The Use of Chemical Restraint for Children in Operating Theatre - Essay Example

Running Head: The use of chemical restraint for children in Operating theatres Student’s name Institution Course Professor Date The scenario for this essay has been drawn from a case of 2years 8 months old boy of Australian aborigine who was accompanied by his mother and father hospital. The chief complains were snoring at night, mouth breathing, sleepiness and lethargy during the day and poor growth for 8 months and had been treated without improvement. He is reported to have episodes of recurrent nasal and ear discharge unresponsive to therapy. No cough and no family history of asthma. No history of bleeding tendencies. Antenatal, past medical history and review of other System was unremarkable. He was seen by ENT surgeon who ordered a postnasal space X-ray and a diagnosis of adenotonsillar hypertrophy was made. He was scheduled for adenotonsillectomy and I was part of the team that was involved in his care during the entire perioperative period. Pre-operative hematological investigations were normal. In this case of elective surgery for adenoidectomy, the nurse plays important roles in preoperative evaluation and preparation for surgery for the child’s safety as well as ensuring pleasant perioperative period for both the child and family. There are many issues to be addressed including provision of information, acquisition of informed consent, communication and information and other aspects of professionalism. The preoperative visit is very important in this process to address various issues concerning the entire perioperative period. It involves giving details of the treatment plan, benefits and risks of therapy, alternative options, general anaesthesia effects and complications that may occur (Chambers & Jones, 2007). Information is provided regarding specific instructions such as preoperative fasting, when to be admitted to hospital, post operative care is necessary prior to surgery, (Evans & Prosser, 2006). The nurse also serves as a link between the anaesthetist and both the child and his parents and organize for pre operative review by the anaesthetist. As the Registered Nurse (RN) performs all these professional duties, the student provides assistant where needed and more importantly takes this as learning opportunity for their training (Brammer, 2008). The preoperative evaluations for this procedure include assessment of physiological and psychological status. Anatomy and physiology differs between children and adults and has important consequences regarding anaesthesia (Aitkenhead et al, 2001). Physiological issues to deal with here include Airway integrity and adequacy of breathing, check for adequacy of circulation and level of Neurological status (Short and Malik, 2009). Airway compromise is paramount as it may be compromised in this procedure given its location and history of mouth breathing. Psychological issues that have to be handled by the nurse include perioperative anxiety that may result from separation from parents during this period, the new and peculiar hospital environment and anticipation of the operation and the pain of the procedure , (Kain & Caldwell, 2005). About half of the children develop preoperative fear and anxiety. Behavioral problems that may occur due to admission, pain and fear as well as from physiological response to the changes and have to be handled. Other problems can also occur during preparation for surgery at the theatre and induction of anaesthesia. The nature of anaesthetic induction affects the response post operatively and behavioral changes such as nightmares and hallucinations may occur if the child is not prepared well and also influenced by the type of anaesthetic drugs used (Short & Malik, 2009). Chemical restrain involves the use of medications to achieve various goals during perioperative period. The medications are used for premedication, induction and maintenance as well as postoperatively. A balance has to be established between the need for these medications, patient comorbidities and the potential adverse effects from their use. Both the nurse and students should understand this, as well as side effects of the various agents allow instituting early measures to prevent or counter them. In adenoidectomy, which was the procedure done, general anaesthesia is used for maintenance given children hardly tolerate regional anaesthesia. Children aged 2 to 3 years are more likely to cause stressful induction and experience post operative withdrawn behavior and hence need for chemical restrain during perioperative period becomes paramount. (Meakin, Tan, 2010 & Karling et al, 2007) The nurse has to fully understand the goals to be achieved the drugs to use, their adverse effects, resuscitation measures and antidotes if any. The following premedication goals and drugs can be used for chemical restraint: Anxiolysis and amnesia with benzodiazepines, Analgesia with Opiates, paracetamol and NSAIDS and Anti- autonomic drugs to reduce secretions such as Atropine. Others that can be used include antiemetics and antacids (Rosenbaum et al, 2009). Induction and maintenance of anaesthesia involves choice among a wide range of inhalational and intravenous anaesthetic agents with an aim of achieving a smooth induction and maintenance of physiological status during the procedure and limit adverse post operative sequelae. Sedative premedication in a child well prepared is not required often given side effects as some of those given below. Children accompanied to the anaesthetic room by their parents usually remain calm. Using regional anaesthesia at induction reduces the amount of anaesthetic needed intraoperatively and also provides postoperative analgesic effects mainly when long-acting agents such as bupivacaine are used. Postoperative nausea and vomiting is also common and antiemetics such as Ondansetron are useful, since it has no sedative