Dental rehabilitation is a common outpatient pediatric surgical procedure. It requires the dentist to restore or extract the teeth of children with severe tooth decay or poor dental hygiene. Medical, physical, or emotional problems can make safe treatment in an outpatient setting impossible. These children require sedation or anesthesia for the dentist to gain access to their oral cavities. This article discusses caring for pediatric patients with spina bifida and latex allergy undergoing dental rehabilitation. Perioperative nurses must act as patient advocates in providing a latex-safe environment and also ensure quality care. AORN J 74 (July 2001) 57-72.
Our society is in the midst of a dental revolution. Most people now reach adulthood with few or no fillings in their teeth. This revolution has transpired partly through advances in dental science and a greater awareness of the importance of oral health through dental education. People also are undergoing innovative forms of treatment, such as aesthetic dentistry, bone-integrated implantation, and adult orthodontics. All of these treatments promote healthier teeth and improve self-image, as well as quality of life. Despite these advances, however, tooth decay remains an epidemic in lower socioeconomic and medically compromised populations because of poor dental hygiene and lack of preventive care.
Dental caries also are present in specific pediatric populations. Children with neural tube defects (NTDs), such as spina bifida, are prone to childhood dental caries because their neurological impairment can make dental care difficult or impossible. Spina bifida can interfere with activities of daily living. Often children with this disability need assistance with eating, clothing, and toileting from caregivers. In the midst of all these needs, diligent oral hygiene may be considered less important and thus be neglected. Dental health in children with special needs is as essential as immunizations, regular physical examinations, and attention to injury prevention. Children with NTDs may acquire dental caries because of poor dental hygiene, poor nutritional intake, and long-term medication therapy.(1)
Neurogenic bladder dysfunction is a common problem found in children with NTDs. A majority of these children suffer from urinary incontinence and are subject to persistent urinary infections. Urological care involves regular emptying of the bladder (ie, intermittent, clean catheterization) performed by a caregiver and, if possible, self-catheterization taught to the child.
Children with NTDs also have predispositions to latex allergy. The prevalence of latex allergy in children with spina bifida ranges from 28% to 67%.(2) This population of children may become sensitized to latex allergens from mucosal latex exposure as a result of procedures involving the use of latex products (eg, gloves, catheters, IV tubing, blood pressure cuffs).
Family members or caregivers of a child with latex sensitivity who needs dental care must make special preparations before the dentist and office staff members can provide safe care. In addition, parental anxiety concerning problems associated with NTDs frequently delays dental care, causing significant oral disease to develop. This delay may lead the pediatric dentist to choose to perform any required dental treatment in an OR with the child under general anesthesia.
Ideally, adults should have 32 permanent teeth. The function of teeth is to begin the digestive process by breaking food into small enough pieces to mix with saliva and be swallowed. Some teeth are specifically designed to aid in the mastication process. Incisors cut food, and cuspid and bicuspid teeth grasp and tear food (Figure 1). The teeth that grind food are referred to as molars. Children have 20 primary teeth that gradually are replaced by permanent teeth.
Good dentition (ie, a healthy mouth with teeth that are free from periodontal disease and caries) depends on the health of the teeth and the hard and soft tissues of the mouth. Primary teeth are for mastication and the facilitation of speech. In addition, they are important for proper facial contour. A child's first set of teeth contributes to appearance, which affects his or her self-confidence and self-esteem. Primary teeth also affect the succession of permanent teeth, determining whether they erupt into good alignment.(3)
Tooth anatomy. There are two parts to a tooth: the crown, which is covered by enamel and is the visible part of the tooth, and the root, which lies underneath the gums. Enamel is the hardest substance in the body, and it protects the teeth from decay; however, it does not regenerate. After teeth erupt, enamel cells die and cannot be replaced if damaged. The root is encased by cementum, which is much thinner than enamel and not as durable. Dentin surrounds the pulp or core of the tooth. The pulp cavity contains nerves and blood vessels, which nourish the tooth.(4)
Dental caries. Dental caries occur when bacteria destroy the enamel surface of the tooth and cause decay. Two major culprits of this disease process are dental plaque and fermentable carbohydrates. Components of dental plaque are a bacterium known as Streptococcus mutans and to a lesser extent Lactobacilli. Fermentable carbohydrates (eg, cake, doughnuts, pastries, ice cream, jams, chocolate milk, carbonated beverages) react with bacterial plaque to metabolize and produce acid. Fermentable carbohydrates are ingested, producing acids that demineralize teeth.(5) Foods create an acid environment for the teeth. The combination of bacteria and sugar weakens the structure of the teeth and causes discomfort. Children on long-term medications for health problems often are susceptible to caries because of the high sucrose content of many medications.
