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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

.

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. Name of the Candidate : Mrs. KAVITHA SUDAR KODI.DAnd Address First Year M.Sc Nursing,

Sushrutha College of Nursing, Bangalore-85.

2. Name of the Institution : Sushrutha College of Nursing, Bangalore-85.

3. Course of study : First Year M.Sc Nursing, And subject Pediatric Nursing

4. Date of Admission : 03.06.2009

5. Title of the Topic : A study to assess the knowledge and

Practice of staff nurses regarding

Common side effects and management of

Anesthesia in pediatric post operative

Patients.

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6.0) BRIEF RESUME OF THE INTENDED WORK:-

ANESTHESIA The word “Anesthetic” is derived from the Greek word meaning

the absence or loss of sensation.

Definition:

Anesthesia means of “loss of sensation” medications that cause

anesthesia are called anesthetics. Anesthetics are used for pain relief during

tests or surgical operation so that you do not feel:

Pain

Touch

Pressure and temperature.

How do anesthetics works?

Anesthetics works by blocking the signals that pass along through nerves

to brain.

The nerves are bundles of fibers that use chemical and electrical signals to

pass information around the body. for example if we cut our finger the pain

signal travels from our finger to our brain through the nerves. when the signal

reaches the brain we realize that our finger hurts.

Anesthetics stop the nerve signals reaching the brain allowing procedures

to be carried out with out feeling of anything when the anesthetics wear off, the

signals will work again and feeling will come back.

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Types of anesthesia

There are several different types of anesthesia. most types do not make

people to be unconscious, but they stop feeling pain in a particular area of

their body.

Different types of anesthesia described bellow.

Local anesthetic

Used for minor procedures and tests to numb. The nerves in

the area where the procedure is taking place during the procedure they stay

conscious but do not feel any pain.

Regional anesthetic

Used for large or deeper operations where the nerves are

harder to reach .local anesthetic is injected near the nerves in order to numb a

larger area but they remain conscious.

Epidural anesthetic

A regional anesthetic to numb the lower half of body, which

is often used for child birth.

Spinal anesthesia

A regional anesthetic that is used to numb spinal nerves so

that surgery can be carried out in this area.

General anesthesia

Used for more extensive operations when need to be

unconscious. the anesthetic stop the brain recognizing any signals from the

nerves so that they can not feel any thing.

Sedation

For minor painful or unpleasant procedures sedation makes

feel sleepy and relaxes both physical and mentally.

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Different type of anesthesia can be used at the same time for example:

A regional anesthetic can be used with the general anesthetic to relieve

pain after an operation or

Sedation may be used in a regional anesthetic to make them relaxed

during the operation as well as pain free.

Anesthesia may be given to you in the form of:

Ointment, spray or drops that are rubbed in to the skin.

An injection in to a vain or

A gas that you breathe in

COMMON SIDE EFFECTS : Feeling sick or vomiting about one in three people may feel sick after an

operation.

Dizziness and feeling faint

Feeling cold and shivering for up to half An hour this possible after a

general anesthetic or during or after a regional anesthetics

Head ache

Itchiness

Bruising and soreness

Complications and risk:

There are number of more serious complications that

are associated with anesthesia but fortunately there are very rare (occurring in

less than one case for every 10,000 anesthetic given.

Complications include:

Permanent nerve damage (causing paralysis or numbness)

A serious allergic reaction to the anesthetic (anaphylaxis) and

Death - which is extremely for every 100,000 GA given.

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LOCAL ANAESTHESIA:

Local anesthetic is a type of pain killing medication that is used

during some surgical procedure to numb the area of the body that is receiving

treatment.

Local anesthetic causes a complete loss of feeling to a specific

area of or body with our making us lose of consciousness. it works by blocking

the nerves from the affected path of the body, so that pain signal can not reach

our brain therefore we’ll not be able to feel any pain during the procedure.

Local anesthetics is after used during

The removal, filling or teeth.

Minor skin surgery, such as removal of moles, warts and verrucas.

Some type of eye surgery such as the removal of cataracts (cloudy areas in the

lens of the eye).

Some type of biopsies such as a needle biopsy where a tissue sample is

removed for examination under a microscope

Local anesthetics also some time used during more major

surgical procedures, such as certain type of brain surgery. For example it may

be used when a brain tumor is located in the area of brain that controls speech

in such cases ,as the tumor is being removed , you will need to remain

conscious in order to respond to the surgeon’s instructions. This helps hem to

ensure that your speech in harmed as little as possible during the procedure.

Some over- the – counter creams and ointments contains local

anesthetic for example gels for mouth ulcers sometimes contains small amounts

of benzocaine which numbs the area around the ulcers.

SPINAL ANESTHESIA:

Indications

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a). Premature infants less than 60 weeks post conceptional age and

infants with a history of apnea and Bradycardia, bronco pulmonary

dysplasia or need for long term ventilators support are at increased

risk for apnea and cardio vascular instability after GA. Spinal

anesthesia may decrease the likelihood of these post operative

anesthetic complications. These infants still require a minimum of 24

hours cardio respiratory monitoring post operatively regardless of the

anesthetic technique. Sedation during spinal anesthesia may regret all

these potential benefits

b). Children at risk for malignant hyperthermia.

c). Children with chronic airways disease such as reactive airway

disease or cystic fibrosis.

d). co-operative older children and adolescents with full stomachs

undergoing peripheral emergency surgery, example fractured ankle.

EPIDURAL ANESTHESIA An epidural is an injection that numbs the lower half of the body

includes abdomen (stomach),pelvic area and legs.

An epidural can either:

Stop feeling any pain (analgesia) or

Stop feeling any sensation at all (anesthetic)

Epidural anesthesia is a firm of medication that is carefully injected

by anesthetist in to “epidural space” in the spine. The medication blocks the

nerve roots in the spine that leads to the lower part of the body will be numbs.

