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Perioperative Care of the

Pediatric Patient With DownSyndrome

www.aorn.org/CE

1.9ANDREA TONGE, BSN, RN, CPN, CSRN

T

he care of children with special needs in

the perioperative environment poses many

challenges for health care workers. Chil-drens unique physical, physiological, and psycho-

logical needs require that the patient care team

members possess extensive knowledge of growth

and developmental milestones and the physiology

of various body systems. This article addresses

perioperative implications for pediatric patients

with Down syndrome. Down syndrome is the

most commonly occurring genetic disorder, and,

because of its association with a high incidence of

congenital abnormalities, many children with thisdisorder will require surgical procedures for cor-

rection and repair that will be performed with the

patient under general anesthesia.1 Technological

advances in the medical field also will likely re-

sult in an increase in the number of surgical inter-

ventions for these patients.2 It is essential that peri-

operative staff members acquire a comprehensive

knowledge base regarding coexisting conditions to

properly manage care of this patient population.

HISTORY

Down syndrome, also known as trisomy 21, is an

autosomal genetic disorder named for J. Langdon

Down, a British physician, in 1866.3 Dr Down

sought to describe common characteristics of

individuals affected by the disorder to distinguish

these individuals from other individuals withcognitive delays. In 1959, a geneticist, Jerome

LeJeune, established one of the causes of Down

syndrome as an abnormality of structure (ie, tri-

somy) in the 21st chromosome.4 The two other

causes of the disorder, translocation and mosa-

icism, were determined within the following

three years.4

PATHOPHYSIOLOGY

Human cells normally have 23 pairs of chromo-

somes, for a total of 46. These cells divide by the

process of meiosis to produce gametes (ie, sperm

and egg cells), which contain one copy of each

pair of chromosomes. In Down syndrome, one of

three different types of alterations in chromosomal

structure occur during the process of gamete

formationnondysjunction, translocation, or mo-

saicism.5 Nondysjunction results when, before

conception, a gamete is produced with an extra

copy of chromosome 21. When this gamete unites

with a normal gamete from the other parent, the

embryo develops with all cells having 47 chromo-

somes (instead of the normal of 46), each with

three copies of chromosome 21hence the term

indicates that continuing education contact hours are available for this activity. Earn the contact hours by

reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and

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SPECIAL NEEDS POPULATIONS

doi: 10.1016/j.aorn.2011.09.005

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trisomy (Figure 1). The maternal gamete is

implicated in 88% of these cases.5 In transloca-

tion, which accounts for 3% to 5% of Down syn-

drome cases, all or part of chromosome 21 is fused

to another chromosome. This form of Down syn-

drome is usually hereditary and is not linked with

an increase in parental age, whereas trisomy and

mosaicism are linked with increased maternal age.

Mosaicism refers to trisomy that occurs in only a

minority of cells (Figure 2). With the majority of

cells remaining normal in chromosomal structure,

affected individuals present with less severe symp-

toms, with the degree of disability relative to the

number of abnormal chromosomes.6

ETIOLOGY

Down syndrome occurs in one in 800 live births,

spanning all ethnicities and economic levels.7

One factor that increases the risk of having a

child with Down syndrome is increased maternal

chronologic age (ie, 35 years or older).8 Most

people believe that maternal age is the primary

predictor of Down syndrome and do not realize

that 80% of children with Down syndrome are

born to women who are younger than age 35. In

addition to maternal age, other theories regarding

the etiology of Down syndrome include environ-

mental factors such as exposure to electromag-

netic radiation and x-rays, toxic effects of

pesticides, smoking, and drinking.7 However,

according to the National Down Syndrome So-

ciety,8 there has been no conclusive research

that links Down syndrome with environmental

factors or parental behavior before conception.

