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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

.

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. Name of the Candidate : Mrs. KAVITHA SUDAR KODI.DAnd Address First Year M.Sc Nursing,

Sushrutha College of Nursing, Bangalore-85.

2. Name of the Institution : Sushrutha College of Nursing, Bangalore-85.

3. Course of study : First Year M.Sc Nursing, And subject Pediatric Nursing

4. Date of Admission : 03.06.2009

5. Title of the Topic : A study to assess the level of knowledge

and Practice of staff nurses regarding

Common side effects and management of

Anesthesia in post operative ward in

selected child health hospital at Bangalore.

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6.0) BRIEF RESUME OF THE INTENDED WORK:-

INTRODUCTION

Alcohol is the anesthesia by which we endure the operation of life -GEORGE BERNARD SHAW

ANESTHESIA: - The word “Anesthetic” is derived from the Greek word

meaning the absence or loss of sensation. Anesthesia means of “loss of

sensation” medications that cause anesthesia are called anesthetics. Anesthetics

are used for pain relief during tests or surgical operation so that you do not feel:

Pain

Touch

Pressure and temperature.

How do anesthetics works?

Anesthetics works by blocking the signals that pass along through

nerves to brain. The nerves are bundles of fibers that use chemical and electrical

signals to pass information around the body. for example if we cut our finger

the pain signal travels from our finger to our brain through the nerves. when the

signal reaches the brain we realize that our finger hurts. Anesthetics stop the

nerve signals reaching the brain allowing procedures to be carried out with out

feeling of anything when the anesthetics wear off, the signals will work again

and feeling will come back.

Drugs that depress the central nervous system produce a progressive

dose-related continuum of effects. Small doses produce light sedation. In this

state, the patient remains conscious, with some alteration of mood, relief of

anxiety, drowsiness, and sometimes analgesia. As the dose is increased, or as

other drugs are added, greater central nervous system depression occurs,

resulting in deepening of sedation and sleep from which the patient can be

aroused. Finally, when consciousness is lost and the patient cannot be

aroused, light general anesthesia begins. General anesthesia can be deepened

by additional drug administration. The amount of training, experience, and 3

skill needed to safely produce and manage central nervous system depression

increases with the degree of depression involved.

The degree and duration of central nervous system depression required

varies with the procedure being performed and with the special requirements

of the patient; these may be altered during the procedure as operative

requirements change. Only a brief period of central nervous system

depression may be necessary to permit the performance of procedures such as

administration of a local anesthetic or the uncomplicated extraction of a tooth.

Pharmacologic approaches used for relief of pain and anxiety in

dentistry, in addition to local anesthesia, include sedation and general

anesthesia. These are defined as follows:

Sedation describes a depressed level of consciousness, which may vary from light to deep. At light levels, termed conscious sedation, the patient retains the ability present before sedation to independently maintain an airway and respond appropriately to verbal command. The patient may have amnesia, and protective reflexes are normal or minimally altered. In deep sedation, some depression of protective reflexes occurs, and although more difficult, it is still possible to arouse the patient.

General anesthesia describes a controlled state of unconsciousness, accompanied by partial or complete loss of protective reflexes, including the inability to independently maintain an airway or respond purposefully to verbal command.

When sedative or anesthetic drugs are used, the exact technique can be further described by specifying route of administration, agents used, and their dosage.

children. These modalities tend to reduce fear and anxiety and assist the uncooperative child to accept and continue to receive regular dental care.

Pediatric patients with extensive and complicated treatment needs, with acute pain and/or trauma, as well as those who are physically disabled or mentally retarded, may require sedation or general anesthesia. At times, the very young child (up to 3 years of age) and those with limited or compromised ability

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to comprehend and communicate also are candidates for such procedures.Additionally, there may be an indication for sedation or general anesthesia when the child would be better served by increasing the length of the appointment time and thus reducing the number of visits to accomplish the required treatment.Although the presence of a severe, compromising medical condition is generally a contraindication to sedation, some patients in this category may benefit from its use. These children should be managed in close cooperation with the physician involved in their medical care.While not necessarily contraindicated in the dental office, general anesthesia in the very young child often is best managed in the hospital or a similar setting, especially for lengthy restorative procedures. In all children, severe, compromising medical conditions contraindicate general anesthesia in the dental office.

6.1). NEED FOR THE STUDY

This research project is to expand the body of knowledge related

to pediatric post-operative. It aims to determine the present level of

knowledge and attitudes regarding pediatric post-operative assessment and

management of registered nurses, side effects of anesthesia for pediatric

patients in small general regional pediatric wards. It is only through the

accurate assessment of nurses’ knowledge, attitudes and needs, as perceived

by the nurse, that appropriate strategies can be developed to address the

educational needs of nurses, related to pediatric nursing management

practices. This research also aims to explore how nurses working in these

areas gained their pediatric post-operative management knowledge, and skills,

and if they felt they were able to implement their knowledge within their

clinical setting. Information gained by conducting this research will inform

the body of knowledge related to pediatric nursing care.

