John, a 12-year-old boy, has been admitted to the ward via the paediatric emergency department. John is complaining of abdominal pain, has been vomiting and has a high temperature.  The surgical registrar believes that John has appendicitis and needs to go to theatre for removal of his appendix urgently.

• How will preparing John for theatre differ from a routine theatre admission?
• What can the children’s nurse do to support John through this admission?

Answer: John is being admitted for emergency surgery, so he will not have had the chance to visit the ward before or participate in the pre-admission activities that are designed to reduce anxiety for children and improve their hospital experiences. John is likely to be more anxious, scared and unfamiliar with his surroundings and this will be exacerbated by the fact that he is in pain and feeling unwell. As he is requiring emergency surgery, he will need to be prepared quickly for theatre. The children’s nurse will need to be mindful of this and use effective communication (see Chapter 2) to support John and his family and to allow him to vocalise any fears or anxieties that he may have.   Establishing a quick rapport with John and his family will aid the children’s nurse in developing a therapeutic relationship, whereby John will hopefully share how he is feeling. It will be essential for the children’s nurse to establish that John understands why he is in hospital and what will happen when he goes for surgery. Often a lack of understanding can cause more anxiety and can be relieved by honest communication. Finding out what interests John has can guide the nurse in the use of distraction and play therapy, to help take John’s mind off his pain. The use of an effective pain assessment tool will guide the nurse in assessing whether John requires pain relief. As John will need to be nil by mouth, IV pain relief may be required.  The nurse can support the doctor or nurse practitioner during the insertion of IV access and act as an advocate for John to ensure that his voice is heard throughout. Sometimes, when children are hospitalised they will regress in their behaviour.  John may look to his family for support and to speak on his behalf. It is important for the children’s nurse to acknowledge this and include the family in discussions, but always keep the main focus on John when communicating by directing questions towards John and encouraging John to speak for himself at all times. As well as ensuring John is prepared psychologically for theatre, the children’s nurse must ensure that John is prepared physically too. Pre-operative checklists and baseline observations will need to be completed and responded to so that John is stabilised effectively.

What are the challenges when caring for a family who are Jehovah’s Witnesses? What considerations need to be taken into account when discussing the potential need for blood products in theatre?

Answer: Jehovah’s Witnesses decline whole blood products based on their religious beliefs. However, some patients who are Jehovah’s Witnesses may accept some transfusion derivatives, e.g. human albumin solution (see link below). This deeply held core value must be recognised and following an honest discussion of the impact on health this may have, an adult patient would be within their rights to refuse blood products. In the case of children, this is slightly less clear. Health professionals will always put the child’s wellbeing first. It is therefore important that a frank discussion occur with the family prior to surgery so that the family’s preferences are recognised, listened to and clearly noted in the documentation. However, if the surgeon believes that blood products may be required and parents do not give consent, then a court order can be obtained. The parents need to be kept informed at each stage of the application.   If blood is required during an emergency in theatre, then the surgeon will be within their legal rights to administer this. However, as this may be against the wishes of the family, then ethical issues will arise. The role of the children’s nurse within this ethical and legal situation is clear. The Nursing and Midwifery Council’s The Code (2015) states that nurses must ‘uphold patient’s dignity, listen to their preferences, assess and respond to people’s psychological and social needs and act in best interests of people at all times’ (2015, pp.4–6). By following The Code, children’s nurses can support the family through this process. However, this can be a challenging situation for the children’s nurse if this does not match their views. For further information read the following handbook:

www.transfusionguidelines.org/transfusion-handbook/12-management-of-patients-who-do-not-accept-transfusion/12-2-jehovah-s-witnesses-and-blood-transfusion

Think about the last time you witnessed a good handover between two members of staff. What was good about that handover? Was a structured handover tool such as SBAR (Situation, Background, Assessment, Recommendation) used?

Answer: A good handover will ensure accurate, focused, specific information about the child to be delivered either between individuals or between teams. The handover will depend on the two parties using effective communication skills, including active listening. In the case of transferring children for surgery, this may include a handover using verbal and written communication. In the verbal handover, personal information including DOB (ensure correct patient), surgical condition and expected surgery, any allergies, last time pain relief given, time since NBM is provided. In the handover of documentation, the notes, drug chart, consent form and pre-theatre checklist are given and checked.  SBAR (Situation, Background, Assessment, Recommendation) is a structured tool that is often used when delivering a handover of a patient to another team or individual. SBAR is recognised as a framework upon which the healthcare professional can share information in a concise manner. For more details, refer to link below:

www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/sbar_-_situation_-_background_-_assessment_-_recommendation.html

Jessica is 3 years old and is being discharged home following surgery for intussusception.  Jessica has not been eating well and her wound is slow to heal.

• What information/documentation is required to ensure seamless transition of care?

Answer: Effective transition of care into the community is essential if Jessica is to recover from surgery. SBAR can be used to handover the care from the hospital to community staff efficiently.  An individualised plan of care needs to be developed, with the focus on wound care management and encouraging Jessica to meet her nutritional needs following surgery, to aid this. For optimum wound healing, increased amounts of calories, protein, vitamins A and C are required. Identifying child friendly foods that can provide the essential nutrition is therefore a priority, e.g. smoothies/juices to meet vitamin requirements. Through family-centred care, the community children’s nurse can identify foods from the list that Jessica likes and create a nutritional plan to enable these requirements to be met. Encouraging Jessica to eat several small meals throughout the day will enable her to meet these nutritional requirements. Recording nutritional input will aid the community children’s nurse to assess whether nutrition is affecting the wound healing. The community children’s nurse needs to support Jessica’s family in caring for her following discharge home. Wound management will include regular wound assessment and application of appropriate wound dressing, as required. The individualised care plan needs to be reviewed regularly and amended as required, when condition changes. As Jessica is so young, the use of effective communication and play will be essential for the children’s nurse to develop a rapport with her. Working collaboratively with the family will aid Jessica’s recovery from surgery and will also provide a positive experience for Jessica should she need to go into hospital in the future.