Risk and side effects

Epidural anesthesia is a safe and reliable method of pain relief but

there can be some side effects.7

a). Low blood pressure:

Low blood pressure is treated by medication or by giving fluids

through a drip, blood pressure will be monitoring regularly during the

procedure.

b). Bach ache:

After having an epidural some people experience back pain that last

for several weeks or months in the area where the injection was given. This

sometimes happens because the back muscles relax after the epidural anesthetic

has been inserted.

c). Inability to move legs :

Following an epidural, the person will be unable to move their legs.

Which will only last until the anesthetic wears off.

d). Itchy skin :

Some of the medication that is used for epidurals can cause

itchiness.

e). Uneven pain relief:

Some times the epidural anesthetic does not spread evenly around

your spinal cord, they will have less feeling in one side of their body than the

other. a top up dose can usually fix this.

f). Vomiting :

Vomiting some times happens after an epidural anesthesia, but it is

less chance than the general anesthesia.

g). Loss of bladder control:

After an epidural unable to tell need to pass urine or not due to loss

of sensation in the lower limbs.

Rare side effect:

1). Severe head ache:

Occasionally during epidural anesthesia, there is a small leak of

fluid from the spinal cord that causes a severe head ache. This can last for a 8

week or (some times longer)the person as to remain lying down until the

puncture has healed.

2). Infection:

Following an epidural as infection can some times occur at the site

of the injection. However this is unlikely because the needle is sterile and the

skin is cleaned thoroughly before the procedure is carried out.

COMPLICATIONS: Serious complications of epidural anesthesia are rare, but

complications include,

Fits and breathing difficulties

Patches of numbness that can last for up to three months

Paralysis (complete loss of sensation and movement).

NURSING INTERVENTION:

IMMEDIATE RECOVERY

a). Airway:

Maintain patency keep head tilted up and back may position on side with the

face down and neck slightly extended.

Note presence of hoarseness, cramp, strider, wheezes or decreased breath

sounds, or absence of gag / swallowing reflex.

Suction until awake and alert.

Provide oxygen if necessary.

b). Breathing:

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Evaluate depth, rate, sounds, rhythm and chest movement

Assess color of mucous membrane

Place hand above nose to detect respirations of shallow

Initiate coughing and deep breathing as soon as able to respond

Chart time oxygen is discontinued

c). Consciousness:

Able to extubate airway

Responds to commands

Verbalizes responses

Reacts to stimuli

d). Circulation:

Monitor temp, pulse, respiration, BP, every 15 minutes take axiliary or

rectal temperature, if necessary

Assess rate, rhythm, and quality of pulse

Evaluate color and warmth of skin and nail beds

Check peripheral pulse if indicated

Monitor IVS solution, rate and site

e). System review:

Assess neurological functions

Monitor drains, tubes, color and amount of out put

Evaluate pain response may need to give analgesics

Observe for allergic reactions

Assess urinary out put if Foley’s catheter is in place.

NURSING ACTIONS AFTER POST ANESTHESIA PATIENTS:

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a). Continuous assessment of respiratory and circulatory assessment

Monitor and record vital signs frequently assessment order may vary, but usual

frequency includes taking vital signs every 15 minutes the first hour, every 30

minutes the next two hours, every hour for 4 hours and finally every 4 hours.

b). Ensure optimal respiratory function:

1. Coughing and deep breathing - To promote lungs expansion

2. Initiative spirometery encourage the patient to continue to take deep breaths

to maximize voluntary lung expansion these helps expand collapsed lung

and prevent post operative pneumonia and atelectsis coughing exercise help

to guard the suture

c).Frequent position change.

1. Turning exercises:

These help to prevent venous stasis, thrombophlebitis, decubitus

ulcer formation and respiratory complication

2.Extremity exercises:

It helps to prevent circulatory problems such as thrombophlebitis

by facilitating venous return to the heart

d). Early ambulation:

When appropriate helps to prevent post operative complications

e). Maintain adequate circulation:

1. Maintenance of intravenous therapy

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2. Early ambulation

3. Application of antiembolic stockings if ordered by physician

4. Leg and range of motion exercises if not contra indicated

f). Relief of pain and postoperative discomforts:

The degree and severity of post operative pain depend on the physiologic

and psychological make up of the Childs tolerance level, the incision site, the

nature of the operation, the extent of surgical trauma and the type of anesthetic

agents administered

Narcotic analgesics are often prescribed for pain and immediate post

operative restlessness. how ever pain in the first 24 hours after an operation

requires relief by narcotics and these medications should not be with held when

the patient is in pain.

Patient controlled analgesia (PCA)permits the self administration of older

children of pain medication via the intravenous or epidural route with in time and

dosage limits, self administration promotes patients participation in care and

eliminates delayed pain medications for thoracic and major abdominal surgery

certain narcotics may be administered by epidural infusion via an epidural

catheter inserted in the operating room.

g). Relief of restlessness12

Postoperative restlessness may be a symptom that is significant

restlessness may be a result of oxygen deficit or hemorrhage.

a). Administrated analgesics and changing the patients position frequently

b). Assess other possible causes of discomfort such as tight, drainage soaked

bandages. Reinforcing or changing the dressing complete, makes the patient

more comfortable.

c). Urinary out put is noted and the bladder is palpated for distention. Urinary

retention can cause restlessness various techniques are used to encourage voiding

before catheterization is performed.

h). Relief of nausea and vomiting:

1. Postoperative nausea, vomiting is uncommon under the age of two years.

Predictors of risk include high-risk procedures (adeno tonsillectomy, squint

surgery), travel sickness and previous PONV morphine increases the risk of

PONV by 30%

2. Combination of antiemetics and the use of 5-HT3 antagonists with

Dexamethazone 0.1 mg/kg may be more efficacious than simple

monotherapy.

3. Children considered high risk should receive 0.15 mg/kg ondensetron at

induction.

4. At the slightest indication of nausea, the patient is turned completely on

the side to promote mouth drainage.

5. To prevent aspiration of vomitus, which can cause asphyxiation and death.

i). Relief of abdominal distention:

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Postoperative distention of the abdomen results from the accumulation

of gas in the intestinal tract. Manipulation of the abdominal organs during the

operation may produce a loss of normal peristalsis for 24-48 hours

Ambulate

Turn patient frequently

Nasogastric tube may remain in place until full peristaltic activity

(passage of flatus) has resumed.

