Incorporating Age-Specific Plans of Care to Achieve Optimal

CONTINUING EDUCATION

Incorporating Age-Specific Plansof Care to Achieve OptimalPerioperative Outcomes 3.9 www.aorn.org/CE

JULIANA MOWER, MSN, RN, CNS, CNS-CP, CNOR

Continuing Education Contact Hoursindicates that continuing education (CE) contact hours are

available for this activity. Earn the CE contact hours by readingthis article, reviewing the purpose/goal and objectives, andcompleting the online Examination and Learner Evaluation athttp://www.aorn.org/CE. A score of 70% correct on the exami-nation is required for credit. Participants receive feedback onincorrect answers. Each applicant who successfully completesthis program can immediately print a certificate of completion.

Event: #15541Session: #1001Fee: Members $31.20, Nonmembers $62.40

The contact hours for this article expire October 31, 2018.Pricing is subject to change.

Purpose/GoalTo provide the learner with knowledge related to using age-specific plans of care to achieve optimal perioperative outcomes.

Objectives1. Describe how to develop an age-specific nursing care plan

for a surgical patient.2. Explain the purpose of a concept map.3. Identify age-related characteristics pertinent to providing

perioperative care.4. Define polypharmacy.5. Identify methods for improving communication with pa-

tients who have sensory impairments.

AccreditationAORN is accredited as a provider of continuing nursing ed-ucation by the American Nurses Credentialing Center’sCommission on Accreditation.

ApprovalsThis program meets criteria for CNOR and CRNFA recerti-fication, as well as other CE requirements.

AORN is provider-approved by the California Board of Regis-tered Nursing, Provider Number CEP 13019. Check with yourstate board of nursing for acceptance of this activity for relicensure.

Conflict-of-Interest DisclosuresJuliana Mower, MSN, RN, CNS, CNS-CP, CNOR, has nodeclared affiliation that could be perceived as posing a po-tential conflict of interest in the publication of this article.

The behavioral objectives for this program were created byHelen Starbuck Pashley,MA,BSN,RN,CNOR, clinical editor,with consultation from Susan Bakewell, MS, RN-BC, director,Perioperative Education.Ms Starbuck Pashley andMs Bakewellhave no declared affiliations that could be perceived as posingpotential conflicts of interest in the publication of this article.

Sponsorship or Commercial SupportNosponsorshipor commercial supportwas received for this article.

DisclaimerAORN recognizes these activities as CE for RNs. Thisrecognition does not imply that AORN or the AmericanNurses Credentialing Center approves or endorses productsmentioned in the activity.

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Incorporating Age-Specific Plansof Care to Achieve OptimalPerioperative Outcomes 3.9 www.aorn.org/CE

JULIANA MOWER, MSN, RN, CNS, CNS-CP, CNOR

ABSTRACTWhen developing a nursing plan of care, a perioperative nurse identifies nursing diagnoses duringthe preoperative patient assessment. The ability to identify age-specific outcomes (ie, infant/child,adolescent, adult, elderly adult) in addition to those that are universally applicable is a major re-sponsibility of the perioperative RN. Having an individualized plan of care is one of the best ways todetermine whether desired patient outcomes have been successfully attained. Nursing care plansaddress intraoperative and postoperative risks and allow for a smooth transfer of care throughoutthe perioperative experience. A good nursing care plan also includes education for the patient andhis or her caregiver. Within an overall plan of care, the use of methods such as a concept or mindmap can visually demonstrate the relationships between systems, nursing diagnoses, nursing in-terventions, and desirable outcomes. AORN J 102 (October 2015) 370-385. ª AORN, Inc, 2015.http://dx.doi.org/10.1016/j.aorn.2015.07.014

Key words: age-specific outcomes, pediatric, adult, geriatric, plan of care.

One size does not fit all in developing plans of carefor patients undergoing operative or otherinvasive procedures. In addition to identifying

universally applicable outcomes, the perioperative nurse mustidentify age-specific outcomes. Two patients undergoing thesame procedure may require very different preparations basedon their ages. Adding to this challenge is the fact that a pa-tient’s physiological age may not accurately reflect his or herdevelopmental stage. This is particularly true in children andadolescents, who may not fall neatly into a predetermined,age-specific category. The perioperative RN’s critical thinkingskills are a valuable asset in identifying a patient’s uniqueneeds, determining desirable outcomes, and then incorpo-rating this information into an individualized plan of care thathelps ensure safe, efficient, and effective nursing care.

Providing age-specific care requires addressing the typicalchanges that occur as a part of the normal aging process. Thepurpose of this article is to provide the basic or global com-ponents of a care plan and then develop it further by using thebasic components as the foundation for expanding care in-terventions to all age groups with addendums that addressseveral of the challenges specific to each age group. A sampleconcept map is provided to demonstrate the interrelationshipof systems and desired outcomes for a pediatric patient.

