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Special Needs of Older Adults Undergoing Surgery
Special Needs of Older Adults Undergoing Surgery JUDITH L. CLAYTON, RN, CNOR
T
he face of aging in the United States is changing dramatically and rapidly. Today’s older Americans are very different from their predecessors. They live longer, have lower rates of disability, have achieved higher levels of education, and live in poverty less often. The first of the Baby Boomers, approximately 2.9 million people, celebrated their 60th birthdays in 2006.1 A substantial increase in the number of older adults will occur from 2010 to 2030 after the first Baby Boomers turn 65 in 2011.2 The population of older adults in 2030 is projected to be twice as large as in 2000, growing from 35 million to 72 million. This age group is anticipated to represent nearly 20% of the total United States population.2 Older adults are at higher risk than younger individuals for complications during and after surgery. Successful surgical management of an older adult’s health problems depends on the nurse’s understanding of the age-related factors that may affect the outcome of normal surgical procedures. Carefully planned, effective nursing care during the perioperative period will help reduce surgical morbidity in older adults.
LIFE EXPECTANCY The average life expectancy is increasing every year in the United States as Baby Boomers are fast approaching
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 571–572 and then completing the answer sheet and learner evaluation on pages 573–574. You also may access this article online at http://www.aornjournal.org.
© AORN, Inc, 2008
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old age.2 These increases can be attributed to a focus on prevention of disease and illness with increased socialization and advancements in disease control and health technology. During the past century, improvements that have affected life expectancy in the United States occurred in two stages. First, death during childhood became less likely, largely because sanitation processes improved and vaccines and treatments for childhood diseases were developed. Second, disease and disability are less likely to develop or have been postponed in older adults because health care and disease prevention have improved. Historically, female life expectancy has been higher than male life expectancy at most ages.2 Gender differences in life expectancy can be attributed to differences in attitudes, behaviors, social roles, and biological risks between men
ABSTRACT DURING THE PAST CENTURY, life expectancy in the United States has increased as a result of improved sanitation, development of vaccines and treatments for childhood diseases, and vast improvements in health care and disease prevention. OLDER ADULTS ARE AT HIGHER RISK than younger individuals for complications during and after surgery. Carefully planned, effective nursing care during the perioperative period will help reduce surgical morbidity in older adults. AGE-SPECIFIC NURSING CARE techniques that are provided during the preoperative, intraoperative, and postoperative phases of a surgical experience are discussed in this article, with a particular focus on how to manage pain and prevent infection. AORN J 87 (March 2008) 557-570. © AORN, Inc, 2008.
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and women. In 2000, life expectancy at birth was 79.5 years for women and 74.1 years for men.2 This was largely a result of reductions in mortality at older ages. Not only are more people surviving past the age of 65, but they also have more years of productive life remaining than people did a century ago.2 Like their younger counterparts, members of the “old-old” generation also have better survival prospects today than at any other point in the past century.2 Confusion exists regarding age category definitions. According to the AARP, the categories are • middle age—40 to 59 years of age, • young old—60 to 74 years of age, and • old old—75 to 100+ years of age.3 Centenarians [ie, people who are 100 years of age and older] are the fastest growing segment of the US population.4 In 1990, there were approximately 37,000 centenarians; in 1998, there were 61,000 centenarians; and in the year 2000, 50,454 people were 100 years of age or older.2 About 80% of all centenarians are women.2
Like their younger counterparts, members of the old-old generation also have better survival prospects today than at any other point in the past century.
FACTORS AFFECTING
THE
HEALTH
OF
OLDER ADULTS
Smoking, overuse of alcohol, being overweight, lack of exercise, and inadequate consumption of fruits and vegetables are some of the risk factors researchers associate with morbidity and mortality at older ages. Evidence suggests, however, that positive behavior change, even at older ages, can provide health benefits and improve quality of life. Smoking cessation, following a nutritious diet, exercising regularly, taking prescribed medications to
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control illness, and staying mentally active have proven to reduce the risk of developing several disorders that commonly occur as people age. As centenarian and legendary jazz musician Eubie Blake said, “If I’d known I was gonna live this long, I’d have taken better care of myself.” FALLS. Older adults, who currently represent 12% of the population, account for 75% of deaths from falls.3 The number of falls increases progressively with age in both genders and in all racial and ethnic groups.5 The injury rate for falls is highest among adults 85 years of age and older.5 In 2003, more than 1.8 million adults 65 years of age and older were treated in emergency departments for fall-related injuries, and more than 421,000 were hospitalized.5 The most common fractures are of the hip, vertebrae, shoulder, and wrist.6 Fall-related injuries account for approximately 5% of hospitalizations in patients older than 65 years. Approximately 5% of the falls result in a fracture of the humerus, wrist, or pelvis.6 Other serious injuries, such as head and internal injuries and lacerations, occur in about 5% of the falls.6 Approximately 2% of falls result in a hip fracture,6 and about 5% of older adults with hip fractures die while hospitalized.5 Annually, 1,800 falls directly result in death, and approximately 9,500 deaths in older Americans are associated with falls each year (Figure 1).5 The overall mortality in the 12 months after a hip fracture ranges from 18% to 33%.6 Many older adults who fall are frail and have preexisting deficits in activities of daily living (eg, personal care tasks such as bathing, eating, toileting, dressing) and instrumental activities of daily living (eg, preparing one’s own meals, doing light housework, managing one’s own money, using the telephone, shopping).2,5 These people are at risk for other complications after a fall in which a fracture occurs (ie, increased risk of pneumonia, thrombus formation, pressure ulcers, renal calculi, fecal impaction, contractures). About 50% of those who fall cannot get up without help.5 The risk of dehydration, pressure ulcers, rhabdomyolysis, hypothermia, and pneumonia increases when an older adult remains on the floor for longer than two hours after a fall.5 Function and quality of life may deteriorate
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FIGURE 1
25 |
Men Women
10 |
15 |
20 |
Rate
30 |
35 |
Rate* of Unintentional Fall-Related Deaths Among Adults Aged ≥ 65 Years, by Sex—United States, 1987-1996
| | 1987 1988
| 1989
| 1990
| | 1991 1992
| 1993
| 1994
| | 1995 1996
Year * Per 100,000 population Reprinted from Stevens JA, Hasbrouck L, Durant TM, et al. Rate* of unintentional fall-related deaths among adults aged ≥ 65 years by sex—United States, 1987-1996. In: Surveillance for Injuries and Violence Among Older Adults. Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss4808 a3.htm. Accessed January 8, 2008.
drastically after a fall; at least 50% of older adults who were ambulating before fracturing a hip do not recover their previous level of mobility.6 After falling, older adults may fear falling again, so their mobility sometimes is reduced because they have lost confidence. Decreased activity can increase joint stiffness and weakness, further reducing mobility. Falls reportedly contribute to 40% of nursing home admissions.6 The high incidence of falls in older adults may be a result of many factors, such as • age-related changes (eg, reduced visual capacity); • caregiver-related factors (eg, improper use of restraints, delays in responding to requests, poor supervision of problem behavior); • disease-related symptoms, such as ataxia, confusion, mood disturbances, orthostatic hypotension, and weakness; • environmental hazards, such as extension cords, uneven sidewalks, and wet surfaces; • improper use of mobility aids;
•
unsafe clothing (eg, long robes or pant legs, poorly fitting shoes and socks, shoes with slippery soles or heels); and • use of medications, particularly those that can cause dizziness, drowsiness, and orthostatic hypertension.7 Most falls occur when several causes interact. For example, a person with Parkinson’s disease (ie, a disease) and impaired vision (ie, a physical condition) may trip on an extension cord (ie, an environmental hazard) while hurrying to answer the telephone.6 Older adults who reported both vision and hearing loss were more likely than those without either impairment to have fallen or broken a hip.2 Risk factors for falls include • being 65 years of age or older, especially older than 75 years; • being Caucasian; • being female (ie, women are two to three times more likely to fall than men); • being housebound; AORN JOURNAL •
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heredity, because genetic factors influence Osteoporosis is one of the major risk facbone size, bone mass, and bone density; and tors for hip fracture.6 Loss of bone strength tends to be greatest in the spine, lower fore• living alone.5 Neurological changes (eg, postural instabilarms, and femurs. Other medical conditions ity, diminished sensory awareness for light also may lead to bone fragility either by slowtouch) increase an older adult patient’s risk of ing bone formation or speeding up bone loss. cognitive impairment, difficulty rising from a Women lose bone density at a faster rate than chair, foot problems, and difficulty hearing. men. A family history of osteoporosis or fracRisky behaviors such as poor eating habits tures later in life is a strong predictor of low (eg, calcium and vitamin D deficiency) and bone mass, although not necessarily of fractobacco and alcohol use increase an older tures themselves. Caucasians and Asians have adult’s risk of falling.5 Smoking and excessive the highest risk of osteoporosis.6 consumption of alcohol can Lack of sufficient intake of interfere with normal bonecalcium and vitamin D in the building processes and bone diet when a person is young remodeling, resulting in bone lowers peak bone mass and loss. These habits also interincreases risk of fracture later fere with the production of in life.11 Serious eating disorIn 2000, approximately estrogen and testosterone, ders, such as anorexia nervosa two hormones that contribute and bulimia, can damage the 350,000 older adults to bone mass. In addition, skeleton by depriving the women who smoke tend to body of essential nutrients were hospitalized for hip enter menopause earlier than needed for bone building.11 6 do nonsmokers. Certain medications can fractures. By 2050, hip HIP FRACTURES. The hip is the accelerate bone loss, thus inmost common nonvertebral creasing the risk of osteoporofractures are expected fracture site.8 More than 90% sis and hip fracture. Longof hip fractures are associated term use of corticosteroids to reach 650,000 per with falls, and most of these may lower bone mass.11 Other fractures occur in adults older medications that may conyear, averaging nearly than 70 years of age.8 Hip fractribute to bone loss or to calture is the leading fall-related cium or vitamin D deficien1,800 per day. injury that results in hospitalcies, if used for long periods ization, with significantly proof time, include anticonvullonged and costly hospital sants, thyroid medications, stays. In the year 2000, 1.6 miland certain diuretics and lion older adults were treated blood thinners.11 for fall-related injuries with 350,000 hospitalSome medications may affect balance and izations for hip fractures.8 “From 1988 to 2000, cause dizziness. These include antidepressants, the hospital admission rate for hip fractures cold and allergy medications, pain relievers, among women [was] twice the rate for men.”9 sedatives, sleep medications, some blood presFigure 2 demonstrates the rate of hospitalizasure medications, and tranquilizers.11 tion for hip fractures among older adults. Historical risk factors for hip fractures include SURGERY IN OLDER ADULTS use of a cane or walker; previous falls; acute illMany older patients, even those in their ness; chronic conditions, especially neuromuscu70s, 80s, and 90s, tolerate elective surgery lar disorders; and medications, especially the use quite well if clinicians carefully plan and proof four or more prescription medications.2 By vide effective preoperative and postoperative 2050, hip fractures are expected to reach 650,000 nursing care. Age is no longer a major factor per year, averaging nearly 1,800 per day.10 in deciding whether to schedule surgery if the
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FIGURE 2
Women
800 | 600 |
Rate
1,000 |
1,200 1,400 | |
Rate* of Hospitalization for Hip Fracture Among Adults Aged ≥ 65, by Sex—United States, 1988-1996
200 |
400 |
Men
| | 1988 1989
| 1990
| | 1991 1992
| 1993
| 1994
| | 1995 1996
Year * Per 100,000 population Reprinted from Stevens JA, Hasbrouck L, Durant TM, et al. Rate* of hospitalization for hip fracture among adults aged ≥ 65 years by sex—United States, 1988-1996. In: Surveillance for Injuries and Violence Among Older Adults. Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss4808 a3.htm. Accessed January 8, 2008.
