of Ontario Institute of Technology
Within my first half hour of being on a
pediatric unit, I was confronted with a situation I was not prepared for. Having only worked with adults thus far in my
clinical placements, I was not accustomed to speaking to a child and their
parent about the care we were going to provide.
I was also not anticipating speaking to a child who would then translate
for his mother. Furthermore, I was not
expecting to reassure a 7-year-old boy about his tonsillectomy and
adenoidectomy when I have not been through the procedure myself. The patient was quite nervous, and I did my
best to ease his anxiety, but my research has shown that there are several
interventions that I could have included in my care. The following reflection will discuss nursing
interventions to address preoperational anxiety in school-aged children.
Patient X is a 7-year-old male who came
into my care when he was admitted into the pediatric acute care unit before his
scheduled tonsillectomy and adenoidectomy.
This is usually a day surgery; however, Patient X was to stay overnight
for observation due to his weight (55 kg) and history of sleep apnea. Patient X was present with his mother who does
not speak fluent English. Patient X was
very nervous about the upcoming procedure and did not want to sit down or come
near the health care team for a preoperational assessment. This experience is significant to my nursing
praxis, because I had not experienced this before. Preoperative anxiety in children is
unfortunately common (Noronha & Shanti, 2015). It has been associated with maladaptive
behaviours postoperatively as well as longer recovery times. Therefore, I did what I could in the situation
with my current nursing knowledge to reduce this anxiety, but upon reflection
and conducting research, I found that there are evidence-based interventions
that I could have explored.
I first met Patient X and his mother when
they entered the room in the acute care unit of the pediatric floor. Patient X shuffled his feet and did not want
to make eye contact with either myself or my co-assigned nurse. His mother was also hesitant but offered a
shy smile and nod when I introduced myself as a student nurse. When we completed the preoperative checklist,
it became apparent that Patient X’s mother was having difficulty understanding
what my co-assigned nurse was saying. I made a point of facing her, repeating the
questions and enunciating, so she could better understand. Patient X helped as well by saying some of
the words in the language that they speak together at home. Although Perry et al. (2016) state that a
child should not be interpreting for parents, for these questions about
previous hospitalizations and conditions, his assistance was effective. In future, I would be looking for a translator
if the language barrier was an issue. As
I spoke with his mother, she became more at ease and began to address her
questions to me instead of my co-assigned nurse. As we were finishing the preoperational
questionnaire and the mother’s stress seemed to abate, I began to focus my
attention on Patient X.
Patient X was restless and did not want to
sit down for long. He avoided the bed
and instead hovered in the corner of the room behind the vitals machine. Perry et al. (2016) state that preoperative
care for children includes both psychological and physical preparation. Children are subjected to many preoperative
procedures that can act as stress points.
This includes the admission process and assessments. I am comfortable with children, so I started
the conversation by asking him if he was missing school and which subjects are
his favourites. When he told me math and
French, we immediately had something to talk about until it was time to do his
vitals. Before we took his vitals, he
asked me what each machine did and if they would hurt. I explained them to him in a way that he
could understand and assured him that doing them would help him. When he said that he just wanted to go home
and not have the surgery, I explained to him that the surgery would be tough,
but he would be much better because of it.
When he asked me how, I let him know that the surgery was to stop his
throat hurting by removing the part that is causing him to be sick (tonsils)
will be gone. He seemed pleased with
this answer and, like his mother, began to look to me for reassurance and
answers. When we had completed the preoperational
checklist, Patient X was able to go to the playroom while he waited to be taken
to his surgery. He was still a little
nervous, so I brought him to the playroom and showed him some toys. Once he was settled in to play and seemed to
be more at ease, I excused myself to check on my other patient and connect with
my co-assigned nurse.
While reflecting on this experience, I
conducted some research to find interventions that have been shown to decrease
anxiety in pediatric patients preoperatively.