In addition to the aging process, lifestyle factors and chronicdisease processes affect body systems and may enhance oraccelerate changes that are believed to be “normal” parts ofaging, especially in adult and elderly populations. It is beyondthe scope of this discussion to include comorbidities and

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lifestyle choices (eg, sedentary lifestyle; the use of tobacco,alcohol, or illicit drugs) in the development of an age-specificplan of care. These effects are well documented in the litera-ture, and perioperative nurses are encouraged to conductfurther exploration as needed to incorporate evidence-basedinterventions that are based on identified patient needs spe-cific to comorbidities and lifestyle choices.

CARE PLAN BASICSA good perioperative nursing plan of care addresses intra-operative and postoperative risks and allows for a smoothtransfer of care as the patient progresses through the periop-erative experience. Different methods have been used toorganize and categorize nursing diagnoses and to standardizeterms to be used consistently regardless of the care providerusing them. In the perioperative setting, the PerioperativeNursing Data Set (PNDS)1 is used to identify the risks orneeds that are affected by nursing interventions for patientswho are undergoing operative or other invasive procedures.The PNDS is a standardized language recognized byperioperative nurses and other health care providers; itprovides uniform definitions of diagnostic terms, desiredpatient outcomes, and associated perioperative nursinginterventions. Many electronic medical records incorporatePNDS language into intraoperative charting systems.

Some nursing interventions are applicable regardless of thepatient’s age (eg, preventing wrong patient, wrong site, orwrong procedure; preventing unintended retention of surgicalitems). Others, although universally relevant, vary according tothe patient’s age and developmental stage. For instance,although every patient is in danger of experiencing intra-operative hypothermia, infants are at increased risk because ofsurface area and adipose tissue distribution. Because someinterventions vary according to the patient’s age, this discus-sion is organized around the basic plan of care developed foran adult, and subsequent discussion highlights the differencesencountered in other age groups during the perioperativeexperience.

Outcomes are the goals or desired end results of nursing-sensitive interventions. These should be realistic, relevant tothe patient’s condition, based on available resources, andwritten in measurable terms so that the degree to which theyhave been met can be measured. The PNDS provides out-comes associated with specific perioperative nursinginterventions.1

Plans of care are developed using the information obtainedduring the patient assessment and contain corresponding

nursing diagnoses. The plan of care (Table 1) provides anexcellent opportunity for the nurse to prioritize problems andcorresponding actions. At first glance, every problem mayseem to be of equal importance, but using a standardizedtemplate may be useful for organizing what often can be avery complex plan of care. For instance, a systems approachmay be used to distinguish normal physiological changes fromcomorbidities that the body undergoes, as during aging. It isimportant to remember that changes in one system can affectseveral others. For instance, hypothermia can affect infectionrates (ie, the immune system) and clotting times (ie, thecirculatory system).2

Many nurses use a focused systems approach to determine themajor areas of concern around which to build a concept map.Martin3 discussed the use of a concept or mind map as amethod of visually capturing the central topic of interest (inthis case, the surgical patient) and demonstrating therelationships between systems, nursing diagnoses, nursinginterventions, and desirable outcomes. To help illustrate theformulation of a care plan, a concept map for the scenarioof a 35-year-old woman with a torn anterior cruciateligament highlights the importance of individualizing theplan of care to account for predictable age-related responsesto surgical stressors (Figure 1). With a little practice, it iseasy to alter the map to account for age-related concernsencountered for specific surgical procedures.

Education should be a part of every patient’s plan of care.Although the preoperative holding area may not be an idealenvironment for teaching, at a minimum the patient should beinformed about the immediate intraoperative experience andexpectations for postoperative recovery. Involving familymembers in the education process is key at this point becauseit is likely that the patient may not remember or may misre-member what is said by the perioperative team because ofanxiety. Providing information in multiple formats (eg, verbal,written) facilitates retention of postoperative instructions. Ifeither the patient or his or her designated support person isunclear about the purpose of the surgery and the risks, ben-efits, or alternatives, the nurse should contact the surgeon foradditional counseling of the informed consent process andshould delay the procedure until all questions have beensatisfactorily answered.

In the next sections, general information regarding an age-related population is provided. A case scenario is then pre-sented with a care plan specific to a patient in that populationand his or her condition. The populations discussed are adults,infants and children, adolescents, and older adult/geriatric patients.

October 2015, Vol. 102, No. 4 Age-Specific Perioperative Care



Table 1. Basic Nursing Care Plan for a Patient Undergoing Surgery

Diagnosis Nursing Interventions Interim Outcome Statement Outcome Statement

Risk for injury relatedto wrongpatient, site,side, and level

� Confirms patient identity� Verifies operative procedure, surgical site, andlaterality

� Verifies consent for planned procedure� Implements protective measures prior to theoperative or invasive procedure

� Records devices implanted during theoperative or invasive procedure

� Evaluates the verification process for correctpatient, site, side, and level of surgery

� The surgical consent issigned according to facilitypolicy; the patient and/ordesignated support personparticipates in verification ofthe procedure, site, andlaterality with signedconsent; the time out isperformed immediatelybefore the start of theprocedure according tofacility policy

� The correct surgical site ismarked before theprocedure according tofacility policy

