O RIGINAL ARTICLES
Nurses’ Diagnoses and Treatment Decisions
Regarding Care of the Agitated Child
Terri Voepel-Lewis, MSN, RN
Constance Burke, BSN, RN
Sue M. Hadden, BSN, RN
Alan R. Tait, PhD
Shobha Malviya, MD
Postoperative agitation has many potential etiologies and remains a significant clinical
issue in the pediatric PACU setting. Caring for the agitated child requires a thorough
assessment and calls for targeted interventions. This observational study evaluated
nurses’ diagnoses and treatment decisions regarding care of the agitated child. Nurses
were observed during their care of 194 agitated children over a 3-month period. Pain
and anxiety were the most commonly identified sources of agitation in the pediatric
PACU setting (27% and 25% of cases, respectively), and nurses’ targeted, primary
interventions for these problems were fairly effective (48% and 67% effective, respec-
tively). Anesthesia-induced agitation was less often identified as the etiology (11%), and
primary interventions were more varied and less effective (38%). Physiologic abnor-
malities were identified as the source for agitation in only 3 cases, but went unrecog-
nized for an extended period in 2 children. Results of this study underscore the
complexity of assessment and treatment decisions when caring for agitated children. A
decision algorithm based on this study is described as a potential aid toward differen-
tiation of agitation and appropriate intervention.
© 2005 by American Society of PeriAnesthesia Nurses.
POSTOPERATIVE AGITATION is a common
occurrence in children recovering from general
anesthesia. Recent reports indicate that as many
as 18% of children exhibit agitation on emer-
gence,
1
and as many as 30% are agitated at some
point during their PACU stay,
2
highlighting the
significance of this clinical issue. Agitation
places patients at risk for injury and may pro-
long their stay in the PACU,
1
and challenges the
nurse to carefully assess the child and identify
the source of agitation and then intervene ac-
cordingly.
Terri Voepel-Lewis, MSN, RN, is a Clinical Nurse Specialist
in the Department of Anesthesiology, Section of Pediatrics,
University of Michigan Health Systems, Ann Arbor, MI; Con-
stance Burke, BSN, RN, is a Clinical Care Coordinator in the
Department of Anesthesiology, Section of Pediatrics, Univer-
sity of Michigan Health Systems, Ann Arbor, MI; Sue M.
Hadden, BSN, RN, is a Staff Nurse, Pediatric Post Anesthesia
Care Unit, in the Department of Anesthesiology, Section of
Pediatrics, University of Michigan Health Systems, Ann Ar-
bor, MI; Alan R. Tait, PhD, is a Professor of Anesthesiology in
the Department of Anesthesiology, Section of Pediatrics, Uni-
versity of Michigan Health Systems, Ann Arbor, MI; Shobha
Malviya, MD, is an Associate Professor of Anesthesiology in
the Department of Anesthesiology, Section of Pediatrics, Uni-
versity of Michigan Health Systems, Ann Arbor, MI.
Address correspondence for all authors to Department of
Anesthesiology, Section of Pediatrics, University of Michigan
Health Systems, F3900 Mott Children’s Hospital, Box 0211,
1500 E Medical Center Drive, Ann Arbor, MI 48109-0211.
© 2005 by American Society of PeriAnesthesia Nurses.
1089-9472/05/2004-0003$30.00/0
doi:10.1016/j.jopan.2005.05.006
Journal of PeriAnesthesia Nursing, Vol 20, No 4 (August), 2005: pp 239-248 239