procedure is needed to prolong life, make living more comfortable, or both. Older adults do not tolerate emergency or long, complicated surgery as well as younger people, however, because of their decreased ability to adapt to physical and psychological stress.11 Despite higher numbers of older adults having surgery, morbidity and mortality rates have declined. Studies show a decline in perioperative mortality rates from 20% in the 1960s to 10% in the 1970s and 5% to 6% in the 1980s.8,12 “This trend of declining mortality rates extends even to those on the extreme end of the age spectrum.”12 Several risk factors for perioperative mortality have been identified. “Emergency procedures are associated with a higher mortality rate regardless of the age group.”8 The location of the surgical site also has an important
effect on mortality rate. Multiple studies have shown that procedures involving the thorax or abdomen have higher complication and mortality rates.8,12 In addition, coexisting conditions have been found to be important risk predictors of perioperative mortality. The effects of coexisting conditions outweigh the effects of age alone on anesthetic outcome.12 When age and severity of illness are compared, the number of coexisting conditions is more significant.12 Literature does not substantiate delaying surgery because of the patient’s age.12 Early surgical treatment should be considered whenever possible because emergency procedures increase perioperative risk. Every effort should be made to perform a thorough preoperative evaluation aimed at identifying intraoperative risk and the risk of postoperative AORN JOURNAL •
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complications and optimizing the status of the patient’s chronic medical conditions as much as possible before surgery. There may not be time to perform a complete evaluation and correct risk factors before emergency surgery; however, even performing a partial evaluation and correction can reduce surgical risks. Assessment and care should continue postoperatively, especially after emergency surgery in which there was insufficient time for preoperative stabilization.12
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therapy for replacement of fluid and electrolytes. Enemas and diuretics should be avoided before surgery because they increase the risk of dehydration. If possible, surgery should be scheduled early in the day, or, if that is not possible, the patient should be allowed to have a light breakfast (eg, clear liquids and easily digested toast) first thing in the morning.11 The most prevalent chronic health problems of older adults include arthritis; cataracts or glaucoma; circulatory problems; hypertension; osteoporosis; presbycusis (ie, hearing PREOPERATIVE PHASE loss associated with aging); The goal of the preoperaand urinary tract infections tive phase is to ensure that the (UTIs). Perioperative nurses patient is in the best possible should recognize how these A preoperative condition for surgery through conditions will affect the care careful assessment and thorof the surgical patient during evaluation geared ough preparation. A preoperathe entire perioperative period. tive evaluation geared toward MEDICATION HISTORY. Older toward risk assessment, risk assessment and impleadult patients are likely to be mentation of risk-reduction taking numerous medications, and implementation of strategies will decrease the both prescription and over-therisk of perioperative morbidicounter. Medications that an risk-reduction strategies ty and mortality. Factors that older adult may have been takare most likely to contribute to ing routinely before surgery will decrease the risk of a successful surgical experiand that may cause complicaence include tions during the perioperative perioperative morbidity period include • stabilizing nutritional and hydration status; antidepressants, because • and mortality. they may lower blood pres• controlling related comorbidities and evaluating sure during anesthesia; medications; and • any medications with anticholinergic effects, because • preparing the patient physically and psychologically they increases the potential for the perioperative experience, including for confusion; adequate explanations about what to expect • aspirin, because it may increase bleeding; during and after surgery. • bromide, because it can accumulate and BASELINE DATA. Baseline data on all body sysproduce signs or symptoms of dementia; tems is important for comparison with assess• nonsteroidal anti-inflammatory drugs, bement data obtained postoperatively. The preopcause they increase the risk of stress ulcers erative assessment should include the patient’s and displace other medications from blood skin status, psychological status, ability to perproteins; and form activities of daily living and adequate • steroids because they suppress immunity.11 range of motion, and nature of the home enviSKIN CARE. Whenever possible, hair on the ronment and family members’ competence to older adult patient’s skin should not be shaved provide care after discharge. Assessment of nuor clipped because traumatized skin increases tritional status and adequate hydration should the risk of postoperative infection.13 If the hair include documenting recent weight loss, labora- needs to be removed from the surgical site, spetory values, intake and output (I&O), and IV cial care should be taken to prevent injury. Hair
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growth in older adults is decreased, especially in the pubic and axillary regions, and the skin is likely to be thin, dry, and wrinkled, making shaving more difficult. Lotion should not be used on the older patient’s skin before surgery because it likely will retain bacteria.11 THROMBOEMBOLIC DISEASE (TED) STOCKINGS. Postoperative embolism is a particular threat to older adults. Slow circulation and hypotension predispose older adults to thrombus formation and emboli. Dehydration, decreased muscle tone, decreased cardiac output, and the restrictions placed on physical activity make thrombophlebitis an even greater threat for older adult patients. If TED stockings are ordered for the patient’s lower legs, they should be applied in the preoperative area if possible.11 URINARY CATHETER. If a urinary catheter is not to be inserted before surgery, the preoperative nurse should ensure that the patient voids immediately before going into the OR. If surgery is anticipated to be long or complicated, the circulating nurse usually inserts a catheter because “the size and holding capacity of the bladder decreases with age.”11(p288) ASSISTIVE DEVICES. Some anesthesia care providers prefer that dentures be left in place to help with the facial fit of the oxygen mask. Whenever possible, the preoperative nurse should not remove the patient’s dentures, glasses, or hearing aids until the patient is ready to be anesthetized to minimize communication difficulties and prevent embarrassment. If the patient is to remain conscious intraoperatively, these items should remain with the patient throughout the perioperative period when possible.11 PATIENT EDUCATION. As with all patients, the older adult should be informed about what to expect, especially in the immediate preoperative, intraoperative, and postoperative phases. Preoperative teaching should include the usual explanations about the postoperative recovery, such as the need for and how to perform coughing and deep breathing exercises and how to manage postoperative pain. Perioperative nurses should listen attentively, allowing the patient time to respond. The nurse may need to speak a little lower, more slowly, and more clearly than normal when speaking to an older adult to ensure that the patient can hear and understand the
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Postoperative embolism is a particular threat to older adults because slow circulation and hypotension predispose them to thrombus formation and emboli. Thromboembolic disease stockings should be applied in the preoperative area, if possible.
conversation and to give the patient more time to absorb the information and ask questions. Nurses can reinforce and amplify what the surgeon and the anesthesia care provider have said, teaching the patient and family members what to expect before, during, and after surgery. All explanations should be clear and concise, taking cues (eg, nonverbal communication) from the patient about how much or how little he or she has a need or desire to know. Some older adults would prefer not to know the minute details as long as they trust the surgeon and nurse and feel comfortable with the situation. Explanations and support also should be given to family members, who may be very anxious about the safety and outcome of the surgery because of the patient’s age. If the patient is confused, disoriented, or otherwise unable to give consent, a close relative or legal guardian should be asked to do so. FEARS. Older adult patients have most of the same fears about surgery that younger patients have. Older adults also may fear • loss of control, • pain, • separation from family, • disfigurement, • loss of a body part, and • death. An additional fear, particularly for older AORN JOURNAL •
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The physical and psychological stress of surgery makes it difficult for an older adult to return to his or her previous level of functioning. Dependency often creates the fear of increased reliance on family members or having to be admitted to a nursing home.
patients facing major surgery for cancer or a fractured hip, is that surgery will increase their dependence on others and they will no longer be able to live independently in their own home. Older adults in their 80s and 90s often are able to function quite well independently until a major surgery or illness occurs. The physical and psychological stress of surgery makes it difficult for an older adult to return to his or her previous level of functioning. Dependency often creates the fear of increased reliance on family members or having to be admitted to a nursing home.11
COMPLICATIONS THAT MAY OCCUR DURING THE INTRAOPERATIVE PHASE Close monitoring of body temperature is important for all patients because of the cool temperature of the OR and the effect of anesthetic agents, but older patients are particularly at risk for hypothermia because older adults have a decreased metabolism and normally lower body temperature.11,14 The cool environment and shivering that may result can increase cardiac output and ventilation, increasing oxygen consumption and depriving the heart and brain of necessary oxygen. “The slowing of metabolism that occurs with hypothermia delays awakening and the return of reflexes.”7(p190) The circulating nurse is the patient’s advocate and, as such, is responsible for helping to prevent
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hypothermia. Hypothermia may be prevented by • keeping the patient adequately covered in the holding area or prewarming the patient (eg, with forced-air warming or circulating-water garments) in the preoperative holding area; • increasing the room temperature until the patient is completely draped; • using warm IV and irrigating solutions; • warming the patient intraoperatively (eg, using forced-air warming, circulating-water garments, energy transfer pads) if possible, depending on the surgical site; • keeping the patient’s head and feet covered; • humidifying and warming the airway; and • uncovering the patient for a minimal amount of time only (eg, during positioning and skin preparation).14 The circulating nurse should carefully prepare the patient’s skin using the solution that is least likely to irritate the sensitive, fragile skin of the older adult. As with all patients, it is particularly important for the circulating nurse to prevent chemical burns to the patient by ensuring that the prep solution does not pool underneath the patient or under equipment such as tourniquet cuffs. “Skin preparation solutions should be used at a temperature recommended by the solution manufacturer. Heating some skin preparation agents may increase the risk of a chemical thermal burn.”14(p413) THROMBOEMBOLISM. Pulmonary embolism may be the most frequent cause of death postoperatively in the older adult age group.11 Thromboembolic disease stockings may have been applied in the preoperative area. Sequential compression devices or foot compression devices should be used intraoperatively to prevent thrombophlebitis. FLUID AND ELECTROLYTE PROBLEMS. Decreases in renal function caused by aging affect fluid, electrolyte, and acid-base balance. The stress of the surgical procedure, pain, anesthetics, and many medications given preoperatively increase the patient’s serum levels of sodium and fluid-retaining hormones.11 An excess of these electrolytes and hormones and a decreased ability of the cardiovascular system to expand make the older patient prone to hypovolemia. Electrolyte imbalances occur because the kidneys are no longer able to reabsorb or
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secrete electrolytes well. Acid-base imbalances treme caution is taken. For the lateral position, may occur as the kidneys lose their ability to perioperative personnel should turn the pasecrete ammonia. Hypovolemia and electrolyte tient’s trunk like a log; for the lithotomy posiand acid-base imbalances can be prevented or tion, personnel should flex both of the paat least minimized through careful monitoring tient’s knees at the same time and place them of I&O. Fluid status and vital signs should be simultaneously into the stirrups to prevent assessed frequently during surgery, especially lumbosacral strain.14 Perioperative personnel on patients undergoing long procedures, and should remove the patient’s legs from the leg should be reported to the postanesthesia care holders slowly and simultaneously to protect unit (PACU) nurse when the patient is transthe patient’s hip rotation and prevent lumferred to the recovery area. bosacral strain and then slowly return one leg POSITIONING INJURIES. Perioperative personnel at a time to the OR bed to maintain hemodyshould transfer the older adult namic status.15 patient to and from the OR The circulating nurse bed carefully and slowly, enshould check the patient’s deavoring to prevent hypotenarms, fingers, legs, and feet to sion, muscle or joint discomensure that they are not Perioperative personnel fort, skin injury, and psychocramped in an unusual posilogical trauma. After the tion or touching metal on the should carefully transfer patient is transferred to the OR bed. Skin that presses OR bed and anesthetized, peagainst an object for several older adult patients, rioperative personnel should hours during surgery easily carefully place the patient in can incur tissue injury and endeavoring to prevent the required position. Posiischemia because of the thintioning should allow for optiness and fragility of the older hypotension, skin injury, mal exposure without patient adult patient’s skin and poor compromise, optimal body circulation to the extremities. muscle or joint alignment, anesthesia access, The circulating nurse should safety, and adequate body syscheck all of the patient’s exdiscomfort, and tem functioning. Musculotremities carefully before the skeletal changes to be considsurgeon and scrub person psychological trauma. ered include apply the sterile drapes. Peripheral and superficial • loss of protective tone as a nerves are vulnerable to damresult of aging and muscle age from mechanical pressure. relaxants that further reThe longer and more superfiduce muscle tone; cial the nerve, the greater the possibility of • strain on muscles resulting in injury and damage as a result of pressure, stretching, or needless postoperative discomfort; and • that tension is placed on ligaments and ten- twisting. The principle cause of nerve injury is ischemia associated with stretching or comdons at joint lines when the muscles relax, pression of the nerve.11 Injury to nerves can causing the ligaments and tendons to become overstretched. cause paralysis, numbness, or paresthesia to Perioperative personnel should ensure that the muscles and the skin of the trunk, shoulthe patient’s legs and arms are moved slowly der, and hand.15 and carefully using normal range of motion as a The median nerve is injured frequently beguide. With an older woman who has marked cause of pressure to the lateral aspect of the osteoporosis, turning the patient to the lateral humerus. Injury results in weakness and atroposition for kidney surgery or positioning her phy of the forearm, creating an ape-like hand legs in lithotomy position could cause a femoral or claw-hand deformity. Injury to the radial head fracture or lumbar spine strain unless exnerve that supplies the extensive muscles of AORN JOURNAL •
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Tourniquets may cause pressure that can result in skin breakdown, and the skin of older adults is fragile so it is sensitive and more prone to shearing. The perioperative nurse, therefore, should take special care when applying the tourniquet and surgical dressings.
