CONTINUING EDUCATION

Preoperative Care of Children:

Strategies From a Child Life
Perspective 1.7 www.aornjournal.org/content/cme

JUDY J. PANELLA, BS, CCLS

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The behavioral objectives for this program were created by

Purpose/Goal
To provide the learner with knowledge specific to develop-
mentally appropriate preoperative care of children.
Kristi Van Anderson, BSN, RN, CNOR, clinical editor, with
consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Van Anderson and Ms Bakewell
have no declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this article.

Objectives
Sponsorship or Commercial Support
1. Explain the role of the child life specialist.
No sponsorship or commercial support was received for this article.
2. Discuss the role of the perioperative nurse in decreasing
preoperative parental and child anxiety.
3. Describe strategies for providing developmentally appro- Disclaimer
priate care to infants, children, and adolescents. AORN recognizes these activities as CE for RNs. This recognition
4. Describe strategies for providing care to children with does not imply that AORN or the American Nurses Credentialing
developmental delays. Center approves or endorses products mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2016.05.004
ª AORN, Inc, 2016

www.aornjournal.org AORN Journal j11

Preoperative Care of Children:
Strategies From a Child Life
Perspective 1.7 www.aornjournal.org/content/cme

JUDY J. PANELLA, BS, CCLS

ABSTRACT
The experience of surgery can be extremely stressful for children and their family members. Many
children’s hospitals offer a formal surgical preparation program to patients and their families, usually
led by a child life specialist. However, smaller hospitals or ambulatory surgery centers may not be
able to use this approach to preparing children for surgery. In this scenario, the perioperative nurse
is in the ideal position to provide developmentally appropriate surgical preparation and education
at the bedside. Knowledge of normal child development and age-appropriate diversional activities
are necessary to implement an effective surgical preparation program. This age-appropriate prep-
aration can help facilitate a positive medical experience that can reduce anxiety and affect the
child’s and his or her family’s view of future medical encounters. AORN J 104 (July 2016) 12-19.
ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2016.05.004
Key words: pediatric, preoperative, age-appropriate preparation, child life, coping.