effect. Understanding this helps in informing the patient and for perioperative management and care. For instance a disadvantage of using opiates is that drug effects persist into the postoperative period, causing respiratory depression requiring postoperative mechanical ventilation and monitoring (Aitkenhead et al, 2001) In some situations non pharmacological measures to achieve this to either avoid the untoward response to the drugs or other limitations such as comorbidities or as additional ways to augment the chemical restraint. Pre-operative preparation by providing adequate information and meeting other legal aspects is crucial in reducing parental anxiety which has been found to reduce child’s anxiety. Use of play stations and play therapy by trained play therapists as well use of visual aids such as videos is also useful in children to reduce anxiety during pre anaesthetic stage, (Meakin & Tan, 2010 , Aitkenhead et al, 2001 & Rosenbaum et al, 2009). Communication is important in this case considering the cultural background, this allows ample environment for evaluation of the child for the operation as well as to explain to the parents about the intervention in detail and seek consent. The nurse has to breakdown the information of the child’s problem in simple understandable way to enable understanding the implication of the procedure and what can happen if nothing is done (Adams & Parrott, 2009). In this case involving a minor, the parents were explained to as the toddler could not understand due to age. His was done with ease since the parents were educated and even demanded more details of the procedure. Both oral and written information were provided including the sequence of events that occurs during perioperative period. The professional issues at this point and ethical conduct principles were observed including respecting the dignity of the parents, cultural values and beliefs, keeping patient’s information private and confidential and the duty to inform in an impartial, honest and accurate manner during care. The parents were given information on the available options regarding the operation and the underlying risks of the procedure. This process demanded the nurse to have a great wealth of knowledge regarding the procedure and the operation. This episode created a rapport between both the parents and the boy and also gave them confidence regarding their child’s care in line with the professional code of conduct that requires nurses to enhance informed decision making to people requiring or receiving care through effective communication and informing patients (Adams & Parrott, 2009, Short & Malik, 2009 & Paget et al, 2011). Legally and ethically, a patient must have informed consent while receiving any form of treatment from healthcare provider (Berg et al, 2001). In this case the three legal aspects of consent had to be met; competency to give consent, the patient must have been sufficiently informed to give consent and not under duress to gain surgical consent for the procedure, (Shields, 2009). In this case, the minor was unable to give a valid consent and this had to be obtained from the parents. This informed consent must be obtained in writing from the parents or responsible guardian. Both parents consented after a thorough explanation of everything and documentation was made with a witness in place. This is a very important learning point for student since this has important legal implications. Consent provision is therefore a process involving thorough discussion and giving the parent/guardian sufficient information to enable them make decisions. Giving appropriate time to make an informed decision is also important in seeking consent (ANMC, 2006, Berg et al, 2001). Veracity is the duty to communicate truthfully to the patient; this also has to be upheld. In this case, since the toddler could not understand the family was honestly informed about every aspect of care they had to know regarding their child’s condition and interventions in line with professional conduct and ethics (Shields, 2009). Another fundamental ethical principle is the autonomy of the patient. This means that the patient has the right to make decisions regarding his/her health matters and makes the health care provider only offer advisory roles. In this regard the individual decides without coercion. This, just as for consent above is sought from the patient's lawful parents or guardians. Keeping patient’s information private and confidential is an important aspect of nursing practise (Shields, 2009). Since we were dealing with a minor who could not understand what was happening, the confidentiality between nurse and patient was transferred to their parents. The information concerning this interaction is not supposed to be passed to a third party (ANMC, 2006). This was maintained during this case. The practise recommendations developed as a result of learning from this professional issue are include: developing a goal directed care template for each patient during care, teamwork and have a practice of patient centered care. Each of these recommendations is further discussed in paragraphs below. Developing a template for each individual patient during care is helpful. From this case, there are very many issues to be addressed for each patient with chances of leaving out others or delays in some aspect of care. Having a template or a goal directed plan for each patient enhances efficiency of practice and patient care. This approach provides a link between assessment and care of the patient (McCormack & McCance, 2010). For instance in the perioperative care for this boy, assessment of many issues and preparations are numerous and hence order is achieved by having established and specific goals to be met. Patients may be multiple with different needs, assessments, investigations, postoperative care observations and comorbidities to consider which are efficiently and effectively met by having