the arm and forearm can cause wrist drop. The sciatic nerve consists of both the tibial and common peroneal nerves that are located in the muscles of the buttocks and from there enter the thigh. These nerves are susceptible to injury during positioning, causing sciatica with severe pain that runs from the back or thigh to the toes. Injury can cause ischemia that may result in paralysis of various muscles, which may result in foot drop (ie, inability of the patient to dorsiflex his or her ankle) or lateral lower extremity paresthesia.15 The common peroneal nerve branches off the sciatic nerve just above the popliteal fossa. Compression or prolonged pressure of the nerve against the bone may result in foot drop. The tibial nerve branches off the sciatic nerve and goes deep beneath the calf muscles. The tibial nerve can be injured with prolonged pressure behind the ankle when the feet are crossed, resulting in motor loss of the calf muscles and sensory loss of the skin and sole of the foot. Perioperative nurses should ensure that positioning devices and the bed are well padded to prevent positioning injuries. When positioning the patient’s arms on the arm boards, the nurse should place the patient’s arms with palms up and with adequate padding of the elbows and fingers.15 If abduction is necessary,
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the nurse should ensure that the patient’s arms are positioned at less than 90 degrees from the long axis of the OR bed and gently secured so as not to constrict circulation.15 When tucking the patient’s arms at his or her sides, the circulating nurse should ensure that the patient’s arms and hands are faced in toward the body, the elbows are adequately padded, and the hands are enclosed in padding. A draw sheet should secure the arms and should be tucked under the mattress. If necessary, a well-padded sled can be used to support the arms. Perioperative personnel should avoid jerking or suddenly moving the patient during positioning and should avoid manipulating the patient after the procedure starts. All perioperative personnel should avoid leaning on the patient intraoperatively. Other considerations include using a tourniquet and applying surgical dressings. The perioperative nurse needs to keep in mind that the skin of older adults is fragile, so it is sensitive and more prone to shearing. Tourniquets may cause pressure that can result in skin breakdown. The circulating nurse should ensure that the patient’s extremity is effectively padded and should prevent pooling of prep fluids under the tourniquet cuff. If at all possible, the circulating nurse should work with the surgeon to minimize tourniquet time. The circulating nurse also should assess the patient for tape allergies and should use tape sparingly. ANESTHESIA CONSIDERATIONS. The use of anesthetic agents presents greater risks for older adult patients than for younger patients. For instance, recovery from anesthetic medications is longer, and complications may be more severe for older adult patients. With decreased liver and kidney function, medication metabolism and clearance often decreases in older adults. The minimum anesthetic concentration required declines progressively with advanced age. Oxygen masks may be difficult to fit because of lost teeth or decreased bony mass in the jaw. Ventilation may be difficult because of chronic obstructive pulmonary disease or emphysema. Older patients are susceptible to hypoxia, stroke, renal failure, and myocardial in-
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farction related to a rapid fall in blood pressure. Cardiac output and pulmonary capacities diminish with age, which decreases maximal oxygen uptake. Anesthetics may further reduce oxygen to the heart, kidneys, and brain. Older adult patients also are prone to postoperative hypotension, hypothermia, cerebral edema, and hypoxemia as a result of anesthetics.16 INFECTION CONTROL. Infections develop more easily in older adults because of immune system changes, and infections are more difficult to identify early as a result of altered symptomatology. Bacterial pneumonia is the leading cause of infection-related death in older adults, but the most common infection in older adults is UTI.16 Anorexia, confusion, incontinence, nausea, vague abdominal pain, and vomiting could be signs of a UTI in an older adult.17 Patients with diabetes may experience a loss of glycemic control. An imbalance in intraoperative blood glucose levels may predispose the patient to postoperative infections and complications.11 Symptoms of an infectious process can be atypical and include confusion, lethargy, and anorexia, in addition to the typical signs associated with any age group. Careful attention must be paid to infection prevention in older adults by • promoting good hydration and nutritional status; • monitoring vital signs, mental status, and general health status; • ensuring coughing and deep breathing and use of an incentive spirometer; • maintaining intact skin and mucous membranes; • avoiding immobility; • restricting contact with people who have infections or suspected infections; and • ensuring that all staff members adhere to strict infection control practices.17
POSTOPERATIVE PHASE The goal of providing care to all patients in the PACU is to reduce morbidity and mortality associated with surgery and anesthesia. For the older adult patient, this becomes increasingly important when considering all of the physio-
Infections develop more easily in older adults because of immune system changes, and infections are more difficult to identify early as a result of altered symptomatology. Symptoms of an infectious process can be atypical and include confusion, lethargy, and anorexia.
logic changes associated with aging. Ventilation; cardiovascular stability; fluid management; activity stir-up routine (eg, the process of awakening the patient); and pain management and comfort are PACU nursing priorities. VENTILATION AND AIRWAY MANAGEMENT. The first goal of airway management is to promote optimal gas exchange. The PACU nurse first must perform a respiratory assessment, including evaluating pulse oximeter readings, auscultating breath sounds, and determining the respiratory rate, rhythm, and ease of effort. Simultaneously, the PACU nurse initiates oxygen therapy for any patient who received general anesthesia and for most patients who have undergone conscious sedation. The nurse elevates the head of the patient’s bed, unless this is contraindicated by the surgical procedure, and encourages the patient to take frequent deep breaths to promote the uptake of oxygen and elimination of carbon dioxide and residual inhalation anesthetics. The PACU nurse also monitors the patient for compromised respiratory function (eg, atelectasis, pneumonia, respiratory infections), which requires that the PACU nurse • evaluate the patient for residual anesthetics; • consider preexisting conditions and health history (eg, smoking history); AORN JOURNAL •
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Reversal agents do not last as long as narcotics and neuromuscular blockers, so the postanesthesia care unit nurse should note whether reversal agents were administered intraoperatively. The nurse also should ensure that oxygenation and ventilation are adequate.
• •
maintain artificial airways; and encourage the patient to take deep breaths. The nurse should encourage the patient to splint the abdomen; take frequent, deep breaths; and cough and use the incentive spirometer hourly while awake. The PACU nurse should note whether reversal agents were administered intraoperatively because reversal agents do not last as long as narcotics and neuromuscular blockers. If the patient arrives in the PACU with an endotracheal tube in place, the PACU nurse must use sterile technique when suctioning the endotracheal tube. CARDIOVASCULAR STABILITY. The PACU nurse assesses the patient’s heart rate and rhythm, blood pressure, and heart sounds. The nurse initiates continuous electrocardiogram (ECG), blood pressure, and pulse oximetry monitoring. The goal is to detect myocardial compromise, not simply by the blood pressure readings, but also by corresponding symptoms. The most common cause of postoperative arrhythmias is hypoxemia.18 Therefore, careful attention must be directed toward verifying and maintaining adequate oxygenation and ventilation. Other causes of rhythm disturbances include electrolyte alterations and acid-base disturbances. The nurse also should check the patient’s peripheral pulses, capil-
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lary refill, and circulation as indicated. FLUID MANAGEMENT. The first goal of fluid management is to correct preoperative dehydration. In many cases, the patient will have been NPO since midnight. Many older adult patients may have been on diuretic therapy preoperatively or may have had a preoperative problem with nausea and vomiting. In correcting dehydration, however, the PACU nurse should prevent fluid overload. Nursing interventions include maintaining I&O records, monitoring IV rates, auscultating breath sounds when fluid boluses are administered, and monitoring vital signs. Monitoring urine output is a priority because of the decreased bladder capacity and sphincter tone of older adult patients. ACTIVITY STIR-UP ROUTINE. Stimulating the patient to awaken, breathe deeply, and follow commands promotes circulation and ventilation. This routine also allows the nurse to assess neurological functioning, which includes the patient’s ability to move all extremities, follow commands, and demonstrate orientation to person and place. The stir-up routine also promotes thermoregulation. Achievement of normothermia promotes cardiovascular stability and patient comfort and decreases myocardial demands for oxygen. Ongoing temperature monitoring and active postoperative rewarming with a temperature-regulating unit may be required.18 PAIN MANAGEMENT AND COMFORT. Implementing comfort measures is a priority. Older adult patients have decreased responses to pain and delayed renal and hepatic clearance of medications; therefore, pain medications should be administered judiciously with attention to ventilation and airway management, particularly in the older adult ambulatory surgery patient.11 Pain assessment must be regular, systematic, and documented in order to accurately evaluate the effectiveness of pain management treatment. Pain is subjective so it is difficult to assess, particularly in the elderly. The task becomes more difficult when the patient has dementia and cannot verbalize his or her pain. Numeric rating scales (ie, from 0 to 10 with 10 being the worst imaginable pain) and the Wong-Baker FACES pain rating scale (Figure 3)
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0 No Hurt
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1 Hurts Little Bit
2 Hurts Little More
3 Hurts Even More
4 Hurts Whole Lot
5 Hurts Worse
Figure 3 • The Wong-Baker FACES pain rating scale offers clinicians a tool to assess pain in older adult patients who may be cognitively impaired. The scale also provides a visual description for patients who do not have the verbal skills to explain how they feel. Reprinted with permission from Hockenberry MJ, Wilson D, Winkelstein ML. Wong’s Essentials of Pediatric Nursing. 7th ed. St Louis, MO: Mosby, 2005:1259.
are available. The FACES pain rating scale, which uses different facial expressions from neutral to grimacing to represent levels of pain, is a particularly effective and easy assessment tool to use. Many cognitively impaired older adults can respond to pain scales reliably if asked about the pain in the present and given sufficient time to comprehend the tool and develop a response.19 The PACU nurse also must carefully observe the patient’s behavior and changes in vital signs (eg, increased heart rate, pulse, respiration) to evaluate for pain and document the patient’s response to pain management interventions. Another step in the implementation of comfort measures is to provide psychological support, which includes reorienting the patient and using touch and clear communication. The PACU nurse should state information simply and repeat it as necessary.18 The PACU nurse should take special care when positioning an older patient. Repositioning the patient should be accomplished with sufficient support to prevent tugging on extremities or shearing the patient across the sheets. The PACU nurse should pad the patient’s bony prominences and may consider padding the side rails with side rail pads or by covering them with blankets. Skin care also is a priority. The PACU nurse should change wet sheets and ensure that the patient’s skin is dry. Care should be taken when applying tape to an older patient’s more fragile skin and the PACU nurse also should be careful when removing ECG leads and tape.11
SUMMARY Surgical intervention has provided many older adults not only with more years of life, but years that may be more functional than they would have been in decades past. Although older adults are at higher risk than younger individuals for complications during and after surgery, they tolerate elective surgery well if they are in good general physical condition and have excellent preoperative, intraoperative, and postoperative care. Emergency surgery increases the perioperative risk but performing thorough preoperative evaluations aimed at identifying intraoperative and postoperative risks and complications and endeavoring to optimize the status of the patient’s chronic medical conditions as much as possible before surgery can reduce surgical risk. Successful surgical management of an older adult’s health problems depends on the nurse’s understanding of the age-related factors that may affect the outcome of normal surgical procedures.