T he experience of surgery, including its unfamiliar

routines, clothing, sights, sounds, and smells, can
be extremely stressful for children and their family
members. Nurses caring for children preoperatively must be
prepared to provide developmentally appropriate care to
help relieve the anxiety of children and the children’s family
members.1 Allowing time for age-appropriate preoperative
preparation activities and involving the child’s parents or
caregivers in the process may benefit the child by reducing
anxiety.2 Fortier et al3 found that preventing preoperative
anxiety in children may help prevent negative outcomes after
surgery, such as negative behavioral changes and postoperative
pain. Because anxiety may have a substantial effect on a
patient’s well-being, it is important to understand that a single
experience can drastically shape how a child views future
medical visits and encounters with health care professionals.
Perioperative anxiety in both children and their family mem-
bers is a normal aspect of the surgical experience.4 High
parental anxiety may perpetuate high anxiety in the child, so
it is important to address the fears and concerns of the
child’s family members and involve them in the child’s
care.2,3,5 If a patient or family member is made to feel that
his or her reactions are abnormal or that the surgical
experience should be “easy,” medical personnel can be
perceived as demeaning and unsupportive.
Most major medical centers and children’s hospitals have child
life departments that provide formal surgical preparation
programs, generally led by child life specialists. A child life
specialist is a trained professional who has experience helping
children and family members cope with health care experi-
ences. Child life specialists often meet children and adolescents
during preoperative testing appointments to help explain
anesthesia and surgery in developmentally appropriate terms.
This may include providing preoperative tours and facilitating
medical play to promote familiarization and mastery of unfa-
miliar and often scary equipment. Ideally, children should
http://dx.doi.org/10.1016/j.aorn.2016.05.004
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July 2016, Vol. 104, No. 1
meet the child life specialist for age-appropriate preparation
anywhere from 24 hours to several days before a planned
surgical event. Although younger children may benefit from
preparation closer to the date of surgery to avoid building
anxiety, adolescents may benefit from preparation at least 7 to
10 days in advance.4
A small hospital or ambulatory surgery center may not employ
a child life specialist, and children may arrive with little to no
formal preparation for a surgical or anesthetic event. The
surgical and anesthesia team explains the surgical process and
anesthesia sequence to children and family members in this
situation. However, the perioperative nurse remains a consis-
tent and trusted presence throughout the preoperative period
and should understand how to help children and their family
members cope with preoperative anxiety. When preoperative
preparation by a child life specialist cannot be provided,
perioperative nurses are in the best position to assist children
and family members in coping with the surgical environment
and its routines. Depending on the information that has been
provided by the surgeon at a clinic visit and the independent
research family members or patients may have performed on
their own, children can arrive with varying levels of under-
standing and misconceptions about surgery. An in-depth
knowledge of development can guide nurses and other pro-
viders to deliver age-appropriate care that can enhance chil-
dren’s ability to cope effectively with a stressful situation and
create an atmosphere that promotes positive coping for future
medical experiences. A summary of the developmental norms
and implications to consider for the preparation of children
and adolescents undergoing a surgical or anesthetic event is
provided in Table 1.
When preparing the child for surgery, the role of the parent or
caregiver cannot be overstated. Nurses must be aware that
preoperative preparation relies on developing a collaborative
relationship with the caregiver. The presence and involvement
of a parent or caregiver can help normalize the hospital envi-
ronment for the child, provide support, and reduce stress.6
Nurses can use their knowledge of development to teach
parents or caregivers coping strategies to use with the child
during the preoperative and postoperative periods. This
article provides developmentally appropriate interventions
nurses can use to improve the surgical experience for
children and their family members.
DEVELOPMENTALLY APPROPRIATE
SURGICAL PREPARATION
By taking into consideration the child’s developmental level
and the associated parental concerns, nurses can make
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Preoperative Care of Children
alterations in their care to provide adequate preparation while
performing preoperative assessments and tasks. However,
some planning is required to institute effective diversional and
educational interventions that can improve the surgical expe-
rience for children and their family members. Gathering
appropriate medical equipment such as an IV catheter with
extension tubing, blood pressure cuff, stethoscope, anesthesia
mask, or electrocardiogram (ECG) leads that are clearly labeled
for teaching purposes can serve as excellent show and tell items
for what children may see or experience during their visit
(Figure 1). Books, bubbles, handheld games or tablets, and
light-up or musical toys can also be kept in a box on the
unit and used as diversional activities for children of
different developmental ages. These materials must be
thoroughly cleaned according to the facility’s infection
control policy between uses. Suggested interventions that the
perioperative nurse can implement to support children and
their family members throughout their surgical experience
are described by age group in the following sections.
Preparing Infants and Toddlers
Preparing the parents of neonates (birth to 27 days old), in-
fants (28 days to one year old), and toddlers (one year to two
years old)7 for what to expect before a procedure and how they
can help care for their children may lead to lower stress levels
for both the parents and the children.8 Validating a parent’s
fears and concerns and providing supportive listening can be
helpful in reducing parent stress, thus reducing patient
stress. If the situation seems appropriate, using humor can
sometimes be a starting point to build rapport with parents.
If there is communication with caregivers before the day of
surgery, the nurse should remind parents to bring comfort
items (eg, a blanket that smells like home, pacifier, favorite
stuffed animal, familiar bottle and nipple for use in recovery)
that can aid in coping and help address issues related to a
change in environment and routine.1 Because separation from
caregivers is the primary source of stress for this age group,
parents should be encouraged to remain with their children
whenever feasible.4 Parents should be at their children’s
bedside in the postanesthesia care unit (PACU) as quickly as
medically possible to decrease separation anxiety. 4 Informing
parents of the anesthesia and surgical sequence, postoperative
dressings, and monitoring equipment may help decrease
some of their anxiety, thus creating a calmer environment
for their children.
Infants and toddlers likely do not benefit from a direct
explanation of a surgical procedure. Infants rely on their
parents to meet their needs and may be soothed preoperatively
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Table 1. Developmental Considerations When Caring for Children Undergoing Surgery1-5