The dentist's need for a cooperative and quiescent patient for the rendering of high-quality care is a prime indication for the use of sedation or general anesthesia in some Reliable national estimates of mortality or morbidity associated with the use of general anesthesia and sedation in the dental office are not available for the United States. The most valid data, derived from a population-based study in Great Britain, indicate a mortality rate of 1:250,000

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general anesthetic administrations for the period 1970-1979. Two large surveys of oral and maxillofacial surgeons in the United States suggest lower estimates of risk, ranging from 1:350,000 to 1:860,000; however, the validity of these latter estimates cannot be evaluated because of questions about the survey methods, completeness of data collection, and the degree to which the findings can be generalized.

The British study indicates that treatment with local anesthesia with or without conscious sedation carries less risk than treatment with deep sedation or general anesthesia. Risks may increase in the medically compromised, the elderly, and the very young.

Data concerning morbidity are extremely limited and do not permit the calculation of rates. A general impression suggests that an increased morbidity and mortality are associated with greater duration of anesthesia and complexity of the dental procedure.

Confounding effects of medications being taken by the patient may increase the risks associated with sedation and general anesthesia. A consultation with the patient's physician may be advisable prior to the administration of sedative or general anesthetic agents.

Another important consideration in risk assessment relates to the choice and dosage of specific sedative and anesthetic agents. The use of any effective drug is almost always associated with some undesirable effects. For example, opioid drugs in therapeutic dosage cause respiratory depression and may cause airway obstruction. The use of central nervous system depressants for conscious sedation, especially when used in combinations, requires careful titration and close monitoring to avoid unanticipated deep sedation or general anesthesia.

Special caution is advised when considering anesthetic care for the patient who may develop malignant hyperthermia. A high index of suspicion based on the patient's family history indicates the need for further evaluation and management in the hospital.For the medically compromised patient, the benefits of using sedation to relieve stress sometimes clearly outweigh the risk of aggravating the medical condition.

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So, as an investigator i undertook a study to assess the of

knowledge of staff nurses regarding side effects of anesthesia after

postoperative patients.

6.2). LITERATURE REVIEW:

CLEVELAND – A study aimed at giving health care providers a better

understanding of the multidimensional nature and effects of school-age

children's post-operative pain concludes that using imagery with analgesics

reduced tonsillectomy and adenoidectomy pain and anxiety following surgery.

Findings of the study, "Imagery reduces children's post-operative pain,"

authored by Myra Martz Huth, a 2002 graduate of Case Western Reserve

University's Frances Payne Bolton School of Nursing and co-authored by

Marion Good, professor of nursing at Case, was published in the September

2004 issue of Pain, the influential publication of the International Association

for the Study of Pain. Seventy-three children between the ages of 7-12

participated in the study during a 53-week period, from June 1999 to July 2000.

All children in the study were scheduled for an elective tonsillectomy or

adenoidectomy and were expected to be discharged the same day of surgery.

The children were randomly assigned to one of two groups – a "treatment

group" made up of those who received imagery and analgesic treatment, and an

"attention-control group," or those children who received only pain medication

and no imagery intervention. The intervention was "To Tame the Hurting

Thing," a professionally produced videotape, audiotape and booklets for

school-age children, developed by one of the co-authors, Marion E. Broome,

dean and professor of nursing at the Indiana University School of Nursing in

Indianapolis. They included deep breathing, relaxation and imagery techniques.

The videotape was viewed before surgery and the audiotape was used after

surgery and in the home. "This was the first study to demonstrate a reduction in

school-age children's post-operative pain and anxiety," said Huth, an assistant

vice president at the Center for Professional Excellence at Cincinnati Children's

Hospital Medical Center. Children in the treatment group had significantly less 7

pain and anxiety after surgery than the attention-control group that received

only attention and medication. Imagery did not decrease the amount of pain

medication used, either at the hospital or at home, she added. Children in this

sample reported moderate pain the day of and mild pain on the day after

surgery. "We found that health care professionals and parents need to give

adequate amounts of pain medication in conjunction with non-pharmacology

interventions, like imagery,

Huth :- also said it is hoped that this intervention study will enable

healthcare providers to better understand the nature and effects of children's

post-operative pain and that it will assist them in providing relief for kids. "In

future studies, researchers need to explore imagery tape interventions in

children having different surgical procedures as well as children with chronic

pain," she said.

