CONTINUING EDUCATION Surgical Risk Factors in Geriatric Perioperative Patients MARIE BASHAW, MS, RN, NEA-BC, CNOR; DANA N. SCOTT, BSN, RN 2.9 www.aorn.org/CE Continuing Education Contact Hours indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feed- back on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion. Event: #12520 Session: #0001 Fee: Members $14.50, Nonmembers $29 The contact hours for this article expire July 31, 2015. Purpose/Goal To educate perioperative nurses about surgical risk factors in older adults undergoing surgical interventions. Objectives 1. Describe the changes associated with aging. 2. Discuss the nurse’s role in caring for geriatric patients in the OR. Accreditation AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Approvals This program meets criteria for CNOR and CRNFA recertifi- cation, as well as other continuing education requirements. 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. Conflict of Interest Disclosures Marie Bashaw, MS, RN, NEA-BC, CNOR, and Dana N. Scott, BSN, RN, have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. The behavioral objectives for this program were created by Helen Starbuck Pashley, MA, BSN, RN, CNOR, clinical editor, and Susan Bakewell, MS, RN-BC, director, Perioper- ative Education. Ms Starbuck Pashley and Ms Bakewell have no declared affiliations that could be perceived as posing potential conflicts of interest in the publication of this article. Sponsorship or Commercial Support No sponsorship or commercial support was received for this article. Disclaimer AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity. doi: 10.1016/j.aorn.2011.05.025 58 j AORN Journal July 2012 Vol 96 No 1 Ó AORN, Inc, 2012
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CONTINUING EDUCATION
Surgical Risk Factors in GeriatricPerioperative PatientsMARIE BASHAW, MS, RN, NEA-BC, CNOR; DANA N. SCOTT, BSN, RN 2.9
www.aorn.org/CE
Continuing Education Contact Hoursindicates that continuing education contact hours are
available for this activity. Earn the contact hours by reading
this article, reviewing the purpose/goal and objectives, and
completing the online Examination and Learner Evaluation
at http://www.aorn.org/CE. A score of 70% correct on the
examination is required for credit. Participants receive feed-
back on incorrect answers. Each applicant who successfully
completes this program can immediately print a certificate of
completion.
Event: #12520
Session: #0001
Fee: Members $14.50, Nonmembers $29
The contact hours for this article expire July 31, 2015.
Purpose/GoalTo educate perioperative nurses about surgical risk factors in
older adults undergoing surgical interventions.
Objectives
1. Describe the changes associated with aging.
2. Discuss the nurse’s role in caring for geriatric patients
in the OR.
AccreditationAORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
58 j AORN Journal � July 2012 Vol 96 No 1
ApprovalsThis program meets criteria for CNOR and CRNFA recertifi-
cation, as well as other continuing education requirements.
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.
Conflict of Interest DisclosuresMarie Bashaw, MS, RN, NEA-BC, CNOR, and Dana N. Scott,
BSN, RN, have no declared affiliations that could be perceived
as posing potential conflicts of interest in the publication of
this article.
The behavioral objectives for this program were created
by Helen Starbuck Pashley, MA, BSN, RN, CNOR, clinical
editor, and Susan Bakewell, MS, RN-BC, director, Perioper-
ative Education. Ms Starbuck Pashley and Ms Bakewell have
no declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this article.
Sponsorship or Commercial SupportNo sponsorship or commercial support was received for this
article.
DisclaimerAORN recognizes these activities as continuing education for
registered nurses. This recognition does not imply that AORN
or the American Nurses Credentialing Center approves or
Figure 1. Older population by age from 1900 projected to 2050.
July 2012 Vol 96 No 1 BASHAWdSCOTT
hearing aids, glasses). It is important to ensure that
the patient has his or her hearing aids or glasses in
place and that these are functioning properly in
the preoperative setting, when the patient arrives
in the postanesthesia care unit (PACU), and when
he or she arrives on the patient care unit or is ready
to return home.5
The perioperative nurse should allow the patient
to use assistive devices in the perioperative setting
for as long as possible.6 In addition, it is important
for the nurse to speak slowly and clearly, increase
his or her speech volume if necessary, reduce
background noise whenever possible, and always
face the patient when speaking. Written informa-
tion given to the patient should be provided in
a large, clear typeface and should be printed in
dark ink on a light background.5 It is important
60 j AORN Journal
for the health care provider to limit the amount
of information presented at one time and to allow
adequate time for the patient to process the infor-
mation and respond.7 When transporting the patient
into the OR, perioperative team members should
keep all mechanical noises as low in volume as
possible or turn off equipment to facilitate the
patient’s hearing.
