1. Bayne, Alice RN, CAPA, CPN, MN
  2. Kirkland, Patricia CCLS, CHES, BSMS

Article Content

Each year, more than 2 million children undergo surgical procedures.1 The perioperative process can be stressful for children, their parents, and the nurses who care for them. Children may experience anxiety and fear about surgery, pain, separation from parents, unfamiliar surroundings, the unknown, unpleasant sensory stimulation, and loss of autonomy and control.1 Psychological problems can continue into the postoperative period with increased anxiety, disturbances in eating and sleeping, as well as increased pain and analgesic use.2 Parents may also experience anxiety and concern about the competency of staff, possible complications, and how to support their child. Unfamiliarity of surroundings and role expectations add to parental stress, and this anxiety can transmit to their children.1 Nurses must have an understanding of the impact of surgery on children and families to help ease the stress of this difficult time.2

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A child's past experience with the healthcare system, especially if perceived as negative, can impact current stress levels and the delivery of information. Experts recommend that children with frequent hospital visits receive both procedural information and instruction on coping skills such as relaxation and breathing techniques.3


Additionally, a child's developmental stage can determine his level of understanding and coping mechanisms regarding the perioperative process.1 An appropriate developmental approach to a child is important in all phases of the surgical process, as well as all aspects of postoperative care. Develop mental stages of childhood were identified by Erik Erikson and Jean Piaget. Erikson studied the impact of parents and society on a child's personality. Piaget determined that children learn about the world around them through their own actions and explorations.


The age ranges identified in the following sections are approximate. Not all children reach developmental milestones at the same age. Therefore, developmental stage, both emotional and cognitive, should guide the perioperative nurse in preparing children and families for the surgical process.1 (See Age divisions of childhood.)



Infants (birth to 1 year) develop relationships based on trust and depend on parents and caregivers to meet their needs. Separation from parents can cause distress, which is primarily expressed through crying.4 Encourage parents to remain with the infant through as much of the process as possible, as they derive comfort from familiar faces and voices. Encourage parents to bring a security object such as a blanket or stuffed animal to help soothe the infant when separated from his parents.3 Reunite the infant with his parents as soon as possible after the procedure to minimize distress. Limit the number of caregivers, if possible, as strangers also cause fear.3


Other comfort measures such as soft music, a pacifier, cuddling, gentle stroking, or rocking can help calm infants. Infants also enjoy nursery rhymes and simple rhythmic play. Preparation at this stage focuses on the parent due to the limited cognitive abilities of the child. Inform the parents about the procedure and provide support; their infant is likely to be less anxious if the parents are calm.4



Toddlers (1 to 3 years) differ from infants as they're just beginning to gain autonomy by attempting to do things for themselves. This is an active period with short attention spans. Although verbal skills are limited, they understand more than they're able to say.5 Provide simple, concrete explanations about what the toddler will hear, feel, smell, taste, and see. It isn't necessary to cover all details of the surgery.


In general, preparation should be done a day or two before surgery at a level the child will understand.3 Toddlers possess a limited concept of time, so use explanations the child is familiar with. For example, tell the child, "The surgery will be before lunch."3 Unfamiliar faces, routines, and scary equipment may cause stress.1 Encourage family members to bring his favorite activities or toys to distract the child from boredom, fears, and the new routine. Toddlers fear abandonment; as a result, separation from family can be extremely stressful.1 Minimizing separation from a parent can further a toddler's ability to cope in a stressful situation. A favorite toy, stuffed animal, or photograph that the child can hold while going to surgery can offer comfort. Toddlers may sometimes temporarily lose newly acquired skills such as walking or toilet training. Provide reassurance that this is okay and encourage family members to be accepting and supportive. It's important to answer questions about pain and separation truthfully. Also, provide simple choices whenever possible to heighten a toddler's sense of independence and control.4 For example, allow the toddler to choose his favorite of two character adhesive bandages for use after the I.V. is removed.