Good:- says that distracting the child plays a large role in reducing their

pain."The purpose of this study was to examine the effects of imagery – in

combination with routine pain medication – in reducing pain and anxiety

surgery," Good said. Tonsillectomy with or without an adenoidectomy is the

most common ambulatory surgery performed on children under 15 years of age

in the United States. Analgesics are the standard of care in post-operative pain

management with children; however, children and parents have consistently

reported moderate, and in some cases, severe post-operative pain after a

tonsillectomy even after receiving pain medication. The study was funded by a

National Research Service Award received by the researchers from the National

Institute of Nursing Research of the National Institutes of Health.

Post-operative management in children after anesthesia:-

Nurses need to understand pain, be able to assess and manage pain, to

improve the experiences and outcomes of the children in their care. Literature

reviewed for this thesis suggests that for too long, too many children have

suffered unnecessary pain post-operatively, because of the poor understanding

of pain and its management, by medical and nursing professionals (Bennett, 8

2001; Beyer et al., 1983; Burokas, 1985; Collins, 1999; Coyne et al., 1999;

Craig et al., 1996; Eland, 1990; Elander et al., 1993; Ely, 2001; Hammers et al.,

1998; Jacob & Puntillo, 1999b; Lavis et al., 1992; Mather & Mackie, 1983;

Price, 1990; Simons & Robertson, 2002). Unrelieved or poorly managed post-

operative pain delays healing, alters immune function and increases the levels

of stress and anxiety of the child and their family, resulting in increased length

of stay, higher readmission rates, and more frequent outpatient visits. It can also

have profound long lasting consequences, and may increase emotional and

behavioral responses during future painful events. Inconsistent approaches to

the management of post-operative pain in hospitalized children has been

attributed to a lack of knowledge, specifically that of the concept of pain, the

ability to assess pain accurately, and the use of pharmacological and non-

pharmacological interventions (Carr & Mann, 2000; Coyne et al., 1999). Many

studies into the management of pediatric post-operative pain have occurred

(Bennett, 2001; Burokas, 1985; Carr & Mann, 2000; Eland & Anderson, 1977;

Elander et al., 1993; Ely, 2001; Frank et al., 2000; Hammers et al., 1998; Jacob

& Puntillo, 1999b; Mather & Mackie, 1983; Salantera, 1999; Simons &

Robertson, 2002). Most of these are retrospective studies, using questionnaires

or individual and group interviews, and all support the belief that children

receive insufficient pain relieving medication when compared with adults in

similar circumstances. Furthermore, the findings in the more recent studies

reflect similar issues to those that were reported more than two decades ago

(Beyer et al., 1983; Burokas, 1985; Hester & Barcus, 1986; Schechter, 1989).

Key issues relating to the post-operative management of pain in

children that repeatedly appear in literature are those of the attitudes and

misbeliefs of the doctors, nurses, children and their families; time and workload

of nurses; and the lack of relevant knowledge and education of nurses, medical

staff, children and their families. This lack of knowledge and education appears

to be intrinsic in the inadequate assessment and management of post-operative

paediatric pain.

Attitudes and misbeliefs related to children and pain :-9

Attitudes and misbeliefs held by nurses have been identified by many

researchers as contributing to how well nurses are able to achieve effective pain

assessment and pain management (Adams & Field, 2001; Brown et al., 1999;

Burokas, 1985; Carr & Mann, 2000; Chapman, Ganendran, Scott, & Basford,

1987; Clarke et al., 1996; Eland & Anderson, 1977; Heath, 1998; Lavis et al.,

1992; Lebovits et al., 1997; Manworren, 2000, 2001; McInerney, Goodenough,

Jastrzab, & Kerr, 2003; Miller, 1994; Salantera, 1999; Schechter, 1989; Sofaer,

1992; Wessman & McDonald, 1999). Furthermore, in a survey of pediatric

critical care nurses, attitude was identified as a key influence in the

management of pain (Pederson & Bjerke, 1999). Poor attitudes about pain and

pain management are often based on misbeliefs.

Misbeliefs related to narcotic use and administration :-

Many of the poor attitudes and misbeliefs identified, relate particularly

to the use of narcotics and the fear of subsequent respiratory depression or

addiction (Bishop-Kurylo, 2002; Burokas, 1985; Eland, 1990; Miller, 1994).

Because of potential side effects, research has revealed that many nurses

believe children should not be given opioid analgesia for pain. A consequence

of this belief is a reluctance to administer narcotic analgesia to children,

resulting in poorly managed pain experiences for children. Research has also

identified that many nurses and other health professionals feel that children are

at greater risk of complications and addiction. However, all drugs have side

effects. Respiratory depression, the most likely adverse effect of a narcotic, and

the side effect that causes the most concern, is quickly reversible should it

occur. Studies show that children and infants, when given appropriate dosages

of narcotics, have no greater risk of respiratory depression than adults

(Atkinson, 1996; Carter, 1998; Eland, 1990). Side effects of other commonly

given drugs, for example penicillin, can be potentially more lethal. It is

important for nurses to remember that 15 out of every 1000 people who take

penicillin will develop true anaphylaxis, yet it is prescribe and administered

intravenously, more freely than narcotic analgesia (Atkinson, 1996).