Age Developmental Considerations Implications of Medical Experiences

Neonatal/infancy: birth to 1 year ● Learn through senses and motor ● Separation anxiety
movements ● Lack of stimulation
● Reliant on caregivers for basic needs, ● Disruption of sleeping and feeding routine
building trust with caregivers
Toddlerhood: 1-2 years ● Interact with environment through senses ● Separation anxiety
● Begin seeking autonomy ● Fear forced dependence
● Developing free will ● Distractions during medical care may
reduce anxiety (songs, toys)
Early childhood (preschoolers): ● Language and social skills are developing ● Fear of mutilation and pain
2-5 years ● Developing symbolic thought ● Misconceptions regarding surgery
● Seeking initiative; want to assert control ● Separation anxiety
over their world ● May view surgery as punishment for some
● Primarily perceptive thinkers; reasoning wrongdoing
may be distorted ● Do not have an understanding of the
● Feel remorse for inappropriate actions body’s organs
Middle childhood (school-aged ● Acquire capacity for rational, logical ● Fear the unknown, loss of control
children): 6-11 years thought and abstract thinking ● Fear of bodily injury and pain, especially
● Gain the capacity for hypothetical and intrusive procedures in the genital area
deductive reasoning ● Fear of illness and disability
● Gain the ability to understand rules, the ● Better tolerance for separation anxiety, but
concept of fairness, and cooperation with still present
others ● Misconceptions about surgery may still be
● Gain mastery and sense of competence by present, may still see surgery as
demonstrating knowledge and skills (like to punishment
be involved in care)
Early adolescence: 12-18 years ● Rapidly maturing physically and ● Fear of bodily injury, death, and pain
emotionally ● Fear of loss of identity and control
● Developing one’s own identity ● Concerned about body image, may worry
● Progressing toward mature thinking and about cosmetic implications of surgery
abstract thought ● Concern about peer group status after
● Better able to understand causation of surgery or hospitalization
disease
● Value privacy, independence
● Peer relationships are of supreme
importance
References
1. Difusco LA. Pediatric surgery. In: Rothrock JC, ed. Alexander’s Care of the Patient in Surgery. 15th ed. St Louis, MO: Mosby; 2015:1008-1080.
2. McLeod S. Erik Erikson. Simply Psychology. http://www.simplypsychology.org/Erik-Erikson.html. Published 2008. Updated 2013. Accessed
April 7, 2016.
3. Harris TB, Sibley A, Rodriguez C, Brandt ML. Teaching the psychosocial aspects of pediatric surgery. Semin Pediatr Surg. 2013;22(3):161-166.
4. McLeod S. Jean Piaget. Simply Psychology. http://www.simplypsychology.org/piaget.html. Published 2009. Updated 2015. Accessed
April 7, 2016.
5. Leack KM. Perioperative preparation of the child and family. In: Tkacz Browne N, Flanigan LM, McComiskey CA, Pieper P, eds. Nursing Care of
the Pediatric Surgical Patient. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2013:3-16.

with gentle rocking, pacifiers, and warm blankets. Infants and
toddlers interact with their environment through their senses
and therefore may benefit from music or toys for distraction.1
Toddlers may also benefit from hands-on manipulation of
appropriate medical equipment (eg, blood pressure cuff,
anesthesia mask).1,9 Using simple words and allowing the
toddler to hold and explore equipment used during
assessments can be helpful in gaining trust and cooperation.
For example, stating “I need to check your blood pressure;
this is the cuff,” and allowing the toddler to hold and play
with the cuff before placing it on the arm or leg may be
beneficial. Hearing the words and modeling can help gain
cooperation during an examination: “I need to listen to your
heart; how about I listen to Mom’s heart first?” Infants and