Preschoolers (3 to 5 years) develop their own identities, are very inquisitive, and have active imaginations. Fantasies and misconceptions related to surgery are common. Offer simple explanations and descriptions, allowing the child to see and handle some of the medical equipment that will be used.3 Although their vocabulary is developing rapidly, they don't have the full ability to reason. Therefore, explanations about a procedure should be kept simple and matter-of-fact, focusing on what the child will hear, feel, smell, taste, and see, as well as what the child is expected to do. Demonstrate with props, models, and pictures whenever possible. As a preschooler's concept of time is limited, the nurse must review and reinforce the sequence and duration of all events. Use time concepts the child is familiar with: "The operation will take less time than it takes to watch a cartoon."4 Preparation for surgery for this developmental stage is recommended a day or two in advance.3


Preschool children fantasize and may feel that their operation is punishment for bad behavior. Reassure the child that he isn't to blame and that the surgery is to fix something specific. Be honest, especially about separation and potential pain. Playing during the preoperative phase can help distract children who are distressed. As with all children, this age group will benefit from having a familiar toy, stuffed animal, or photograph. Offer choices whenever possible to promote a sense of control.3 One example might be the choice of flavored lip preparations used on the anesthesia mask to provide a more pleasing scent for the child. Another choice might be the type of transport to surgery the child would prefer such as walking, riding in a wagon, or being carried by the nurse.


School-age children

School-age children (5 to 12 years) devote most of their energy to school and peers. Mastery of skills, experiences, and self-esteem are increasingly important issues for this age group. Although still engaged in some imaginary thinking, they're capable of concrete, logical reasoning and are gaining an increased understanding of cause and effect. They are better able to cooperate with treatment because they can think before they act.5


School-age children have an increased awareness of internal body parts and body function. They are also able to understand a series of actions and can therefore benefit from hearing about all steps involved in the surgical process. Preparation should begin a week in advance of the surgery. Allow the school-age child to participate in care when possible. For example, to provide a sense of control and encourage acceptance of treatment, ask the child to help hold the anesthesia mask.5 Provide choices when possible such as asking, "Which arm should we use to measure your blood pressure?"


Offer simple explanations about sensory and procedural information as well as what's expected of the child. When starting an I.V., tell him, "your job is to hold your arm very still." Try to use language that's accurate, but not scary. For example, "The doctor will make a small opening" is less scary than, "the doctor will make a cut." Be honest if something is going to hurt. When asked, the nurse can respond, "some kids say it feels like a pinch and some kids say they don't feel anything at all. You'll have to tell me how it felt to you." These children can express their feelings in words and have a greater grasp of time, so separation from parents tends to be less of an issue.3


School-age children may fear other body parts will be hurt during the operation. Offer a simple explanation of what part of the body the operation will affect. Body outlines, pictures, or dolls may be helpful.4 For example, a child's understanding of a surgical site can be quickly assessed by asking him to mark the site on the doll. Any misconceptions revealed can then be corrected.


Fear of death is common; the child's previous experience with illness and death will determine the explanation needed for reassurance. Be sure to express confidence in the surgeon and staff.6



During adolescence (12 to 18 years), abstract thinking begins and adolescents can understand how the body functions, the nature of the problem, and the reason for surgery. Provide honest, detailed explanations about the diagnosis and need for surgery, including what the adolescent will hear, feel, smell, taste, and see. Adolescents often want to know the results of surgery and what'll happen next. Involve them in decisions about their health as much as possible.


Common fears include waking during the procedure, pain, and the possibility of death. They may need reassurance in their anesthesia provider's ability and an explanation that they won't wake up during the procedure but will wake up afterward.3


The location and extent of surgical scars are often a major concern as adolescents may worry about how surgery will affect their appearance. If the adolescent wants to, allow him to see any changes after the procedure using mirrors as necessary. Provide reassurance that changes are temporary if that's true, but if not, be honest.4 Encourage parents to be available to talk after the procedure if the adolescent is willing.