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Lack of knowledge and education :-

As effective pain management is viewed as a patient’s right, nurses

need a background of appropriate education and sufficient resources to

administer effective pain management. (Leek et al., 1995, p. 1) According to

the literature reviewed, attitudes and misbeliefs about post-operative pain and

its management often occur as a result of lack of knowledge. Several authors

hypothesise that schools of nursing have not adequately educated nurses to

enable them to effectively assess, critically analyse and manage pain (Chui,

Trinca, Lim, & Tuazon, 2003; Manias & Bullock, 2002; Zalon, 1995). Nurses’

knowledge relating to pain management issues, and their ability to incorporate

pain management theory into practice, is dependent on the education they

receive, in both the academic and clinical setting (Carr & Mann, 2000; Zalon,

1995). Lavis et al. (1992) conducted a questionnaire survey of adult patients,

doctors and nurses, in an attempt to identify beliefs and attitudes to post-

operative pain. Their study conclusion was that education was clearly needed

for all groups involved in pain management. Ideally this should begin for

doctors and nurses at the undergraduate level, while patients’ education should

begin at first presentation to a health professional. Whilst this was a survey of

nurses in an adult area, other literature reviewed would support the assumption

that these findings would be the same in the pediatric setting (Craig et al., 1996;

Hammers et al., 1994; Jacob & Puntillo, 1999b; Manworren, 2000). Following

their review of current research and professional literature Craig et al. (1996)

proposed that all health care professionals required further education, not only

in ways of treating pain, but also in the understanding of the nature of pain and

the social context of pain. Manworren (2000) in a survey of pediatric nurses’

noted that nurses with masters’ degrees and those that worked in specialised

areas like intensive care units and haematology/oncology wards consistently

ranked higher, than other nursing units, in areas of pain assessment, drug

interactions, and effectiveness of dosing. This would appear to support the

theory that post graduate education and increased knowledge improves

pediatric pain management with regard to pain assessment and pain

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management. The current literature would suggest that many nurses when

compared to physicians, were more knowledgeable on the subject of pain

assessment and management of pain, but they understand less about other

aspects of pain, for example pharmacology (Chui et al., 2003; Coyne et al.,

1999; Furstenberg et al., 1998; Manias & Bullock, 2002). In the New Zealand

context there is no undergraduate education specific to child health nurses. The

lack of such specific educational programs, possibly impacts on the extent of

pediatric pain pharmacology, assessment and management content that there is

within the current nursing curriculum. This also impacts on how much of this

knowledge is held by registered nurses undertaking clinical practice in the

pediatric setting for the first time. When beginning to practice for the first time

nurses are guided by competencies as set out by their governing body, and the

policies and protocols of the organisation and area that they work in. However,

nursing practice should be viewed as a continuum, ranging from basic nursing

practice to advanced nursing practice. The Most international surveys into

nurses’ knowledge and attitude towards post-operative pain are undertaken in

large teaching or university hospitals (Clarke et al., 1996; Hamilton & Edgar,

1992) or in multiple settings (Van Niekerk & Martin, 2001). While many of

these surveys do not identify if any of their respondents work in a paediatric

setting (Clarke et al., 1996; Hamilton & Edgar, 1992; Heath, 1998), those that

do, report only small numbers 6.9% (Brown et al., 1999) and 5.9% (Van

Niekerk & Martin, 2001). Questionnaires are reported to be distributed either

by identified people (Hamilton & Edgar, 1992), or posted out to the identified

sample (Van Niekerk & Martin, 2001). Return rates and overall size of the

surveys ranged from 26% (n=260) (Brown et al., 1999) to 54.7% (n=318)

(Hamilton & Edgar, 1992). However one survey of nurses’ knowledge of pain

management undertaken closer to New Zealand was the survey of Tasmanian

nurses by Van Niekek and Martin (2000). By adapting the Pain Management

Nurses’ Knowledge and Attitude survey instrument first developed by Ferrell

and Leek in 1987 and revised in 1993, Van Niekek and Martin surveyed 2710

Tasmanian nurses, receiving a 38% (n=1015) return rate.

