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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Purpose/Goal
To provide the learner with knowledge specific to develop-
mentally 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
appro-priate care to infants, children, and adolescents.
4. Describe strategies for providing care to children with
developmental delays.
http://dx.doi.org/10.1016/j.aorn.2016.05.004
ª AORN, Inc, 2016
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Conflict-of-Interest Disclosures
Judy J. Panella, BS, CCLS, has no declared affiliation that
could be perceived as posing a potential conflict of interest
in the publication of this article.
The behavioral objectives for this program were created by
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
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AORN Journal j 11
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
parental anxiety may perpetuate high anxiety in the child,
so it is important to address the fears and concerns of the
stressful for children and their family child’s family members and involve them in the child’s
members. Nurses caring for children preoperatively must be 2,3,5
care. If a patient or family member is made to feel that
prepared to provide developmentally appropriate care to help his or her reactions are abnormal or that the surgical
relieve the anxiety of children and the children’s family experience should be “easy,” medical personnel can be
1 perceived as demeaning and unsupportive.
members. Allowing time for age-appropriate preoperative
preparation activities and involving the child’s parents or
Most major medical centers and children’s hospitals have child
caregivers in the process may benefit the child by reducing
2 3 life departments that provide formal surgical preparation
anxiety. Fortier et al found that preventing preoperative anxiety
programs, generally led by child life specialists. A child life
in children may help prevent negative outcomes after surgery,
specialist is a trained professional who has experience helping
such as negative behavioral changes and postoperative pain.
children and family members cope with health care experi-ences.
Because anxiety may have a substantial effect on a patient’s well-
Child life specialists often meet children and adolescents during
being, it is important to understand that a single experience can
preoperative testing appointments to help explain anesthesia and
drastically shape how a child views future medical visits and
encounters with health care professionals. surgery in developmentally appropriate terms. This may include
providing preoperative tours and facilitating medical play to
Perioperative anxiety in both children and their family mem- promote familiarization and mastery of unfa-miliar and often
4 scary equipment. Ideally, children should
bers is a normal aspect of the surgical experience. High
http://dx.doi.org/10.1016/j.aorn.2016.05.004 ª
AORN, Inc, 2016

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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-
6
ronment for the child, provide support, and reduce stress.
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
7
years old) for what to expect before a procedure and how
they can help care for their children may lead to lower stress
8
levels for both the parents and the children. 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
1
change in environment and routine. Because separation from
caregivers is the primary source of stress for this age group,
parents should be encouraged to remain with their children
4
whenever feasible. Parents should be at their children’s
bedside in the postanesthesia care unit (PACU) as quickly as
4
medically possible to decrease separation anxiety. 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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1-5
Table 1. Developmental Considerations When Caring for Children Undergoing Surgery

Age Developmental Considerations Implications of Medical Experiences

Neonatal/infancy: birth to 1 year
Toddlerhood: 1-2 years
Early childhood (preschoolers):
2-5 years
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
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)
Language and social skills are Fear of mutilation and pain
developing 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; wrongdoing
reasoning may be distorted Do not have an understanding of the
Feel remorse for inappropriate actions body’s organs

Middle childhood (school-aged
children): 6-11 years
Acquire capacity for rational, logical
thought and abstract thinking
Gain the capacity for hypothetical and
deductive reasoning
Gain the ability to understand rules, the
concept of fairness, and cooperation with
others
Gain mastery and sense of competence
by demonstrating knowledge and skills
(like to be involved in care)
Fear the unknown, loss of control
Fear of bodily injury and pain, especially
intrusive procedures in the genital area
Fear of illness and disability
Better tolerance for separation anxiety, but
still present
Misconceptions about surgery may still be
present, may still see surgery as
punishment