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Figure 1. A box of medical supplies clearly labeled for
teaching purposes only that is easily accessible in the
preoperative space can hold “show and tell” items.
toddlers may use their parents as barometers for how they
should feel about a situation.10 If a parent appears calm and
compliant with a nurse, the child may demonstrate the
same behavior.
Preparing Preschoolers
Children in early childhood (ie, preschool children ages two to
five years)7 have verbal abilities, and it is important to
understand the tendency of the child to misinterpret words
and concepts that require abstract thinking.4 For example,
using terms such as “gas” anesthesia or saying “we are going
to put you to sleep” can often be misunderstood. Instead
try language and explanation, such as “medicine air” or
“hospital medicine sleep that is different from sleep you
have at home.” Preschoolers may believe they did something
wrong to deserve what is happening to them. Explaining to
children that they had no role in causing their illness will
decrease guilt and worry about punishment.4
When assessing a patient in this age group, the nurse should
preferably sit at the child’s eye level. Children may be more
cooperative when remaining close to a parent and may be most
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Preoperative Care of Children
comfortable sitting on his or her lap. The nurse should try to
elicit from the parent the understanding of the child regarding
the reason he or she is at the hospital. Determining the child’s
point of reference can be helpful in proceeding with additional
explanation. For example: “I understand you are here today
because you have been getting a lot of sore throats and your
tonsils are causing some trouble.” It is important to use the
correct anatomic term for body parts and medical equipment
in addition to child-friendly descriptors to help provide extra
explanation. For example: “This is the pulse oximeter; it
checks your oxygen and how your heart is beating. It is a
sticker that wraps around your finger or toe and has a red
light inside.”
Preschool children may be frightened by surgical attire and
experience distress related to separation from caregivers. 4 The
nurse should encourage parents to be present and involved in
as much of the preoperative and postoperative process as
medically possible. It may be appropriate to give the parent
and the child a surgical hat and mask to wear and play with
to help normalize the environment. Remind the child that
when the doctor works on his or her body, he or she will be
asleep with anesthesia (ie, “hospital sleeping medicine”) and
will not feel anything the doctor is doing until it is time to
wake up.
Allowing preschoolers to explore and manipulate appropriate
medical equipment can lead to familiarization and may
decrease stress.1 Modeling by performing a blood pressure or
temperature check on a parent can be helpful in gaining
cooperation from the child. If the child brings a stuffed
animal, always ask permission first before listening to
“Fluffy’s” heart. Reminders about postoperative dressings
and the “surgery spot” (ie, incision) can be helpful. The
preschooler should be prepared for a sore spot but should be
reminded that it will get better. Reinforce the times and
places that parents or caregivers will be present with the child.
Preparing Children in Middle Childhood
Children in middle childhood (school-aged children between
6 and 11 years old)7 should have a greater capacity than
toddlers or preschoolers to tolerate separation from caregivers
and are increasingly able to understand the concepts of
illness.4 A school-aged child should have some degree of
understanding about the surgical procedure on arrival at the
hospital or surgical center. Children in this age group gain a
sense of competence by demonstrating their knowledge and
skills. An effective way to elicit information is simply to ask.
For example: “Tell me what you know about why you are
here today” can be a great starting point. It is important to
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direct this question to the child rather than the parent.

Children in this age group have had more exposure to media
and peer influence,6 which can lead to misconceptions or
worries of not waking up from anesthesia or awakening during
surgery. Using clear language and explaining the differences
between sleep at home and “hospital sleeping medicine” can be
quite helpful.

Because children in this age group fear the unknown, illness,

and bodily harm,1,6 a concern that sometimes arises with
school-aged children related to anesthesia is what they will or
will not remember. When the patient hears “you won’t
remember anything,” particularly when describing a preoper-
ative medication, patients may fear they will wake up not
remembering their name, family members, or fundamental
traits about themselves.

Pictures and other visual aids are particularly effective in

explaining surgery to this age group. A simple children’s
anatomy book can be useful for visual learners and help
reinforce medical explanations. At this age, some children may
just be beginning to understand that organs and body systems
are complex entities, but unseen body functions may need to
be explained by the nurse.1 Younger children in this age range
may still think their heart is similar to what they see on
Valentine’s Day cards and may generalize the term Figure 2. A doll with a cast or bandage may show
“stomach” to their entire abdomen (“tummy” or “belly”). children how their “surgery spot” may appear after
Using an anatomy book can help children gain a more surgery.
accurate understanding of their body, the size and location
of the surgical site, where to look for the incision after the asking school-aged children to help develop their own
surgery, or why they will not be able to see the surgical site coping strategies can be helpful in supporting their
after surgery. Creating a flip book of pictures containing independence. Help them choose from several options; for
common surgical sites, such as the tonsils, adenoids, and ear example: “Some kids like to watch me start the IV, others
canal, can be helpful for both children and parents. If a like to look away or listen to music on their phones, and
facility has a high rate of orthopedic procedures and casting, others like to hold their mom’s or dad’s hand. Which do
having a doll that is casted can be a great visual for what to you think would help you most?”
anticipate (Figure 2).