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Studies on dexamethasone’s antiemetic and analgesic

Potential in children undergoing tonsillectomy have produced

conflicting results. The aim of this study was to evaluate the effects of a single

dose of dexamethasone on the incidence and severity of postoperative

vomiting and pain in children undergoing electrocautery tonsillectomy under

standardized general anesthesia. Methods  In a double-blinded study 120

patients were randomly allocated to receive either dexamethasone 0.5

mg·kg−1 (maximum dose 8 mg)iv or an equivalent volume of saline

preoperatively. The incidence of early and late vomiting, need for rescue

antiemetics, time to first oral intake, time to first demand of analgesia and

analgesic consumption were compared in both groups. Pain scores used

included Children’s Hospital Eastern Ontario Pain Scale, “faces”, and a 0–10

visual analogue pain scale.

Results  Compared with placebo, dexamethasone significantly

decreased the incidence of early and late vomiting (P < 0.05,P < 0.001

respectively). Fewer patients in the dexamethasone group needed antiemetic

rescue (P < 0.01). The time to first oral intake was shorter, and the time to

first dose of analgesic was longer in the dexamethasone group (P < 0.01). Pain

scores 30 min after extubation were lower (P < 0.05) in the dexamethasone

group. At 12 and 24 hr postoperative swallowing was still significantly less

painful in the dexamethasone group than in the control group (P < 0.01).

Conclusion  Preoperative dexamethasone 0.5 mg·kg−1 iv reduced both

postoperative vomiting and pain in children after electrocautery tonsillectomy.

La dexaméthasone réduit les vomissements et la douleur postopératoires après

une amygdalectomie pédiatrique Résumé

The purpose of this evidence-based clinical update was to identify

the best evidence to determine if behavioural outcomes are

improved in children after oral midazolam premedication.

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Methods  A literature search was conducted using both PubMed and

OVID programs, utilizing the terms ‘midazolam’, and either ‘premedication’ or

‘preoperative treatment’. Search limits that were employed included

randomized controlled trials (RCTs), English language, human studies, children

aged 0–18 yr, and publication dates 1990 — present (January 2006). A review

of the 171 abstracts obtained was undertaken and, of these, 30 papers were

identified that concerned oral midazolam in children prior to general anesthesia,

and that involved a RCT with a placebo or control arm. These studies were

assigned levels of evidence, and grades of recommendation were made

according to Centre for Evidence-Based Medicine criteria. Results  Oral

midazolam premedication in children was found to reduce the anxiety

associated with separation from parents/ guardians, and with induction of

anesthesia. Recovery times are not significantly delayed. There is no consistent

evidence to suggest a reduction in the phenomenon of emergence agitation.

Evidence suggesting an improvement in behavioural outcomes at home is also

inconsistent. Conclusion  Premedication with midazolam 0.5 mg·kg−1 po

administered 20–30 min preoperatively, is effective in reducing both separation

and induction anxiety in children (grade A recommendation), with minimal

effect on recovery times. However improved postoperative behavioural

outcomes in the postanesthesia care unit, or at home cannot be predicted on a

consistent basis.

Patient-controlled regional analgesia (PCRA):

Purpose  To report a preliminary analysis of prospectively recorded

data in 27 children in whom patient-controlled regional analgesia (PCRA) was

used for postoperative pain control following lower limb surgery.

Methods  Under general anesthesia, perineural catheters (popliteal and fascia

iliaca compartment block) were inserted and infused with ropivacaine 0.2%

(0.02 mL·kg−1hr−1). Additional demand doses were left to the child’s

discretion (0.1 mL·kg−1 and a 30-min lockout interval). Results  The average

total dose of ropivacaine administered was 4.9 ± 2 mg·kg−1 over 48 hr. Visual

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analogue scale and Children’s Hospital of Eastern Ontario Pain Scale scores

were always inferior to 5/10 and 6/13, respectively. Motor block was observed

in two children and two children needed rescue analgesia. Conclusions  Our

preliminary observations indicate that PCRA in children provides satisfactory

postoperative pain relief following lower limb surgery.

Purpose  To evaluate intranasally administered fentanyl for

postoperative analgesia in pediatric patients.

Methods  Thirty-two children aged four to eight years, ASA physical

status I and II were included in this prospective randomized controlled study.

In the postoperative care unit, patients were allocated to receive fentanyl, using

a double-blind study design, either intranasally (Group I) or intravenously

(Group II) in small titrated doses until they became pain free or side effects

appeared which prohibited continuation of the drug. Results  Satisfactory

analgesia was achieved in both groups, though the required drug dosage was

higher in the intranasal group ( 1.43 ± 0.39 μ· kg−1). Onset of analgesia tended

to be slower via the intranasal route compared to theiv route ( 13 ± 4.5vs 8.3 ±

3.08 min;P = not significant). Side effects observed in this series were within an

acceptable range and similar for both modalities. Conclusion  The intranasal

route provides a good alternative for administration of fentanyl in pediatric

surgical patients.

