Programs face challenge with older patients

Physiological, psychological needs differ

With individuals who are ages 65 and older undergoing almost one-third of the 25 million surgical procedures performed annually, and with people ages 85 and older representing the fastest growing segment of our population1, it is important that any surgical program pay close attention to the special needs of older patients. Because you send patients home within hours of their procedures, it is especially important for outpatient surgery staff to be aware of these special needs, according to experts.

"Perioperative nurses must become geriatric specialists in order to fully meet the needs of this burgeoning population," says Patricia Stein, RN, MAOL, CNOR, nurse education specialist for perioperative services at Palomar Pomerado Health System in Escondido, CA. "An elderly surgical patient has less 'bounce back' after surgery, and there is less wiggle room for error of any kind," she says.

Assessment particularly important

While perioperative care for all patients requires thoroughness and attention to detail, it is particularly important to pay close attention to your assessment of an older patient, says Jim B. Wilkerson, RN, BSN, CCRN, outpatient surgery supervisor at Pomerado Hospital in Poway, CA. "Older patients are often on a number of medications, and you must be aware of how those medications, as well as their own physiological changes, might affect surgery," he says.

"The definition of elderly or older may differ for various outpatient programs, but generally it is defined as age 65," says Jackie Close, RN, MSN, certified nurse specialist in gerontology at Palomar Pomerado Health System. "Age 65 is used only because it has been set by the government as the age for retirement and therefore the beginning of 'old age,' but 65 is nothing more than an arbitrary number with no scientific data to support the decision," she says. Nurses must consider individual differences and characteristics when planning and implementing care for the older adult, such as overall health, activity level, and cognitive function, Close recommends.

One example of a difference between a younger patient and an older patient is skin resilience, Wilkerson points out. "A patient that might have been on steroids for a long time will have fragile skin," he says. This fragile skin means that the patient might bruise easily from a blood draw or have skin torn by adhesive bandages, he adds. "Also, be sure to ask if the patient is bruised or suffering from skin breakdown anywhere on their body so you can pad and position the patient to prevent further pressure on these injured areas," he suggests.

Even starting an intravenous line should be done with special care, recommends Stein. An everyday elastic tourniquet can injure fragile skin, so consider using a blood pressure cuff instead of a tourniquet to apply a more even, less pinching device to properly obtain access, she suggests.

Another key difference between an older patient and a younger patient is mental status, Stein says.

"There is a decrease in short-term memory, and patients are at risk for postoperative dementia and confusion," she says. Add these cerebral function changes to the effects of multiple medications for a variety of medical conditions, and you must be especially careful that the older patient understands what will happen during their time in the surgery program and after discharge, she points out.

Patients also experience sensory changes that they may not want to admit, says Wilkerson.

"A patient may not be able to see clearly enough to read discharge instructions or may not clearly hear or comprehend the instructions you give verbally, but they will nod and react as if they do," he says. To ensure comprehension, Wilkerson suggests that nurses ask the patient to point to or read something, such as the phone number of the physician to call if there are problems. Asking the patient to repeat information back to the nurse also is effective, he adds.

Requiring a family member, friend, or other responsible adult who will be with the patient when he or she goes home to listen to the discharge instructions is also critical, Wilkerson says. "We require the responsible adult to sign the discharge forms because the patient is still under the effects of anesthesia and won't know what is being signed," he says. "Older patients often don't remember being told anything about care at home, so it is important for another adult to be there to hear the instructions and remind the patient that the nurse explained everything before discharge."

An important point to explain to the adult caregiver is an older person's susceptibility to delirium following anesthesia, says Wilkerson.

It doesn't occur with every patient, but it is not uncommon for a patient to become delirious, confused, and even combative in the middle of the night following surgery," he says. Because this can be very frightening to a caregiver, be sure that you explain the possibility of this occurring so that they are not surprised, he adds.

Because the first step in caring for an older surgical patient is the initial assessment, Close suggests, "allow yourself extra time for the interview and assessment. We must not hurry our older patients because when we don't listen, we miss out on very valuable information that could impact their surgical experience."

Reference

1. Muravchick S. Geriatric anesthesia — Are you ready? American Society of Anesthesiologists 2006; Web site: www.asahq.org/clinical/geriatrics/geron.html.