Ways you can tackle concerns with geriatrics

Geriatric patients can present a host of challenges in outpatient surgery. In addition to concomitant chronic diseases and multiple medications, there might be information literacy issues and concerns about the patient's home care after surgery, says Kathryn Parrish, RN, MSN, assistant professor of nursing at North Georgia College and State University in Dahlonega, GA.

To address the issues of caring for geriatrics, the Association of periOperative Registered Nurses (AORN) has released a position statement on care of the older surgical patient (www.aorn.org/PracticeResources/AORNPositionStatements/OlderAdult). Consider these points from that statement:

• Cognitive decline may limit older adults' ability to participate in informed consent and the identification verification processes.

Don't assume all older adults are confused, says Bonnie G. Denholm, RN, BSN, MS, CNOR, perioperative nursing specialist at the Nursing Department, AORN.

"Give them the benefit of a doubt," Denholm says. "But if they're confused about which side, give them some basic mental checks: time, date, place, where are you." If the patient exhibits any confusion about this information, that's a red flag, she says.

Have an informed consent policy that addresses what happens when the patient doesn't appear to be informed about what's happening, she says. This aspect of care shouldn't be different than with any other patient. The goal should be to not show prejudice against older adults, Denholm says. "There should be the same type of assessments with every patient," she says.

• Slowed motor skills, limited range of motion, and a decline in strength and coordination increase the risk for injury from falls or positioning.

Be attentive to the possibility of falls, especially in patients having eye surgery where their vision will be impacted, Denholm advises.

Be aware of a patient's history of bone loss, and change positioning or transferring procedures as needed, Parrish says. Assess the patient's stability, Denholm says. If the patient was walking with a cane upon admission or describes occurrences of dizziness, these are indicators of a need for further assessment of medication, nutritional status, and muscle weakness, she advises.

Elderly patients are at a higher risk of fracturing a bone if they fall or are positioned inappropriately, Parrish says. "There are osteoporotic patients who are standing; their hip bone breaks, and they fall," Parrish says. "It's not always related to an actual fall."

For this reason, positions or the way a patient is moved on the OR table can cause an injury or fracture, she says. Some ORs are attempting to go to a "no lift" environment in which the patient isn't moved from the stretcher/table so no transfers or lifts occur that could cause injury to the patient or staff, Parrish says.

• Changes in the integumentary system put older adults at greater risk for chemical or thermal burns and pressure ulcers.

Older adults can be injured when skin and muscles aren't as well padded as they should be, Denholm points out. AORN has a positioning recommended practice, she says. (For ordering information, see resource box, p. 102.) That document covers risk factors for falling and patient assessment for pressure ulcers and positioning, Denholm says.

Even in outpatient surgery, pressure ulcers are a risk, Parrish says. "It does not take long for an area to have decreased blood flow due to positioning and begin to cause tissue damage," she says.

Also, the risk is great for geriatrics who have nutritional deficits or have been taking medications that impair skin integrity such as blood thinners and steroids. "Shearing is a problem as well," Parrish says. "Pulling a patient across the sheets or pulling them up in bed causes friction and can create impaired skin."

The amount of time a patient remains in one position in the OR is critical in preventing pressure ulcers, she says. "A change in position should probably be done every two hours," Parrish says. "Also, padding and protecting bony prominences may help."

• Decline in functional status may affect discharge planning and recovery needs.

One of the biggest considerations with elderly patients is whether they have reliable help at home, Denholm says. Perform a thorough psychosocial assessment, she advises. "The person having surgery may be a primary caregiver," she says. The patient might be the person who runs the household, and there might not be anyone else at home to take care of them.

Also emphasize hydration and nutritional needs, Denholm says. "They might be depleted going into surgery," she says. Afterword, they might not have as good an appetite, Denholm says. They might not have things ready to eat after surgery, and they don't always drink enough, she says.

Ensure elderly patients understand the discharge planning and instructions, Parrish says. An information literacy assessment is helpful to determine what the patient knows, what the patient doesn't know, whether they can review or accesses information and resources, and if they know what to do with the information, she says.

• The aging process may affect pharmacokinetics and pharmacodynamics (e.g., absorption, distribution, metabolism, excretion), putting older adults at risk for adverse drug events.

Avoiding adverse drug events basically comes down to understand the patient's medications, understanding what new medications are coming, and knowing what the interactions might be, Denholm says. "In the outpatient setting, you don't always have a pharmacist to help you determine that," she says. In some cases, anesthesia staff can help, Denholm says. Regardless, staff need to be aware of the patient's medications and allergies, she says.

Provide the patient with a copy of the drug information, Parrish advises.

Keep in mind that with elderly patients, one size doesn't fit all, Parrish says.

"A healthy geriatric patient will differ from one that has chronic diseases," Parrish says. "As long as we do adequate patient teaching, and the patient understands and follows directions, the less likely we are to have an adverse event."

Resources

Perioperative Standards and Recommended Practices, 2010 Edition is available from the Association of periOperative Registered Nurses (AORN) in book, CD-ROM, and e-document formats. Go to www.aorn.org/PracticeResources/AORNStandardsAndRecommendedPractices.