Myringotomy and insertion of grommets as day surgery: a case study

Airway

Jack was able to speak to his mother and therefore showed no signs of airway occlusion. The nurse listened and observed carefully for any abnormal respiratory signs of stridor, wheeze or grunting (RCN, 2017b). These signs were absent, meaning there were no concerns about Jack's airway.

Breathing

As children younger than 7 years are primarily abdominal breathers, Jack's rate of breathing was assessed by counting his abdominal movements for one full minute (RCN, 2017b). Jack's respiratory rate was noted to be 39 breaths per minute which was within the normal range for his age (20 to 40 breaths per minute) (HSE, 2017). Respiratory movements were symmetrical and there was no evidence of any intercostal or subcostal recessions (Macqueen et al, 2012). A pulse oximeter was applied to measure Jack's oxygen saturation; a reading of 98% was obtained, indicating a normal (above 94%) oxygen saturation level, which indicated a score of zero on the PEWS chart (HSE, 2017).

Circulation

Since Jack was over 2 years of age, his pulse and heart rate could be measured at the radial site on his wrist rather than at the heart apex (RCN, 2017b). The artery was palpated by placing the nurse's first two finger tips gently upon his radial pulse. The rate, rhythm and depth of his pulse were noted by counting for one full minute for accuracy (Macqueen et al, 2012). Jack had a strong steady pulse and a heart rate of 130 beats per minute, which again was within the normal range of 130 to 180 beats per minute for his age (HSE, 2017). Jack's central capillary refill time (CRT) was checked by pressing on his forehead for 5 seconds and counting the refill time (RCN, 2017b). Jack's refill rate was under 2 seconds, which is within the normal range (HSE, 2017). His skin colour was pink and he appeared well perfused, meaning he was well hydrated.

Jack's blood pressure (BP) was measured using an electronic device after the selection of the correct sized cuff for his arm (RCN, 2017b). The normal BP range for a 2-year-old boy is 86–106/42–63 millimetres of mercury (mmHg), dependent on their age, gender, height and weight (Blood Pressure Remedies, 2021). Jack's reading was slightly elevated at 112/80 mmHg. Jack became upset while his BP was being recorded, which may have had an effect on the reading (Ball et al, 2019). Following a period of 10 minutes relaxation, his BP was retaken and it was 105/75 mmHg, which was within the normal range for his age (HSE, 2017).

Disability

This section assesses the level of consciousness by using the alert, voice, pain and unresponsive (AVPU) scale. (HSE, 2017). Jack was awake and speaking to his mother, so it was noted in the chart that he was alert.

Exposure

Jack's temperature was taken using a child-sized tympanic thermometer (RCN, 2017b). The normal temperature range for a child is 36.2-37.8°C. Jack's was 36.9°C, which was within the normal range (HSE, 2017; NICE, 2019). Any elevation in temperature is important to note as contraindications to paediatric ambulatory surgery include an active infection (Robinson and Engelhardt, 2017). Pyrexia prior to surgery may also lead to postoperative complications (Macqueen et al, 2012).

The nurse noted that Jack's mother did not have any concerns regarding his health at that time, which is a unique feature of the Irish PEWS since it allows for any parental concern to be recorded (HSE, 2017). Following Jack's full assessment, an overall PEWS score was calculated by adding the score from each parameter: concern from the parents or clinician, respiratory rate, respiratory effort, oxygen therapy, oxygen saturation, heart rate, CRT, BP and level of consciousness (HSE, 2017). Temperature and skin colour are non-scoring parameters, but the results may trigger the sepsis pathway if required (HSE, 2017). The score determines how frequently observations should be taken and whether there is a need to escalate to the nurse in charge, or if medical review is required (HSE, 2017). Clinical judgement should be taken into account at all times, regardless of the PEWS score (HSE, 2017). Jack's score was zero without any signs of active infection, indicating his observations were optimal for surgery to proceed as planned (Robinson and Engelhardt, 2017).

Problem 1. Risk of anxiety

Pre-operative anxiety is commonly experienced in children undergoing elective surgery (Dai and Livesley, 2018). The nursing goal was to ensure Jack and his mother did not experience anxiety. Research has shown that, if anxiety is not controlled, it may have negative consequences post-surgery; such as behavioural problems, delay in the healing process and increased pain levels (He et al, 2015a; Al-Yateem et al, 2016; Pomicino et al, 2018).