CLINICAL PRESENTATION

Children with Down syndrome commonly present

with abnormalities in physical features, congenital

malformations of various organ systems, and im-

pairment in physical and cognitive abilities.9 They

appear smaller in size than their average counter-

parts and develop at a slower rate both mentally

and physically.10 Fifty percent of affected chil-

dren have congenital heart disease, and they are

at increased risk for thyroid dysfunction; gastroin-

testinal, hematologic, and endocrine disorders;

respiratory problems; sensory impairment; and

mental disabilities.9

Physical features characteris-tic of the disorder include a flat occiput; flat facial

features; slanted eyes with skin folds between the

inner corner of the eyes and upper eyelids; speck-

ling of the iris; small nose and ears; small mouth

with a large, protruding tongue; short neck; and

sparse hair. Other manifestations include in-

creased flexibility of certain joints, hypotonia,

flabbiness of abdominal muscles, a single palmar

TRISOMY

Chromosome 21

MONOSOMYNormal

gamete

Normal

gamete

Meiosis I

Nondysjuncon

Meiosis II

Ferlizaon

Ferlizaon

Figure 1. In Down syndrome, nondysjunction of chromosome 21 occurs when it fails to divide properly,

resulting in monosomy (which is lethal) or trisomy.

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crease in the hands, and short fingers, as well as

small penis and undescended testicles in males.6

All children with Down syndrome have some

measure of developmental delay, including

language and motor skills.1 These become appar-

ent during the first year of life. Cognitive impair-

ment is manifested more in verbal short-term

memory than in visual processing.6 One study

demonstrated that short-term memory and com-

prehension could be improved through visual im-agery and cues.11 Social skills are usually not

impaired in children with Down syndrome. Men-

tal capabilities vary from mild to moderate, with

an IQ ranging from 50 to 70 and 35 to 50, re-

spectively.9 Some individuals will require exten-

sive supervision to lead a life of optimal poten-

tial, whereas others can maintain a level of

independence with fewer support systems.

TREATMENT

Clinical specialists gear the treatment of children

with Down syndrome toward managing any com-

promise in physical, physiological, or cognitive

function. The goal is to use early interventions

and therapies to help affected individuals lead

productive lives.12 Management includes assess-

ing all physiological systems at birth; educating

the childs parents and family members about

diagnostic procedures, the potential for impaireddevelopment, and treatments and medications that

are indicated for medical conditions commonly

associated with Down syndrome; and making ap-

propriate referrals. It is also important for health

care providers to assist parents with their coping

ability; to provide the childs caregivers with the

necessary resources for short-term and long-term

care involving physical, occupational, and speech

Figure 2. In Mosaicism, trisomy occurs in only a minority of cells. Reprinted with permission from the National

Genetics Education and Development Centre (www.geneticseducation.nhs.uk).

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therapies; to discuss diagnostic procedures and

therapeutic regimens; and to emphasize the im-

portance of follow-up care for managing medical

conditions.12 These interventions will help children

with Down syndrome maintain a healthy lifestyle

and promote their physical and psychological

well-being during the entire lifespan.

PERIOPERATIVE IMPLICATIONS

According to Zuckerberg and Maxwell,13 8% to

10% of patients diagnosed with Down syndrome

develop perioperative complications during non-

cardiac surgical procedures. These include ob-

struction of the airway, bronchospasm, and diffi-

culty with intubation. Cardiac anomalies with

pulmonary hypertension also place these patients

at risk from the use of anesthetic agents.1 Because

of the significance of these and other associated

problems, a thorough preoperative evaluation with

careful planning is essential to ensure the best out-

comes for these patients. The preoperative evalua-

tion should include assessment of the patients

cardiac, pulmonary and respiratory, musculosk-

eletal, gastrointestinal, endocrine, hematologic,

developmental/psychosocial, and neurological

systems. The preoperative nurse must develop

an individualized plan of care to guide the

management of the patient during the entire

perioperative period, based on comprehensive

assessment data that addresses all commonly coex-

isting conditions (Table 1).

Cardiac

Approximately 40% to 50% of children with

Down syndrome have congenital cardiac anoma-

lies that will require corrective surgical repair.1

An echocardiogram with cardiology consult is

indicated preoperatively for patients with a car-

diac history because of the effects of anesthetics

and the stress of surgery on the heart.14 Nurses in

the presurgical clinic can play an important role

in ensuring that the patient with Down syndrome

is screened preoperatively by educating the pa-

tients parents on the importance of keeping pre-

operative medical appointments. Nurses can also

assist the anesthesia professionals in obtaining

laboratory, radiology, and other diagnostic re-

ports. On the day of surgery, the perioperative

nurse should obtain baseline vital signs, including

oxygen saturation level. To prevent endocarditis,

patients may need antibiotics prophylactically

30 to 60 minutes before some surgical proce-

dures. The nurse should screen for a history of

allergies and perform a reconciliation of all of

the patients medications to prevent possible

adverse medication interactions.