REFERENCES 1. Dramatic changes in US aging highlighted in new census, NIH report. Impact of baby boomers anticipated. US Census Bureau. http://www.census .gov/PressRelease/www/releases/archives/aging _population/006544.html. Accessed January 28, 2008. 2. He W, Sengupta M, Velkoff VA, Debarros KA. 65+ in the United States: 2005. In: US Census Bureau, Current Population Reports. Washington, DC: US Government Printing Office; 2005. http://www .census.gov/prod/2006pubs/p23-209.pdf. Issued December 2005. Accessed December 29, 2007. AORN JOURNAL •
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3. Rimkus A, Melinchok MD, eds. Thesaurus of Aging Terminology. 8th ed. Washington, DC: AARP; 2005. 4. A look at centenarians. Boston University Medical Campus. http://www.bumc.bu.edu/Dept/Content PF.aspx?PageID=5749&DepartmentID=361. Accessed January 28, 2008. 5. Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61(7):2159-2174. http://www.aafp.org/afp /20000401/2159.html. Accessed December 29, 2007. 6. Beers MH, ed. Falls. In: Merck Manual of Health & Aging. New York, NY: Ballantine Books; 2000:287-289. 7. Eliopoulas C. Safety. In: Gerontological Nursing. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:189-191. 8. Falls among older adults: an overview. Centers for Disease Control and Prevention. http://www .cdc.gov/ncipc/factsheets/adultfalls.htm. Accessed January 28, 2008. 9. A tool kit to prevent senior falls: figures. Centers for Disease Control and Prevention. http://www .cdc.gov/ncipc/pub-res/toolkit/figures.htm. Accessed January 29, 2008. 10. Falls and hip fractures. American Academy of Orthopedic surgeons. http://orthoinfo.aaos.org /topic.cfm?topic=A00121&return_link-0. Accessed January 28, 2008. 11. Hogstel MO, Taylor-Martof M. Perioperative care. In: Hogstel MO, ed. Gerontology: Nursing Care of the Older Adult. 3rd ed. Clifton Park, NY: CENGAGE Delmar Learning; 2001:288-289. 12. Liu LL, Leung JM. Syllabus on geriatric anesthesiology—perioperative complications in elderly patients. American Society of Anesthesiologists. http://www.asahq.org/clinical/geriatrics/perio_
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comp.htm. Accessed December 29, 2007. 13. Recommended practices for preoperative patient skin antisepsis. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:537-555. 14. Recommended practices for prevention of unplanned hypothermia. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:407-420. 15. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:497-520. 16. Beers MH, ed. Anesthesia considerations. In: The Merck Manual of Geriatrics. 3rd ed. Clifton Park, NY: CENGAGE Delmar Learning; 2000. http://www .merck.com/mrkshared/mmg/sec3/ch27/ch27a.jsp. Accessed December 29, 2007. 17. Elipoulas C. Meeting acute care needs. In: Gerontological Nursing. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:482. 18. Litwack K. The elderly patient. In: Postanesthesia Care Nursing. 2nd ed. St Louis, MO: Mosby; 1995:326-328. 19. Scott A. No time for pain. Adv Nurs. 2002;2(2):33.
Judith L. Clayton, RN, CNOR, is an RN clinician at Gwinnett Health System, Lawrenceville, GA. Ms Clayton has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
Patricia C. Seifert Appointed Editor-in-Chief of Journal
A
ORN is pleased to announce that Patricia C. Seifert, RN, MSN, CNOR, CRNFA, FAAN, will be the next editor-in-chief of the AORN Journal effective with the July 2008 issue. Seifert succeeds Nancy Girard, PhD, RN, FAAN, who has served as editor-inchief since December 2002. Seifert served two terms on the AORN Journal editorial board. Her editorial experience also includes service as a peer reviewer for the AORN Journal as well as for the Journal of Cardiovascular Nursing and the American Journal of Critical Care, among others. She will step down from her current role as editor of Perioperative Nursing Clinics as of July. She has authored four books, including the first textbook dedicated to perioperative nursing care of cardiac patients. She also has written numerous book chapters and scholarly articles. Seifert is a recognized expert in cardiac surgery
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nursing, a leader in the perioperative community, and a well-known AORN member. In 1992, she became the first recipient of the AORN National President’s Award. She served on the AORN Board of Directors from 1994 to 2000, culminating her service as AORN President in 2000. She was awarded the AORN Award for Excellence in 2003 and the AORN Jerry G. Peers Distinguished Service Award in 2007 for her years of dedicated service to perioperative education. She speaks frequently at perioperative conferences, both in the United States and abroad, and her presentation activities include leading three perioperative nursing delegations to China. Seifert received her master’s degree in nursing from Catholic University, Washington, DC. She currently holds the position of education coordinator, Cardiovascular Operating Room at Inova Fairfax Hospital in Fairfax, Virginia.
Examination
3.2
Special Needs of Older Adults Undergoing Surgery PURPOSE/GOAL To educate perioperative nurses about the special needs of older adults undergoing surgery.
BEHAVIORAL OBJECTIVES After reading and studying the article on the special perioperative needs of older adults, nurses will be able to
1. describe factors that affect the health of older adults, 2. identify issues pertinent to older adults that may affect hospitalization and surgery, and 3. describe nursing care focused on preventing perioperative complications experienced by the older adult patient.
QUESTIONS 1. At least 50% of older adults who were ambulating before fracturing a hip do not recover their previous level of mobility because 1. mobility sometimes is reduced by the fear of falling again. 2. decreased activity may increase joint stiffness and weakness. 3. the enabling behavior of a caregiver allows the patient to be less mobile. a. 1 b. 3 c. 1 and 2 d. 1, 2, and 3 2. Smoking and excessive consumption of alcohol, specifically in older adults, can 1. interfere with normal bone-building processes and bone remodeling. 2. result in bone loss. 3. interfere with the production of estrogen and testosterone, without which bone mass may be decreased. a. 1 b. 2 c. 1 and 2 d. 1, 2, and 3 3. The risk of osteoporosis and hip fracture may be increased by long-term use of certain medications that can accelerate bone loss. These include 1. anticonvulsants. © AORN, Inc, 2008
2. antidepressants. 3. certain diuretics and blood thinners. 4. corticosteroids. 5. thyroid medications. a. 2 and 3 b. 1, 4, and 5 c. 1, 3, 4, and 5 d. 1, 2, 3, 4, and 5 4. Unless absolutely necessary, nurses should not shave or clip the hair of an older adult patient undergoing surgery because 1. shaving and clipping may traumatize the skin, increasing the risk of postoperative infection. 2. hair growth is decreased especially in the pubic and axillary regions so hair removal may be unnecessary. 3. the skin is likely to be thin, dry, and wrinkled, making shaving more difficult. a. 1 b. 2 c. 1 and 2 d. 1, 2, and 3 5. It is especially important to prevent intraoperative hypothermia in older adult patients because 1. the metabolism of older adults is decreased. 2. shivering can increase cardiac output and ventilation, which increases oxygen MARCH 2008, VOL 87, NO 3 • AORN JOURNAL • 571
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consumption and deprives the heart and brain of necessary oxygen. 3. awakening and the return of reflexes is delayed because of the slowing of metabolism that occurs with hypothermia. 4. an older person’s body temperature is normally lower. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 6. Older adult patients are prone to hypovolemia because 1. serum levels of fluid-reducing hormones and sodium may be increased by pain, medications, and anesthetics. 2. the cardiovascular system has a decreased ability to expand. 3. the kidneys are no longer able to reabsorb or secrete electrolytes. 4. most older adults have a altered skin integrity, which affects the patient’s ability to perspire. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 7. Unless extreme caution is taken, placing an older adult patient who has osteoporosis into the lateral or lithotomy position
The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.
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Examination
could cause a femoral head fracture or lumbar spine strain. a. true b. false 8. Prolonged pressure behind the ankle when the patient’s feet are crossed may result in tibial nerve injury that may be reflected as 1. loss of the autonomic nervous system response to pain. 2. motor loss of the calf muscles. 3. neuroendocrine abnormalities of the superficial sweat glands of the feet. 4. sensory loss of the skin on the soles of the feet. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 9. The risks presented by anesthetic agents are the same for older adult patients as for younger patients. a. true b. false 10. Pain medications should be administered judiciously to older adults because they have decreased responses to pain and delayed renal and hepatic clearance of medications. a. true b. false
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 Center’s Commission on Accreditation. 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.
Answer Sheet Special Needs of Older Adults Undergoing Surgery
3.2 Event #08016 Session #3018
lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:
P
AORN Customer Service c/o AORN Journal Continuing Education 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax with credit card information to (303) 750-3212. Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.
Signature ______________________________________ 1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the time you needed to complete this 3.2 continuing education contact hour (192-minute) program. ______ 4. Enclose fee if information is mailed. AORN (ID) #____________________________________________ Name__________________________________________________ Address ________________________________________________ City ___________________________________________________
State __________ Zip __________
Phone number __________________________________________ RN license #____________________________________________
State __________
Fee enclosed ___________________________________________ or bill the credit card indicated
■ MC
■ Visa
Card # ___________________________________
■ American Express
■ Discover
Expiration date _____________________
Signature _______________________________________________________________ (for credit card authorization) Fee: Members $16 Nonmembers $32
A score of 70% correct on the examination is required for credit.
Program offered March 2008
Each applicant who successfully completes this program will receive a certificate of completion.
The deadline for this program is March 31, 2011 © AORN, Inc, 2008
Participants receive feedback on incorrect answers.
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3.2
Learner Evaluation
Special Needs of Older Adults Undergoing Surgery his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.
T
PURPOSE/GOAL To educate perioperative nurses about the special needs of older adults undergoing surgery.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Describe factors that affect the health of older adults. 2. Identify issues pertinent to older adults that may affect hospitalization and surgery. 3. Describe nursing care focused on preventing perioperative complications experienced by the older adult patient.
CONTENT To what extent 4. did this article increase your knowledge of the subject matter? 5. was the content clear and organized? 6. did this article facilitate learning? 7. were your individual objectives met? 8. did the objectives relate to the overall purpose/goal?
TEST QUESTIONS/ANSWERS To what extent 9. were they reflective of the content? 10. were they easy to understand? 11. did they address important points?
LEARNER INPUT 12. Will you be able to use the information from this article in your work setting? 1. yes 2. no 13. I learned of this article via 1. the Journal I receive as an AORN member. 2. a Journal I obtained elsewhere. 3. the AORN Journal web site.