Assist with diet progression

Encourage fluid intake

Monitor intake.

6.1). NEED FOR THE STUDY

This research project is to expand the body of knowledge related to

pediatric post-operative. It aims to determine the present level of knowledge

and attitudes regarding pediatric post-operative assessment and management

of registered nurses, side effects of anesthesia for pediatric patients in small

general regional pediatric wards. It is only through the accurate assessment of

nurses’ knowledge, attitudes and needs, as perceived by the nurse, that

appropriate strategies can be developed to address the educational needs of

nurses, related to pediatric nursing management practices. This research also

aims to explore how nurses working in these areas gained their pediatric post-

operative management knowledge, and skills, and if they felt they were able

to implement their knowledge within their clinical setting. Information gained

by conducting this research will inform the body of knowledge related to

pediatric nursing care.

So, as an investigator i undertook a study to assess the of knowledge of

staff nurses regarding side effects of anesthesia after postoperative patients.

6.2). LITERATURE REVIEW:

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CLEVELAND – A study aimed at giving health care providers a better

understanding of the multidimensional nature and effects of school-age

children's post-operative pain concludes that using imagery with analgesics

reduced tonsillectomy and adenoidectomy pain and anxiety following surgery.

Findings of the study, "Imagery reduces children's post-operative pain,"

authored by Myra Martz Huth, a 2002 graduate of Case Western Reserve

University's Frances Payne Bolton School of Nursing and co-authored by

Marion Good, professor of nursing at Case, was published in the September

2004 issue of Pain, the influential publication of the International Association

for the Study of Pain.

Seventy-three children between the ages of 7-12 participated in the study during

a 53-week period, from June 1999 to July 2000. All children in the study were

scheduled for an elective tonsillectomy or adenoidectomy and were expected to

be discharged the same day of surgery. The children were randomly assigned to

one of two groups – a "treatment group" made up of those who received

imagery and analgesic treatment, and an "attention-control group," or those

children who received only pain medication and no imagery intervention.

The intervention was "To Tame the Hurting Thing," a professionally produced

videotape, audiotape and booklets for school-age children, developed by one of

the co-authors, Marion E. Broome, dean and professor of nursing at the Indiana

University School of Nursing in Indianapolis. They included deep breathing,

relaxation and imagery techniques. The videotape was viewed before surgery

and the audiotape was used after surgery and in the home.

"This was the first study to demonstrate a reduction in school-age children's

post-operative pain and anxiety," said Huth, an assistant vice president at the

Center for Professional Excellence at Cincinnati Children's Hospital Medical

Center. Children in the treatment group had significantly less pain and anxiety

after surgery than the attention-control group that received only attention and

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medication. Imagery did not decrease the amount of pain medication used,

either at the hospital or at home, she added. Children in this sample reported

moderate pain the day of and mild pain on the day after surgery.

"We found that health care professionals and parents need to give adequate

amounts of pain medication in conjunction with non-pharmacology

interventions, like imagery," Huth said.

Huth also said it is hoped that this intervention study will enable health care

providers to better understand the nature and effects of children's post-operative

pain and that it will assist them in providing relief for kids.

"In future studies, researchers need to explore imagery tape interventions in

children having different surgical procedures as well as children with chronic

pain," she said.

Good says that distracting the child plays a large role in reducing their pain.

"The purpose of this study was to examine the effects of imagery – in

combination with routine pain medication – in reducing pain and anxiety

surgery," Good said.

Tonsillectomy with or without an adenoidectomy is the most common

ambulatory surgery performed on children under 15 years of age in the United

States. Analgesics are the standard of care in post-operative pain management

with children; however, children and parents have consistently reported

moderate, and in some cases, severe post-operative pain after a tonsillectomy

even after receiving pain medication.

The study was funded by a National Research Service Award received by the

researchers from the National Institute of Nursing Research of the National

Institutes of Health.

Post-operative management in children after anesthesia

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Nurses need to understand pain, be able to assess and manage pain, to improve

the experiences and outcomes of the children in their care. Literature reviewed

for this thesis suggests that for too long, too many children have suffered

unnecessary pain post-operatively, because of the poor understanding of pain

and its management, by medical and nursing professionals (Bennett, 2001;

Beyer et al., 1983; Burokas, 1985; Collins, 1999; Coyne et al., 1999; Craig et

al., 1996; Eland, 1990; Elander et al., 1993; Ely, 2001; Hammers et al., 1998;

Jacob & Puntillo, 1999b; Lavis et al., 1992; Mather & Mackie, 1983; Price,

1990; Simons & Robertson, 2002). Unrelieved or poorly managed post-

operative pain delays healing, alters immune function and increases the levels

of stress and anxiety of the child and their family, resulting in increased length

of stay, higher readmission rates, and more frequent outpatient visits. It can also

have profound long lasting consequences, and may increase emotional and

behavioral responses during future painful events.

Inconsistent approaches to the management of post-operative pain in

hospitalized children has been attributed to a lack of knowledge, specifically

that of the concept of pain, the ability to assess pain accurately, and the use of

pharmacological and non-pharmacological interventions (Carr & Mann, 2000;

Coyne et al., 1999). Many studies into the management of pediatric post-

operative pain have occurred (Bennett, 2001; Burokas, 1985; Carr & Mann,

2000; Eland & Anderson, 1977; Elander et al., 1993; Ely, 2001; Frank et al.,

2000; Hammers et al., 1998; Jacob & Puntillo, 1999b; Mather & Mackie, 1983;

Salantera, 1999; Simons & Robertson, 2002). Most of these are retrospective

studies, using questionnaires or individual and group interviews, and all support

the belief that children receive insufficient pain relieving medication when

compared with adults in similar circumstances. Furthermore, the findings in the

more recent studies reflect similar issues to those that were reported more than

two decades ago (Beyer et al., 1983; Burokas, 1985; Hester & Barcus, 1986;

Schechter, 1989).