Children with spina bifida are prime candidates for dental caries. Many of these children tend to be overweight, which can be attributed to frequent snacking and impaired mobility due to the nature of their disability.(6) Caloric intake for these children often exceeds energy expended and is coupled with a lack of stimulation from physical activities. Caregivers may use food as a demonstration of affection or as a reward. Without good oral hygiene, this creates a perfect environment for bacteria and sugar to be retained in the mouth, making the teeth susceptible to decay. These children often are seen for extensive dental rehabilitation.(7)
Preventing caries. There are numerous ways to prevent dental caries. The most obvious is to brush the teeth at least twice per day using fluoridated water and fluoridated toothpaste. Dental hygiene, however, is a life-long process. Caregivers should provide dental care as soon as the child's first teeth erupt, according to the American Academy of Pediatric Dentistry.(8) Parents or caregivers should clean the gums and mouth of children who do not have teeth yet with moist gauze. Children older than one year and children with disabilities need an appropriately sized tooth brush and require assistance with brushing. The use of an electric toothbrush can be beneficial for children who have poor plaque removal technique because of their lack of manual dexterity.(9)
A regularly scheduled dentist visit starting as soon as the child's first teeth erupt is essential to maintaining healthy teeth. Brushing does not reach all the surfaces of the teeth; flossing is a necessity for preventing plaque. Plaque accumulates in the proximal surfaces between teeth and in the v-shaped sulcus between the teeth and gums. Children should start flossing under supervision as soon as there are two surfaces of teeth that meet.(10)
Statistical data on how many children with spina bifida experience dental caries are difficult to find. These children, however, are at greater risk for periodontal disease than the general population because of their disabilities and potential defects in the developmental formation of their enamel.(11) At the Childrens' Hospital of Philadelphia, a large percentage of these children present to the dental clinic with both dental caries and latex allergy.
There are two common forms of this NTD--spina bifida occulta and myelomeningocele (meningomyelocele) (Figure 2). These two forms can be grouped further into two classifications described as opened and closed forms. Spina bifida aperta (ie, open) refers to true myelomeningocele defects. This form is the most severe because the spinal cord, spinal fluid, and membranes protrude in a sac through the defect in the laminae of the vertebral column. Surgical intervention to close the defect is performed as soon as possible to prevent infection of the nonepithelialized meningeal sac. The myelomeningocele defect has many associated problems, such as hydrocephalus, paralysis, orthopedic deformities, and genitourinary abnormalities.(12)
Children with spina bifida occulta (ie, closed) present with a skin covering the area. The defect occurs in the vertebral column with tissue protrusion through a bony cleft. It usually is observed as a tuft of hair, a dimple, or a pigmented area above a defect. Sometimes with growth, children with this condition may develop foot weakness or bowel and bladder sphincter disturbances.(13) Figure 2 shows a normal spine and the types of spina bifida defects commonly seen.