Respiratory Changes
Structural and physiologic changes of the upper and
lower airways occur with age. Loss of pharyngeal
support can lead to obstruction of the upper airway,
and weakening or loss of the protective swallowing
and coughing reflexes contribute to respiratory
problems, especially increasing a patient’s risk for
aspiration and pneumonia.8 Weakened diaphragm
TABLE 1. Nursing Care Plan for Geriatric Patients in the Perioperative Environment
Diagnosis Nursing interventionsInterim outcome
statementOutcomestatement
Risk for imbalancedfluid volume
n Assesses vital signs.n Verifies the patient’s perioperative hydration status.n Monitors and documents fluid intake and output.n Monitors physical parameters and reports
discrepancies.n Collaborates in fluid and electrolyte management.n Administers fluids and medications as prescribed.
n The patient’s vitalsigns are within theexpected range atdischarge from theOR, procedureroom, orpostanesthesiacare unit (PACU).
n The patient’s bloodpressure and pulseare within theexpected rangeand remain stablewith positionchange at the timeof transfer to thePACU and atdischarge from thePACU.
n The patient’surinary output iswithin the expectedrange at dischargefrom the OR,procedure room,or PACU.
n The patient’s fluid,electrolyte, andacid-base balanceare within theexpected ortherapeutic rangesthroughout theperioperativeperiod.
Impaired physicalmobility
n Assesses the patient’s range of motion.n Assesses and documents any physical limitations
to movement.n Adapts the nursing plan of care to accommodate
the patient’s physical limitations.
n The patient’sphysical limitationsare within theexpected range attime of transfer tothe PACU and atdischarge from thePACU.
n The patient’sphysical limitationsand range ofmotion are withinthe expected ortherapeutic rangesthroughout theperioperativeperiod.
Disturbed sensoryperception (visual,auditory)
n Assesses the patient for the use of hearingaids and glasses.
n Ensures that the patient is allowed to wear his orher hearing aids and glasses whenever possibleduring the perioperative period.
n Ensures that the patient’s hearing aids arefunctional.
n The patientdemonstrates thathe or she hears andunderstands verbalcommunication.
n The patientdemonstrates thathe or she can readand understandwrittencommunication.
n The patient is ableto participate in andunderstand his orher care whenevernecessarythroughout theperioperativeperiod.
(table continued)
AORN Journal j 61
RISK FACTORS IN GERIATRIC SURGICAL PATIENTS www.aornjournal.org
TABLE 1. (continued) Nursing Care Plan for Geriatric Patients in the Perioperative Environment
Diagnosis Nursing interventionsInterim outcome
statementOutcomestatement
Risk for imbalancedbody temperature
n Assesses risk for normothermia regulation.n Assesses risk for inadvertent hypothermia.n Identifies physiologic status.n Reports deviation in diagnostic study results.n Implements thermoregulation measures.n Monitors body temperature.n Monitors physiologic parameters.n Evaluates response to thermoregulation measures.
n The patient’stemperature ishigher than 36 � C(96.8� F) atdischarge from theOR or procedureroom.
n The patient is at orreturning tonormothermia atthe conclusion ofthe immediatepostoperativeperiod.
Risk for perioperativepositioning injury
n Confirms the patient’s identity.n Verifies the surgical procedure, surgical site, and
precautions for procedure-specific positioning.n Verifies presence of prosthetics or corrective devices.n Positions the patient.n Implements protective measures to prevent skin
and tissue injury caused by mechanical sources.n Applies safety devices.n Evaluates tissue perfusion.n Evaluates musculoskeletal status.n Evaluates for signs and symptoms of physical
injury to skin and tissue.
n The patient’spressure pointsdemonstratehyperemia for lessthan 30 minutes.
n The patient has fullreturn of movementto extremities atdischarge from theOR or procedureroom.
n The patient’speripheral tissueperfusion isconsistent withpreoperative statusat discharge fromthe OR orprocedure room.
n The patient is freefrom pain ornumbnessassociated withsurgical positioning.
n The patient is freefrom signs andsymptoms of injuryrelated topositioning.
Risk for acuteconfusion
n Assesses the patient’s preoperative baselineneurological status.
n Evaluates for orientation to place, date, and timeand understanding of the scheduled procedure.
n Assesses the patient postoperatively for neurologicalstatus and orientation to place, date, and time.
n Allows family members to remain with the patient ifthe patient shows signs of confusion.
n Orients the patient to the environment and careroutines and practices.
n Reinforces the physician’s explanations and clariesmisconceptions.
n The patientverbalizesorientation to time,place, and datebefore and after thesurgicalintervention.
n The patient is calm,cooperative, andverbalizes anunderstanding ofwhat is happeningaround him or her.
n The patientdemonstratescomprehension ofthe surgicalexperience.
n The patientcooperates withcare.