Purpose  To investigate if 50% nitrous oxide reduces the pain

during injection of propofol mixed with lidocaine in children.

Methods  Healthy children undergoingiv induction of general

anesthesia for elective surgery were recruited into this prospective, randomized,

double-blind study. None of the patients received any premedication except for

eutectic mixture of local anesthetics cream. Before induction of anesthesia with

propofol 1% mixed with lidocaine 0.05% (propofol dose 3 mg·kg−1), the

treatment group received 50% N2O in O2 and the control group received 100%

oxygen. Pain due to propofol administration was rated with a four-point

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behavioural scale: none, mild, moderate or severe. Results  There were 28

subjects in the control group and 26 subjects in the treatment group.

Demographic data were similar in both groups. The incidence of pain at

induction was 4% after N2O and 36% in the control group,P < 0.01. No

patients had severe pain. Most patients had mild pain. Three of the ten patients

with pain in the control group had moderate pain. The number needed to treat

was 3:1. Conclusion  Nitrous oxide reduces pain during induction with propofol

mixed with lidocaine in healthy children.

Purpose  Evaluate the efficacy of advanced life support

interventions using the pediatric Utstein guidelines.

Methods  Charts from all patients for whom a cardio respiratory arrest

code was called during a six-year period in a university affiliated center were

reviewed. Data were recorded according to the pediatric Utstein guidelines and

aP < 0.05 was considered significant. Results  Of the 234 calls, 203 were

retained for analysis. The overall survival rate at one year was 26.0% of which

10% had deterioration of their neurologic status compared to the pre-

cardiorespiratory arrest evaluation. Time to achieve sustained return of

spontaneous circulation (ROSC;P < 0.0001) and sustained measurable blood

pressure (P = 0.002), to perform endotracheal intubation (P = 0.04) and the dose

of sodium bicarbonate (P < 0.0001) were indicators of long-term survival. Two

patients were alive at one year with unchanged neurologic status despite a time

to achieve sustained ROSC longer than 30 min (38 and 44 min). The mean first

epinephrine dose of patients for whom ROSC was achieved but unsustained

was higher than those for whom ROSC was achieved and sustained (0.038 ±

0.069 mg·kg−1 vs 0.01 1 ± 0.006 mg·kg−1; P = 0.004). Survival rate and mean

first epinephrine dose of patients who received their first epinephrine dose

endotracheally(13.3%; 0.01 1 ± 0.004 mg·kg−1) were comparable to those of

patients who received their first epinephrine dose intravenously (7%; 0.015 ±

0.027 mg·kg−1). Conclusions  For intravenously administered epinephrine, a

dose of 0.01 mg·kg−1 seems appropriate as the first dose. The endotracheal

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route is a valuable alternative for epinephrine administration and, for infants,

the dose does not need to be increased. A minimal resuscitation duration time

of 30 min can be misleading if ROSC is used as the indicator.

NEW RESEARCH: CHILDREN ARE NOT BEING TREATED FOR

POST-OPERATIVE PAIN:

British Pharmaceutical Conference, Manchester. Children

recovering from day case surgery are not being treated for post-operative pain

because their parents do not see it as a priority, according to (the interim results

of) new research by the School of Pharmacy in Manchester, launched today at

the British Pharmaceutical Conference.More than 50% of children’s surgery is

now performed on a day-case basis and postoperative pain is a relatively

common problem1. This study indicated that 54% of parents reported that their

children experienced pain at home after day-case surgery.Parents are

responsible for post-operative care of the child after discharge from daycase

surgery but the evidence suggests that parents do not effectively manage

postoperative pain. Children’s post-operative pain is a relatively low priority

following surgery to parents.

The new research found that parent’s prioritised their child’s needs as follows:

(in order of importance from most to least)

• quality of recovery from anaesthesia

• parental presence during anaesthesia induction

• parental involvement in medical decision making

• staff attitude

• post-operative pain and

• cost to the parent.

Pharmacist, Wendy Gidman, said that parents often don’t give their children

enough analgesics following day-case surgery and, until now, the reason for this

has not been understood.

“Previous research shows that parents do not effectively treat the child’s pain

following surgery - even when they are aware that their child is in pain3,” she

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explained. “We know that this has adverse effects on the health and well being

of the child such as poor fluid intake, sleep disturbance and behavioural

changes4.”

Ms Gidman said that the new research has given a clear indication that parents

have different priorities for their child following surgery, other than treating the

pain. “It is vital that health professionals help parents to understand the

importance of pain management in the recovery process of their child following

surgery,” she concluded.

