Infant perioperative patients

AORN Journal,  Nov, 2007  by Elaine Taylor

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Pediatric patients are not just small adults; each child is a unique individual. Similarities in children do exist, however, based on their developmental levels. Several developmental theories, including those of Sigmund Freud, (1) Jean Piaget, (2) and Erik Erikson, (3) can help provide an excellent foundation on which to develop an approach to treating children at each psychosocial and cognitive level of development. By adjusting the approach to patient care accordingly, health care providers can provide holistic, family-centered care.

From a developmental perspective, infancy ranges from birth until the child's first birthday. Family-centered care is especially important during this period, and this type of care can make the perioperative process less stressful for everyone involved.

The information presented in this column is designed to provide a developmental theory foundation to augment the psychosocial competency outlined in Age-Specific Care: Competency Assessment Module. (4) Infants also have very specific physiological needs based on their size and the maturity of their body systems. These needs also are addressed in the module.

PHYSICAL CHARACTERISTICS OF INFANTS

The average, full-term newborn weighs 7.5 lbs at birth; this weight doubles by the sixth month of life and triples by the time the infant is one year old. (5) This time of rapid growth is accompanied by a larger body surface area and a higher metabolic rate compared to those of older children. Infants also have a delicate balance of fluid and electrolytes. (5) These differences necessitate vigilant attention to and close monitoring of an infant's temperature, vital signs, and hydration status during the perioperative process. Also important and unique to this population is the evaluation and treatment of postoperative pain.

THERMOREGULATION. Thermoregulation in perioperative infant care can be supported by keeping areas of the body that are not involved with a surgical procedure covered both during and after surgery. Health care providers also should use a temperature probe or monitor, employ warming devices to prevent cold stress during anesthesia, and warm the irrigation fluids used intraoperatively to the infant's body temperature.

HYDRATION. Strict monitoring of fluid intake and output is essential, and care should be taken to insure that IV fluids are given based on the weight of the infant. The weight of sponges should be reported to anesthesia personnel to further account for fluid loss.

PAIN. The assessment of pain in infants is difficult because they are nonverbal. Crying may indicate pain, or it may be the result of the infant not having his or her needs met. Behavioral pain scales can help to support more reliable rating of crying, movement, facial expression, agitation, and consolability. (5) For infant perioperative patients, a behavioral pain assessment tool should be identified and an infant's baseline assessment should be documented preoperatively. The pain assessment tool should be used consistently during the postoperative period to evaluate the child's pain status. Pain medications should be provided postoperatively, and dosages should be based on the infant's weight.

DEVELOPMENTAL THEORY AND NURSING IMPLICATIONS

According to Freud, infants receive their main source of pleasure from oral sensations through sucking and receiving oral gratification. (1) Based on this information, the nurse should ensure that an infant who uses a pacifier has his or her pacifier available during the perioperative course and that the pacifier is labeled and kept with the child throughout the perioperative process. If an infant is a thumb or finger sucker, the preferred digit should be noted on the medical record, and every effort should be made to maintain its accessibility to the infant. In addition, those in charge of the infant's care should avoid using the preferred extremity for venous access or to attach a monitoring device. If the infant has a preferred cup or bottle, this item should be labeled carefully and either kept with the infant or put in the postoperative recovery area for use in determining the infant's ability to tolerate fluids after surgery.

Breast-fed infants offer a particular challenge. Breast feeding should be noted on the medical record, and the infant's parents or caregivers should be advised preoperatively to offer the infant a bottle or cup frequently enough to ensure that the infant will accept one before and after surgery when clear liquids are necessary. Accommodations may need to be made for the mother to use a breast pump while the infant is unable to breast feed. She will need access to a private location to pump her breast milk, and she will need to label and store it properly. Health care providers should follow universal precautions in the handling and storing of breast milk as they would for other body fluids.

With the approval of the anesthesia care provider, if the infant is NPO, an additional intervention that could be used to promote oral gratification is to offer the infant a pacifier that has been dipped in a 24% sucrose solution. This intervention will produce a soothing and analgesic response. (6) Kracke et al (7) identified that even though the sucrose solution does not directly influence the patient's opioid receptors, it most likely indirectly stimulates a release of endogenous opioids. (7)