62 j AORN Journal
July 2012 Vol 96 No 1 BASHAWdSCOTT
TABLE 1. (continued) Nursing Care Plan for Geriatric Patients in the Perioperative Environment
Diagnosis Nursing interventionsInterim outcome
statementOutcomestatement
Risk for pain n Assesses the patient for pain control.n Administers pain medication as prescribed.n Implements pain guidelines.n Implements alternative methods of pain control.n Evaluates the patient’s response to pain
management interventions.
n The patient is ableto describe andreport his or herpain.
n The patientverbalizes controlof pain.
n The patientcooperates withthe plan of care.
n The patient displaysa relaxed bodyposition.
n The patient doesnot display signsof discomfort(eg, grimacing,guarding, agitation,weeping).
n The patientdemonstrates anability to cope.
n The patient’s vitalsigns are improvedor equal topreoperativevalues.
n The patient is freefrom signs andsymptoms of pain.
RISK FACTORS IN GERIATRIC SURGICAL PATIENTS www.aornjournal.org
function can lead to lung atelectasis and pneumonia
after surgery.8 Forty percent of all surgical com-
plications and 20% of deaths related to surgery
in the geriatric population are the result of respi-
ratory complications, including those related to
reduced elasticity of the chest wall and decreased
vital capacity.5
Preoperative fasting allows for gastric emptying
and reduces aspiration risk during induction and
emergence from anesthesia; therefore, it is impor-
tant for the nurse to ascertain the patient’s NPO
status.9 Lying in the supine position can restrict
movement of the patient’s diaphragm, thus im-
peding air flow.10 This position is often required
for surgery; however, proper positioning (eg,
elevating the head and chest) can reduce respira-
tory problems.
In the PACU and on the patient care unit,
frequent turning (eg, every two hours) improves
the patient’s gas exchange and reduces the risks
of respiratory complications.8 Encouraging the
patient to cough and breathe deeply after sur-
gery helps maintain proper lung function, and
providing oral hygiene for the patient on me-
chanical ventilation helps to prevent postopera-
tive pneumonia.5 Minimizing sedation, whenever
possible, and instituting weaning protocols for
patients on mechanical ventilation and prophy-
lactic treatment for stress ulcers have been
found to reduce the incidence of postoperative
pneumonia.11
Cardiovascular and Circulatory Changes
Age-related cardiovascular and circulatory sys-
tem changes include stiffening of the walls of
large arteries from atherosclerosis, which in turn
positioning is crucial in reducing the risk of ves-
sel damage. According to Millsaps,10 prolonged
or improper positioning “can cause the greatest
amount of damage to the cardiovascular sys-
tem,”10(p62) and proper positioning can minimize
cardiac problems from pressure on or obstruction
of a vessel.
Acute and chronic cardiovascular conditions
put older patients at higher risk for adverse surgical
outcomes. For example, heart blocks can cause
cardiac arrest during surgery5; however, the use
of beta blockers has been shown to reduce this risk.
Geriatric patients also have changes in stroke
volume, conduction, and degeneration of heart
valves.12 The perioperative nurse should assess an
older patient for signs of heart failure and closely
monitor for electrocardiogram changes.12 Proper
positioning during surgery can minimize cardiac
problems and reduce bleeding by preventing
venous congestion.10
Deep Vein Thrombosis
Deep vein thrombosis (DVT) can occur in any
surgical patient; however, risk factors increase
when a patient
n is older than 40 years,
n is obese,
n experiences prolonged immobility,
n undergoes general anesthesia for more than two
hours,
n has varicose veins, or
n is a smoker.13
Geriatric patients are at increased risk for DVT
because they often have several of these risk
factors.5 To minimize this risk for an elderly
patient, the perioperative nurse can implement
several safety measures. He or she can maintain
the patient’s body in proper alignment and ad-
minister DVT prophylaxis medications (eg,
heparin, enoxaparin) or ask about their adminis-
tration if they are not ordered, perform range
64 j AORN Journal
of motion exercises, and apply antiembolism
stockings.5 The use of sequential compression
devices with thigh-high or foot pumps also helps
blood return to the heart and reduces the risk
of pooling of the blood in the lower extremities
and DVT.6
Musculoskeletal System
As people age, they experience progressive loss of
muscle strength and muscle mass. Posture can be
affected by bone loss and increased bone break-
down because of osteoporosis, which can increase
older patients’ risk of fractures. Mobility and range
of motion are lost because of tissue elasticity changes,
joint breakdown, and stiffness. In addition, many
older patients have long-standing issues of chronic
pain from arthritis, neuralgias, and ischemic disor-
ders, making pain assessment a necessary part of
nursing care.14
Gastrointestinal System
Geriatric patients have an increased risk of pep-
tic ulcer disease. The gastric mucosa of older
patients has a reduced capacity to resist damage
from nonsteroidal anti-inflammatory drugs and
from Helicobacter pylori.2 Older patients often
have impaired dentition, decreased saliva produc-
tion, and decreased peristalsis.2,6 Age-related
slowing of peristalsis, low fiber and fluid intake,
medications, and sedentary lifestyles put elderly
patients at risk for constipation.2 Preoperative
fasting can lead to dehydration, which has been
shown to increase postoperative nausea and
vomiting.15 The nurse should assess the patient
for signs and symptoms of
n fluid or electrolyte imbalance,
n nausea and vomiting,
n constipation, and
n diarrhea.
