the period prescribed prior to surgery. Place an
“NPO” sign on the bed & on the childs clothing, if the child is ambulatory either the
parents or the nurse can take the child away from the area while other children are
eating breakfast.
Prevention of vomiting and aspiration of gastric contents during anesthesia.
3. Make certain that all other prescribed pre-op procedures have been completed (eg:
enema).

-Prevent necessity for rescheduling of surgery.

- Prevention of infection of the operative site.

4. Bath the child & give or help with mouth care the evening before or the morning of
surgery. Remind the child not to swallow the rinse water.
5. The nurse should check the childs body for rashes ,scratches,bruises or other skin
lesions.
6. Dress child in clean hospital gown or other attise according to institutional
procedure.
7. Observe for loosened teeth,dental appliances such as portal plates or traces and
report it,present dental appliances are removed,presence of loose teeth is reported to
the anesthetist.
8. Remove contact lenses or prosthetic devices & give to parents.
9. Eye glasse & hearing aids may be worn to the operating room then taken to the
recovery room so that the child can seen and communicate when gaining to sleep
and awakening.
10. Remove make-up & nail polish

-Permits obstruction of adequate of tissue oxygenation during and after


anesthesia.

11. Urge child to urinate immediately before medication is given pre-operatively.


–prevention of bladder incontinence or distension during GA. GA decreases normal
bladder emptying reflexes.
12. Prepare pre-operative medication before surgery as ordered.

Protective measures:-
1) Ensure that a consent form for this anesthesia and surgical procedure has
been signed correctly and witnessed by child’s parents or legal guardian.
Adolescents old enough according to also can sign consent forms themselves
prior to pre-medication.
2) Ensure that all laboratory reports(urine, blood & others) radiologic reports
and the result of any other tests are included in the chart from admission and
other tests are include in the chart from admission and hospitalization.
–reports may show sign of infection, bleeding technologies anemia or the
some other result that would contraindicative surgery.
3) Administer correct dosage of pre-op medication.
4) Record complete notations on nurses notes regarding pre-op procedures and
child’s emotional and physical state before surgery.
-protects the nurse in the event of legal action by the parents.

Pre -operative check list:-


 Check the consent forms are witnessed and signed in the pt’s chart.
 Be sure the child’s name band is in place.
 Be sure any allergies are prominently noted in the child’s chart.
 Remove any prosthetic devices,including orthopedic appliances.
 Check the child’s mouth for loose teeth.
 Remove eye glasses or contacts and jewellery.
 Bath and cleanse the operative site if ordered.
 Put the child in a hospital gown,allowing the child to wear underwear.
 Check that alla special tests have been completed and the results are in the
child’s chart.
 Have the child void before surgery.
 Keep the child NPO before surgery.
 Give the child prescribed medications.
 Transport the child safely to the operating room.
Post – operative care:-
 Ensure that preparations are are made to recieve child.
 Bed is ready,
 IV equipment, such as pumps and any other relevant equipment, such
as suction apparatus,O2 flow meter.
 Obtain base line information
 Take vital signs,including BP.
 Inspect operative areas(bleeding).
 Assess skin color and characteristics
 Assess Loc and activity.
 Notify physicians if any irregularities in child’s condition.
 Assess for evidence of pain.
 Review surgeons orders after completing initial assessment and check
medications have been ordered and can be given by available routes( oral
preparations may be contraindicated).
 Monitor vital signs as ordered & more often if indicated.
 Check dressings for bleeding or other abnormalities.
 Check bowel sounds.
 Observe for sign of shock,abdominal distension and bleeding.
 Assess for bladder distension.
 Observe for signs of dehydration.
 Detect presence of infection.
 Take vital signs every 2-4 hrs as ordered.
 Collect or request needed specimens.
 Inspect wound for sign of infection-redness, sweeling, heat,pain &
purulent drainage.

Nursing diagnosis:-
1) Impaired gas exchange related to anesthesia.
2) Pain related to surgical procedure.
3) Risk for fluid volume deficit related to NPO status before and after surgery,
loss of appetite and vomiting.
4) Anxiety / fear of surgery, unfamiliar envt, seperation from support systems,
discomfort equipment & surgical outcome.
5) Risk for infection related to surgical procedure.
6) Knowledge deficit related to follow up care.
7) Risk for constipation related to surgical procedure.

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