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14. What factor most affects whether you take an AORN Journal continuing education examination? 1. need for continuing education contact hours 2. price 3. subject matter relevant to current position 4. number of continuing education contact hours offered What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): __________________________________ __________________________________________ __________________________________________ Author names and addresses: _______________ __________________________________________ __________________________________________
© AORN, Inc, 2008
T
he face of aging in the United States is changing dramatically and rapidly. Today’s older Americans are very different from their predecessors. They live longer, have lower rates of disability, have achieved higher levels of education, and live in poverty less often. The first of the Baby Boomers, approximately 2.9 million people, celebrated their 60th birthdays in 2006.1 A substantial increase in the number of older adults will occur from 2010 to 2030 after the first Baby Boomers turn 65 in 2011.2 The population of older adults in 2030 is projected to be twice as large as in 2000, growing from 35 million to 72 million. This age group is anticipated to represent nearly 20% of the total United States population.2 Older adults are at higher risk than younger individuals for complications during and after surgery. Successful surgical management of an older adult’s health problems depends on the nurse’s understanding of the age-related factors that may affect the outcome of normal surgical procedures. Carefully planned, effective nursing care during the perioperative period will help reduce surgical morbidity in older adults.
LIFE EXPECTANCY The average life expectancy is increasing every year in the United States as Baby Boomers are fast approaching
indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 571–572 and then completing the answer sheet and learner evaluation on pages 573–574. You also may access this article online at http://www.aornjournal.org.
© AORN, Inc, 2008
3.2
old age.2 These increases can be attributed to a focus on prevention of disease and illness with increased socialization and advancements in disease control and health technology. During the past century, improvements that have affected life expectancy in the United States occurred in two stages. First, death during childhood became less likely, largely because sanitation processes improved and vaccines and treatments for childhood diseases were developed. Second, disease and disability are less likely to develop or have been postponed in older adults because health care and disease prevention have improved. Historically, female life expectancy has been higher than male life expectancy at most ages.2 Gender differences in life expectancy can be attributed to differences in attitudes, behaviors, social roles, and biological risks between men
ABSTRACT DURING THE PAST CENTURY, life expectancy in the United States has increased as a result of improved sanitation, development of vaccines and treatments for childhood diseases, and vast improvements in health care and disease prevention. OLDER ADULTS ARE AT HIGHER RISK than younger individuals for complications during and after surgery. Carefully planned, effective nursing care during the perioperative period will help reduce surgical morbidity in older adults. AGE-SPECIFIC NURSING CARE techniques that are provided during the preoperative, intraoperative, and postoperative phases of a surgical experience are discussed in this article, with a particular focus on how to manage pain and prevent infection. AORN J 87 (March 2008) 557-570. © AORN, Inc, 2008.
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and women. In 2000, life expectancy at birth was 79.5 years for women and 74.1 years for men.2 This was largely a result of reductions in mortality at older ages. Not only are more people surviving past the age of 65, but they also have more years of productive life remaining than people did a century ago.2 Like their younger counterparts, members of the “old-old” generation also have better survival prospects today than at any other point in the past century.2 Confusion exists regarding age category definitions. According to the AARP, the categories are • middle age—40 to 59 years of age, • young old—60 to 74 years of age, and • old old—75 to 100+ years of age.3 Centenarians [ie, people who are 100 years of age and older] are the fastest growing segment of the US population.4 In 1990, there were approximately 37,000 centenarians; in 1998, there were 61,000 centenarians; and in the year 2000, 50,454 people were 100 years of age or older.2 About 80% of all centenarians are women.2
Like their younger counterparts, members of the old-old generation also have better survival prospects today than at any other point in the past century.
FACTORS AFFECTING
THE
HEALTH
OF
OLDER ADULTS
Smoking, overuse of alcohol, being overweight, lack of exercise, and inadequate consumption of fruits and vegetables are some of the risk factors researchers associate with morbidity and mortality at older ages. Evidence suggests, however, that positive behavior change, even at older ages, can provide health benefits and improve quality of life. Smoking cessation, following a nutritious diet, exercising regularly, taking prescribed medications to
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control illness, and staying mentally active have proven to reduce the risk of developing several disorders that commonly occur as people age. As centenarian and legendary jazz musician Eubie Blake said, “If I’d known I was gonna live this long, I’d have taken better care of myself.” FALLS. Older adults, who currently represent 12% of the population, account for 75% of deaths from falls.3 The number of falls increases progressively with age in both genders and in all racial and ethnic groups.5 The injury rate for falls is highest among adults 85 years of age and older.5 In 2003, more than 1.8 million adults 65 years of age and older were treated in emergency departments for fall-related injuries, and more than 421,000 were hospitalized.5 The most common fractures are of the hip, vertebrae, shoulder, and wrist.6 Fall-related injuries account for approximately 5% of hospitalizations in patients older than 65 years. Approximately 5% of the falls result in a fracture of the humerus, wrist, or pelvis.6 Other serious injuries, such as head and internal injuries and lacerations, occur in about 5% of the falls.6 Approximately 2% of falls result in a hip fracture,6 and about 5% of older adults with hip fractures die while hospitalized.5 Annually, 1,800 falls directly result in death, and approximately 9,500 deaths in older Americans are associated with falls each year (Figure 1).5 The overall mortality in the 12 months after a hip fracture ranges from 18% to 33%.6 Many older adults who fall are frail and have preexisting deficits in activities of daily living (eg, personal care tasks such as bathing, eating, toileting, dressing) and instrumental activities of daily living (eg, preparing one’s own meals, doing light housework, managing one’s own money, using the telephone, shopping).2,5 These people are at risk for other complications after a fall in which a fracture occurs (ie, increased risk of pneumonia, thrombus formation, pressure ulcers, renal calculi, fecal impaction, contractures). About 50% of those who fall cannot get up without help.5 The risk of dehydration, pressure ulcers, rhabdomyolysis, hypothermia, and pneumonia increases when an older adult remains on the floor for longer than two hours after a fall.5 Function and quality of life may deteriorate
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FIGURE 1
25 |
Men Women
10 |
15 |
20 |
Rate
30 |
35 |
Rate* of Unintentional Fall-Related Deaths Among Adults Aged ≥ 65 Years, by Sex—United States, 1987-1996
| | 1987 1988
| 1989
| 1990
| | 1991 1992
| 1993
| 1994
| | 1995 1996
Year * Per 100,000 population Reprinted from Stevens JA, Hasbrouck L, Durant TM, et al. Rate* of unintentional fall-related deaths among adults aged ≥ 65 years by sex—United States, 1987-1996. In: Surveillance for Injuries and Violence Among Older Adults. Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss4808 a3.htm. Accessed January 8, 2008.
drastically after a fall; at least 50% of older adults who were ambulating before fracturing a hip do not recover their previous level of mobility.6 After falling, older adults may fear falling again, so their mobility sometimes is reduced because they have lost confidence. Decreased activity can increase joint stiffness and weakness, further reducing mobility. Falls reportedly contribute to 40% of nursing home admissions.6 The high incidence of falls in older adults may be a result of many factors, such as • age-related changes (eg, reduced visual capacity); • caregiver-related factors (eg, improper use of restraints, delays in responding to requests, poor supervision of problem behavior); • disease-related symptoms, such as ataxia, confusion, mood disturbances, orthostatic hypotension, and weakness; • environmental hazards, such as extension cords, uneven sidewalks, and wet surfaces; • improper use of mobility aids;
•
unsafe clothing (eg, long robes or pant legs, poorly fitting shoes and socks, shoes with slippery soles or heels); and • use of medications, particularly those that can cause dizziness, drowsiness, and orthostatic hypertension.7 Most falls occur when several causes interact. For example, a person with Parkinson’s disease (ie, a disease) and impaired vision (ie, a physical condition) may trip on an extension cord (ie, an environmental hazard) while hurrying to answer the telephone.6 Older adults who reported both vision and hearing loss were more likely than those without either impairment to have fallen or broken a hip.2 Risk factors for falls include • being 65 years of age or older, especially older than 75 years; • being Caucasian; • being female (ie, women are two to three times more likely to fall than men); • being housebound; AORN JOURNAL •
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heredity, because genetic factors influence Osteoporosis is one of the major risk facbone size, bone mass, and bone density; and tors for hip fracture.6 Loss of bone strength tends to be greatest in the spine, lower fore• living alone.5 Neurological changes (eg, postural instabilarms, and femurs. Other medical conditions ity, diminished sensory awareness for light also may lead to bone fragility either by slowtouch) increase an older adult patient’s risk of ing bone formation or speeding up bone loss. cognitive impairment, difficulty rising from a Women lose bone density at a faster rate than chair, foot problems, and difficulty hearing. men. A family history of osteoporosis or fracRisky behaviors such as poor eating habits tures later in life is a strong predictor of low (eg, calcium and vitamin D deficiency) and bone mass, although not necessarily of fractobacco and alcohol use increase an older tures themselves. Caucasians and Asians have adult’s risk of falling.5 Smoking and excessive the highest risk of osteoporosis.6 consumption of alcohol can Lack of sufficient intake of interfere with normal bonecalcium and vitamin D in the building processes and bone diet when a person is young remodeling, resulting in bone lowers peak bone mass and loss. These habits also interincreases risk of fracture later fere with the production of in life.11 Serious eating disorIn 2000, approximately estrogen and testosterone, ders, such as anorexia nervosa two hormones that contribute and bulimia, can damage the 350,000 older adults to bone mass. In addition, skeleton by depriving the women who smoke tend to body of essential nutrients were hospitalized for hip enter menopause earlier than needed for bone building.11 6 do nonsmokers. Certain medications can fractures. By 2050, hip HIP FRACTURES. The hip is the accelerate bone loss, thus inmost common nonvertebral creasing the risk of osteoporofractures are expected fracture site.8 More than 90% sis and hip fracture. Longof hip fractures are associated term use of corticosteroids to reach 650,000 per with falls, and most of these may lower bone mass.11 Other fractures occur in adults older medications that may conyear, averaging nearly than 70 years of age.8 Hip fractribute to bone loss or to calture is the leading fall-related cium or vitamin D deficien1,800 per day. injury that results in hospitalcies, if used for long periods ization, with significantly proof time, include anticonvullonged and costly hospital sants, thyroid medications, stays. In the year 2000, 1.6 miland certain diuretics and lion older adults were treated blood thinners.11 for fall-related injuries with 350,000 hospitalSome medications may affect balance and izations for hip fractures.8 “From 1988 to 2000, cause dizziness. These include antidepressants, the hospital admission rate for hip fractures cold and allergy medications, pain relievers, among women [was] twice the rate for men.”9 sedatives, sleep medications, some blood presFigure 2 demonstrates the rate of hospitalizasure medications, and tranquilizers.11 tion for hip fractures among older adults. Historical risk factors for hip fractures include SURGERY IN OLDER ADULTS use of a cane or walker; previous falls; acute illMany older patients, even those in their ness; chronic conditions, especially neuromuscu70s, 80s, and 90s, tolerate elective surgery lar disorders; and medications, especially the use quite well if clinicians carefully plan and proof four or more prescription medications.2 By vide effective preoperative and postoperative 2050, hip fractures are expected to reach 650,000 nursing care. Age is no longer a major factor per year, averaging nearly 1,800 per day.10 in deciding whether to schedule surgery if the
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FIGURE 2
Women
800 | 600 |
Rate
1,000 |
1,200 1,400 | |
Rate* of Hospitalization for Hip Fracture Among Adults Aged ≥ 65, by Sex—United States, 1988-1996
200 |
400 |
Men
| | 1988 1989
| 1990
| | 1991 1992
| 1993
| 1994
| | 1995 1996
Year * Per 100,000 population Reprinted from Stevens JA, Hasbrouck L, Durant TM, et al. Rate* of hospitalization for hip fracture among adults aged ≥ 65 years by sex—United States, 1988-1996. In: Surveillance for Injuries and Violence Among Older Adults. Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss4808 a3.htm. Accessed January 8, 2008.