Key issues relating to the post-operative management of pain in children that

repeatedly appear in literature are those of the attitudes and misbeliefs of the 17

doctors, nurses, children and their families; time and workload of nurses; and

the lack of relevant knowledge and education of nurses, medical staff, children

and

their families. This lack of knowledge and education appears to be intrinsic in

the inadequate assessment and management of post-operative paediatric pain.

Attitudes and misbeliefs related to children and pain

Attitudes and misbeliefs held by nurses have been identified by many

researchers as contributing to how well nurses are able to achieve effective pain

assessment and pain management (Adams & Field, 2001; Brown et al., 1999;

Burokas, 1985; Carr & Mann, 2000; Chapman, Ganendran, Scott, & Basford,

1987; Clarke et al., 1996; Eland & Anderson, 1977; Heath, 1998; Lavis et al.,

1992; Lebovits et al., 1997; Manworren, 2000, 2001; McInerney, Goodenough,

Jastrzab, & Kerr, 2003; Miller, 1994; Salantera, 1999; Schechter, 1989; Sofaer,

1992; Wessman & McDonald, 1999). Furthermore, in a survey of pediatric

critical care nurses, attitude was identified as a key influence in the

management of pain (Pederson & Bjerke, 1999). Poor attitudes about pain and

pain management are often based on misbeliefs.

Misbeliefs related to narcotic use and administration

Many of the poor attitudes and misbeliefs identified, relate particularly to the

use of narcotics and the fear of subsequent respiratory depression or addiction

(Bishop-Kurylo, 2002; Burokas, 1985; Eland, 1990; Miller, 1994). Because of

potential side effects, research has revealed that many nurses believe children

should not be given opioid analgesia for pain. A consequence of this belief is a

reluctance to administer narcotic analgesia to children, resulting in poorly

managed pain experiences for children. Research has also identified that many

nurses and other health professionals feel that children are at greater risk of

complications and addiction. However, all drugs have side effects. Respiratory

depression, the most likely adverse effect of a narcotic, and the side effect that

causes the most concern, is quickly reversible should it occur. Studies show that

children and infants, when given appropriate dosages of narcotics, have no

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greater risk of respiratory depression than adults (Atkinson, 1996; Carter, 1998;

Eland, 1990). Side effects of other commonly given drugs, for example

penicillin, can be potentially more lethal. It is important for nurses to remember

that 15 out of every 1000 people who take

penicillin will develop true anaphylaxis, yet it is prescribe and administered

intravenously, more freely than narcotic analgesia (Atkinson, 1996).

Lack of knowledge and education

As effective pain management is viewed as a patient’s right, nurses need a

background of appropriate education and sufficient resources to administer

effective pain management. (Leek et al., 1995, p. 1)

According to the literature reviewed, attitudes and misbeliefs about post-

operative pain and its management often occur as a result of lack of knowledge.

Several authors hypothesise that schools of nursing have not adequately

educated nurses to enable them to effectively assess, critically analyse and

manage pain (Chui, Trinca, Lim, & Tuazon, 2003; Manias & Bullock, 2002;

Zalon, 1995). Nurses’ knowledge relating to pain management issues, and their

ability to incorporate pain management theory into practice, is dependent on the

education they receive, in both the academic and clinical setting (Carr & Mann,

2000; Zalon, 1995).

Lavis et al. (1992) conducted a questionnaire survey of adult patients, doctors

and nurses, in an attempt to identify beliefs and attitudes to post-operative pain.

Their study conclusion was that education was clearly needed for all groups

involved in pain management. Ideally this should begin for doctors and nurses

at the undergraduate level, while patients’ education should begin at first

presentation to a health professional. Whilst this was a survey of nurses in an

adult area, other literature reviewed would support the assumption that these

findings would be the same in the pediatric setting (Craig et al., 1996; Hammers

et al., 1994; Jacob & Puntillo, 1999b; Manworren, 2000).

Following their review of current research and professional literature Craig et

al. (1996) proposed that all health care professionals required further education, 19

not only in ways of treating pain, but also in the understanding of the nature of

pain and the social context of pain. Manworren (2000) in a survey of pediatric

nurses’ noted that nurses with masters’ degrees and those that worked in

specialised areas like intensive care units and haematology/oncology wards

consistently ranked higher, than other nursing units, in areas of pain

assessment, drug interactions, and effectiveness of dosing. This would appear to

support the theory that post graduate education and increased knowledge

improves pediatric pain management

with regard to pain assessment and pain management. The current literature

would suggest that many nurses when compared to physicians, were more

knowledgeable on the subject of pain assessment and management of pain, but

they understand less about other aspects of pain, for example pharmacology

(Chui et al., 2003; Coyne et al., 1999; Furstenberg et al., 1998; Manias &

Bullock, 2002). In the New Zealand context there is no undergraduate

education specific to child health nurses. The lack of such specific educational

programs, possibly impacts on the extent of pediatric pain pharmacology,

assessment and management content that there is within the current nursing

curriculum. This also impacts on how much of this knowledge is held by

registered nurses undertaking clinical practice in the pediatric setting for the

first time.

When beginning to practice for the first time nurses are guided by competencies

as set out by their governing body, and the policies and protocols of the

organisation and area that they work in. However, nursing practice should be

viewed as a continuum, ranging from basic nursing practice to advanced

nursing practice. The

Most international surveys into nurses’ knowledge and attitude towards post-

operative pain are undertaken in large teaching or university hospitals (Clarke

et al., 1996; Hamilton & Edgar, 1992) or in multiple settings (Van Niekerk &

Martin, 2001). While many of these surveys do not identify if any of their

respondents work in a paediatric setting (Clarke et al., 1996; Hamilton & Edgar,

1992; Heath, 1998), those that do, report only small numbers 6.9% (Brown et

20

al., 1999) and 5.9% (Van Niekerk & Martin, 2001). Questionnaires are reported

to be distributed either by identified people (Hamilton & Edgar, 1992), or

posted out to the identified sample (Van Niekerk & Martin, 2001). Return rates

and overall size of the surveys ranged from 26% (n=260) (Brown et al., 1999)

to 54.7% (n=318) (Hamilton & Edgar, 1992). However one survey of nurses’

knowledge of pain management undertaken closer to New Zealand was the

survey of Tasmanian nurses by Van Niekek and Martin (2000). By adapting the

Pain Management Nurses’ Knowledge and Attitude survey instrument first

developed by Ferrell and Leek in 1987 and revised in 1993, Van Niekek and

Martin surveyed 2710 Tasmanian nurses, receiving a 38% (n=1015) return rate.

