Providing developmentally based care for toddlers

AORN Journal, May, 2008 by Elaine Taylor

Pediatric patients are not just small adults; each child is a unique individual. Even during the "terrible twos," as many refer to the toddler years when children are actively engaged in learning about their world, however, similarities do exist in perioperative care based on the child's developmental level. From a developmental perspective, toddlerhood lasts from a child's first birthday to his or her third birthday. It is a time during which the child throws temper tantrums and demonstrates negativism, passionate exploration, and assertiveness. Parenting a toddler often is demanding and challenging. The prospect of a surgical procedure creates additional stress for the child as well as his or her family members, and this may exacerbate a toddler's outbursts and hinder parental coping mechanisms.

Developmental theories offered by Freud, (1) Piaget, (2) and Erikson (3) can help provide a theoretical foundation for understanding children at each psychosocial and cognitive level (Table 1). Nurses who understand these theories may be better equipped to provide holistic, family-centered care. Nurses also must be aware that all humans have the potential to regress developmentally when under stress. The developmental theories presented in this column are intended to help nurses care for patients at this stage of development; if a toddler does regress, developmental interventions that are appropriate for infants should be considered.

CONSIDERATIONS IN THE CARE OF TODDLERS

The information presented here is designed to provide a developmental and theoretical foundation to augment the psychosocial competency as outlined in the Age-Specific Care: Competency Assessment Module published by the Competency & Credentialing Institute. (4) Toddlers have specific physiological needs based on their size and the maturity of their body systems that also are addressed in the module.

PHYSIOLOGY. The average two-year-old weighs 26.5 lbs (12 kg) with an average weight gain of 4 lbs to 6 lbs (1.8 kg to 2.7 kg) per year. (5) The height of an average two-year-old is 34 inches (86.6 cm), and the average rate of growth is 3 inches per year. (5) Most of this growth occurs in the legs rather than in the trunk. This growth rate is considerably less than that of children during infancy. With the closing of the anterior fontanelle by 18 months, growth in the child's head circumference also slows. (5)

During the perioperative period, vital signs and hydration status should be monitored very carefully, but because physiologic systems are comparatively mature by the end of this stage, the toddler usually is able to adapt easily to minor changes without experiencing problems. Because of the child's small size, strict monitoring of intake and output is essential and care should be taken to ensure that IV fluids and medications are administered based on the child's weight. Blood loss should be weighed and monitored, and these measurements should be reported frequently to the surgeon and anesthesia care provider to prevent hypovolemia. Urine output should be at least 1 mL/kg/hour, and there should be a balance between intake and output amounts. (5)

HEAD, NECK AND LUNGS. Even though the child's respiratory tract has matured from infancy, the internal structures of the ear and throat are still short and straight with enlargement of the tonsils and adenoids. These factors, along with the child's short neck and trachea, can make intubation more difficult and make laryngospasm during extubation more likely. These physical characteristics also predispose toddlers to ear infections and upper respiratory infections. (5) This physiologic susceptibility necessitates a thorough preoperative respiratory assessment to ensure that the toddler does not have an infection prior to surgery.

Primary caregivers also should be asked whether the toddler has any history of asthma, bronchiolitis, reactive airway disease, or respiratory syncytial virus infection. Because of the lack of maturity of the child's pulmonary and immune systems, any of these conditions could predispose the toddler to wheezing. (6) This necessitates accurate documentation of breath sounds in all lung fields before surgery. Health care providers must be aware that a toddler with a history of any of these conditions may have alteration in breath sounds postoperatively and, therefore, may require treatment.

IMMUNIZATIONS. By the time a child reaches toddlerhood, he or she should have received all basic immunizations. This should be documented in the child's medical record. If the child has not been immunized, communicable disease exposures, especially to varicella (ie, chicken pox), should be determined. If there is a potential exposure, isolation precautions should be exercised throughout the perioperative period and on the nursing unit.

PAIN. Pain assessment in toddlers is difficult because they have limited verbal skills, and crying could indicate pain, a response to not having their developmental needs met, or simply that they have not gotten something they want. A child's primary caregiver should be interviewed to determine what words or actions the toddler uses to express that he or she is experiencing pain. In addition, a behavioral pain assessment tool should be selected, and a baseline measurement should be documented preoperatively. The identified tool should be used consistently in the postoperative period to evaluate the child's pain status. Behavioral pain scales will support a more reliable measurement of the child's crying, movement, facial expression, agitation, and consolability. (5) In addition to the application of other pain management modalities, medication to treat pain should be provided postoperatively, and dosages should be based on the child's weight.