Pulmonary and Respiratory

The presence of a small buccal cavity, large

tongue, and small nasal passages predispose chil-dren with Down syndrome to an increased risk

for airway obstruction and complications related

to anesthetic agents and sedatives.1,15 Airway ob-

struction can occur while these patients are awake

or asleep, which is of special consideration in

patients who receive procedural sedation without

an artificial airway in place. Children with Down

syndrome also have a higher incidence of subglot-

tic stenosis and may require intubation with

smaller-than-expected endotracheal tubes.

7

Physi-cians and nurses must assess for a history of ob-

structive sleep apnea, stridor, barky cough, snor-

ing, or unusual sleeping positions because of the

possibility of subglottic stenosis. Nurses assisting

with procedural sedation must anticipate the need

for smaller airway adjuncts and have them

available if necessary. Obesity, hypotonia, and

cardiac disease also have been associated with

both lower and upper airway problems in this

population.

7

When performing a preoperativeassessment, the perioperative nurse also must

consider these other factors.

Musculoskeletal

Approximately 20% of children with Down syn-

drome have atlantoaxial instability (AAI), a con-

dition in which there is increased mobility be-

tween the two cervical bones at the top of the

neck. This causes instability of the cervical spine


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and predisposes these children to spinal cord

compression.1,16 The American Academy of Pedi-

atrics recommends cervical spine radiographs of

children with Down syndrome who are three to

five years old to detect possible AAI. Because the

majority of children with Down syndrome are

asymptomatic for AAI, it is important that the

perioperative nurse obtain a pertinent history

regarding neck pain, changes in gait, muscle

weakness, or changes in bowel and bladder func-

tion before surgery.13 A history of increased flex-

ibility of joints in the fingers and elbows is asso-

ciated with AAI.7 Because of the prevalence of

hypotonia and delay in motor development in these

patients,1 the perioperative nurse should obtain base-

line data about any impairment in motor skills

TABLE 1. Perioperative Nursing Implications: Children With Down Syndrome

Preoperative care

Schedule procedures for children with diabetes early in the day to decrease fasting time.

Encourage parents to comply with preoperative screening of patients.

Obtain a relevant history, including information about cardiac disease, obstructive sleep apnea, stridor, diabetes,

hypothyroidism, gastroesophageal reflux disease, vomiting, obesity, hypotonia, neck pain, changes in gait, muscle weakness,

and changes in bowel and bladder function.

Obtain baseline data regarding the childs developmental age and impairment in motor skills.

Assist in obtaining relevant laboratory and diagnostic reports (eg, echocardiogram, cervical spine radiograph, blood glucose

level, thyroid function tests).

Obtain baseline vital signs on the day of surgery.

Perform a medication reconciliation and obtain the patients history of allergies.

Administer antibiotics prophylactically to prevent endocarditis.

For procedural sedation cases, have a large selection of airway adjuncts available.

Enforce practice guidelines governing infection control and prevention.

Encourage family members to participate in all procedures by giving the child his or her medications, encouraging the child to

communicate with staff members, providing comforting measures during invasive procedures, and incorporating the childs

routine in the plan of care.

Use visual aids and gestures when communicating with the child.

Prepare the patients family members for a longer-than-usual observation period postoperatively.

Intraoperative care

Limit neck manipulation.

Prepare to assist with cricoid pressure before anesthesia induction.

Observe for adverse effects from anesthetics, sedatives, or analgesics.

Assess for adequate cardiopulmonary function by monitoring vital signs and ventilation status as well as level of

consciousness in sedation cases.

Protect the patient from heat loss and hypothermia.

Maintain proper body alignment and support of extremities during patient positioning and transfer.

Monitor intake and output.