Early adolescence: 12-18 years Rapidly maturing physically Fear of bodily injury, death, and pain
and 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
1
and therefore may benefit from music or toys for distraction.
Toddlers may also benefit from hands-on manipulation of
appropriate medical equipment (eg, blood pressure cuff,
1,9
anesthesia mask). 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
7 that parents or caregivers will be present with the child.
to five years) have verbal abilities, and it is important to
understand the tendency of the child to misinterpret words
4
and concepts that require abstract thinking. 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
4 hospital or surgical center. Children in this age group gain a
guilt and worry about punishment.
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
4
experience distress related to separation from caregivers.
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
1
decrease stress. 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
Preparing Children in Middle Childhood
Children in middle childhood (school-aged children between
7
6 and 11 years old) should have a greater capacity than
toddlers or preschoolers to tolerate separation from caregivers
and are increasingly able to understand the concepts of
4
illness. A school-aged child should have some degree of
understanding about the surgical procedure on arrival at the
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
6
and peer influence, 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 Figure 2. A doll with a cast or bandage may show
the term “stomach” to their entire abdomen (“tummy” or children how their “surgery spot” may appear after
“belly”). Using an anatomy book can help children gain a surgery.
more accurate understanding of their body, the size and
location of the surgical site, where to look for the incision asking school-aged children to help develop their own
after the surgery, or why they will not be able to see the coping strategies can be helpful in supporting their
surgical site after surgery. Creating a flip book of pictures independence. Help them choose from several options; for
containing common surgical sites, such as the tonsils, example: “Some kids like to watch me start the IV, others
adenoids, and ear canal, can be helpful for both children like to look away or listen to music on their phones, and
and parents. If a facility has a high rate of orthopedic others like to hold their mom’s or dad’s hand. Which do
procedures and casting, having a doll that is casted can be you think would help you most?”
a great visual for what to 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-
1 7
tion. 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). Adolescents
11
fear a loss of self-control and autonomy 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
4
for independence. 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
11
reduce the need for preoperative anxiolytic medication.
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
12
under-standing. 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
13
challenging for this group of patients.
A hospitalization or surgical procedure may provoke chal-
lenging behaviors in children with autism spectrum disorder.
These behaviors can include aggression, tantrums, hitting,
13
kicking, biting, and scratching. 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
12
rooms or separation from a caregiver?
AORN Journal j 17
Panella
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”
13
or “place the doctor is going to fix” may be sufficient. 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
13
avoid triggering tantrums or other challenging behaviors. 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
13
alarms are still audible for the nurse. 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 Preoperative Care of Children

9. Ahmed MI, Farrell MA, Parrish K, Karla A. Preoperative anxiety in 13. Johnson NL, Rodriguez D. Children with autism spectrum
children: risk factors and non-pharmacological management. disorder at a pediatric hospital: a systemic review of the
Middle East J Anaesthesiol. 2011;21(2):153-164. literature. Pediatr Nurs. 2013;39(3):131-141.
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 Judy J. Panella, BS, CCLS, is a child life specialist at
intervention using smartphone application for preoperative anxiety in Duke Children’s Hospital and Health Center, Durham, NC.
pediatric patients. Korean J Anesthesiol. 2013;65(6):508-518. Ms Panella has no declared affiliation that could be
perceived as posing a potential conflict of interest in the
12. Scarpinato N, Bradley J, Kurbjun K, Bateman X, Holtzer B, Ely B.
publication of this article.
Caring for the child with an autism spectrum disorder in the
acute care setting. J Spec Pediatr Nurs. 2010;15(3):244-254.

www.aornjournal.org AORN Journal j 19

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

1. A child life specialist is a trained professional who has coping 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
2. Child life specialists often meet children and
medical sup-plies for “show and tell,” such as
adolescents during preoperative testing appointments,
1. medications.
which may involve
2. stethoscopes.
1. explaining anesthesia and surgery in
3. anesthesia masks.
developmentally 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.

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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 c. 1, 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6
this age group may
1. misinterpret words that require abstract thinking. 9. When caring for children with autism spectrum
2. believe they did something wrong to deserve what disorder, the perioperative nurse should use family-
is happening to them. centered care 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
parent. development 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 a. 1 and 2 b. 1 and 3
his or her care, the perioperative nurse should c. 2 and 3 d. 1, 2, and 3
consider 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 j 21

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

this continuing education program met your
learning needs. The evaluation is printed
which 7.
here for your convenience. To receive continuing education
credit, you must complete the online Examination and Learner 8.
Evaluation at http://www.aornjournal.org/content/cme. Rate the
items as described below.
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 question #8B.)

8A. How will you change your practice? (Select all that apply)

OBJECTIVES 1. I will provide education to my team regarding

why change is needed.
To what extent were the following objectives of this
2. I will work with management to
continuing education program achieved?
change/implement 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
2. Discuss the role of the perioperative nurse in need for change.
decreasing preoperative parental and child anxiety. 4. I will implement change and evaluate the effect
Low 1. 2. 3. 4. 5. High of 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
change.
5. To what extent did this article increase your
4. Other: __________________________________
knowledge of the subject matter?
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