Nursing 622: Evidence Based Practice Paper

M.B. is an 11 year old girl who has come to the doctor’s office with her mother complaining of a sore throat, difficulty swallowing, and a fever. M.B.’s mother states that although M.B. has been complaining of difficulty swallowing, she has been trying to keep the child hydrated. This is the fourth time this year, that M.B. has made a visit to the doctor’s office for this complaint, but she has no medical history otherwise. Upon assessment, the nurse finds that M.B. has a temperature of 99.8 degrees Fahrenheit, and her throat appears red and inflamed. M.B.’s primary physician did a throat culture and a rapid strep screening to determine the source of infection and to choose the most beneficial treatment. The rapid strep screening showed that there was in fact a strep infection present. The doctor then scheduled M.B. for a tonsillectomy a week from the day she was seen. M.B. appears to be nervous about the sound of needing surgery, and looks unsure of what the procedure will involve. M.B.’s mother also appears somewhat anxious and worried. When confronted about her worried look, M.B.’s mother explained that when she was younger, she too had her tonsils removed, but she had a very bad experience both before and after the surgery.

The setting for nursing care in this case is within a doctor’s office. The nurse will play the role of both an educator and a form of support for both M.B. and her mother. While in the doctor’s office, the nurse can provide her patient and the patient’s mother with information that will hopefully decrease any anxiety and lessen the fear that may arise with experiencing a surgical procedure.

Some nursing diagnoses that can be developed by M.B.’s diagnosis of tonsilitis are: risk for deficient fluid volume related to decreased intake due to throat pain during swallowing, acute pain related to surgical excision of tonsils, and risk for injury: bleeding related to surgical incision into a highly vascular site (Potts 712). Other nursing diagnoses that can be developed from the case of M.B. based on her need for a tonsillectomy include: mild anxiety related to the need for a surgical procedure, deficient knowledge related to the routines involved in surgery, and fear related to unfamiliarity with surgery.

Based on the location and role of the nurse at the current time, the primary nursing diagnosis would be, deficient knowledge related to the surgical procedure and the routines involved. The secondary nursing diagnosis would be, mild anxiety related to the need for a surgical procedure, and third would be fear related to unfamiliarity with surgery. I would place the nursing diagnosis, risk for deficient fluid volume related to decreased intake due to throat pain during swallowing, as fourth. Although it is an issue, the mother is currently addressing the issue by keeping M.B. hydrated by enforcing her to drink plenty of fluids. The other diagnoses, acute pain related to surgical excision of tonsils, and risk for injury: bleeding related to surgical incision into a highly vascular site, are diagnoses that the PACU nurse would tend to. These nursing diagnoses are ones that cannot be dealt with in the doctor’s office, because they only become an issue once surgery has been completed.

The top three nursing diagnoses were placed as they were to give some logic to the order in which they are addressed, and how the nurse will intervene. Deficient knowledge was placed as the primary nursing diagnosis because if information is given regarding the surgical procedure and all the routines involved, then perhaps the second and third diagnoses of anxiety and fear can be lessened. If a patient has a more clear understanding on the surgery and what to expect, then it is very likely that the patient will experience less anxiety and fear towards the surgical procedure.

The one single nursing issue that will be addressed is, how to tend to a patient’s deficient knowledge regarding a surgical procedure, in order to decrease that patient’s levels of anxiety and fear. It is through this issue, that literature will be reviewed to find the best possible ways to educate adolescents on surgical procedures in hopes of decreasing anxiety and fear. The aim of the nurse is to provide enough appropriate and useful information or sources, to make the child feel more comfortable with the procedure, and at the same time, ensure that parent’s become more at ease with the procedure also.

There are many forms of information that could be found to address a patient’s knowledge deficit in order to lessen anxiety and fear. Some information that may be useful includes: how to provide education to an adolescent, a clear understanding of which developmental stage the child is at, ways in which to lessen a child’s anxiety and fear, what methods of education are most effective in teaching young adolescents, and the best method for communicating with an adolescent. Also, a nurse may want to consider what information should and should not be told to a child of a specific age group. Depending on which developmental stage the child is in, it may be appropriate to leave out certain details of a surgical procedure. The nurse will also want to find an evaluation method to determine the effectiveness of his or her interventions.

In an attempt to find information and articles regarding the issue at hand, I chose to use the MEDLINE data base through EBSCOhost and the Academic Search Premier. I am most familiar with these data bases and find them both to be very resourceful. Some key words that I used to search for my information were: tonsillectomy, child, surgery, comfort, pediatric, preparation, education and anxiety and fear. Through using these terms, I was able to come across many useful articles that addressed the exact issue that I was aiming to treat. In looking through the many articles, I chose the ones in which I was supplied with different forms of providing information to enhance comfort in young children who are about to undergo a surgical procedure. I also chose to review articles in which actual interventions were implemented to decrease pre-operative anxiety, rather than articles that reviewed other research literature. I chose to do this because I found it to be more useful in approaching my issue. In reading such articles, I am more able to conclude which forms and methods would be best in educating my patient while aiming to reduce anxiety levels of both the patient and her mother.