The etiology of spina bifida is unknown, although it is thought to be the result of a genetic predisposition manifested by the environment. It is an arrest in the orderly formation of the vertebral arches and spinal cord that occurs between the fourth and sixth week of embryogenesis. Recent evidence shows that NTDs may be caused by the interaction of a genetic predisposition for the defect and a deficiency of folic acid or poor metabolism of folic acid. Multivitamins containing folic acid taken during the first six weeks of pregnancy can prevent more than 50% of NTD occurrence.(14)
Geographic distribution and incidence of NTDs are varied. Approximately one out of every 1,000 live births in the United States will have a confirmed NTD. It is more prevalent in Caucasians and Hispanics. Furthermore, NTDs are believed to be the most common developmental defect of the central nervous system.(15) Complications of this congenital abnormality range from paralysis, hydrocephalus, scoliosis, contractures, and joint dislocation to potential skin erosion of sensory denervated areas.(16)
Latex sensitivity is a life-threatening allergy and is common in pediatric patients with NTDs. The actual reported incidence of latex sensitivity varies, but it has increased between 1980 and the present. The incidence in the general population, which has been less than 1%, now may be as high as 6%.(17) Children with spina bifida have a latex allergy prevalence of 28% to 67%.(18) The present treatment for latex allergy is careful avoidance of latex products. There are three main types of latex sensitivity reactions: contact dermatitis (ie, irritant and allergic responses), allergic contact dermatitis, and immediate hypersensitivity.(19)
Contact dermatitis. Contact dermatitis may be caused by sweating under gloves, incomplete drying of the hands, soap or detergent residuals, other irritants, or prolonged contact with gloves (ie, glove occlusion) and glove powder.(20) Symptoms can include redness, cracks, fissures, and scaling of areas exposed to latex products. These reactions are not considered true allergic reactions to latex. They are not life threatening and can be avoided by removing contact with the irritant (eg, latex gloves).(21)
Allergic contact dermatitis. This reaction begins six to 48 hours after contact with latex products. Symptoms, also caused by rubber accelerators and chemical additives, include redness, itching, crusting, and blisters, resembling the reaction to poison ivy or poison oak. Approximately 80% of allergic reactions are this type.
Immediate hypersensitivity. The third type of reaction is an immediate hypersensitivity, or immune globulin E (IgE)-mediated reaction, caused by the natural latex proteins found in rubber, which can result in anaphylaxis. This is a potentially severe reaction that begins within minutes of exposure to latex products and requires treatment. Early symptoms include itching and burning of hands and a runny nose. More severe symptoms include hives, light-headedness, swelling of the lips or eyelids, nausea, vomiting, abdominal cramps, wheezing, and anaphylactic shock.(22) As anaphylactic shock progresses, laryngeal edema, bronchospasm, hypotension, and circulatory collapse may occur.(23)
Anaphylactic episodes can occur through systemic exposure to latex via mucous membranes, internal tissues, inhalation, and cutaneous contact. Immediate hypersensitivity is a systemic or local reaction to the proteins found in latex. Natural latex rubber contains many natural proteins, amino acids, lipids, and other substances added during the vulcanization process that are thought to be the source of latex sensitization.(24) Latex-allergic individuals test positive for IgE antibodies, the immune-mediated response to latex allergy.(25)
Other considerations. Children with spina bifida and latex sensitivity may present initially with an allergic contact dermatitis reaction. These children are treated as latex allergic when this occurs, and latex precautions are required to prevent sensitivity reactions from progressing to anaphylactic shock.(26) Often, parents or caregivers are not aware of the risk of sensitivity to natural rubber latex. They should be encouraged to have their child tested for possible latex allergy, especially if latex sensitivity is suspected.
Numerous materials contain latex. Some health care products contain latex, including gloves, urinary catheters, dental dams, and bite blocks (Table 1). Latex allergic individuals often have cross-sensitivity to certain foods that contain some of the polypeptides found in latex (eg, bananas, avocados, kiwi, raw potatoes, tomatoes, chestnuts).(27)
Table 1 EXAMPLES OF HEALTH CARE PRODUCTS CONTAINING LATEX Patient care items Anesthesia items * Bandages (eg, elastic * Airway masks bandage wraps, adhesive, sterile adhesive bandage * Anesthesia bags, strips) tubing, and bellows * Blood pressure cuffs, * Ambu bags tubing, and bladders * Nasal airway * Catheters (eg, gastric, urinary, IV) * Catheter leg bag straps * Electrocardiogram pads * IV injection ports, medication vial ports * Stethoscopes * Syringe plunger tips * Gloves
It is crucial to remember that children with spina bifida who have tested negative for latex allergy should be considered negative only for the day they were tested, as they are capable of becoming allergic in the future. It is becoming standard practice to treat all patients with spina bifida as latex sensitive regardless of their test status because of increased risk for latex allergy. Health care facilities should provide a latex-safe environment to protect latex-sensitive patients and health care workers. Information regarding latex allergy should be available to patients and employees at every health care facility. Early intervention to eliminate and decrease exposure to latex through education is vital in preventing the development of latex allergy.