Allowing the child appropriate choices and opportunities to be Preparing Adolescents

involved in his or her care can often lead to better coopera-
tion.1 Telling the child, “I have to check your temperature and
blood pressure and listen to your heart and lungs” and then
asking, “Which would you like me to do first?” is an
example of how to offer an appropriate limited choice.
Asking “yes” or “no” questions such as “Can I check your
temperature?” allows the child to say “no,” placing the nurse
in a difficult situation. The temperature must be obtained
regardless, violating the trust the nurse is building with the
child. Consider allowing the child to perform simple tasks,
such as removing his or her own ECG leads in the PACU,
to help the child feel more involved in his or her care. Also,
The nurse may encounter a wide range of emotions and be-
haviors from early adolescents (12 to 18 years).7 Adolescents fear
a loss of self-control and autonomy11 and therefore may react
negatively to being told what to wear (ie, hospital gown), how
to behave (ie, answering questions related to their medical
history, discussing uncomfortable or private topics), or to
maintain NPO status by withdrawing or not cooperating with
the health care team. Many of the strategies used for younger
children also work for adolescents, with a few modifications
and additions. Address the adolescent patient, rather than the
parents, from the beginning of the check-in process to
support their desire for independence.4 Many adolescents

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should be able to answer most, if not all, of the interview
questions related to allergies, NPO status, and pain scores. It
can be easy for a parent to take over the conversation, which
may cause the adolescent patient to withdraw.
Peer relationships are of supreme importance to adolescents.
Allowing the adolescent access to their phone to text friends
can help them feel connected to their peer group. Setting
ground rules from the beginning, reminding the adolescent
that he or she may keep the phone in the preoperative or
postoperative area but must still attend to the discussion and
answer questions when asked by the health care team, is
essential. Playing a favorite game or phone application can
help distract adolescents and normalize the situation, which
can lower anxiety and help reduce the need for preoperative
anxiolytic medication.11
The adolescent should have had a role in the surgical
decision-making process and have an understanding of the
need and indications for surgery. Even so, teens can still
benefit from more detailed explanations and visual aids.
Many adolescents are interested in science and the human
body. Using anatomy books or diagrams can be useful in
helping the teen become more comfortable and provides an
opportunity to ask questions. Common concerns for this
age group may include an altered body image, peer rejec-
tion, disability, loss of control, and fear of death.1 When
addressing these concerns, the nurse should not dismiss
the teen’s worries because a question may be difficult to
answer. This does not allow the adolescent to feel as if
his or her concerns are heard and validated. When
answering questions, an honest approach can be helpful in
building rapport.
Because of heightened concerns about body image, adolescents
are often extremely worried about the resulting cosmetic effects
of an operation.4 They may seem more concerned about what
their scar will look like than the actual surgical and anesthesia
process. Validating these concerns without judgment or
minimizing them can lead to more effective cooperation and
conversation. Adolescents also value their privacy, and the
nurse should be especially mindful of this.1 For example, if
the adolescent needs to use the restroom, offer an additional
gown to wear around the back to help him or her feel more
covered. Inform teens about who will need to examine them
and why.
Children With Developmental Delays
Medical experiences can be stressful for many children who fall
within developmental norms, but can be much more
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Preoperative Care of Children
challenging for those with developmental delays or a sensory
processing disorder (eg, autism spectrum disorder). As with any
disorder, the patient’s impairments may fall at different points
on a spectrum. A child or teen could have minimal impairment
in only one or two domains of development, such as social
interactions and language, or have significant deficits across
multiple domains that greatly affect their cognitive under-
standing.12 For this reason, the nurse should not make
assumptions about the patient’s abilities based on the
diagnosis listed in the chart. Another factor to consider,
especially in children with autism spectrum disorder, is that
many are concrete thinkers and may not understand abstract
thoughts or common idioms such as “frog in your throat.” A
child may literally picture themself swallowing a frog.
Sensory integration is also an important consideration.
Sometimes, the noise level or brightness of the lights may be
a negative trigger. Emotional regulation can be extremely
challenging for this group of patients.13
A hospitalization or surgical procedure may provoke chal-
lenging behaviors in children with autism spectrum disorder.
These behaviors can include aggression, tantrums, hitting,
kicking, biting, and scratching.13 The challenge is delivering
care in an effective, safe manner. Family-centered care
principles, such as acknowledging parents and caregivers as
the experts about their children and involving them in the
development of an optimal care plan, are crucial when
planning interventions for any child, but they are especially
important when caring for children with special needs or
developmental delays. It is advisable to try to speak privately
with a parent first to determine the most effective approach
for the child. Parents know their child’s likes and dislikes,
trigger words and behaviors, and communication preferences
and interventions that have helped redirect challenging
behaviors in the past and can lead to more compliance from
the patient. Some questions to consider when talking with
parents include the following:
● What is the child’s level of understanding regarding the
procedure?
● What interventions have worked well during past medical
encounters?
● How does the child communicate (verbally or nonverbally)?
Does he or she use any communication devices (eg, picture