Postoperative care

Continue to monitor cardiopulmonary status.

Observe for signs and symptoms of airway obstruction.

Monitor for postoperative bleeding and drainage.

Assess for adverse effects of muscle relaxants.

Make clinical judgments regarding pain control based on cues and information from the patients family members.

Communicate with patients who have sensory impairment to prevent feelings of isolation.

Provide a favorite toy or other objects of comfort.

Ensure patient safety to prevent physical injury.

Provide discharge instructions to the patients family members based on the interdisciplinary plan of care.


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preoperatively to properly assess for adverse events

related to the administration of muscle relaxants.

Gastrointestinal

Abnormalities in the gastrointestinal system, in-

cluding tracheoesophageal fistula, pyloric stenosis,and Hirschsprung disease, occur in about 12% of

children with Down syndrome, and many will

need surgical repair in the neonatal period.1 Be-

cause gastroesophageal reflux disease frequently

occurs in individuals with Down syndrome, the

preoperative nurse should assess for a history of

vomiting because of the implication for possible

aspiration during anesthesia induction.

Endocrine

There is an increased risk for diabetes and a preva-

lence of hypothyroidism in individuals with Down

syndrome.1 Therefore, it is important for the preop-

erative nurse to collaborate with the anesthesia team

in obtaining and reviewing relevant history and cur-

rent laboratory values before the surgical procedure.

Nurses must be knowledgeable about the signs and

symptoms of these disorders to identify and report

significant findings to the physician. An infant with

hypothyroidism may present with a large tongue and

an umbilical hernia. Older children with hypothy-

roidism might be noted with slow heart rate and

intolerance to cold.15 Some perioperative implica-

tions for hypothyroidism include decreased cardiac

output and delayed gastric

emptying. Children with dia-

betes should be scheduled for

surgery early in the day to

decrease their hours of

fasting.

Hematology

Patients with Down syn-

drome have some measure

of immune system deficiency

that renders them prone to a

higher incidence of infection

relative to the general popu-

lation and dramatically in-

creases their likelihood of developing acute leuke-

mia.1 It has been documented in the literature

that, although there is a high success rate in sur-

gical procedures performed to repair cardiac

anomalies in patients with Down syndrome, there

is also an increase in postoperative complications

and deaths that are possibly associated with recur-

rent infections.7 The nurse has an essential role

in managing the perioperative environment to

ensure that all members of the perioperative

team comply with practice guidelines for infec-

tion control and prevention.

Developmental and Psychosocial

Compared with adults, young children in general

have unique psychological responses to hospital-

ization in terms of feelings of separation anxiety,

fear, and punishment.3 The perioperative nurse

caring for the child with Down syndrome is faced

with the added challenges of cognitive and sen-

sory delays in these patients. Because these chil-

dren vary in their degree of cognitive delay and

may have vision and hearing deficits, nurses need

to know the level of impairment to communicate

effectively with them. One way that nurses can

do this is to collaborate with parents and family

members to properly assess and determine the

childs developmental age. These children also

may have some difficulty expressing their feelings

verbally, which can result in added anxiety and

Online Resources

National Human Genome Research Institute

http://www.genome.gov/19517824National Down Syndrome Congress

http://www.ndsccenter.org/

National Down Syndrome Society

http://www.ndss.org

National Dissemination Center for Children with Disabilities

http://nichcy.org/disability/specific/downsyndrome

Web site access verified August 16, 2011.


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frustration.8 Adolescent patients with Down syn-

drome might present with a history of emotional

and behavioral problems such as aggression and

exaggerated anger.17 The administration of anx-

iolytics or sedatives might be beneficial. The

nurse should communicate with the patient on the

patients cognitive level by using simple instruc-

tions, preferably with visual aids and gestures. The

nurse also can observe the childs social interac-

tion with family members to identify cues that

might decrease anxiety and fear. Nurses should

explore their own feelings and attitudes about

caring for these children to reveal possible

biases and barriers that could affect their

nursing care.6

According to Hayes,16 many children with

Down syndrome resist changes in their routine.