Avoiding latex products is the best safeguard against an allergic response. Individuals known to be latex sensitive should wear medical identification and carry information on how to respond to a reaction. In addition, patients should keep a prefilled emergency syringe with injectable epinephrine to use if exposure occurs. Dosages for children range from 0.15 mg for a child weighing 15 kg (33 lbs) or less to 0.3 mg for a child weighing more than 15 kg (33 lbs).(28)
The age of children with spina bifida and latex allergy who require dental rehabilitation varies, but they usually are between the ages of two and four. Obvious dental problems usually do not manifest until approximately 18 months of age. It is strongly recommended that infants visit a dentist as soon as the infant's first teeth erupt. It is recommended that a child visit a dentist by one year of age.(29) The location of early caries is found most often in children's maxillary incisors and first molars.(30) Treatment includes an oral examination, cleaning, topical fluoride application, restoration of carious teeth, pulp therapy, and, when necessary, tooth extraction.
Preoperative care. When severe dental problems are present and the child is too young to cooperate or has disabilities that prevent cooperation, the dentist may recommend dental rehabilitation under general anesthesia. He or she obtains surgical consent from the child's parents or legal guardian. Dental clinic staff members arrange a surgical date and time, and the dentist alerts the hospital admitting staff members that the latex-allergic child will need to be handled with latex precautions. The child's latex allergy is noted when scheduling the surgical procedure and as dictated by dental office and hospital protocols. The OR schedule reflects this information on the printed schedule the day of surgery, and it is relayed to OR staff members assigned to care for the patient. The Childrens' Hospital of Philadelphia is proactive in promoting an institution-wide, latex-safe environment for patients. Children with a primary diagnosis of spina bifida are automatically placed on an institutional latex-allergy protocol that includes
* assessment of latex allergy or risk during admission screening;
* documentation of allergy status in the patient record;
* placement of an identification bracelet on the patient documenting the allergy;
* placement of latex precaution signage on the patient's room, bed, and medical record; and
* use of latex-free supplies throughout the patient's care.
Unless a hospital can provide an institution-wide, latex-free environment, latex-sensitive patients should be cared for according to currently acceptable published patient care guidelines.(31)
Dental clinic staff members arrange an appointment for the patient and parents to meet with care providers before the scheduled surgical date. During this hospital visit, all laboratory testing and patient data forms are completed. The nurse practitioner performs a physical examination of the child and explains general anesthesia to the parents. A physician completes a history and physical examination of the child. The child life therapist may offer family members a tour of the facility before surgery.
The child and parents check into day surgery. Nurses in this unit greet the patient and his or her family members and review the chart for any missing information or current updates. The patient and family members are given an opportunity to ask additional questions about the impending surgery. The nurse obtains and records the patient's baseline vital signs. Preoperative medication is given after the nurse is notified by the anesthesia care provider and the patient is transferred to the preoperative holding area. Midazolam usually is the preoperative medication of choice. It is a short-acting preoperative sedation that decreases anxiety, and the dosage range is from 0.5 mg per kg to 15 mg per kg.(32) This medication usually is given orally, and the premedication peak time is 20 to 40 minutes. Parents are encouraged to either hold their child or keep side rails of the stretcher up to prevent any potential injuries from the sedative effect of this medication. The OR team members (eg, anesthesia care provider, dentist, RN) greet the family members in the perioperative holding area, where family members and the patient can ask questions before surgery. This area is staffed by a perioperative nurse who can answer questions and provide support.
The OR team members make special preparations for the patient. Everyone is informed of the child's medical history and latex allergy. Equipment and supplies to be used are latex free. Latex-safe alternative products and powder-free gloves are used.