Studies on dexamethasone’s antiemetic and analgesic

Potential in children undergoing tonsillectomy have produced conflicting

results. The aim of this study was to evaluate the effects of a single dose of

dexamethasone on the incidence and severity of postoperative vomiting and

pain in children undergoing electrocautery tonsillectomy under standardized

general anesthesia.

Methods  In a double-blinded study 120 patients were randomly allocated to

receive either dexamethasone 0.5 mg·kg−1 (maximum dose 8 mg)iv or an

equivalent volume of saline preoperatively. The incidence of early and late

vomiting, need for rescue antiemetics, time to first oral intake, time to first

demand of analgesia and analgesic consumption were compared in both groups.

Pain scores used included Children’s Hospital Eastern Ontario Pain Scale,

“faces”, and a 0–10 visual analogue pain scale.

Results  Compared with placebo, dexamethasone significantly decreased the

incidence of early and late vomiting (P < 0.05,P < 0.001 respectively). Fewer

patients in the dexamethasone group needed antiemetic rescue (P < 0.01). The

time to first oral intake was shorter, and the time to first dose of analgesic was

longer in the dexamethasone group (P < 0.01). Pain scores 30 min after

extubation were lower (P < 0.05) in the dexamethasone group. At 12 and 24

21

hr postoperative swallowing was still significantly less painful in the

dexamethasone group than in the control group (P < 0.01).

Conclusion  Preoperative dexamethasone 0.5 mg·kg−1 iv reduced both

postoperative vomiting and pain in children after electrocautery tonsillectomy.

La dexaméthasone réduit les vomissements et la douleur postopératoires après

une amygdalectomie pédiatrique Résumé

Purpose     To evaluate the analgesic efficacy and duration of

varying doses of caudal neostigmine with plain bupivacaine and

its side effects in children undergoing genito-urinary surgery.

Methods  In a randomized double-blind prospective study 80 boys aged

two to eight years scheduled for surgical repair of hypospadias were allocated

randomly to one of four groups (n = 20 each) and received either only caudal

0.25% plain bupivacaine 0.5 mL · kg−1 (Group 1) or 0.25% plain bupivacaine

0.5 mL · kg−1 with neostigmine (Groups II-IV) in doses of 2, 3 and 4βg ·

kg−1 respectively. Postoperative pain was assessed for 24 hr using an

objective pain score. Blood pressure, heart rate, oxygen saturation, total

amount of analgesic consumed and adverse effects were also recorded.

Results  The duration of postoperative analgesia in Group I (5.1 ± 2.3 hr) was

significantly shorter than in the other three groups (II–16.6 ± 4.9 hr; III —

17.2 ± 5.5 hr; IV-17.0 ± 5.8 hr; P < 0.05). Total analgesic (paracetamol)

consumption was significantly more in Group 1 (697.6 ± 240.7 mg) than in

the groups receiving caudal neostigmine (II — 248.0 ± 178.4; III — 270.2 ±

180.8 and IV − 230.6 ± 166.9 mg; P < 0.05). Groups II, III and IV were

comparable with regards to duration of postoperative analgesia and total

analgesic consumption (P > 0.05). Incidence of nausea and vomiting were

comparable in all four groups. No significant alteration in vital signs or any

other adverse effects were observed.

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Conclusions  Caudal neostigmine (2, 3 and 4μg · kg−1) with bupivacaine

produces a dose-independent analgesic effect (≈ 16–17 hr) in children as

compared to those receiving caudal bupivacaine alone (approximately five

hours) and a reduction in postoperative rescue analgesic consumption without

increasing the incidence of adverse effects.

The purpose of this evidence-based clinical update was to identify

the best evidence to determine if behavioural outcomes are

improved in children after oral midazolam premedication.

Methods  A literature search was conducted using both PubMed and OVID

programs, utilizing the terms ‘midazolam’, and either ‘premedication’ or

‘preoperative treatment’. Search limits that were employed included

randomized controlled trials (RCTs), English language, human studies, children

aged 0–18 yr, and publication dates 1990 — present (January 2006). A review

of the 171 abstracts obtained was undertaken and, of these, 30 papers were

identified that concerned oral midazolam in children prior to general anesthesia,

and that involved a RCT with a placebo or control arm. These studies were

assigned levels of evidence, and grades of recommendation were made

according to Centre for Evidence-Based Medicine criteria.

Results  Oral midazolam premedication in children was found to reduce the

anxiety associated with separation from parents/ guardians, and with induction

of anesthesia. Recovery times are not significantly delayed. There is no

consistent evidence to suggest a reduction in the phenomenon of emergence

agitation. Evidence suggesting an improvement in behavioural outcomes at

home is also inconsistent.

Conclusion  Premedication with midazolam 0.5 mg·kg−1 po administered 20–

30 min preoperatively, is effective in reducing both separation and induction

anxiety in children (grade A recommendation), with minimal effect on recovery

times. However improved postoperative behavioural outcomes in the

postanesthesia care unit, or at home cannot be predicted on a consistent basis.

23

Purpose     To compare the epidural administration of fentanyl (1

μg·mL−1) combined with lidocaine 0.4% to preservativefree

morphine for postoperative analgesia and side effects in children

undergoing major orthopedic surgery.