Nurses should try to incorporate the childs rou-

tine into the plan of care to decrease anxiety

and promote cooperation. Parents can identify

activities that the child can do independently

(eg, changing clothes to don hospital attire, self-

administering oral medications with supervision).

These activities should be encouraged to develop

the childs sense of trust in the environment.6 The

patients family members should be prepared with

the knowledge that their child might need to be

observed for a longer period postoperatively than

is typically expected for the procedure, depending

on the childs status after the procedure. Patients

undergoing ambulatory surgery might require an

overnight stay for further observation. It might be

beneficial to have the childs favorite toy, blanket,

or other comforting object on hand in case the

postoperative stay is prolonged.

There is an increased rate of mental illness in

older individuals with Down syndrome. In some

health care institutions, care for the pediatric pop-

ulation extends past 18 years of age. Nurses and

health care providers in these institutions need to

be knowledgeable of state laws and regulations

and of institutional policies that address the issue

of consent for treatment for persons with mental

illness.10

Neurological

Individuals with Down syndrome may have a

higher pain threshold than the general population

and may react to pain more slowly.10 Research

results have shown that these children also differ

in their ability to precisely identify the location of

painful stimuli and are less likely to communicate

their pain verbally.18 Parents can provide the

health care team with information about pain indi-

cator behaviors that their child exhibits (eg, use

of certain words, pointing, expressions of anger,

acting out) to help effectively assess and control

the childs pain.

INTRAOPERATIVE CARE

The goal in the intraoperative period focuses on

patient safety while the patient is anesthetized or

sedated. Precautions should be taken to limit neck

manipulation in all children with Down syndrome

because some patients are asymptomatic for AAI.

The childs neck should be maintained in a neu-

tral position with a soft collar to avoid extreme

neck flexion, extension, or rotation.7 Because of

the incidence of airway abnormalities, it is impor-

tant to have different sizes of airway modalities

available to effectively manage respiratory com-

plications. The intraoperative nurse should be pre-

pared to assist anesthesia professionals with the

application of cricoid pressure in the event of a

rapid sequence induction in a child with a history

of gastroesophageal reflux and vomiting.

Nurses administering or assisting with proce-

dural sedation should have substantial knowledge

of sedatives, analgesics, and reversal medications,

and implications for patients with Down syn-

drome who have coexisting conditions. The seda-

tion nurse should constantly assess for adequate

cardiopulmonary function by monitoring vital

signs, ventilation status, and level of conscious-

ness. Infection control measures should continue

to be instituted by the intraoperative nurse. In the

event of hypothyroidism, coupled with the chal-

lenge of temperature regulation in the pediatric

age group, care should be taken to protect against


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heat loss and hypothermia. Proper body position-

ing and support of extremities are also important

in this population because of possible hypotonia.

Nurses must ensure that extra care is taken to

appropriately support joints and limbs throughout

patient transfer.

POSTOPERATIVE CARE

Postoperative care of the pediatric patient with

Down syndrome focuses on continued monitor-

ing of cardiopulmonary status, with an empha-

sis on observing for signs and symptoms of

airway obstruction, laryngospasm, and postextuba-

tion croup. The patient care team in the postanes-

thesia care unit should determine the critical as-pects of the patients status that could affect his

or her recovery.3 Nurses should monitor for post-

operative bleeding or drainage, which could affect

hemodynamic status. Strict intake and output

should also be observed to prevent possible fluid

overload.3 The patient care team should use base-

line data to assess for adverse effects of muscle

relaxants because of the prevalence of motor de-

lays in these children. Nurses must make clinical

judgments regarding pain control and the adminis-tration of analgesics, because children with Down

syndrome may not show obvious evidence of dis-

comfort.10 The nurse might need to make a deci-

sion based on the type of procedure and the anes-

thetic agents and medications used during the

procedure.3 In patients with a history of hearing

loss or vision impairment, nurses must be espe-

cially sensitive to anticipate the childs needs and

communicate with him or her to prevent feelings

of isolation.6 Patient safety must be considered,and the childs immediate surroundings must be

secured to prevent physical injury. Discharge

plans from the postoperative area should incorpo-

rate an interdisciplinary approach, addressing the

patients physical, physiological, and psychosocial

needs, and should be based on the preoperative

assessment and on intraoperative and postopera-

tive events.