A recent study by Ozdogan et al. (2017) looked at the effects of
maternal presence during anesthesia induction on the stress levels of children
undergoing tonsillectomy and adenoidectomy procedures. The authors determined the salivary cortisol
levels as a measure of stress. It was
concluded that salivary cortisol levels were decreased in the group of children
that were accompanied by their mothers until anesthesia induction. If it is in line with the policies and
procedures of the hospital where Patient X had his tonsillectomy and
adenoidectomy, it could have been suggested that his mother accompany him until
he is anesthetized. She did go with him
until the operating room, but I am not certain when they were separated. In a future situation where I have a
pediatric patient that is very anxious, I can consider this intervention. This intervention can also be used on a
smaller scale by ensuring a parent is with a child during a procedure.
A study by Li and Lopez (2008) examined
the usefulness of therapeutic play when preparing children for surgery. The study included giving a group of children
therapeutic play intervention and another group information intervention. Through their randomized control trial, they
found that children in the first group reported lower anxiety levels than those
who received the information intervention.
This study is applicable to Patient X and my future nursing praxis,
because it highlights the importance of including therapeutic play in the
holistic nursing care that can be provided to reduce anxiety preoperatively. Play
is a very important part of a child’s life and they need to be able to play
even under stressful circumstances. For
Patient X, I did not realize the full effect that play could have on his
anxiety until I reflected on it.
Surgery can be a distressing experience
for anyone, especially children. This
anxiety can be exacerbated if a child feels that their parent cannot fully
understand the procedure or advocate for them.
Children are vulnerable in this situation as they look to their parent
for guidance. In this case, Patient X
looked to me to make him feel more at ease.
He saw me as a friendly face that was knowledgeable enough to guide him
through the preoperative process using child-appropriate terms. By speaking to Patient X and his mother in a
friendly manner, I was able to relieve some of their anxiety. While I did the best that I could given my
nursing knowledge at the time, this may not have been effective in another
situation. In my future praxis, I will
be sure to look for more opportunities to lessen preoperative stress on
patients and their families.
Surgery can be a threatening experience for
everyone, especially for children (Li & Lam, 2003; O’Conner-Von, 2000). Children are more vulnerable due
to their lack of knowledge of procedures, a lack of perceived control, a lack
of explanation in child-appropriate
terms, and a lack of pain management.
Mrs. X had undergone elective total hip arthroplasty the day
before coming into my care. Although it
was only her first post-operative day, Mrs. X seemed to underreport her pain
and was hesitant to use her patient-controlled analgesia pump. This made it difficult for me to assess and
help treat her pain. I believe her
hesitation was due to fear and misunderstanding of the medication that would be
administered through the PCA pump. By
educating Mrs. X and showing her how much the analgesic assisted with her return
to activity, I was able to assist Mrs.
X in controlling her pain. This granted
her the ability to be an active participant in her own recovery. In my future nursing practice, I will be
looking for more educational materials to be available to patients to ensure
they are able to make the best possible decisions for their care.
Li, H. C., & Lopez, V. (2008). Effectiveness and
appropriateness of therapeutic play intervention
in preparing children for surgery: A randomized controlled
trial study. Journal for Specialists in
Pediatric Nursing, 13(2), 63-73. Retrieved from
Noronha, J. R., & Shanti, S. (2015). Effectiveness of
picture book on preoperative anxiety
among children (6-12 years) in
selected hospitals in Mangalore. Asian
Journal of Nursing
Education and Research, 5(4), 523-525. Retrieved from https://search-proquest-com.uproxy.library.dc-uoit.ca/nahs/docview/1758156302/ECB2439D643C4DF4PQ
Ozdogan, H. K., Cetinalp, S., Kuran, G., Tugal, O.,
Tahiroglu, M., Herdem, U. E., & Haytoglu,
S. (2017). The effects of maternal presence during
anesthesia induction on salivary cortisol levels in children undergoing
tonsillectomy and/or adenoidectomy. Journal
of Clinical Anesthesia, 39, 64-66. Retrieved from http://dx.doi.org.uproxy.library.dc-uoit.ca/10.1016/j.jclinane.2017.03.001
Perry, S. E., Hockenberry, M. J.,
Lowdermilk, D. L., Wilson, D., Keenan-Lindsay, L., & Sams, C. S. (2016). Maternal Child Nursing Care in Canada (2nd Edition). Toronto: Elsevier