The perioperative nurse must recognize materials used during an oral rehabilitation procedure that contain latex. The nurse must anticipate and plan an acceptable substitute for a standard dental pack when caring for patients with latex allergy. The Childrens' Hospital of Philadelphia has custom packs for dental procedures that contain latex items, such as dental dams (ie, barriers used to isolate teeth), prophylaxis angles (ie, tips for hand pieces), and plastic sleeves for drill cords. Items containing latex are listed with an asterisk on the outside label of the dental custom pack to designate them as containing latex. The dental instrument tray contains latex items, such as a latex mouth prop; therefore, the nurse must use a specially prepared, latex-free dental instrumentation tray. In addition, a resource book is available that lists all other dental supplies containing latex (Table 2).
Table 2 EXAMPLES OF DENTAL PRODUCTS CONTAINING LATEX Product Alternative * Dental dams * Nonlatex dams * Prophylaxis angles (latex tips) * Nonlatex angles * Mouth prop padding * Nonlatex mouth props * Polishing cups * Nonlatex toothbrushes * Blue/red pencils (rubber erasers) * Blue/red markers * Injectable ampules (rubber plungers * Injectable vials in syringe) * Dental custom pack (many items) * Pick items for procedure separately from nonlatex alternatives * Bite blocks * Nonlatex bite blocks * Orthodontic elastics used for oral * Sterile wire to secure arch fixation bars * Dental medications and solutions in * Medications and solutions in containers with rubber droppers (eg, containers without rubber etching gel) droppers * Bite blocks * Alternative mouth props * Toothbrush handles * Nonlatex alternatives from dental manufacturers * Home care products (eg, irrigation * Nonlatex alternatives from tips, gum stimulators) dental manufacturers * Instrument bands, impression * Nonlatex alternatives from material, polishing points, and dental manufacturers wheels * Prophylaxis cup * Gutta percha
The scrub person and circulating nurse carefully open sterile OR supplies for the oral rehabilitation procedure, being alert for any latex products. They then connect a portable dental drill to nitrogen power and fill the plastic water reservoir of the drill with sterile water. The drill has low-speed or high-speed hand piece attachments and an air and water irrigating tip. The nurses provide a selection of the various dental materials and solutions for the dental assistant, who also must be informed about the patient's allergy to latex.
After all preparations have been made to maintain a latex-safe environment, the perioperative nurse reviews the patient's chart. He or she checks the child's NPO status, vital signs, surgical consent, history, and physical examination. Special attention is given to the patient's neurological and developmental needs. Children with spina bifida usually are immobile below the waist, and some have contractures of the lower extremities. The perioperative nurse is aware that a child may experience anxiety when parents leave; therefore, the nurse allows the preoperative sedation to peak before removing the child from the preoperative holding area to promote cooperation.
The nurse faces a challenge when attempting to form a relationship with the child. Premedication often is ineffective and may not decrease the child's anxiety. This can be a result of the child spitting out, vomiting, or refusing to take the medication. With a child who has undergone many surgical interventions, it may be difficult for the nurse to establish a trusting relationship. Under these circumstances, a parent can accompany the child to the OR. Family member presence during induction is permitted to provide emotional support for the child and parents. The anesthesia care provider gives permission for family member presence during induction after discussing it with the parents and assessing the child. The nurse must arrange for a parent services coordinator to assist the parents to and from the OR suite. The parent services department at the Childrens' Hospital of Philadelphia includes two RNs employed in the perioperative complex who act as liaisons between OR personnel and family members. They are present during the induction of a child to assist with care of family members. Their role also focuses on updating family members regarding progress and reuniting family members and the child as soon as possible in the postanesthesia care unit (PACU). Staff members or the parent chosen to be present during induction often carry the child to the OR, or the child may be transported on a stretcher.
Intraoperative care. Before intubation of the patient, the nurse assists the anesthesia care provider with the placement of a pulse oximetry probe, electrocardiogram leads, blood pressure cuff, and temperature probe and provides a calm atmosphere for the patient. The perioperative nurse then inserts an IV fluid line. Anesthesia is induced with inhalation or IV agents according to the preference of the anesthesia care provider. Anesthesia care providers at the Childrens' Hospital of Philadelphia usually prefer inhalation agents (eg, sevoflurane, nitrous oxide) and oxygen delivered by face mask. The parent is allowed to stay by the child's side until the child is unresponsive (ie, usually about five minutes after induction has begun), and the parent services coordinator escorts the parent out of the OR at this time. If complications occur during induction, the patient services coordinator escorts the parent out of the room immediately and explains that the anesthesia care provider will speak to him or her as soon as possible. The anesthesia care provider intubates using a nasal RAE tube (ie, nasotracheal tube), which allows the dentist access to the child's oral cavity. This tube is secured via tape across the upper lip. Care must be taken that this tape is not too restrictive on the skin near the lips or swelling could occur. The nares must be checked for pressure from the nasal RAE tube during the taping process to prevent tissue necrosis (Figure 3). The anesthesia care provider pads the patient's forehead with foam to eliminate any skin breakdown and to secure the nasal RAE tube into position for surgery.