procedure is needed to prolong life, make living more comfortable, or both. Older adults do not tolerate emergency or long, complicated surgery as well as younger people, however, because of their decreased ability to adapt to physical and psychological stress.11 Despite higher numbers of older adults having surgery, morbidity and mortality rates have declined. Studies show a decline in perioperative mortality rates from 20% in the 1960s to 10% in the 1970s and 5% to 6% in the 1980s.8,12 “This trend of declining mortality rates extends even to those on the extreme end of the age spectrum.”12 Several risk factors for perioperative mortality have been identified. “Emergency procedures are associated with a higher mortality rate regardless of the age group.”8 The location of the surgical site also has an important
effect on mortality rate. Multiple studies have shown that procedures involving the thorax or abdomen have higher complication and mortality rates.8,12 In addition, coexisting conditions have been found to be important risk predictors of perioperative mortality. The effects of coexisting conditions outweigh the effects of age alone on anesthetic outcome.12 When age and severity of illness are compared, the number of coexisting conditions is more significant.12 Literature does not substantiate delaying surgery because of the patient’s age.12 Early surgical treatment should be considered whenever possible because emergency procedures increase perioperative risk. Every effort should be made to perform a thorough preoperative evaluation aimed at identifying intraoperative risk and the risk of postoperative AORN JOURNAL •
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complications and optimizing the status of the patient’s chronic medical conditions as much as possible before surgery. There may not be time to perform a complete evaluation and correct risk factors before emergency surgery; however, even performing a partial evaluation and correction can reduce surgical risks. Assessment and care should continue postoperatively, especially after emergency surgery in which there was insufficient time for preoperative stabilization.12
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therapy for replacement of fluid and electrolytes. Enemas and diuretics should be avoided before surgery because they increase the risk of dehydration. If possible, surgery should be scheduled early in the day, or, if that is not possible, the patient should be allowed to have a light breakfast (eg, clear liquids and easily digested toast) first thing in the morning.11 The most prevalent chronic health problems of older adults include arthritis; cataracts or glaucoma; circulatory problems; hypertension; osteoporosis; presbycusis (ie, hearing PREOPERATIVE PHASE loss associated with aging); The goal of the preoperaand urinary tract infections tive phase is to ensure that the (UTIs). Perioperative nurses patient is in the best possible should recognize how these A preoperative condition for surgery through conditions will affect the care careful assessment and thorof the surgical patient during evaluation geared ough preparation. A preoperathe entire perioperative period. tive evaluation geared toward MEDICATION HISTORY. Older toward risk assessment, risk assessment and impleadult patients are likely to be mentation of risk-reduction taking numerous medications, and implementation of strategies will decrease the both prescription and over-therisk of perioperative morbidicounter. Medications that an risk-reduction strategies ty and mortality. Factors that older adult may have been takare most likely to contribute to ing routinely before surgery will decrease the risk of a successful surgical experiand that may cause complicaence include tions during the perioperative perioperative morbidity period include • stabilizing nutritional and hydration status; antidepressants, because • and mortality. they may lower blood pres• controlling related comorbidities and evaluating sure during anesthesia; medications; and • any medications with anticholinergic effects, because • preparing the patient physically and psychologically they increases the potential for the perioperative experience, including for confusion; adequate explanations about what to expect • aspirin, because it may increase bleeding; during and after surgery. • bromide, because it can accumulate and BASELINE DATA. Baseline data on all body sysproduce signs or symptoms of dementia; tems is important for comparison with assess• nonsteroidal anti-inflammatory drugs, bement data obtained postoperatively. The preopcause they increase the risk of stress ulcers erative assessment should include the patient’s and displace other medications from blood skin status, psychological status, ability to perproteins; and form activities of daily living and adequate • steroids because they suppress immunity.11 range of motion, and nature of the home enviSKIN CARE. Whenever possible, hair on the ronment and family members’ competence to older adult patient’s skin should not be shaved provide care after discharge. Assessment of nuor clipped because traumatized skin increases tritional status and adequate hydration should the risk of postoperative infection.13 If the hair include documenting recent weight loss, labora- needs to be removed from the surgical site, spetory values, intake and output (I&O), and IV cial care should be taken to prevent injury. Hair
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growth in older adults is decreased, especially in the pubic and axillary regions, and the skin is likely to be thin, dry, and wrinkled, making shaving more difficult. Lotion should not be used on the older patient’s skin before surgery because it likely will retain bacteria.11 THROMBOEMBOLIC DISEASE (TED) STOCKINGS. Postoperative embolism is a particular threat to older adults. Slow circulation and hypotension predispose older adults to thrombus formation and emboli. Dehydration, decreased muscle tone, decreased cardiac output, and the restrictions placed on physical activity make thrombophlebitis an even greater threat for older adult patients. If TED stockings are ordered for the patient’s lower legs, they should be applied in the preoperative area if possible.11 URINARY CATHETER. If a urinary catheter is not to be inserted before surgery, the preoperative nurse should ensure that the patient voids immediately before going into the OR. If surgery is anticipated to be long or complicated, the circulating nurse usually inserts a catheter because “the size and holding capacity of the bladder decreases with age.”11(p288) ASSISTIVE DEVICES. Some anesthesia care providers prefer that dentures be left in place to help with the facial fit of the oxygen mask. Whenever possible, the preoperative nurse should not remove the patient’s dentures, glasses, or hearing aids until the patient is ready to be anesthetized to minimize communication difficulties and prevent embarrassment. If the patient is to remain conscious intraoperatively, these items should remain with the patient throughout the perioperative period when possible.11 PATIENT EDUCATION. As with all patients, the older adult should be informed about what to expect, especially in the immediate preoperative, intraoperative, and postoperative phases. Preoperative teaching should include the usual explanations about the postoperative recovery, such as the need for and how to perform coughing and deep breathing exercises and how to manage postoperative pain. Perioperative nurses should listen attentively, allowing the patient time to respond. The nurse may need to speak a little lower, more slowly, and more clearly than normal when speaking to an older adult to ensure that the patient can hear and understand the
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Postoperative embolism is a particular threat to older adults because slow circulation and hypotension predispose them to thrombus formation and emboli. Thromboembolic disease stockings should be applied in the preoperative area, if possible.
conversation and to give the patient more time to absorb the information and ask questions. Nurses can reinforce and amplify what the surgeon and the anesthesia care provider have said, teaching the patient and family members what to expect before, during, and after surgery. All explanations should be clear and concise, taking cues (eg, nonverbal communication) from the patient about how much or how little he or she has a need or desire to know. Some older adults would prefer not to know the minute details as long as they trust the surgeon and nurse and feel comfortable with the situation. Explanations and support also should be given to family members, who may be very anxious about the safety and outcome of the surgery because of the patient’s age. If the patient is confused, disoriented, or otherwise unable to give consent, a close relative or legal guardian should be asked to do so. FEARS. Older adult patients have most of the same fears about surgery that younger patients have. Older adults also may fear • loss of control, • pain, • separation from family, • disfigurement, • loss of a body part, and • death. An additional fear, particularly for older AORN JOURNAL •
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The physical and psychological stress of surgery makes it difficult for an older adult to return to his or her previous level of functioning. Dependency often creates the fear of increased reliance on family members or having to be admitted to a nursing home.
patients facing major surgery for cancer or a fractured hip, is that surgery will increase their dependence on others and they will no longer be able to live independently in their own home. Older adults in their 80s and 90s often are able to function quite well independently until a major surgery or illness occurs. The physical and psychological stress of surgery makes it difficult for an older adult to return to his or her previous level of functioning. Dependency often creates the fear of increased reliance on family members or having to be admitted to a nursing home.11
COMPLICATIONS THAT MAY OCCUR DURING THE INTRAOPERATIVE PHASE Close monitoring of body temperature is important for all patients because of the cool temperature of the OR and the effect of anesthetic agents, but older patients are particularly at risk for hypothermia because older adults have a decreased metabolism and normally lower body temperature.11,14 The cool environment and shivering that may result can increase cardiac output and ventilation, increasing oxygen consumption and depriving the heart and brain of necessary oxygen. “The slowing of metabolism that occurs with hypothermia delays awakening and the return of reflexes.”7(p190) The circulating nurse is the patient’s advocate and, as such, is responsible for helping to prevent
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hypothermia. Hypothermia may be prevented by • keeping the patient adequately covered in the holding area or prewarming the patient (eg, with forced-air warming or circulating-water garments) in the preoperative holding area; • increasing the room temperature until the patient is completely draped; • using warm IV and irrigating solutions; • warming the patient intraoperatively (eg, using forced-air warming, circulating-water garments, energy transfer pads) if possible, depending on the surgical site; • keeping the patient’s head and feet covered; • humidifying and warming the airway; and • uncovering the patient for a minimal amount of time only (eg, during positioning and skin preparation).14 The circulating nurse should carefully prepare the patient’s skin using the solution that is least likely to irritate the sensitive, fragile skin of the older adult. As with all patients, it is particularly important for the circulating nurse to prevent chemical burns to the patient by ensuring that the prep solution does not pool underneath the patient or under equipment such as tourniquet cuffs. “Skin preparation solutions should be used at a temperature recommended by the solution manufacturer. Heating some skin preparation agents may increase the risk of a chemical thermal burn.”14(p413) THROMBOEMBOLISM. Pulmonary embolism may be the most frequent cause of death postoperatively in the older adult age group.11 Thromboembolic disease stockings may have been applied in the preoperative area. Sequential compression devices or foot compression devices should be used intraoperatively to prevent thrombophlebitis. FLUID AND ELECTROLYTE PROBLEMS. Decreases in renal function caused by aging affect fluid, electrolyte, and acid-base balance. The stress of the surgical procedure, pain, anesthetics, and many medications given preoperatively increase the patient’s serum levels of sodium and fluid-retaining hormones.11 An excess of these electrolytes and hormones and a decreased ability of the cardiovascular system to expand make the older patient prone to hypovolemia. Electrolyte imbalances occur because the kidneys are no longer able to reabsorb or
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secrete electrolytes well. Acid-base imbalances treme caution is taken. For the lateral position, may occur as the kidneys lose their ability to perioperative personnel should turn the pasecrete ammonia. Hypovolemia and electrolyte tient’s trunk like a log; for the lithotomy posiand acid-base imbalances can be prevented or tion, personnel should flex both of the paat least minimized through careful monitoring tient’s knees at the same time and place them of I&O. Fluid status and vital signs should be simultaneously into the stirrups to prevent assessed frequently during surgery, especially lumbosacral strain.14 Perioperative personnel on patients undergoing long procedures, and should remove the patient’s legs from the leg should be reported to the postanesthesia care holders slowly and simultaneously to protect unit (PACU) nurse when the patient is transthe patient’s hip rotation and prevent lumferred to the recovery area. bosacral strain and then slowly return one leg POSITIONING INJURIES. Perioperative personnel at a time to the OR bed to maintain hemodyshould transfer the older adult namic status.15 patient to and from the OR The circulating nurse bed carefully and slowly, enshould check the patient’s deavoring to prevent hypotenarms, fingers, legs, and feet to sion, muscle or joint discomensure that they are not Perioperative personnel fort, skin injury, and psychocramped in an unusual posilogical trauma. After the tion or touching metal on the should carefully transfer patient is transferred to the OR bed. Skin that presses OR bed and anesthetized, peagainst an object for several older adult patients, rioperative personnel should hours during surgery easily carefully place the patient in can incur tissue injury and endeavoring to prevent the required position. Posiischemia because of the thintioning should allow for optiness and fragility of the older hypotension, skin injury, mal exposure without patient adult patient’s skin and poor compromise, optimal body circulation to the extremities. muscle or joint alignment, anesthesia access, The circulating nurse should safety, and adequate body syscheck all of the patient’s exdiscomfort, and tem functioning. Musculotremities carefully before the skeletal changes to be considsurgeon and scrub person psychological trauma. ered include apply the sterile drapes. Peripheral and superficial • loss of protective tone as a nerves are vulnerable to damresult of aging and muscle age from mechanical pressure. relaxants that further reThe longer and more superfiduce muscle tone; cial the nerve, the greater the possibility of • strain on muscles resulting in injury and damage as a result of pressure, stretching, or needless postoperative discomfort; and • that tension is placed on ligaments and ten- twisting. The principle cause of nerve injury is ischemia associated with stretching or comdons at joint lines when the muscles relax, pression of the nerve.11 Injury to nerves can causing the ligaments and tendons to become overstretched. cause paralysis, numbness, or paresthesia to Perioperative personnel should ensure that the muscles and the skin of the trunk, shoulthe patient’s legs and arms are moved slowly der, and hand.15 and carefully using normal range of motion as a The median nerve is injured frequently beguide. With an older woman who has marked cause of pressure to the lateral aspect of the osteoporosis, turning the patient to the lateral humerus. Injury results in weakness and atroposition for kidney surgery or positioning her phy of the forearm, creating an ape-like hand legs in lithotomy position could cause a femoral or claw-hand deformity. Injury to the radial head fracture or lumbar spine strain unless exnerve that supplies the extensive muscles of AORN JOURNAL •
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Tourniquets may cause pressure that can result in skin breakdown, and the skin of older adults is fragile so it is sensitive and more prone to shearing. The perioperative nurse, therefore, should take special care when applying the tourniquet and surgical dressings.