a guide. Moreover, this planning eases communication between staff during care and avoids confusion especially in multiple patient care setting. Greater satisfaction is achieved giving a sense of motivation to the nurse and makes work environment less chaotic as it happens during disorder. Planned patient care helps to identify deficits in knowledge and action allowing seek clarification to be sought from reference materials or colleagues. This is also beneficial for students since planning sets learning objectives and makes it easier and more objective (Manley et al, 2007, McCormack & McCance, 2010). Being part of team during practice and learning are important in improving client care and safety (Sargent, 2008) as well as achieving learning and competency goals. Recognizing that no one can work without the help and input from others such as fellow RNs, doctors, anaesthetists and even students among others is crucial. Team work also helps to build trust among colleagues and between patients and their families with healthcare providers. This is even more necessary as health care becomes complex due to innovations, comorbidities and legal issues among others. This set up where input of various people is required to achieve quality care and also to ensure smooth patient care during changes of duty between nursing staff that depend on information and action from colleagues to ensure order is achieved (Williams et al, 2007). This helps to curtail any systematic inefficiencies and errors. In pediatric patients, patient centred care emphasizes the centrality of the patient and their active role in the provision of care. For children, parents take a bigger role in influencing how the objectives are met. It provides means of understanding the parents through which the child can be understood and served appropriately in context their prevailing sociocultural background. Both Professional and ethical codes and this recommendation have similarity regarding their core elements and enhance synergy and improve performance, (McCormack & McCance, 2010). This approach leaves the patient and the family satisfied by this client centred care offered due to effective communication, information provision and interaction; also the nurse feels motivated and satisfied with work environment. References A.M.A. Opinion 8.08—Informed Consent. Code of medical ethics of the American Medical Association: Current opinions with annotations. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical- ethics/opinion808.page Adams. J, R & Parrott. R. (2009). Pediatric nurses’ communication of role expectations to parents of hospitalized children. Journal of Applied Communication Research; 22, 1, pg 36-47 Aitkenhead, A. R, Rowbotham, J. D & Graham Smith,. G. (2003). Textbook of Anaesthesia. 4th Ed. Sydney: Churchill Livingstone. Armstrong, T. S. H, Aitken, H .L. (2000). The developing role of play preparation in pediatric anaesthesia. Pediatric Anaesthesia; 10: pp 1-4 Australian Nursing and Midwifery Council, (2006). National Competency Standards for the Registered Nurse, ANMC, Canberra. Available at: www.anmc.org.au. Australian Nursing and Midwifery Council. (2006). National Competency Standards for the Nurse Practitioner, ANMC, Canberra. Available at: www.anmc.org.au. Berg, J, Appelbaum, P, Lidz, C & Parker, L. (2001). Informed consent: Legal theory and clinical practice.2nd Ed. New York: Oxford University Press. Brammer, J. (2008). The RN as gatekeeper: Gatekeeping as monitoring and supervision, Journal of Clinical Nursing 17, 1868–1876. Chambers M & Jones S. (2007). Surgical Nursing of Children: Butterworth Heinemann: Elsevier. Evans, L and Prosser, D. (2006). Preoperative Assessment and Preparation for Anaesthesia in Children. Anaesthesia and Intensive Care; 7: 375‐379. Kain, Z. N & Caldwell-andrews A A. (2005). Preoperative psychological preparation of the child for surgery: an update. Anesthesiol Clin North Am. 23:597-614. Kain .Z. N, Mayes L, Wang S M, et al. (1998). Parental presence during induction of anesthesia versus sedative premedication: which intervention is more effective? Anesthesiology; 89:1147-1156 Karling, M, Stenlund, H & Hagglof ,B. (2007). Child behaviour after anaesthesia: associated risk factors. Acta Paediatr. 96:740-747. Manley, K, Sanders, K, Cardiff, S, Davren, M & Garbarino, L. (2007) .Effective workplace culture: a concept analysis. Royal College of Nursing. Workplace Resources for Practice Development. RCN, London, 6-10 McCann, M, Kain, Z. (2001). The Management of Preoperative Anxiety in Children: An Update. Anesthesia and Analgesia. 93: 98‐105. McCormack B & McCance T. (2010). Person-centred Nursing: Theory and Practice. Oxford: Wiley Blackwell Meakin, G.H, Tan, L. (2010). Anaesthesia for the uncooperative child. Contin Educ Anaesth Crit Care Pain; 10: 48–52 Paget, L, Han, P, Nedza S, et al. (2011). Patient-clinician communication: Basic principles and expectations. Discussion Paper, Institute of Medicine. www.iom.edu/pcc Rosenbaum, A, Kain, Z. N, Larsson, P, Lonnqvist, P.A & Wolf, .A R. (2009). The place of premedication in pediatric practice. Paediatr Anaesth; 19:817-828. Sargent, S. Loney, E. & Murphy, G. (2008). Effective Interprofessional Teams: “Contact is not enough” to build a team. Journal of Continuing Education in the Health Professions, 28(4), 228-234. Shields, L. (2009) Ethical and Legal Issues in Paediatric Perioperative Care, in Perioperative Care of the Child: A Nursing Manual (ed L. Shields). Oxford: Wiley-Blackwell. Short J & Malik D. (2009). Preoperative assessment and preparation for anaesthesia in children. Anaesthesia and Intensive Care Medicine; 10: 489‐494. The Interprofessional Education Collaborative(2011). Core competencies for Interprofessional collaborative practice: Report of an expert panel. Washington, DC. Williams, R.G, Silverman R, Schwind C, et al. (2007). Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann Surg; 245(2):159-169. Read More