CONCLUSION

Pediatric patients with Down syndrome pose con-

siderable challenges for the entire perioperative

team. A careful preoperative screening and evalu-

ation is crucial to target issues of special concern

relative to this population. Nurses can function as

facilitators to ensure that a multidisciplinary

approach is used in anticipation of perioperative

complications and in the development of a com-

prehensive plan of care. The psychosocial needs

of these children must be given special attention

because of the incidence of cognitive and sensory

impairment, and effective communication with

parents and families must be used to meet these

needs. Extra time must be secured to allow for

the management of possible adverse events re-

lated to coexisting medical conditions. With

the application of the most current knowledge,

evidence-based practice, and careful planning, the

health care team can prevent complications and

ensure a positive perioperative experience for pe-

diatric patients with Down syndrome.

Acknowledgement: The author thanks Michelle

Byrne, PhD, RN, CNE, CNOR, associate profes-

sor and coordinator for the Master of Science in

Nursing Education Program at North Georgia

College and State University, Dahlonega, GA, for

her guidance and support in the preparation of

this manuscript.

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2008. https://www.pediatriccareonline.org/pco/ub/view/

Point-of-Care-Quick-Reference/397156/3 [subscription

required]. Accessed July 19, 2011.

18. Davies RB. Pain in children with Down syndrome: as-

sessment and intervention by parents. Pain Manag

Nurs. 2010;11(4):259-267.

Andrea Tonge, BSN, RN, CPN, CSRN, is a

resource staff nurse, Childrens Healthcare of

Atlanta, GA. Ms Tonge has no declared affilia-

tion that could be perceived as posing a potential

conflict of interest in the publication of this

article.


614 AORN Journal
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CONTINUING EDUCATION PROGRAM

1.9

www.aorn.org/CEPerioperative Care of the PediatricPatient With Down Syndrome

PURPOSE/GOAL

To educate perioperative nurses about caring for the pediatric surgical patient with

Down syndrome.

OBJECTIVES

1. Discuss the pathophysiology of Down syndrome.

2. Identify the etiology of Down syndrome.

3. Describe the clinical presentation of Down syndrome.

4. Describe treatments used for children with Down syndrome.

5. Discuss implications of perioperative care for a patient with Down

syndrome.

The Examination and Learner Evaluation are printed here for your conve-

nience. To receive continuing education credit, you must complete the Exami-

nation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS

1. In Down syndrome, the types of alteration in

chromosomal structure that may occur during the

process of gamete formation include

1. mosaicism

2. nondysjunction

3. translocation

4. trisomy

a. 1 and 2 b. 3 and 4

c. 1, 2, and 3 d. 1, 2, 3, and 4

2. Down syndrome occurs in one in _________ live

births.

a. 800 b. 1,000

c. 1,200 d. 1,500

3. Children with Down syndrome commonly present

with

1. abnormalities in physical features.

2. congenital malformations of various organ

systems.

3. heightened cognitive abilities.

4. impaired physical abilities.

a. 1 and 2 b. 3 and 4

c. 1, 2, and 4 d. 1, 2, 3, and 4

4. Children with Down syndrome are at an in-

creased risk of

1. congenital heart disease.

2. gastrointestinal, hematologic, and endocrine

disorders.

3. respiratory problems.

4. sensory impairment.

5. thyroid dysfunction.

a. 1 and 5 b. 2, 3, and 4

c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5

EXAMINATION

AORN, Inc, 2011 December 2011 Vol 94 No 6 AORN Journal 615
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5. Interventions that can help children with Down

syndrome maintain a healthy lifestyle include

1. assessing all physiologic systems at birth.

2. educating the childs parents and family mem-

bers about diagnostic procedures, the potential

for impaired development, and treatments and

medications that may be needed.

3. assisting the parents with their coping abilities.