cards)?
● Is the child sensitive to touch or noise?
● Are there any items of fixation or self-stimulating behaviors
that the child uses?
● What strategies work best for transitions such as moving
rooms or separation from a caregiver?12
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Resources for Pediatric Surgical Patients and Their
Family Members
Bhatia S. The Surgery Book: For Kids. Bloomington, IN:
AuthorHouse; 2010.
Colombo L. Uncover the Human Body: An Uncover It
Book. San Diego, CA: Silver Dolphin Press; 2003.
Duncan D. When Molly Was in the Hospital: A Book for
Brothers and Sisters of Hospitalized Children. Windsor, CA:
Rayve Productions, Inc; 1994.
Kids worry too: a guide for adults helping children
understand hospitalization. Nebraska Medicine. http://
www.nebraskamed.com/app_files/pdf/childlife/kids-worry
.pdf. Accessed April 7, 2016.
Matt M, Ziemian J. Human Anatomy Coloring Book.
Mineola, NY: Dover Publications, Inc; 1982.
When the child arrives, if more than one caregiver is present, it
may be possible to complete many of the admission questions
with one parent or caregiver while the child remains in a space
where he or she may be more comfortable, such as in the
waiting room, with another caregiver. For children who have
had multiple medical encounters, being in a preoperative
holding room may produce anxiety. Although there is clearly an
indication for the child to know or have some understanding of
what is happening during the surgical encounter, what is often
most helpful with this population is to simply manage the
environment. Upon meeting the child, speak softly and slowly
and allow time for the patient to process information and
respond. Depending on a patient’s developmental level, it may
not be sensible to engage in a detailed preparation discussion,
but simple pictures of spaces or reminders about a “sore surgery
spot” or “place the doctor is going to fix” may be sufficient.13
For some children, saying the word “no” can provoke a
tantrum. Remove unnecessary equipment from the patient’s
room if possible and keep supplies and materials out of view
until just before use to avoid triggering tantrums or other
challenging behaviors.13 For example, if the nurse is setting
up supplies to start an IV, it may be helpful to collect the
tourniquet, alcohol swabs, IV catheter, and tape on a
treatment tray outside the room and roll it in just before the
procedure. If noises or lights trigger difficult behaviors in a
patient, keep environmental stimuli to a minimum and offer
to turn down lights or reduce volume on alarms, but ensure
18 j AORN Journal
July 2016, Vol. 104, No. 1
alarms are still audible for the nurse.13 The best strategy to
keep in mind is individualized care. Every child is different,
and strategies that worked for one patient with a
developmental challenge may not work for the next.
CONCLUSION
Understanding the interaction of development and the
potential psychosocial effect of surgery helps providers address
the common concerns and fears experienced by children and
their family members. Optimal care is provided when the
medical team understands and respects the child’s develop-
mental level, includes family members and caregivers in
decision making, and works to create a positive medical
experience. The strategies presented in this article are not
intended to increase the nurses’ workload in an already busy
and fast-paced perioperative work environment. Rather, they
are meant to provide the reader with effective interventions
that can be practically implemented by nurses and positively
affect children and their family members. In the future, more
research on outcomes associated with quality preoperative
preparation, such as improved pain management and
decreased anxiety, is necessary to gain a better understanding
of the benefits associated with these strategies. ●
References
1. Difusco LA. Pediatric surgery. In: Rothrock JC, ed. Alexander’s
Care of the Patient in Surgery. 15th ed. St Louis, MO: Mosby;
2015:1008-1080.
2. Perry JN, Hooper VD, Masiongale J. Reduction of preoper-
ative anxiety in pediatric surgery patients using age-
appropriate teaching interventions. J Perianesth Nurs.
2012;27(2):69-81.
3. Fortier MA, Del Rosario AM, Martin SR, Kain ZN. Perioperative
anxiety in children. Paediatr Anaesth. 2010;20(4):318-322.
4. Harris TB, Sibley A, Rodriguez C, Brandt ML. Teaching the psy-
chosocial aspects of pediatric surgery. Semin Pediatr Surg. 2013;
22(3):161-166.
5. Chorney JM, Kain ZN. Family-centered pediatric perioperative
care. Anesthesiology. 2010;112(3):751-755.
6. Leack KM. Perioperative preparation of the child and family. In:
Tkacz Browne N, Flanigan LM, McComiskey CA, Pieper P, eds.
Nursing Care of the Pediatric Surgical Patient. 3rd ed. Burlington,
MA: Jones & Bartlett Learning; 2013:3-16.
7. Williams K, Thomson D, Seto I, et al; StaR Child Health Group.
Standard 6: age groups for pediatric trials. Pediatrics. 2012;
129(suppl 3):S153-S160.
8. Fincher W, Shaw J, Ramelet AS. The effectiveness of a stand-
ardised preoperative preparation in reducing child and parent
anxiety: a single-blind randomised controlled trial. J Clin Nurs.
2012;21(7-8):946-955.
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July 2016, Vol. 104, No. 1
9. Ahmed MI, Farrell MA, Parrish K, Karla A. Preoperative anxiety in
children: risk factors and non-pharmacological management.
Middle East J Anaesthesiol. 2011;21(2):153-164.
10. Lieberman AF, Van Horn P. Psychotherapy With Infants and Young
Children: Repairing the Effects of Stress and Trauma on Early
Attachment. New York, NY: Guilford Press; 2008.
11. Lee JH, Jung HK, Lee GG, Kim HY, Park SG, Woo SC. Effect of behavioral
intervention using smartphone application for preoperative anxiety in
pediatric patients. Korean J Anesthesiol. 2013;65(6):508-518.
12. Scarpinato N, Bradley J, Kurbjun K, Bateman X, Holtzer B, Ely B.
Caring for the child with an autism spectrum disorder in the acute
care setting. J Spec Pediatr Nurs. 2010;15(3):244-254.
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Preoperative Care of Children
13. Johnson NL, Rodriguez D. Children with autism spectrum disorder
at a pediatric hospital: a systemic review of the literature. Pediatr
Nurs. 2013;39(3):131-141.
Judy J. Panella, BS, CCLS, is a child life specialist at
Duke Children’s Hospital and Health Center, Durham, NC.
Ms Panella has no declared affiliation that could be
perceived as posing a potential conflict of interest in
the publication of this article.
AORN Journal j19
EXAMINATION