The nurse ensured this goal was met by carrying out an array of nursing interventions. As grommet insertion is an elective surgery, it was important that the family were made aware of the preparation material available (Trigg and Mohammed, 2010). For example, there is a video available on the Children's Health Ireland (CHI) at Temple Street website, entitled ‘Ben and Tara's visit to the hospital’ (CHI at Temple Street, 2016). This video allows the child to prepare for surgery by following Tara and Ben's journey through the elective surgery process. This covers what assessments the nurse will do pre-operatively to what to expect when they return from surgery.

On the day of admission, the nurse encouraged Jack and his mother to voice any concerns they might have so that questions could be answered in an effort to build a strong rapport from the beginning (Ball et al, 2019). The principles of child- and family-centred Care (CFCC), which are applied within the hospital, mean that nurses take into account how any procedure will impact on the family (Park et al, 2018). This can be a stressful time for the parents and often, if not managed appropriately, the stress can be transferred to the child (Short and Gordon, 2015; Pomicino et al, 2018).

Research has shown the importance of getting to know the family to ensure the strategies being implemented are suitable to their needs and cultural values (Bray et al, 2012; Dai and Livesley, 2018). The level of information to be provided and the extent to which the child should be involved is discussed, because providing too much information may cause additional anxiety in some children (Bray et al, 2012). The nurse spoke to Jack in age-appropriate language to determine his interests, such as favourite toys and games. In addition to building a relationship with Jack, this information can be used later to help explain the procedure to him (Ball et al, 2019). After spending some time with the family, the nurse discovered that Jack liked to look at picture books and had a teddy that he used as a comforter.

Once a relationship had been established, the nurse explained to Jack what his surgery would involve, using a doll and equipment. She allowed Jack to play with the doll and explained what would happen when he went for surgery and what to expect afterwards (Ball et al, 2019). The nurse also showed Jack a book that had pictures of a boy having surgery. Research suggests that therapeutic play involving multiple components can reduce pre-operative anxiety (Dai and Livesley, 2018). However, in a study carried out by He et al (2015b), it was found that, although therapeutic play was beneficial for the child, it did not reduce the parents' anxiety. The nurse was aware that the mother was displaying behaviour that might suggest anxiety. She provided her with additional information on the surgery and encouraged her to ask questions (Pomicino et al, 2018).

Despite the nurse's best efforts, Jack was anxious and unsettled. At this stage, recognising her limitations, the nurse asked one of the hospital's play specialists to become involved (Macqueen et al, 2012; OLCHC, 2018b). The play specialist used distraction techniques and blew bubbles with Jack to help him take deep breaths. As a result, Jack became calm (Hockenberry et al, 2017; White, 2017).

The nurse spoke to Jack's mother regarding her wish to accompany Jack to theatre and be present while he received anaesthesia. It is important to discuss this topic as although it may help ease anxiety for the child, some parents can find the process of their child being anaesthetised distressing (Pomicino et al, 2018), and this anxiety can then be transferred to the child (Short and Gordon, 2015). Jack's mother wished to accompany him and therefore the nurse ensured that she was well prepared and knew what to expect. The nurse accompanied Jack and his mother as far as the operating theatre check-in desk. Despite still showing slight signs of anxiety, the family appeared prepared and at ease overall, illustrating that the goals associated with this problem had been met.

Problem 2. Risk of fluid volume imbalance and risk of unstable blood glucose (associated with fasting)

Fasting is necessary before undergoing general anaesthesia in order to reduce the risk of pulmonary aspiration of stomach contents (Dennhardt et al, 2016). The reflex that normally protects the airway is lost while under sedation (Rai and Toms, 2019). The hospital guidelines for fasting (OLCHC, 2018c) state that:

Despite these recommendations, studies have shown that children often exceed the fasting guidelines (Tagg, 2018). Scheduling practical operation times and the communication of associated fasting times to children and their parents, in language they can understand, are extremely important in order to achieve compliance (National Adult Literacy Agency (NALA), 2019).