Preliminary evidence suggests that the use of the Parents’ Post-Operative

Pain Measure (PPPM) promotes 1 to 6- year-old childre n ’s non-pharma

cologicalpain alleviation at home aftersurgery. Lehikoinen (2007) found that

the parents who were given the PPPM used several non-pharmacological pain

alleviation methods more thanp a rents in the control group. However, no diffe

rences in the use of analgesics between the intervention group and the control

group of parents were found. Lehikoinen (2007) studied children ages 1 to 6

years. According to Bonham (1996), children’s responses to pain differ during

their developmental stages. Children ages 1 to 3 years express their pain mainly

by crying, screaming, identifying pain location, and talking aggressively, while

older children can describe the intensity of pain. There f o re, it was necessary

to explore the influence of the PPPM with children ages 1 to 2 years who

express their pain in a similar way. The purpose of this study was to evaluate

the influence of parental use of PPPM on the use of pain medication at home

for 1 to 2-year-old children. The re s e a rch questions were:

• How intensive is children’s postoperative pain at home during the day of

surgery and on the first two post-operative days?

• Which analgesics do parents give to their children at home?

• How much are analgesics used among the children?

• How does the use of PPPM influparticipation in the total amount of analgesics

and the optimal dose given to the child?

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Methods:-Sample and Setting P a rents of 100 children scheduled for day

surgery in three university hospitals in Finland were invited to participate

in the study between January 2006 and June 2007. The parents of 50

children between 1 and 2 years of age agreed to participate, and 50 refused

to participate. One pare n t from each family participated in the study.

Convenience sampling was used. The study nurses invited every second

consecutive parent whose child had a surgical day case procedure into the

intervention (n = 29) or control group (n = 21). Every parent was asked to

participate: first parent to the intervention group, second parent to the

control group, third parent to the intervention group, and so on.

STATEMENT OF THE PROBLEM: - A study to assess the level of knowledge and Practice of staff nurses

regarding Common side effects and management of Anesthesia in post operative

ward in selected child health hospital at Bangalore.

6.3) OBJECTIVES: -

To assess the level of knowledge of staff nurse’s regarding common

side effects of anesthesia by conducting pretest.

.

To determine the assess the effectiveness of structured teaching

programme by conducting post test.

To find out the association between pretest knowledge scores with

selected demographic variables.

6.4) HYPOTHESIS: -

H1 - There is a significant association between the demographic

variables

and knowledge regarding side effects of anesthesia.

6.5)RESEARCH VARIABLES: -

INDEPENDENT VARIABLES: - Nursing management of post operative

patients.19

DEPENDENT VARIABLES: - Knowledge regarding common side effects of

anesthesia.

DEMOGRAPHIC VARIABLES: - Selected demographic variable such as age,

sex, education, years of experience, working experience in pediatric ward,

previous knowledge about post operative care.

6.5) OPERATIONAL DEFINITION: -

Assessment: - It refers to evaluate the staff nurse’s knowledge on post operative

management of pediatric patients after anesthesia.

Effectiveness: - It refers to significant difference between the pretest and

post test knowledge scores of staff nurse’s on common side effects of

anesthesia in post operative patients.

Structured teaching programme: - It is an education given by the investigator

for 45 to 60 minutes with the help of the A.V aids. It includes definition, types

and side effects of anesthesia and pediatric post operative nursing

management.

Knowledge: - It refers to the level of understanding of staff nurse’s regarding

side effects of anesthesia and pediatric post operative nursing management.

6.6) ASSUMPTIONS:

Staff nurse’s posses some knowledge regarding anesthesia and it’s side

effects.

Knowledge can be assessed with the help of knowledge questions.

6.7) DELIMITATIONS:20

The study is limited to the staff nurse’s.

7.0) MATERIAL AND METHODS: -

7.1) SOURCE OF DATA: - Staff nurse’s who are going to get the knowledge

will be the source of data.

7.2) METHODS OF COLLECTION OF DATA: - Self-administered

questionnaire regarding side effects and management of anesthesia.

7.2.1) RESEARCH DESIGN: -

QUASI EXPERIMENTAL RESEARCH DESIGN: - The design adopted for

the present study was represented as.

O1 - Knowledge test before administration of structured teaching

programme.

X - Structured teaching programme on side effects and management of

anesthesia.

O2 - knowledge test after administration of structured teaching programme.

7.2.2) RESEARCH APPROACH: -

7.2.3) SETTING: -

7.2.4) POPULATION: -

The population of present study is staff nurse’s working in a selected hospital,

Bangalore.

7.2.5) SAMPLE SIZE: -

21

The sample of the study consists of 50 staff nurses who are working in

selected hospital.

7.2.6) SAMPLING PROCEDURE: -

Simple Random sampling techniques procedure

7.2.7) CRITERIA FOR THE SAMPLING: -

INCLUSIVE CRITERIA: -

Staff nurse’s who are willing to participate in data collection.