the arm and forearm can cause wrist drop. The sciatic nerve consists of both the tibial and common peroneal nerves that are located in the muscles of the buttocks and from there enter the thigh. These nerves are susceptible to injury during positioning, causing sciatica with severe pain that runs from the back or thigh to the toes. Injury can cause ischemia that may result in paralysis of various muscles, which may result in foot drop (ie, inability of the patient to dorsiflex his or her ankle) or lateral lower extremity paresthesia.15 The common peroneal nerve branches off the sciatic nerve just above the popliteal fossa. Compression or prolonged pressure of the nerve against the bone may result in foot drop. The tibial nerve branches off the sciatic nerve and goes deep beneath the calf muscles. The tibial nerve can be injured with prolonged pressure behind the ankle when the feet are crossed, resulting in motor loss of the calf muscles and sensory loss of the skin and sole of the foot. Perioperative nurses should ensure that positioning devices and the bed are well padded to prevent positioning injuries. When positioning the patient’s arms on the arm boards, the nurse should place the patient’s arms with palms up and with adequate padding of the elbows and fingers.15 If abduction is necessary,
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the nurse should ensure that the patient’s arms are positioned at less than 90 degrees from the long axis of the OR bed and gently secured so as not to constrict circulation.15 When tucking the patient’s arms at his or her sides, the circulating nurse should ensure that the patient’s arms and hands are faced in toward the body, the elbows are adequately padded, and the hands are enclosed in padding. A draw sheet should secure the arms and should be tucked under the mattress. If necessary, a well-padded sled can be used to support the arms. Perioperative personnel should avoid jerking or suddenly moving the patient during positioning and should avoid manipulating the patient after the procedure starts. All perioperative personnel should avoid leaning on the patient intraoperatively. Other considerations include using a tourniquet and applying surgical dressings. The perioperative nurse needs to keep in mind that the skin of older adults is fragile, so it is sensitive and more prone to shearing. Tourniquets may cause pressure that can result in skin breakdown. The circulating nurse should ensure that the patient’s extremity is effectively padded and should prevent pooling of prep fluids under the tourniquet cuff. If at all possible, the circulating nurse should work with the surgeon to minimize tourniquet time. The circulating nurse also should assess the patient for tape allergies and should use tape sparingly. ANESTHESIA CONSIDERATIONS. The use of anesthetic agents presents greater risks for older adult patients than for younger patients. For instance, recovery from anesthetic medications is longer, and complications may be more severe for older adult patients. With decreased liver and kidney function, medication metabolism and clearance often decreases in older adults. The minimum anesthetic concentration required declines progressively with advanced age. Oxygen masks may be difficult to fit because of lost teeth or decreased bony mass in the jaw. Ventilation may be difficult because of chronic obstructive pulmonary disease or emphysema. Older patients are susceptible to hypoxia, stroke, renal failure, and myocardial in-
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farction related to a rapid fall in blood pressure. Cardiac output and pulmonary capacities diminish with age, which decreases maximal oxygen uptake. Anesthetics may further reduce oxygen to the heart, kidneys, and brain. Older adult patients also are prone to postoperative hypotension, hypothermia, cerebral edema, and hypoxemia as a result of anesthetics.16 INFECTION CONTROL. Infections develop more easily in older adults because of immune system changes, and infections are more difficult to identify early as a result of altered symptomatology. Bacterial pneumonia is the leading cause of infection-related death in older adults, but the most common infection in older adults is UTI.16 Anorexia, confusion, incontinence, nausea, vague abdominal pain, and vomiting could be signs of a UTI in an older adult.17 Patients with diabetes may experience a loss of glycemic control. An imbalance in intraoperative blood glucose levels may predispose the patient to postoperative infections and complications.11 Symptoms of an infectious process can be atypical and include confusion, lethargy, and anorexia, in addition to the typical signs associated with any age group. Careful attention must be paid to infection prevention in older adults by • promoting good hydration and nutritional status; • monitoring vital signs, mental status, and general health status; • ensuring coughing and deep breathing and use of an incentive spirometer; • maintaining intact skin and mucous membranes; • avoiding immobility; • restricting contact with people who have infections or suspected infections; and • ensuring that all staff members adhere to strict infection control practices.17
POSTOPERATIVE PHASE The goal of providing care to all patients in the PACU is to reduce morbidity and mortality associated with surgery and anesthesia. For the older adult patient, this becomes increasingly important when considering all of the physio-
Infections develop more easily in older adults because of immune system changes, and infections are more difficult to identify early as a result of altered symptomatology. Symptoms of an infectious process can be atypical and include confusion, lethargy, and anorexia.
logic changes associated with aging. Ventilation; cardiovascular stability; fluid management; activity stir-up routine (eg, the process of awakening the patient); and pain management and comfort are PACU nursing priorities. VENTILATION AND AIRWAY MANAGEMENT. The first goal of airway management is to promote optimal gas exchange. The PACU nurse first must perform a respiratory assessment, including evaluating pulse oximeter readings, auscultating breath sounds, and determining the respiratory rate, rhythm, and ease of effort. Simultaneously, the PACU nurse initiates oxygen therapy for any patient who received general anesthesia and for most patients who have undergone conscious sedation. The nurse elevates the head of the patient’s bed, unless this is contraindicated by the surgical procedure, and encourages the patient to take frequent deep breaths to promote the uptake of oxygen and elimination of carbon dioxide and residual inhalation anesthetics. The PACU nurse also monitors the patient for compromised respiratory function (eg, atelectasis, pneumonia, respiratory infections), which requires that the PACU nurse • evaluate the patient for residual anesthetics; • consider preexisting conditions and health history (eg, smoking history); AORN JOURNAL •
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Reversal agents do not last as long as narcotics and neuromuscular blockers, so the postanesthesia care unit nurse should note whether reversal agents were administered intraoperatively. The nurse also should ensure that oxygenation and ventilation are adequate.
• •
maintain artificial airways; and encourage the patient to take deep breaths. The nurse should encourage the patient to splint the abdomen; take frequent, deep breaths; and cough and use the incentive spirometer hourly while awake. The PACU nurse should note whether reversal agents were administered intraoperatively because reversal agents do not last as long as narcotics and neuromuscular blockers. If the patient arrives in the PACU with an endotracheal tube in place, the PACU nurse must use sterile technique when suctioning the endotracheal tube. CARDIOVASCULAR STABILITY. The PACU nurse assesses the patient’s heart rate and rhythm, blood pressure, and heart sounds. The nurse initiates continuous electrocardiogram (ECG), blood pressure, and pulse oximetry monitoring. The goal is to detect myocardial compromise, not simply by the blood pressure readings, but also by corresponding symptoms. The most common cause of postoperative arrhythmias is hypoxemia.18 Therefore, careful attention must be directed toward verifying and maintaining adequate oxygenation and ventilation. Other causes of rhythm disturbances include electrolyte alterations and acid-base disturbances. The nurse also should check the patient’s peripheral pulses, capil-
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lary refill, and circulation as indicated. FLUID MANAGEMENT. The first goal of fluid management is to correct preoperative dehydration. In many cases, the patient will have been NPO since midnight. Many older adult patients may have been on diuretic therapy preoperatively or may have had a preoperative problem with nausea and vomiting. In correcting dehydration, however, the PACU nurse should prevent fluid overload. Nursing interventions include maintaining I&O records, monitoring IV rates, auscultating breath sounds when fluid boluses are administered, and monitoring vital signs. Monitoring urine output is a priority because of the decreased bladder capacity and sphincter tone of older adult patients. ACTIVITY STIR-UP ROUTINE. Stimulating the patient to awaken, breathe deeply, and follow commands promotes circulation and ventilation. This routine also allows the nurse to assess neurological functioning, which includes the patient’s ability to move all extremities, follow commands, and demonstrate orientation to person and place. The stir-up routine also promotes thermoregulation. Achievement of normothermia promotes cardiovascular stability and patient comfort and decreases myocardial demands for oxygen. Ongoing temperature monitoring and active postoperative rewarming with a temperature-regulating unit may be required.18 PAIN MANAGEMENT AND COMFORT. Implementing comfort measures is a priority. Older adult patients have decreased responses to pain and delayed renal and hepatic clearance of medications; therefore, pain medications should be administered judiciously with attention to ventilation and airway management, particularly in the older adult ambulatory surgery patient.11 Pain assessment must be regular, systematic, and documented in order to accurately evaluate the effectiveness of pain management treatment. Pain is subjective so it is difficult to assess, particularly in the elderly. The task becomes more difficult when the patient has dementia and cannot verbalize his or her pain. Numeric rating scales (ie, from 0 to 10 with 10 being the worst imaginable pain) and the Wong-Baker FACES pain rating scale (Figure 3)
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1 Hurts Little Bit
2 Hurts Little More
3 Hurts Even More
4 Hurts Whole Lot
5 Hurts Worse
Figure 3 • The Wong-Baker FACES pain rating scale offers clinicians a tool to assess pain in older adult patients who may be cognitively impaired. The scale also provides a visual description for patients who do not have the verbal skills to explain how they feel. Reprinted with permission from Hockenberry MJ, Wilson D, Winkelstein ML. Wong’s Essentials of Pediatric Nursing. 7th ed. St Louis, MO: Mosby, 2005:1259.
are available. The FACES pain rating scale, which uses different facial expressions from neutral to grimacing to represent levels of pain, is a particularly effective and easy assessment tool to use. Many cognitively impaired older adults can respond to pain scales reliably if asked about the pain in the present and given sufficient time to comprehend the tool and develop a response.19 The PACU nurse also must carefully observe the patient’s behavior and changes in vital signs (eg, increased heart rate, pulse, respiration) to evaluate for pain and document the patient’s response to pain management interventions. Another step in the implementation of comfort measures is to provide psychological support, which includes reorienting the patient and using touch and clear communication. The PACU nurse should state information simply and repeat it as necessary.18 The PACU nurse should take special care when positioning an older patient. Repositioning the patient should be accomplished with sufficient support to prevent tugging on extremities or shearing the patient across the sheets. The PACU nurse should pad the patient’s bony prominences and may consider padding the side rails with side rail pads or by covering them with blankets. Skin care also is a priority. The PACU nurse should change wet sheets and ensure that the patient’s skin is dry. Care should be taken when applying tape to an older patient’s more fragile skin and the PACU nurse also should be careful when removing ECG leads and tape.11
SUMMARY Surgical intervention has provided many older adults not only with more years of life, but years that may be more functional than they would have been in decades past. Although older adults are at higher risk than younger individuals for complications during and after surgery, they tolerate elective surgery well if they are in good general physical condition and have excellent preoperative, intraoperative, and postoperative care. Emergency surgery increases the perioperative risk but performing thorough preoperative evaluations aimed at identifying intraoperative and postoperative risks and complications and endeavoring to optimize the status of the patient’s chronic medical conditions as much as possible before surgery can reduce surgical risk. Successful surgical management of an older adult’s health problems depends on the nurse’s understanding of the age-related factors that may affect the outcome of normal surgical procedures.