Continuing Education:
Preoperative Care of Children:
Strategies from a Child Life
Perspective 1.7 www.aornjournal.org/content/cme

PURPOSE/GOAL
To provide the learner with knowledge specific to developmentally appropriate preoperative care
of children.

OBJECTIVES
1. Explain the role of the child life specialist.
2. Discuss the role of the perioperative nurse in decreasing preoperative parental and child anxiety.
3. Describe strategies for providing developmentally appropriate care to infants, children, and adolescents.
4. Describe strategies for providing care to children with developmental delays.

The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aornjournal.org/content/cme.

QUESTIONS position to assist children and family members in coping

1. A child life specialist is a trained professional who has with the surgical environment.
experience helping children and their family members a. true b. false
cope with health care experiences.
4. To institute effective educational and diversional in-
a. true b. false
terventions for children undergoing surgery, perioperative
nurses may consider gathering appropriate medical sup-
2. Child life specialists often meet children and adolescents
plies for “show and tell,” such as
during preoperative testing appointments, which may
1. medications.
involve
2. stethoscopes.
1. explaining anesthesia and surgery in developmentally
3. anesthesia masks.
appropriate terms.
4. glass ampules.
2. providing a preoperative tour.
5. blood pressure cuffs.
3. facilitating medical play.
6. electrocardiogram (ECG) leads.
4. admitting the child to the hospital.
a. 1, 3, and 5 b. 2, 4, and 6
a. 1 and 3 b. 2 and 4
c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
c. 1, 2, and 3 d. 1, 2, 3, and 4
5. The primary source of stress for infants and toddlers is
3. When preoperative preparation by a child life specialist a. altered body image.
cannot be provided, anesthesiologists are in the best b. fear of death.