Staff nurse’s who are available at the time of data collection.

It includes who can read and write English.

EXCLUSIVE CRITERIA: -

Staff nurse’s who are not willing to participate in data collection.

Staff nurse’s who are not available at the time of data collection.

DATA COLLECTION TOOLS: -

Pretest and post test will be used to assess the knowledge of anesthesia and

management among staff nurse’s. It consist of two parts; part I & part II

Part I: - Selected demographic variables such as age, sex, education, years of

experience, working experience in pediatric ward, previous knowledge about

post operative care.

Part II: - Self administered questionnaire on anesthesia and management.

DATA ANALYSIS METHOD: -

Data analysis will be through both descriptive and inferential statistic.

7.3) DOES THE STUDY REQUIRE ANY INTERVENTION TO BE

CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS

22

Yes the study will be conducted on staff nurses by improving

knowledge through structured teaching programme.

7.4) HAS ETHICAL CLEARANCE BEEN OBTAINED FROM

YOURS INSTITUTION

Yes, prior permission will be obtained from the research committee of

the Sushrutha College of nursing, Bangalore.

References

A.M. Egbert, L. H. Parks, L. M. Short and M. L. Burnett (1990).

Randomized trial of postoperative patient-controlled analgesia vs.

intramuscular narcotics in frail elderly men. Achieves of Internal

Medicine150 (9).

Ballantyne JC et al (1993). Postoperative patient-controlled analgesia:

meta-analyses of initial randomized control trials. J Clin Anesth. 5(3):182-

93.

Berde, Lehn, Yee, Sethna, Russo (1991).Patient-controlled analgesia in

children and adolescents: a randomized, prospective comparison with

intramuscular administration of morphine for postoperative analgesia. J-

Pediatr 118(3): 460-6.

Behrman RE, kliegmam RM, jonson HB, “Nelson text book of pediatrics”,

17thEdition Philadelphia: WB saunders, 2005.

Gregorry GA, pediatric anesthesia, 4th Edition New york – Churchill

livingstone, 2005.

Brunner and suddarth’s text book of medical surgical nursing, 7th Edition

page 401-473.

Fundamentals of nursing, BT basavanthappa, Jaypee publishers,

page 457 – 485.23

A Lippincott Williams and Williams, hand book of clinical anesthesia

procedures of the Massachusetts General hospital, 7th Edition page 422 –

539.

Pediatric anesthesia volume 19 issue 12 , page 1141 – 1146, Black well

publishing ltd, 2009.

AAP. (2001). The assessment and management of acute pain in infants,

children, and adolescents. Pediatrics, 108(3), 793-797.

Elander, G., Hellstrom, G., & Ovarnstrom, B. (1993). Care of infants after

major surgery: observation of behavior and analgesic administration.

Pediatric Nursing, 19(3), 221 - 226.

Jacob, E. J., & Puntillo, K. A. (1999a). A survey of nursing practice in the

assessment and management of pain in children. Pediatric Nursing, 25(5),

278 - 286.

Jacob, E. J., & Puntillo, K. A. (1999b). Pain in hospitalized children:

pediatric nurses' beliefs and practices. Journal of Pediatric Nursing, 14(6),

379 - 391.

Lavis, N., Hart, L., Rounsefell, B., & Runciman, W. (1992). Identification

of patient, medical and nursing staff attitudes to postoperative opioid

analgesia: stage 1 of a longitudinal study of postoperative analgesia. Pain,

48, 313 - 319.

Hester, N., & Barcus, C. (1986). Assessment and management of pain in

children. Paediatric Nursing Update, 1, 1-8.

Seaman, C. (1987). Research methods: principles, practice, and theory for

nursing (3rd ed.). East Nor Moore, S. E. (2001). A growth of knowledge in

pain management. Pediatric Nursing, 27(3), 307.

walk: Appleton and Lange.

24

http://www.nhs.uk/conditions/epidural-anesthesia/pages/sideeffects.aspx

http://www.brandianestesia.it/english/complications.html.

http://www.righthealth.com/topic/anesthesia-side-effects

http://www.springerlink.com

http://www.virtualpediatrichospital.org/patients/cqqa/painmanagement.shtml

1) SIGNATURE OF THE STUDENT: -

2) REMARK OF THE GUIDE: -

The topic is relevant and it helps to enhance the knowledge of staff

nurse regarding side effect of anesthesia and it’s management.

25

3) NAME & DESIGNATION OF GUIDE:

4) GUIDE NAME & ADDRESS: -

5) SIGNATURE OF GUIDE:-

6) HEAD OF THE DEPARTMENT:

7) SIGNATURE OF HOD:-

8) REMARK OF THE PRINCIPAL: -

9) SIGNATURE OF THE PRINCIPAL: -

26