REFERENCES 1. Dramatic changes in US aging highlighted in new census, NIH report. Impact of baby boomers anticipated. US Census Bureau. http://www.census .gov/PressRelease/www/releases/archives/aging _population/006544.html. Accessed January 28, 2008. 2. He W, Sengupta M, Velkoff VA, Debarros KA. 65+ in the United States: 2005. In: US Census Bureau, Current Population Reports. Washington, DC: US Government Printing Office; 2005. http://www .census.gov/prod/2006pubs/p23-209.pdf. Issued December 2005. Accessed December 29, 2007. AORN JOURNAL •
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3. Rimkus A, Melinchok MD, eds. Thesaurus of Aging Terminology. 8th ed. Washington, DC: AARP; 2005. 4. A look at centenarians. Boston University Medical Campus. http://www.bumc.bu.edu/Dept/Content PF.aspx?PageID=5749&DepartmentID=361. Accessed January 28, 2008. 5. Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61(7):2159-2174. http://www.aafp.org/afp /20000401/2159.html. Accessed December 29, 2007. 6. Beers MH, ed. Falls. In: Merck Manual of Health & Aging. New York, NY: Ballantine Books; 2000:287-289. 7. Eliopoulas C. Safety. In: Gerontological Nursing. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:189-191. 8. Falls among older adults: an overview. Centers for Disease Control and Prevention. http://www .cdc.gov/ncipc/factsheets/adultfalls.htm. Accessed January 28, 2008. 9. A tool kit to prevent senior falls: figures. Centers for Disease Control and Prevention. http://www .cdc.gov/ncipc/pub-res/toolkit/figures.htm. Accessed January 29, 2008. 10. Falls and hip fractures. American Academy of Orthopedic surgeons. http://orthoinfo.aaos.org /topic.cfm?topic=A00121&return_link-0. Accessed January 28, 2008. 11. Hogstel MO, Taylor-Martof M. Perioperative care. In: Hogstel MO, ed. Gerontology: Nursing Care of the Older Adult. 3rd ed. Clifton Park, NY: CENGAGE Delmar Learning; 2001:288-289. 12. Liu LL, Leung JM. Syllabus on geriatric anesthesiology—perioperative complications in elderly patients. American Society of Anesthesiologists. http://www.asahq.org/clinical/geriatrics/perio_
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comp.htm. Accessed December 29, 2007. 13. Recommended practices for preoperative patient skin antisepsis. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:537-555. 14. Recommended practices for prevention of unplanned hypothermia. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:407-420. 15. Recommended practices for positioning the patient in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:497-520. 16. Beers MH, ed. Anesthesia considerations. In: The Merck Manual of Geriatrics. 3rd ed. Clifton Park, NY: CENGAGE Delmar Learning; 2000. http://www .merck.com/mrkshared/mmg/sec3/ch27/ch27a.jsp. Accessed December 29, 2007. 17. Elipoulas C. Meeting acute care needs. In: Gerontological Nursing. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:482. 18. Litwack K. The elderly patient. In: Postanesthesia Care Nursing. 2nd ed. St Louis, MO: Mosby; 1995:326-328. 19. Scott A. No time for pain. Adv Nurs. 2002;2(2):33.
Judith L. Clayton, RN, CNOR, is an RN clinician at Gwinnett Health System, Lawrenceville, GA. Ms Clayton has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
Patricia C. Seifert Appointed Editor-in-Chief of Journal
A
ORN is pleased to announce that Patricia C. Seifert, RN, MSN, CNOR, CRNFA, FAAN, will be the next editor-in-chief of the AORN Journal effective with the July 2008 issue. Seifert succeeds Nancy Girard, PhD, RN, FAAN, who has served as editor-inchief since December 2002. Seifert served two terms on the AORN Journal editorial board. Her editorial experience also includes service as a peer reviewer for the AORN Journal as well as for the Journal of Cardiovascular Nursing and the American Journal of Critical Care, among others. She will step down from her current role as editor of Perioperative Nursing Clinics as of July. She has authored four books, including the first textbook dedicated to perioperative nursing care of cardiac patients. She also has written numerous book chapters and scholarly articles. Seifert is a recognized expert in cardiac surgery
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nursing, a leader in the perioperative community, and a well-known AORN member. In 1992, she became the first recipient of the AORN National President’s Award. She served on the AORN Board of Directors from 1994 to 2000, culminating her service as AORN President in 2000. She was awarded the AORN Award for Excellence in 2003 and the AORN Jerry G. Peers Distinguished Service Award in 2007 for her years of dedicated service to perioperative education. She speaks frequently at perioperative conferences, both in the United States and abroad, and her presentation activities include leading three perioperative nursing delegations to China. Seifert received her master’s degree in nursing from Catholic University, Washington, DC. She currently holds the position of education coordinator, Cardiovascular Operating Room at Inova Fairfax Hospital in Fairfax, Virginia.
Examination
3.2
Special Needs of Older Adults Undergoing Surgery PURPOSE/GOAL To educate perioperative nurses about the special needs of older adults undergoing surgery.
BEHAVIORAL OBJECTIVES After reading and studying the article on the special perioperative needs of older adults, nurses will be able to
1. describe factors that affect the health of older adults, 2. identify issues pertinent to older adults that may affect hospitalization and surgery, and 3. describe nursing care focused on preventing perioperative complications experienced by the older adult patient.
QUESTIONS 1. At least 50% of older adults who were ambulating before fracturing a hip do not recover their previous level of mobility because 1. mobility sometimes is reduced by the fear of falling again. 2. decreased activity may increase joint stiffness and weakness. 3. the enabling behavior of a caregiver allows the patient to be less mobile. a. 1 b. 3 c. 1 and 2 d. 1, 2, and 3 2. Smoking and excessive consumption of alcohol, specifically in older adults, can 1. interfere with normal bone-building processes and bone remodeling. 2. result in bone loss. 3. interfere with the production of estrogen and testosterone, without which bone mass may be decreased. a. 1 b. 2 c. 1 and 2 d. 1, 2, and 3 3. The risk of osteoporosis and hip fracture may be increased by long-term use of certain medications that can accelerate bone loss. These include 1. anticonvulsants. © AORN, Inc, 2008
2. antidepressants. 3. certain diuretics and blood thinners. 4. corticosteroids. 5. thyroid medications. a. 2 and 3 b. 1, 4, and 5 c. 1, 3, 4, and 5 d. 1, 2, 3, 4, and 5 4. Unless absolutely necessary, nurses should not shave or clip the hair of an older adult patient undergoing surgery because 1. shaving and clipping may traumatize the skin, increasing the risk of postoperative infection. 2. hair growth is decreased especially in the pubic and axillary regions so hair removal may be unnecessary. 3. the skin is likely to be thin, dry, and wrinkled, making shaving more difficult. a. 1 b. 2 c. 1 and 2 d. 1, 2, and 3 5. It is especially important to prevent intraoperative hypothermia in older adult patients because 1. the metabolism of older adults is decreased. 2. shivering can increase cardiac output and ventilation, which increases oxygen MARCH 2008, VOL 87, NO 3 • AORN JOURNAL • 571
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consumption and deprives the heart and brain of necessary oxygen. 3. awakening and the return of reflexes is delayed because of the slowing of metabolism that occurs with hypothermia. 4. an older person’s body temperature is normally lower. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 6. Older adult patients are prone to hypovolemia because 1. serum levels of fluid-reducing hormones and sodium may be increased by pain, medications, and anesthetics. 2. the cardiovascular system has a decreased ability to expand. 3. the kidneys are no longer able to reabsorb or secrete electrolytes. 4. most older adults have a altered skin integrity, which affects the patient’s ability to perspire. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 7. Unless extreme caution is taken, placing an older adult patient who has osteoporosis into the lateral or lithotomy position
The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.
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Examination
could cause a femoral head fracture or lumbar spine strain. a. true b. false 8. Prolonged pressure behind the ankle when the patient’s feet are crossed may result in tibial nerve injury that may be reflected as 1. loss of the autonomic nervous system response to pain. 2. motor loss of the calf muscles. 3. neuroendocrine abnormalities of the superficial sweat glands of the feet. 4. sensory loss of the skin on the soles of the feet. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4 9. The risks presented by anesthetic agents are the same for older adult patients as for younger patients. a. true b. false 10. Pain medications should be administered judiciously to older adults because they have decreased responses to pain and delayed renal and hepatic clearance of medications. a. true b. false
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 Center’s Commission on Accreditation. 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.
Answer Sheet Special Needs of Older Adults Undergoing Surgery
3.2 Event #08016 Session #3018
lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:
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AORN Customer Service c/o AORN Journal Continuing Education 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax with credit card information to (303) 750-3212. Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.
Signature ______________________________________ 1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the time you needed to complete this 3.2 continuing education contact hour (192-minute) program. ______ 4. Enclose fee if information is mailed. AORN (ID) #____________________________________________ Name__________________________________________________ Address ________________________________________________ City ___________________________________________________
State __________ Zip __________
Phone number __________________________________________ RN license #____________________________________________
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Fee enclosed ___________________________________________ or bill the credit card indicated
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Signature _______________________________________________________________ (for credit card authorization) Fee: Members $16 Nonmembers $32
A score of 70% correct on the examination is required for credit.
Program offered March 2008
Each applicant who successfully completes this program will receive a certificate of completion.
The deadline for this program is March 31, 2011 © AORN, Inc, 2008
Participants receive feedback on incorrect answers.
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3.2
Learner Evaluation
Special Needs of Older Adults Undergoing Surgery his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.
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PURPOSE/GOAL To educate perioperative nurses about the special needs of older adults undergoing surgery.
OBJECTIVES To what extent were the following objectives of this continuing education program achieved? 1. Describe factors that affect the health of older adults. 2. Identify issues pertinent to older adults that may affect hospitalization and surgery. 3. Describe nursing care focused on preventing perioperative complications experienced by the older adult patient.
CONTENT To what extent 4. did this article increase your knowledge of the subject matter? 5. was the content clear and organized? 6. did this article facilitate learning? 7. were your individual objectives met? 8. did the objectives relate to the overall purpose/goal?
TEST QUESTIONS/ANSWERS To what extent 9. were they reflective of the content? 10. were they easy to understand? 11. did they address important points?
LEARNER INPUT 12. Will you be able to use the information from this article in your work setting? 1. yes 2. no 13. I learned of this article via 1. the Journal I receive as an AORN member. 2. a Journal I obtained elsewhere. 3. the AORN Journal web site.
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14. What factor most affects whether you take an AORN Journal continuing education examination? 1. need for continuing education contact hours 2. price 3. subject matter relevant to current position 4. number of continuing education contact hours offered What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): __________________________________ __________________________________________ __________________________________________ Author names and addresses: _______________ __________________________________________ __________________________________________
© AORN, Inc, 2008