20 j AORN Journal www.aornjournal.org

July 2016, Vol. 104, No. 1 Preoperative Care of Children

c. loss of control. 4. caregiver separation.

d. separation from caregivers. 5. loss of control.
6. fear of death.
6. When interacting with preschoolers, it is important for a. 1, 3, and 5 b. 2, 4, and 6
the perioperative nurse to understand that children in this c. 1, 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
age group may
1. misinterpret words that require abstract thinking. 9. When caring for children with autism spectrum disorder,
2. believe they did something wrong to deserve what is the perioperative nurse should use family-centered care
happening to them. principles, including
3. be concerned about the cosmetic implications of 1. acknowledging parents and caregivers as experts
undergoing surgery. regarding their children.
4. be more cooperative when remaining close to a 2. involving parents and caregivers in the development
parent. of an optimal care plan.
a. 1 and 3 b. 1, 2, and 4 3. speaking privately with a parent first to determine the
c. 2, 3, and 4 d. 1, 2, 3, and 4 most effective approach for the child.
7. To help the school-aged child feel more involved in his a. 1 and 2 b. 1 and 3
or her care, the perioperative nurse should consider c. 2 and 3 d. 1, 2, and 3
allowing the child to perform simple tasks when appro-
priate, such as 10. When managing the environment for a child with autism
a. removing his or her own ECG leads. spectrum disorder, the perioperative nurse should
b. scheduling a postoperative appointment. 1. speak softly and slowly.
c. changing his or her own surgical dressing. 2. avoid using the word “no.”
d. choosing when to be discharged. 3. remove unnecessary equipment from the patient’s
room.
8. Common concerns of adolescent patients include 4. keep supplies out of view until just before use.
1. altered body image. 5. turn down lights and volume of alarms.
2. peer rejection. a. 4 and 5 b. 1, 2, and 3
3. disability. c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

www.aornjournal.org AORN Journal j21

LEARNER EVALUATION

Continuing Education:
Preoperative Care of Children:
Strategies From a Child Life
Perspective 1.7 www.aornjournal.org/content/cme

T his evaluation is used to determine the extent to

which this continuing education program met
your learning needs. The evaluation is printed
here for your convenience. To receive continuing education
credit, you must complete the online Examination and
7.

8.
Will you be able to use the information from this article
in your work setting?
1. Yes 2. No

Will you change your practice as a result of reading this

article? (If yes, answer question #8A. If no, answer
Learner Evaluation at http://www.aornjournal.org/content/cme.
Rate the items as described below. question #8B.)

8A. How will you change your practice? (Select all that apply)
1. I will provide education to my team regarding why
OBJECTIVES
change is needed.
To what extent were the following objectives of this
2. I will work with management to change/implement
continuing education program achieved?
a policy and procedure.
1. Explain the role of the child life specialist.
3. I will plan an informational meeting with physi-
Low 1. 2. 3. 4. 5. High
cians to seek their input and acceptance of the need
2. Discuss the role of the perioperative nurse in decreasing for change.
preoperative parental and child anxiety. 4. I will implement change and evaluate the effect of
Low 1. 2. 3. 4. 5. High the change at regular intervals until the change is
incorporated as best practice.
3. Describe strategies for providing developmentally 5. Other:
appropriate care to infants, children, and adolescents.
Low 1. 2. 3. 4. 5. High 8B. If you will not change your practice as a result of
reading this article, why? (Select all that apply)
4. Describe strategies for providing care to children with 1. The content of the article is not relevant to my
developmental delays. practice.
Low 1. 2. 3. 4. 5. High 2. I do not have enough time to teach others about the
purpose of the needed change.
CONTENT 3. I do not have management support to make a
5. To what extent did this article increase your knowledge change.
of the subject matter? 4. Other:
Low 1. 2. 3. 4. 5. High
9. Our accrediting body requires that we verify the time
6. To what extent were your individual objectives met? you needed to complete the 1.7 continuing education
Low 1. 2. 3. 4. 5. High contact hour (102-minute) program:

22 j AORN Journal www.aornjournal.org