The patient is placed in a supine position. Some dentists use a cerebellar headrest and a small gel roll under the patient's shoulders during the procedure to promote better anatomical exposure of the mouth and to prevent possible back and shoulder discomfort for the patient. The nurse gives special attention to the child's lower extremity contractures by padding those areas with latex-free padding (Figure 4). The dentist, anesthesia care provider, and nurse check the patient for proper body alignment and pressure on any bony prominence. Dental rehabilitation procedures sometimes require two to four hours to perform, and prevention of potential nerve injury and skin breakdown is important.
Temperature monitoring is crucial. Children undergoing dental restoration often suffer from hyperthermia due to the extended length of procedures and the draping materials used to cover them, which trap body heat. To eliminate this problem, perioperative nurses remove the child's hospital gown after placement of the nasotracheal tube and provide a single layer of linen, monitor the OR temperature at 60 [degrees] F (16 [degrees] C), and may opt not to use a temperature regulating blanket for warmth.
After the child is positioned, the circulating nurse places a lead gown over the patient. All persons involved in the radiological procedure wear protective lead apparel to protect against exposure to radiation as the dentist x-rays the child's teeth. It is important to obtain recent, accurate films before starting the procedure. Decay of the child's teeth may have progressed since the last dental office encounter, or accurate films may have been difficult to obtain without the patient's cooperation.
The dentist and dental assistant scrub and gown for the procedure. The dentist drapes the patient and with the dental assistant begins the oral rehabilitation process. The nurse must continue to be vigilant in maintaining a latex-free environment and be aware of the manifestations of anaphylactic reaction (eg, facial edema, rash, skin flushing, bronchospasm, laryngeal edema, hypotension, tachycardia, cardiac arrest) that an anesthetized patient would exhibit as a result of inadvertent exposure to latex. The nurse is vital in helping OR team members recognize these symptoms. Prompt detection and removal of the latex source is imperative in the event of a latex reaction. The nurse may need to help the anesthesia care provider administer epinephrine for bronchospasm or laryngeal edema, albuterol for wheezing, and IV solutions for hypotension. After the latex item has been removed, the anaphylactic reaction should be dealt with in the same manner as any other patient mishap by attending to the patient's airway, breathing, and circulation. Table 3 describes the nursing care plan for pediatric patients with spina bifida and latex allergy.