4. referring patients for physical, occupational,

and speech therapies as appropriate.

a. 1 and 3 b. 2 and 4

c. 1, 2, and 3 d. 1, 2, 3, and 4

6. Research indicates that __________ of patients

with Down syndrome develop perioperative com-

plications during noncardiac surgical procedures.

a. 8% to 10% b. 12% to 15%

c. 20% to 25% d. 33% to 38%

7. Children with Down syndrome have a higher in-

cidence of subglottic stenosis and may require

intubation with smaller-than-expected endotra-

cheal tubes.

a. true

b. false

8. Pediatric patients with Down syndrome who have

endocrine disorders may present with

1. a large tongue.2. an umbilical hernia.

3. decreased cardiac output.

4. delayed gastric emptying.

5. intolerance to heat.

6. increased heart rate.

a. 1, 3, and 5 b. 2, 4, and 6

c. 1, 2, 3, and 4 d. 1, 2, 3, 4, 5, and 6

9. To address the patients unique psychological

responses to hospitalization, the perioperative

nurse should

1. collaborate with the patients parents to deter-

mine the childs developmental age.

2. communicate by using simple instructions with

visual aids, keeping gestures to a minimum.

3. avoid administering anxiolytics or sedatives.

4. incorporate the childs routine into the plan of

care.

5. identify cues that might decrease anxiety and

fear by observing the patients interaction with

his or her family members.a. 2 and 3 b. 1, 4, and 5

c. 1, 3, 4, and 5 d. 1, 2, 3, 4, and 5

10. During the intraoperative period, the perioperative

nurse should

1. be prepared to assist with applying cricoid

pressure in the event of rapid sequence

induction.

2. ensure different sizes of airway modalities are

available to manage respiratory complications.

3. take precautions to limit neck manipulation.

4. take extra care to support joints and limbsthroughout patient transfer.

a. 1 and 4 b. 2 and 3

c. 1, 2, and 3 d. 1, 2, 3, and 4

The behavioral objectives and examination for this program were created by Kimberly Retzlaff, editor, with consultation from

Rebecca Holm, MSN, RN, CNOR, clinical editor, and Susan Bakewell, MS, RN-BC, director, Center for Perioperative Education.

Ms Retzlaff, Ms Holm, and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of in-

terest in the publication of this article.

December 2011 Vol 94 No 6 CE EXAMINATION

616 AORN Journal


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CONTINUING EDUCATION PROGRAM

1.9

www.aorn.org/CEPerioperative Care of the PediatricPatient With Down Syndrome

This evaluation is used to determine the extent

to which this continuing education program

met your learning needs. Rate the items as

described below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?1. Discuss the pathophysiology of Down syndrome.

Low 1. 2. 3. 4. 5. High

2. Identify the etiology of Down syndrome.

Low 1. 2. 3. 4. 5. High

3. Describe the clinical presentation of Down syn-

drome. Low 1. 2. 3. 4. 5. High

4. Describe treatments used for children with Down

syndrome. Low 1. 2. 3. 4. 5. High

5. Discuss implications of perioperative care for a

patient with Down syndrome.

Low 1. 2. 3. 4. 5. High

CONTENT

6. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

7. To what extent were your individual objectives

met? Low 1. 2. 3. 4. 5. High

8. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

9. Will you change your practice as a result of

reading this article? (If yes, answer question

#9A. If no, answer question #9B.)

9A. How will you change your practice? (Select all

that apply)

1. I will provide education to my team regard-

ing why change is needed.

2. I will work with management to change/

implement a policy and procedure.

3. I will plan an informational meeting with

physicians to seek their input and acceptance

of the need for change.

4. I will implement change and evaluate the

effect of the change at regular intervals until

the change is incorporated as best practice.

5. Other:

9B. If you will not change your practice as a result

of reading this article, why? (Select all that

apply)

1. The content of the article is not relevant tomy practice.

2. I do not have enough time to teach others

about the purpose of the needed change.

3. I do not have management support to make

a change.

4. Other:

10. Our accrediting body requires that we verify the

time you needed to complete the 1.9 continuing

education contact hour (114-minute) program:

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center

approves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this

activity for relicensure.

Event: #11525; Session: #0001 Fee: Members $9.50, Nonmembers $19

The deadline for this program is December 31, 2014.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Eachapplicant who successfully completes this program can immediately print a certificate of completion.

LEARNER EVALUATION

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