Methods  In a prospective, double-blind study, 30 children, ASA I–II, 2–16-yr-

old, were randomly allocated to receive immediately after surgery either

epidural F-L (epidural infusion at a rate of 0.1–0.35 mL·kg−1·hr−1 of 1

μg·mL−1 of fentanyl and lidocaine 0.4%) or epidural M (bolus of 20μg·kg−1 of

morphine in 0.5 mL·kg−1 saline every eight hours). Both groups received 40

mg·kg−1 ofiv metamizol (dipyrone) every six hours. In the F-L Group, blood

samples were taken on the second and third postoperative day to determine total

lidocaine concentrations. Adequacy of analgesia using adapted pediatric pain

scales (0–10 score) and side-effects were assessed every eight hours

postoperatively.

Results  Resting pain scores were under 4, 95% of the time in the F-L Group

and 87% of the time in the M Group (Chi square=4.674, P < 0.05). The

frequency of complications was very similar in both groups. The F-L Group

total plasma lidocaine concentrations were directly related to the dose received,

and below the toxic range in all patients.

Conclusions  Postoperative epidural fentanyl with lidocaine infusion provides

slightly better analgesia than conventional bolus administration of epidural

morphine. Side-effects or risk of systemic toxicity were not augmented by the

addition of lidocaine to epidural opioids

Patient-controlled regional analgesia (PCRA):

Purpose  To report a preliminary analysis of prospectively recorded data in 27

children in whom patient-controlled regional analgesia (PCRA) was used for

postoperative pain control following lower limb surgery.

24

Methods  Under general anesthesia, perineural catheters (popliteal and fascia

iliaca compartment block) were inserted and infused with ropivacaine 0.2%

(0.02 mL·kg−1hr−1). Additional demand doses were left to the child’s

discretion (0.1 mL·kg−1 and a 30-min lockout interval).

Results  The average total dose of ropivacaine administered was 4.9 ± 2

mg·kg−1 over 48 hr. Visual analogue scale and Children’s Hospital of Eastern

Ontario Pain Scale scores were always inferior to 5/10 and 6/13, respectively.

Motor block was observed in two children and two children needed rescue

analgesia.

Conclusions  Our preliminary observations indicate that PCRA in children

provides satisfactory postoperative pain relief following lower limb surgery.

Purpose     To evaluate intranasally administered fentanyl for

postoperative analgesia in pediatric patients.

Methods  Thirty-two children aged four to eight years, ASA physical status I

and II were included in this prospective randomized controlled study.

In the postoperative care unit, patients were allocated to receive fentanyl, using

a double-blind study design, either intranasally (Group I) or intravenously

(Group II) in small titrated doses until they became pain free or side effects

appeared which prohibited continuation of the drug.

Results  Satisfactory analgesia was achieved in both groups, though the

required drug dosage was higher in the intranasal group ( 1.43 ± 0.39 μ· kg−1).

Onset of analgesia tended to be slower via the intranasal route compared to

theiv route ( 13 ± 4.5vs 8.3 ± 3.08 min;P = not significant). Side effects

observed in this series were within an acceptable range and similar for both

modalities.

Conclusion  The intranasal route provides a good alternative for administration

of fentanyl in pediatric surgical patients.

25

Purpose     To investigate if 50% nitrous oxide reduces the pain

during injection of propofol mixed with lidocaine in children .

Methods  Healthy children undergoingiv induction of general anesthesia for

elective surgery were recruited into this prospective, randomized, double-blind

study. None of the patients received any premedication except for eutectic

mixture of local anesthetics cream. Before induction of anesthesia with

propofol 1% mixed with lidocaine 0.05% (propofol dose 3 mg·kg−1), the

treatment group received 50% N2O in O2 and the control group received 100%

oxygen. Pain due to propofol administration was rated with a four-point

behavioural scale: none, mild, moderate or severe.

Results  There were 28 subjects in the control group and 26 subjects in the

treatment group. Demographic data were similar in both groups. The incidence

of pain at induction was 4% after N2O and 36% in the control group,P < 0.01.

No patients had severe pain. Most patients had mild pain. Three of the ten

patients with pain in the control group had moderate pain. The number needed

to treat was 3:1.

Conclusion  Nitrous oxide reduces pain during induction with propofol mixed

with lidocaine in healthy children.

Purpose     Evaluate the efficacy of advanced life support

interventions using the pediatric Utstein guidelines.

Methods  Charts from all patients for whom a cardio respiratory arrest code was

called during a six-year period in a university affiliated center were reviewed.

Data were recorded according to the pediatric Utstein guidelines and aP < 0.05

was considered significant.

Results  Of the 234 calls, 203 were retained for analysis. The overall survival

rate at one year was 26.0% of which 10% had deterioration of their neurologic

status compared to the pre-cardiorespiratory arrest evaluation. Time to achieve

sustained return of spontaneous circulation (ROSC;P < 0.0001) and sustained

measurable blood pressure (P = 0.002), to perform endotracheal intubation (P =

26

0.04) and the dose of sodium bicarbonate (P < 0.0001) were indicators of long-

term survival. Two patients were alive at one year with unchanged neurologic

status despite a time to achieve sustained ROSC longer than 30 min (38 and 44

min). The mean first epinephrine dose of patients for whom ROSC was

achieved but unsustained was higher than those for whom ROSC was achieved

and sustained (0.038 ± 0.069 mg·kg−1 vs 0.01 1 ± 0.006 mg·kg−1; P = 0.004).

Survival rate and mean first epinephrine dose of patients who received their

first epinephrine dose endotracheally(13.3%; 0.01 1 ± 0.004 mg·kg−1) were

comparable to those of patients who received their first epinephrine dose

intravenously (7%; 0.015 ± 0.027 mg·kg−1).

Conclusions  For intravenously administered epinephrine, a dose of 0.01

mg·kg−1 seems appropriate as the first dose. The endotracheal route is a

valuable alternative for epinephrine administration and, for infants, the dose

does not need to be increased. A minimal resuscitation duration time of 30 min

can be misleading if ROSC is used as the indicator.