In an article done by Susan O’Conner-Von, titled, Preparation of adolescents for outpatient surgery: Using an internet program, researchers found that with the use of an internet program, compared to a standard hospital preparation program, levels of anxiety for both children and parents were much lower. The study compared the effectiveness of both types of preoperative, educational interventions. In looking at the end results for these interventions, researchers examined a child’s anxiety level, knowledge acquirement, pain intensity, and satisfaction with the provided method of preoperative preparation (O’Conner-Von 2008).

The internet program which offered much more satisfaction, was titled, Tonsils! who needs ‘em? Through this program, children were prepared for an upcoming tonsillectomy. Adolescents were educated on the surgical procedure in a conversational format, where another adolescent was teaching the program. The program was developmentally appropriate and provided children with both procedural and sensory information with descriptions of the normal routines that occur during surgery. Photographs were presented, as well as explanations for medical equipment and the duties of personnel present in the operating room. Once the program ended, children were given the ability to print forms on the information they learned, and in addition, advice for home care after surgery. These forms could be overlooked by the children, and given to their parents. This additional information would provide parents with crucial education on diet, pain assessment and management post-operatively, along with referral phone numbers and other useful resources (O’Conner-Von 2008).

In this study, researchers found that a standard hospital preparation program also had positive outcomes for children and parents. Although outcomes were positive, they were not quite as high as those found with the use of the internet program. A typical hospital preparation program is held once a week, in the evening and focuses on many of the same things as in the internet program. Perhaps it is through this sort of presentation that patients and parents are less satisfied because there is a greater need for more interactive type educational programs rather than lectures (O’Conner-Von 2008).

Information is presented to adolescents and their parents in a developmentally appropriate manner. Both sensory and procedural information is given, along with the routines carried about during the surgery. Photos were shown of the medical equipment used, explanations were given as to how equipment worked and what it did, as was an explanation on the duty of operating room personnel. A tour of the operating room and surgical floor was offered to patient’s and their parents in hopes of making them more familiar with the environment. Other information is also shared with parents about home care after the procedure (O’Conner-Von 2008).

Overall, it was found that any sort of preoperative education program is beneficial to both adolescent patients and their parents. Such pre-operative preparations benefit children by preventing and reducing any negative responses to surgery. It was determined that in addressing an adolescents needs pre-operatively, health care workers need to also pay particular attention to the child’s coping styles, cognitive and developmental level, and past experience with health care. As health care workers, we need to be sensitive towards the needs of an adolescent because, "with their developmental awareness, ability to process information, focus on body image, and desire for privacy and self-control, adolescent patients have unique pre-surgical preparation needs" (O’Conner-Von 2008).

In a study titled, Pre-operative intervention for the reduction of anxiety in pediatric surgery patients, researchers worked with three groups of children to determine which interventions would produce the lowest level of anxiety in children. Within two groups, children were shown either a slide show presentation or given the opportunity to role play. In the third group, children were able to experience both a slide show presentation and participate in role play (Demarest 1984).

Researchers found that the use of role play and child involvement decreased a child’s anxiety much less that children who had been given a presentation. In role play, the children were allowed to dress up in clothing appropriate for the surgery and given the opportunity to play with items such as blood pressure cuffs and stethoscopes, along with riding on a bed to the surgical floor, and wearing a mask. The children who were given a presentation in regards to surgery had no hands on experience. Overall, researchers found that children who were given the presentation and the ability to participate in role playing, had much less anxiety than those who received only the presentation, but showed similar levels of anxiety compared to the group who participated in role play only (Demarest 1984).

In another article called, Paediatric pre-operative teaching: Effects at induction and post-operatively, researchers looked at two groups of children. In one group, children were given pre-operative teaching, while the second group received an interactive teaching book. The pre-operative teaching that was provided to children and their families consisted of tours of the operating room, puppet shows, books and video tapes. While the interactive book showed some of the same things demonstrated in the pre-operative teaching, it also included images of the scrubs worn, a mask that could be removed to expose the doctor’s face, the scents used in the mask for anesthesia induction, and many other interactive methods of teaching children about their upcoming surgery. Parents too were given a book and instructed to take the book home, read it themselves, and with their children in the days prior to surgery (Margolis 1998).