Table 3 CARE PLAN FOR THE PEDIATRIC PATIENT WITH SPINA BIFIDA AND LATEX ALLERGY Nursing diagnosis Interventions Risk of anxiety relat- * Assesses coping mechanisms based on psycho- ed to knowledge logical status. deficit and stress of surgery; risk of * Determines knowledge level based on psycho- caregiver role strain logical status related to latex allergy, related to caring for surgical procedure, and postoperative care. patient with neuro- Identifies individual values and wishes logical deficits; risk concerning care. for impaired verbal communication; * Identifies psychosocial status, risk of impaired family coping. * Includes family members and support person in preoperative teaching (eg, tours, OR care) and discharge planning. * Evaluates responses to learning. * Provides status report to family members or support person. Risk for acute pain * Assesses pain control; uses age appropriate related to surgical assessment tools. intervention. * Identifies cultural and value components related to pain; provides pain management instructions. * Implements pain guidelines; evaluates response to pain management interventions and instruction. Risk for latex-allergy * Implements protective measures to prevent response related to injury due to latex sources. high-risk patient category. * Uses supplies and equipment within safe parameters. * Communicates information about latex allergy to other members of the health care team. Risk of * Implements thermoregulation measures. hypothermia. * Measures body temperature, * Evaluates response to thermoregulation measures. Ineffective manage- * Assesses readiness to learn. ment of therapeutic regimen related to * Identifies individual values and wishes the complexity of about care; provides instruction based on case. age and need. * Includes patient and support person in discharge planning; identifies expectations and evaluates environment for home care. * Evaluates responses to instruction and psychological impact on plan of care. Outcome Outcome Nursing diagnosis statement criteria Risk of anxiety relat- The patient partici- Patient verbalizes or ed to knowledge pates in decisions indicates decreased deficit and stress of affecting his or her anxiety and an ability surgery; risk of plan of care. to cope and an under- caregiver role strain The patient standing of procedure related to caring for demonstrates and the sequence of patient with neuro- knowledge of events; his or her logical deficits; risk psychological questions have been for impaired verbal responses to answered; and his or communication; invasive proce- her expected outcomes risk of impaired dure. met. Patient verbalizes family coping. concern about deci- sions being discussed and participates in decision making. Risk for acute pain The patient demon- Patient demonstrates related to surgical strates or reports adequate pain intervention. adequate pain management and control throughout verbalizes relief the perioperative of pain and period. discomfort. Risk for latex-allergy The patient is free Patient's skin remains response related to from signs and intact, non-reddened, high-risk patient symptoms of nonirritated; respira- category. injury due to extra- tory status is neous objects, maintained or chemical injury, improved from baseline. Risk of The patient is at or The patient's core hypothermia. returning to nor- body temperature mothermia at the remains within the conclusion of the expected range. immediate postop- erative period. Ineffective manage- The patient and Patient and family ment of therapeutic family members members communicate regimen related to demonstrate activities related the complexity of knowledge of the to dental care that case. rehabilitation include diet changes process. and routines for oral care.
Postoperative care. The PACU nursing staff members receive a report on all expected special needs patients at the beginning of the day to allow staff members to prepare for their care. After the procedure, the perioperative nurse informs the PACU staff members of the child's latex allergy and surgical procedure. The anesthesia care provider extubates the patient, and the nurse assists him or her with the transfer of the patient to the unit. The PACU staff members ensure that the environment is latex safe. Care is focused on maintaining an adequate airway and proper fluid hydration. The nurse takes the child's vital signs and assesses his or her oral cavity for any excessive bleeding. Pain medication is administered to the child if he or she complains of any discomfort or displays vital signs that suggest he or she is in pain. The PACU staff members also use formalized pain scales developed for children to help assess pain levels and treat them appropriately. The child's condition is stabilized, and parents are encouraged to be with him or her in the PACU. Most of these patients at the Childrens' Hospital of Philadelphia stay in the PACU less than one hour and then are discharged to the day surgery postoperative area.
In the day surgery postoperative area, the nurse continues to monitor the child closely for stable vital signs, respiratory status, and oral or nasal hemostasis. The child is not required to drink a certain amount of fluids before discharge home because mandatory oral intake before discharge may increase the probability of postoperative vomiting. The dentist discusses any questions family members have regarding the surgery and discusses postoperative instructions for home care. He or she also gives family members appropriate prescriptions for antibiotics and pain medication. Nurses will provide patient teaching of discharge instructions and information about discharge medications. The patient then is discharged home with family members or a designated caregiver.
Perioperative nurses must be aware of their role in caring for pediatric patients with NTDs and latex allergy who require dental rehabilitation procedures. Patients require the expertise of perioperative nurses to ensure the delivery of safe, quality patient care during dental rehabilitation procedures in the OR. Perioperative nurses' ability to provide competent care for children with complex medical problems promotes positive patient outcomes and dental health for children who otherwise would not receive dental treatment.
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Mary E. Hudson, RN, BSN, is a clinical coordinator in the OR at the Childrens' Hospital of Philadelphia.
The author wishes to thank Mark Helpin, DMD, Howard Rosenberg, DDS, and Zuhair Sayany, DMD, for their assistance in preparing this article and Jane Barnsteiner, RN, PhD, FAAN, and the Childrens' Hospital of Philadelphia Writing Workshop for their assistance in the development of this manuscript.