If any of these is present, the nurse should admin-
ister appropriate medications to relieve symptoms6
and should encourage fluids and mobility to help
prevent constipation.16
TABLE 2. Aging Changes and Medication1
Digestive changes affecting absorption
n Reducedn production of hydrochloric acid in the stomachn peristalsis in the stomach and intestinesn blood flow to the viscera
n Delayed stomach emptying
Changes affecting distribution and metabolism
n Decreasedn total body water and plasma volumesn cardiac outputn liver size, blood flow, and enzyme activityn renal blood flow and function (slows excretion and
may allow serum medication levels to increase)n Increased
n adipose tissue (increases lipid-soluble medicationstorage and affects metabolism of medicationssuch as diazepam and lidocaine)
1. Allen SA. Geriatric surgery. In: Alexander’s Care of the Patient inSurgery. 14th ed. Rothrock JC, ed. St Louis, MO: Mosby Elsevier;2011:1157-1181.
RISK FACTORS IN GERIATRIC SURGICAL PATIENTS www.aornjournal.org
Integumentary System
The skin of geriatric patients is fragile because the
dermis is thin, the skin has less elasticity, and these
patients have “less collagen, muscle, and adipose
tissue than a younger adult.”5(p57) These changes
can result in skin tears, bruising, pressure ulcers,
and slow wound healing. Because of compromised
nutrition, which increases the risk of skin break-
down, and because of poor skin turgor and a lower
ability for tissue to heal, women and those patients
with low food intake are at higher risk for devel-
oping pressure ulcers.17 In addition, surgical fasting
can compromise the patient’s nutritional status,
and this can lead to an increased risk of pressure
ulcers and poor wound healing.15 Preoperative
nursing assessment should include determining
the patient’s nutritional status and carefully exam-
ining the patient’s skin, noting any areas of dryness,
lesions, or bruises.10
It is important for the nurse to remember that
“Friction and pressure on soft tissues, especially
over bony prominences, may result in skin changes
ranging from mild irritation to severe pressure-
induced ischemia.”10(p62) The use of padding and
support devices during surgery as well as avoiding
the use of tape on the patient’s skin can reduce
the integumentary problems faced by the geriatric
patient.5 The perioperative nurse must protect
the geriatric patient’s bony prominences during
positioning and pay special attention to posi-
tioning.6 “Positioning devices should maintain
normal capillary interface pressure of 32 mm Hg or
less.”10(p60) The use of special mattresses and
overlays can reduce the risk of pressure ulcers.18,19
The nurse should take special care when removing
dressings, electrocautery pads, and electrocardio-
gram leads to prevent tearing of the patient’s skin.7
In the OR, the perioperative nurse should take
care to ensure prep fluids do not pool on the pa-
tient’s skin to prevent irritation and maceration.6
Aseptic technique should always be used to pre-
vent wound infections.7
Renal System
The changes in renal function that occur when
patients age include decreased kidney size, altered
blood flow through the kidneys, alterations to the
structure of the tubules, and glomerular sclerosis.9
These changes lead to reduced glomerular filtra-
tion rates and altered tubular function (ie, re-
duced ability to effectively filter waste though the
kidneys).9 These changes affect how medications
work, their metabolism, and how they are excreted
(Table 2). The perioperative nurse must under-
stand how medications affect older patients and
any precautions for use in this population and
must watch the patient for signs and symptoms of
toxicity. These include confusion, disorientation,
and elevated blood pressure. The nurse should
be familiar with the medications administered
before, during, and after the patient’s scheduled
surgery and understand their effects on older
patients. Medication doses may need to be indi-
vidually tailored to prevent toxicity. Monitoring
of laboratory values is helpful.5 Renal impairments