Children are particularly vulnerable to the effects of fasting as they are at increased risk of hypovolaemia, dehydration, hypoglycaemia, irritability and catabolic metabolism (Dennhardt et al, 2016; Ball et al, 2019). Hypovolaemia is of a particular concern as infants have a reduced ability to conserve fluids (Ball et al, 2019). This is coupled with the fact that fluid loss from bleeding during surgery can further deplete fluid volume (Ball et al, 2019). Owing to these adverse effects, extensive research has been carried out in a bid to reduce fasting times to safe and reasonable limits (Dennhardt et al, 2016; Tagg, 2018). The nurse was conscious of the risks of prolonged fasting and ensured interventions were implemented so that Jack did not have to fast for longer than necessary.

Jack was admitted to the day unit at 9am on the morning of his surgery as his procedure was due to take place at 11am. While speaking to Jack and his mother, the nurse learnt that Jack has been fasting since 9pm the previous night. The mother explained that she was worried and wanted to ensure that Jack was within the fasting times. Jack was irritable and lethargic. The hospital guidelines (OLCHC, 2018c) indicate that Jack could sip some clear apple juice up to one hour before his surgery as ‘approximately 3 ml/kg/hour is acceptable up to a maximum of 200 ml/hour’ (OLCHC, 2018c:2). Jack's weight on admission was 12.5 kg, therefore he was allowed up to 37.5 ml an hour (up to one hour before surgery). This was explained to Jack's mother. The juice helps to increase overall fluid volume, thus reducing the risk of hypovolaemia and dehydration. It also helps to increase insulin levels, minimises glycogen store depletion and negates the risk of hypoglycaemia (Tagg, 2018).

Communication is fundamental when mitigating the risks associated with pre-operative fasting. Elective surgery can be delayed for a number of reasons; causing the fasting time to be prolonged longer than is necessary (Andersson et al, 2018). The nurse maintained communication with the theatre staff to ensure the family were informed of any delays. The nurse noted that Jack was not called for surgery at 11am as expected. The operating theatre was contacted and the nurse was informed that Jack's surgery would be delayed by a further hour and a half. Taking this information into account the nurse informed Jack and his mother and allowed Jack to have some more clear apple juice (up to 37.5 ml). This approach helped to ease anxiety for the family and resulted in Jack's fasting time not being prolonged and prevented further complications of hypoglycaemia, hypovolaemia or dehydration (Macqueen et al, 2012).

Clear communication with Jack's mother regarding the fasting timelines and why it was necessary for their child to fast was also crucial (NALA, 2019). In the pre-operative period before admission parents can often be very anxious, which can lead to a lack of understanding and non-compliance with fasting guidelines (Kushnir et al, 2015). Taking this into account, the nurse used a simple ‘repeat back technique’ by asking Jack's mother to repeat the information provided to ensure comprehension before Jack was discharged home (Yen and Leasure, 2019).

Jack was transferred to the operating theatre safely. Nursing interventions meant he had not fasted longer than required and he was not showing signs of dehydration, hypovolaemia or hypoglycaemia. The health professionals in the operating theatre department assumed care for Jack and the nurse ensured the parent's contact details were accurate and recorded, in anticipation of the phone call to return and retrieve Jack following his surgery.

Problem 3. Risk of pain

Jack received a rectal suppository of paracetamol as prescribed at his induction before anaesthesia and surgery. The nurse informed Jack's mother that he could have oral paracetamol in 4–6 hours' time if needed or before he settled to sleep at home that evening. Paracetamol is an over-the-counter medication, which means it does not require a prescription but care must be taken to follow the instructions on the package to ensure Jack only received the correct dose at the correct times. His mother was told that Jack should not be too uncomfortable after his surgery but instead would need reassurance from her because he would be able to hear better. He would need lots of affection and praise. Jack appeared quite settled after his surgery and was happy to go home.

Problem 4. Risk of infection

Jack should not get as many infections following the insertion of grommets. However, it is important that Jack's mother follows the after-care advice to prevent any complications. No hair washing, bathing or swimming is permitted initially for the first week after surgery as water could enter through the eardrum, exposing the ear to the risk of infection. Jack's mother was advised to phone the hospital if she has any initial concerns or to visit the GP if she was still worried later on. After the first week, Jack's ears would need to be plugged with cotton wool, with Vaseline applied over it to act as a barrier to water entering the ears. This should be done before hair washing, bathing or swimming. Jack is probably too young for diving too far under water, but this should be avoided as it can dislodge the grommets and cause rupture of the tympanic membrane. A further appointment with the consultant would be arranged approximately 4–6 weeks after his surgery, when further advice would be provided in relation to preventing infections.