NEW RESEARCH: CHILDREN ARE NOT BEING TREATED FOR

POST-OPERATIVE PAIN:

British Pharmaceutical Conference, Manchester. Children recovering from day

case surgery are not being treated for post-operative pain because their parents

do not see it as a priority, according to (the interim results of) new research by

the School of Pharmacy in Manchester, launched today at the British

Pharmaceutical Conference.More than 50% of children’s surgery is now

performed on a day-case basis and postoperative pain is a relatively common

problem1. This study indicated that 54% of parents reported that their children

experienced pain at home after day-case surgery.

Parents are responsible for post-operative care of the child after discharge from

daycase surgery but the evidence suggests that parents do not effectively

manage postoperative pain. Children’s post-operative pain is a relatively low

priority following surgery to parents.

27

The new research found that parent’s prioritised their child’s needs as follows:

(in order of importance from most to least)

• quality of recovery from anaesthesia

• parental presence during anaesthesia induction

• parental involvement in medical decision making

• staff attitude

• post-operative pain and

• cost to the parent.

Pharmacist, Wendy Gidman, said that parents often don’t give their children

enough analgesics following day-case surgery and, until now, the reason for

this has not been understood.

“Previous research shows that parents do not effectively treat the child’s pain

following surgery - even when they are aware that their child is in pain3,” she

explained. “We know that this has adverse effects on the health and well being

of the child such as poor fluid intake, sleep disturbance and behavioural

changes4.”

Ms Gidman said that the new research has given a clear indication that parents

have different priorities for their child following surgery, other than treating the

pain. “It is vital that health professionals help parents to understand the

importance of pain management in the recovery process of their child following

surgery,” she concluded.

Preliminary evidence suggests that the use of the Parents’ Post-Operative

Pain Measure (PPPM) promotes 1 to 6- year-old childre n ’s non-pharma

cologicalpain alleviation at home aftersurgery. Lehikoinen (2007) found that

the parents who were given the PPPM used several non-pharmacological pain

alleviation methods more thanp a rents in the control group. However, no diffe

rences in the use of analgesics between the intervention group and the control

group of parents were found. Lehikoinen (2007) studied children ages 1 to 6

years. According to Bonham (1996), children’s responses to pain differ during

their developmental stages. Children ages 1 to 3 years express their pain mainly

by crying, screaming, identifying pain location, and talking aggressively, while 28

older children can describe the intensity of pain. There f o re, it was necessary

to explore the influence of the PPPM with children ages 1 to 2 years who

express their pain in a similar way. The purpose of this study was to evaluate

the influence of parental use of PPPM on the use of pain medication at home

for 1 to 2-year-old children. The re s e a rch questions were:

• How intensive is children’s postoperative pain at home during the day of

surgery and on the first two post-operative days?

• Which analgesics do parents give to their children at home?

• How much are analgesics used among the children?

• How does the use of PPPM influparticipation in the total amount of analgesics

and the optimal dose given to the child?

Methods

Sample and Setting P a rents of 100 children scheduled for day surgery in three

university hospitals in Finland were invited to participate in the study between

January 2006 and June 2007. The parents of 50 children between 1 and 2 years

of age agreed to participate, and 50 refused to participate. One pare n t from

each family participated in the study. Convenience sampling was used. The

study nurses invited every second consecutive parent whose child had a surgical

day case procedure into the intervention (n = 29) or control group (n = 21).

Every parent was asked to participate: first parent to the intervention group,

second parent to the control group, third parent to the intervention group, and so

on. Sizes of the two groups differ because

PROBLEM STATEMENT: -

A study to assess the knowledge and Practice of staff nurses regarding

Common side effects and management of Anesthesia in pediatric post operative

Patients.

6.3) OBJECTIVES: -

29

To assess the existing knowledge of staff nurse’s regarding

common side effects of anesthesia by conducting pretest.

To develop and implement the knowledge of staff nurses

regarding post operative pediatric patients.

To assess the effectiveness of structured teaching programme by

conducting post test.

To find out the association between pretest knowledge scores with

selected demographic variables.

6.4) RESEARCH HYPOTHESIS: -

H1 - There is a significant association between the demographic variables

and knowledge regarding side effects of anesthesia.

H2 - There is no significant association between the demographic

variables and knowledge regarding side effects of anesthesia.

RESEARCH VARIABLES: -

INDEPENDENT VARIABLES: - Nursing management of post operative

patients.

DEPENDENT VARIABLES: - Knowledge regarding common side effects of

anesthesia.

DEMOGRAPHIC VARIABLES: - Selected demographic variable such as age,

sex, education, years of experience, working experience in pediatric ward,

previous knowledge about post operative care.

6.5) OPERATIONAL DEFINITION: -

30

Assess: - It refers to evaluate the staff nurse’s knowledge on post operative

management of pediatric patients after anesthesia.

Effectiveness: - It refers to significant difference between the pretest and

post test knowledge scores of staff nurse’s on common side effects of

anesthesia in post operative patients.

Structured teaching programme: - It is an education given by the investigator

for 45 to 60 minutes with the help of the A.V aids. It includes definition, types

and side effects of anesthesia and pediatric post operative nursing

management.

Knowledge: - It refers to the level of understanding of staff nurse’s regarding

side effects of anesthesia and pediatric post operative nursing management.

6.6) ASSUMPTIONS:

Staff nurse’s posses some knowledge regarding anesthesia and it’s side

effects.

Knowledge can be assessed with the help of knowledge questions.

6.7) DELIMITATIONS:

The study is limited to the staff nurse’s.

PROJECTED OUTCOME: -

The ultimate goal of this study is to give skill full and knowledgeable nursing

care after post operative patients, who undergone various types of anesthesia, 31

which increase knowledge and practice of staff nurses regarding common side

effects of anesthesia in pediatric patients.

7.0) MATERIAL AND METHODS: -

7.1) SOURCE OF DATA: - Staff nurse’s who are going to get the knowledge

will be the source of data.

7.2) METHODS OF COLLECTION OF DATA: - Self-administered

questionnaire regarding side effects and management of anesthesia.

7.2.1) RESEARCH DESIGN: -

QUASI EXPERIMENTAL RESEARCH DESIGN: - The design adopted for

the present study was represented as.