Adolescents may become uncooperative or withdraw, so allow them as much independence as possible and let them know what's expected of them. Providing opportunities to make realistic choices when possible can help increase their sense of independence. For example, when ready to drink postoperatively, ask what beverage they would prefer.4


Nurses should respect an adolescent's need for privacy. Always knock on the door or announce your presence before opening a curtain to avoid embarrassing them if they're undressing. This kind of courtesy can lead to increased cooperation.3


During preoperative contact, encourage the family to pack the adolescent's familiar toiletries, clothing, and slippers to convey a return to normalcy during the postoperative phase. Encourage the family to bring the adolescent's favorite book, magazines, word search, music with a headset, or a handheld video game to help reduce anxiety. Plan helpful coping behaviors ahead of time such as listening to music or imagining a favorite place, and suggest that the family plan a favorite activity for their adolescent to look forward to after the operation.


Preparing parents

Preoperative preparation processes have been affected by changes in healthcare delivery systems and economic constraints. Preoperative hospital visits are now often replaced with information shared via telephone or Web sites. Parents are becoming increasingly responsible for preparing their child for surgery. Therefore, parents should be partners in the preparation process, receiving not only information about the procedure and sequence of events, but also the guidance and tools to provide support and prepare the child for the experience. In one study, parents who received both written and verbal information expressed a preference for print materials, requiring guidance from the nurse to appropriate written resources.2 It's important to encourage parents to foster the child's normal development despite limitations that may be imposed by illness or injury.


The Joint Commission requires all nurses who have contact with patients to receive education and training related to the needs of the age group in their care. The assessment of this competency is to be ongoing. Competency evaluation criteria must match each facility's standards, policies, and procedures, and be documented to comply with Joint Commission requirements.7OR


Kids Klubhouse

Incorporating all components that impact a child's surgical experience into an optimal plan of care remains a challenge for nurses and surgical facilities providing pediatric care. As a solution, Wolfson Children's Hospital, Jacksonville, Fla., recently created the Kids Klubhouse, an environment for children requiring a preoperative hospital visit to learn through active participation. The Kids Klubhouse encourages children to become familiar with safe medical equipment, provides educational opportunities through games and audiovisual materials, and offers coping strategy ideas that patients and parents can use to successfully deal with the perioperative process. Children are encouraged to choose activities at their level of interest and readiness. Parents are also given tools to reinforce the child's preparation through printed information cards created for each developmental level. A coloring book was created to help parents reinforce information when the child returns to the less stressful home environment. For patients not requiring a preoperative encounter, the information cards and coloring book are available on the hospital Web site at




1. Browne NT, Flanigan LM, McComiskey CA, Pieper P. Nursing Care of the Pediatric Surgical Patient. Boston, Mass: Jones & Bartlett Publishers; 2007:3-16. [Context Link]


2. Kain ZN, Mayes LC, Caldwell-Andrews AA, et al. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics. 2006;118(2): 651-658. [Context Link]


3. LeRoy S, Elixson E, O'Brien P, et al. Recommendations for preparing children and adolescents for invasive cardiac procedures. Circulation. 2003;108:2550-2564. [Context Link]


4. Justus R, Wyles D, Wilson, J, et al. Preparing children and families for surgery: Mount Sinai's multidisciplinary approach. Pediatr Nurs. 2006;32(1): 35-45. [Context Link]


5. Redman B. The Practice of Patient Education: A Case Study Approach. St. Louis, Mo: Mosby Elsevier; 2007:18-24. [Context Link]


6. Craven R, Hirnle C. Fundamentals of nursing: Human health and function. Baltimore, Md: Lippincott Williams & Wilkins; 2007:284-311. [Context Link]


7. The Joint Commission. Management of Human Resources: Standard HR.3.40. Available at: Accessed July 3, 2008. [Context Link]