Upon assessment, researchers found that children who were given the interactive teaching book had higher levels of anxiety than those who were provided with pre-operative teaching. Parents of children who received pre-operative teaching said that it had helped both themselves and their children to understand what would be occurring before, during and after the surgery. While children who received pre-operative teaching were less anxious before surgery, they tended to have an elevated stress response to the operation (Margolis 1998).

In the study done my Margolis (1998), validity of the study is at a fair level, while the study done my Demarest (1984) is poor and the study by O’Conner-Von (2008) is good. They were rated in such a way due to the date in which the study was done. With the older studies, it is much more difficult to determine if the information was valid because the interventions and surgical procedure were done so long ago. Within all three of these studies, there were similar benefits and harms. The benefits were that new ways of intervening to decrease anxiety pre-operatively were found along with the ability to lessen a child’s fear of surgery. The only harm found in all of these studies was that some children were not being benefitted by the interventions provided. Instead, these children still experienced high levels of anxiety pre-operatively and did not benefit from the studies at all. Although some of these articles may be fairly old, all three are applicable in this clinical situation. Many methods of decreasing pre-operative anxiety were provided which allows for healthcare workers to see that there are many options aside from either a pamphlet or a discussion.

In conclusion, it appears as though the nurse has many options in providing education to both M.B. and her mother to decrease their levels of anxiety regarding surgery. Through evaluation of each article, it appears as though both verbal and written information are necessary in reducing anxiety, along with interactive methods of delivering education. It appears as though, for the most part, written and verbal information is more effective for parents rather than the children. From this conclusion, it is determined that pamphlets, along with verbal instructions will be given to M.B. and her mother while M.B. will be able to take a tour of the operating room, along with the PACU, and watch a video.

The methods of preparation being given to M.B. are more hands on and allow for her to be more involved with her surgery. It is in preparing M.B. for surgery in these ways that the nurse can hope to lessen her level of anxiety and fear which will in turn also ease her mother’s anxiety. The nurse should take time to give explanations and allow time for M.B. and her mother to ask questions.

The nurse should begin by providing M.B. with the options available. Perhaps what the nurse thinks will be the most beneficial method in educating M.B., is not the best way in which M.B. retains or understands information. Aside from the nurse his or herself, the patient, patient’s parents, doctor and all other health care providers involved in the case, should take part in the attempts to decrease M.B.’s pre-operative anxiety. With interventions being implemented by the entire healthcare team, it is more likely that M.B.’s level of anxiety will be greatly reduced due to the understanding of her case by the whole team.

In evaluating the effectiveness of the interventions provided to M.B., the nurse will begin by assessing M.B. and her mother’s levels of anxiety on the day when teaching first begins. The nurse should continue to monitor M.B. up until the day of her surgery to ensure that she is making use of the resources on hand and to also assess M.B. and her mother’s levels of anxiety. Perhaps the nurse could question M.B. on some of the information provided to ensure that she is in fact becoming more knowledgeable on the subject. On the day of surgery, anxiety levels should be assessed for a final time. The nurse should expect to see a reduction in the level of anxiety and fear for both M.B. and her mother, and an increase in knowledge of the surgery.
As a nurse, it is one’s job to also be an educator. In educating patients, one is able to provide information that can be useful in making the patient aware of his or her own health and health care, while giving the patient an insight as to what exactly is going on around him or her. Especially in working with children, the nurse plays a crucial role in providing sufficient amounts of appropriate, useful information or resources, that will make the child feel more at ease before and during a procedure. At the same time, the nurse wants to ensure that a patient’s parents are also comfortable with the procedure because this in turn will enhance a child’s comfort level. No matter what role or setting the nurse is in, education plays a huge part in being a nurse. Nurses must always be knowledgeable of ways to educate patients and which methods are most useful, to ensure that the best possible interventions are being implemented to treat a diagnosis of knowledge deficit.


Resources
Demarest, D., Hooke, J., Erikson, M. (1984). Preoperative intervention for the reduction of anxiety in pediatric surgery patients. Children’s Health Care, 12, 179-183. Retrieved March 26, 2008, from the Academic Search Premier.
Margolis, J., Ginsberg, B., Dear, G., Ross, A., Goral, J., Bailey, A. (1998). Paediatric preoperative teaching: Effects at induction and postoperatively. Paediatric Anaesthesia, 8, 17-23. Retrieved March 26, 2008, from the Academic Search Premier.
O’Conner-Von, Susan. (2008). Preparation of adolescents for outpatient surgery: Using an internet program. AORN Journal, 87, 374-398. Retrieved March 19, 2008, from the MEDLINE (through EBSCOhost) database.
Potts, N., Mandleco, B. (2007). Pediatric nursing: Caring for children and their families. United States: Thomson Delmar Learning.