Clinical practice exemplar reflects a perioperative nurse's commitment to patient advocacy

AORN Journal, July, 1996 by Jane M. Murphy

Editor's note: This new column in the Journal focuses on outstanding examples of skilled perioperative nursing practice. Clinical exemplars capture me interpersonal ethical, and clinical judgments that perioperative nurses make in actual practice. The following clinical exemplar illustrates perioperative nurses' important role as patient advocates.

Several months ago, I was circulating nurse for Dan, an 11-year-old male with chronic sinusitis who was scheduled for an endoscopic left maxillary sinus debridement. One week earlier, he had undergone a functional endoscopic sinus procedure.

As I approached Dan's bedside to perform the preoperative patient assessment, I observed that his body language and facial expressions conveyed a high level of anxiety. After speaking with Dan and his mother briefly, I discovered that he had been having night terrors for the past week, which were associated with memories of his recent anesthesia mask induction. I attempted to reassure Dan that the OR staff members would inform him before we did anything and that there would be no surprises.

I explained Dan's fears to the anesthesiologist and suggested that Dan might benefit from having his mother present during anesthesia mask induction. Our hospital's parent-present induction program helps children be more relaxed and less frightened during anesthesia induction and eliminates the distress of separation from parents for many children. Normally, this involves careful assessment of each child and parent as well as parental preparation in the preoperative waiting area. In Dan's case, I believed that it would be appropriate for his mother to be present, and I thought I could convey the necessary information to her rapidly. The anesthesiologist, however, preferred to use an IV induction method, and Dan's mother stated she would agree with any plan that the anesthesiologist recommended.

As the anesthesiologist attempted to insert an IV, Dan's mother and I tried to distract Dan. He was very cooperative, but tears were trickling down his cheeks. We continued to praise his bravery throughout several attempts to insert the IV.

When the IV finally was in place, the anesthesiologist administered a preoperative sedative medication. As the medication began to take effect, Dan became increasingly anxious and tearful, and he verbalized his fear of going into the OR. I moved to where Dan and his mother could not overhear the conversation and suggested to the anesthesiologist--more persistently this time--that I thought it would be helpful for Dan's mother to accompany him into the OR for anesthesia mask induction. At this point, the anesthesiologist agreed with the suggestion.

We asked Dan if he would feel better if his mother accompanied him to the OR for induction, giving him a choice and allowing him to have control over the situation. Dan stated that he would feel less afraid if his mother were with him.

I helped Dan's mother don the OR coverall, hat, and mask, and I quickly reviewed some of the physical changes she might observe in Dan as he moved through stage two of anesthesia. I advised Dan's mother that her role would be to comfort and support Dan, just as she would at home.

As Dan became anesthetized, he was still thanking all of us for allowing his mother to be in the OR. The induction went very smoothly. Dan's fears were greatly decreased because his mother was at his side, holding his hand as he lost consciousness. After the induction, our clinical assistant escorted Dan's mother to the waiting room.

The first thing Dan said when he emerged from anesthesia was, "Thanks for letting my mom be with me." The postanesthesia care unit nurse informed me that Dan and his mother verbalized how grateful they were that they could be together during Dan's induction.

I went home that day feeling like I had made a big difference. I had played an important part in lessening Dan's fears and anxiety.

JANE M. MURPHY, RN, MS, is a level II staff nurse in the main OR, Children's Hospital, Boston.