O1 - Knowledge test before administration of structured teaching

programme.

X - Structured teaching programme on side effects and management of

anesthesia.

O2 - knowledge test after administration of structured teaching programme.

7.2.2) RESEARCH APPROACH: -

A research approach tells the researches from where the data is to be collected ,

what to collect, how to collect and analyses, then it also suggests the possible

conclusions and helps the researcher in answering specific research is the most

accurate and efficient way possible.

{Rose Grippa and Gotenery Lucero 1994}

32

An evaluative research approach was used in order to assess the effectiveness of

structured teaching programme on side effects of anesthesia and it’s

management.

7.2.3) SETTING: -

Setting is the physical location and condition in which data collection takes

place. {Polit & Hungler 1999}

The study will be conducted in selected hospitals, Bangalore.

7.2.4) POPULATION: -

The population of present study is staff nurse’s working in a selected hospital,

Bangalore.

7.2.5) SAMPLE SIZE: -

The sample of the study consists of 50 staff nurses.

7.2.6) SAMPLING PROCEDURE: -

Simple Random sampling techniques procedure

7.2.7) CRITERIA FOR THE SAMPLING: -

INCLUSIVE CRITERIA: -

Staff nurse’s who are willing to participate in data collection.

Staff nurse’s who are available at the time of data collection.

All staff nurse’s (including male & female) working in that hospital.

EXCLUSIVE CRITERIA: -

Staff nurse’s who are not willing to participate in data collection.

Staff nurse’s who are not available at the time of data collection.

DATA COLLECTION TOOLS: -

33

Pretest and post test will be used to assess the knowledge of anesthesia and

management among staff nurse’s. It consist of two parts; part I & part II

Part I: - Selected demographic variables such as age, sex, education, years of

experience, working experience in pediatric ward, previous knowledge about

post operative care.

Part II: - Self administered questionnaire on anesthesia and management.

DATA ANALYSIS METHOD: -

Data analysis will be through both descriptive and inferential statistic.

7.3) DOES THE STUDY REQUIRE ANY INTERVENTION TO BE

CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS

Yes the study will be conducted on staff nurses by improving knowledge

through structured teaching programme.

7.4) HAS ETHICAL CLEARANCE BEEN OBTAINED FROM

YOURS INSTITUTION

Yes, prior permission will be obtained from the research committee of the

Sushrutha College of nursing, Bangalore.

References

A.M. Egbert, L. H. Parks, L. M. Short and M. L. Burnett (1990).

Randomized trial of postoperative patient-controlled analgesia vs.

intramuscular narcotics in frail elderly men. Achieves of Internal

Medicine150 (9).

34

Ballantyne JC et al (1993). Postoperative patient-controlled analgesia:

meta-analyses of initial randomized control trials. J Clin Anesth. 5(3):182-

93.

Berde, Lehn, Yee, Sethna, Russo (1991).Patient-controlled analgesia in

children and adolescents: a randomized, prospective comparison with

intramuscular administration of morphine for postoperative analgesia. J-

Pediatr 118(3): 460-6.

Behrman RE, kliegmam RM, jonson HB, “Nelson text book of pediatrics”,

17thEdition Philadelphia: WB saunders, 2005.

Gregorry GA, pediatric anesthesia, 4th Edition New york – Churchill

livingstone, 2005.

Brunner and suddarth’s text book of medical surgical nursing, 7th Edition

page 401-473.

Fundamentals of nursing, BT basavanthappa, Jaypee publishers,

page 457 – 485.

A Lippincott Williams and Williams, hand book of clinical anesthesia

procedures of the Massachusetts General hospital, 7th Edition page 422 –

539.

Pediatric anesthesia volume 19 issue 12 , page 1141 – 1146, Black well

publishing ltd, 2009.

AAP. (2001). The assessment and management of acute pain in infants,

children, and adolescents. Pediatrics, 108(3), 793-797.

Elander, G., Hellstrom, G., & Ovarnstrom, B. (1993). Care of infants after

major surgery: observation of behavior and analgesic administration. Pediatric

Nursing, 19(3), 221 - 226.

Jacob, E. J., & Puntillo, K. A. (1999a). A survey of nursing practice in the

assessment and management of pain in children. Pediatric Nursing, 25(5), 278

- 286.

Jacob, E. J., & Puntillo, K. A. (1999b). Pain in hospitalized children: pediatric

nurses' beliefs and practices. Journal of Pediatric Nursing, 14(6), 379 - 391.

35

Lavis, N., Hart, L., Rounsefell, B., & Runciman, W. (1992). Identification of

patient, medical and nursing staff attitudes to postoperative opioid analgesia:

stage 1 of a longitudinal study of postoperative analgesia. Pain, 48, 313 - 319.

Hester, N., & Barcus, C. (1986). Assessment and management of pain in

children. Paediatric Nursing Update, 1, 1-8.

Seaman, C. (1987). Research methods: principles, practice, and theory for

nursing (3rd ed.). East Nor Moore, S. E. (2001). A growth of knowledge in

pain management. Pediatric Nursing, 27(3), 307.

walk: Appleton and Lange.

http://www.nhs.uk/conditions/epidural-anesthesia/pages/sideeffects.aspx

http://www.brandianestesia.it/english/complications.html.

http://www.righthealth.com/topic/anesthesia-side-effects

http://www.springerlink.com

http://www.virtualpediatrichospital.org/patients/cqqa/painmanagement.shtml

9) SIGNATURE OF THE STUDENT: -

10) REMARK OF THE GUIDE: -

The topic is relevant and it helps to enhance the knowledge of staff

nurse regarding side effect of anesthesia and it’s management.

11) NAME & DESIGNATION OF GUIDE:

36

11.1) GUIDE NAME & ADDRESS: -

11.1) SIGNATURE OF GUIDE:-

11.2) HEAD OF THE DEPARTMENT:

11.3) SIGNATURE OF HOD:-

12.1) REMARK OF THE PRINCIPAL: -

12.2) SIGNATURE OF THE PRINCIPAL: -

37