The patient’s procedureis performed on thecorrect site, side,and level

Risk forperioperativepositioninginjury

� Assesses baseline skin condition� Identifies baseline tissue perfusion� Identifies baseline musculoskeletal status� Identifies physical alterations that requireadditional precautions for procedure-specificpositioning

� Positions the patient� Implements protective measures to preventskin/tissue injury due to mechanical sources

� Applies safety devices� Uses supplies and equipment within safeparameters

� Maintains continuous surveillance� Evaluates tissue perfusion� Evaluates musculoskeletal status� Evaluates for signs and symptoms of physicalinjury to skin and tissue

� The patient has full return ofmovement of extremities atthe time of discharge fromthe OR or procedure room

� The patient is free from painor numbness associatedwith surgical positioning

The patient is free fromsigns and symptomsof injury related topositioning

The patient is freefrom signs andsymptoms of injurycaused byextraneous objects

Acute pain � Assesses pain control� Identifies cultural and value componentsrelated to pain

� Implements pain guidelines� Implements alternative methods of pain control� Collaborates in initiating patient-controlledanalgesia

� Evaluates response to pain managementinterventions

� The patient verbalizescontrol of pain

� The patient’s vital signs atdischarge from the OR areequal to or improved frompreoperative values

The patientdemonstrates and/or reports adequatepain control

Risk for infection � Assesses susceptibility to infection� Classifies the surgical wound� Implements aseptic technique� Protects from cross-contamination� Initiates traffic control� Administers prescribed prophylactictreatments

� Administers prescribed medications� Administers prescribed antibiotic therapy asordered

� Performs skin preparations� Monitors for signs and symptoms of infection

� The patient’s wound is freefrom signs or symptoms ofinfection and pain, redness,swelling, drainage, ordelayed healing at the timeof discharge

The patient is free fromsigns and symptomsof infection

Mower October 2015, Vol. 102, No. 4



ADULTSPhysiologically, an adult patient is in the best position torecover from surgical stressors. Organs have matured but havenot begun to undergo the alterations affecting their functionsuch as those observed in older adults. Body systems are attheir peak functionality. Laboratory values and diagnostic testsare well established for this population. Educational materialspertinent to this age group are widely available; however, as aresult of health literacy concerns, health care providers shouldbase patient education on a variety of methods, both writtenand oral, and should assess the patient for his or her under-standing of content using a validation means, such as theteach-back approach.4

Adult Case ScenarioThe perioperative nurse admits Ms R, a 35-year-oldwoman, to the preoperative area. Ms R is scheduled toundergo a left knee arthroscopy and anterior cruciate liga-ment repair. The preoperative nurse first reviews Ms R’smedical record, including the history and physical exami-nation and all laboratory and test results. The nurse thenintroduces herself to Ms R and completes a preoperativeassessment of the patient. During the preoperative assess-ment, the nurse notes that Ms R had been preparing for amarathon during which she fell from a curb, twisted herknee, and landed on her knee on the concrete. Ms R

mentions to the nurse that she is worried because her fianc�eis confident that she will recover adequately to run themarathon the following weekend.

The nurse develops a plan of care (Table 2) specific to Ms R.She starts by identifying the following nursing diagnoses forwhich Ms R is at risk:

� impaired physical mobility and� ineffective family therapeutic regimen management.

The nurse selects nursing interventions specific to each diag-nosis and identifies desired outcomes and goals from theimplementation of those interventions. Ms R is a healthy,active adult. Nothing in the nurse’s preoperative assessmentindicates an issue with increased risk for infection, alteredwound healing, or complicated recovery. The nurse selects andimplements nursing-specific interventions related to safe sur-gery practices (ie, preventing wrong patient, wrong site, orwrong procedure; managing acute pain) in the typical plan ofcare as followed for any patient.

Deficient KnowledgeAn area of concern is Ms R’s and her fianc�e’s disconnect intheir perceptions of the extent of her injury, the proposedsurgical procedure, and the rehabilitation process. Using open-ended questions, the perioperative nurse obtains additional

Table 1. (continued)


� Minimizes the length of the invasive procedureby planning care

� Maintains continuous surveillance� Administers care to wound sites� Administers care to invasive device sites� Encourages deep breathing and coughingexercises

� Evaluates factors associated with increased riskfor postoperative infection at the completion ofthe procedure

� Evaluates progress of wound healing� Evaluates for signs and symptoms of infectionthrough 30 days after the perioperativeprocedure

Risk for injury anddelayed surgicalrecovery relatedto anunintendedretained foreignobject

� Verifies operative procedure, surgical site, andlaterality

� Performs required counts� Reports deviation in diagnostic study results� Evaluates results of the surgical count

� The counts are accurate,correct, or reconciledaccording to facility policy

The patient is free fromunintended retainedforeign objects




print&web4C=FPO

Figure 1. An adult concept map highlights the importance of individualizing the plan of care to account for pre-dictable age-related responses to surgical stressors. The map can be altered to account for age-related concernsand surgical procedure. This concept map is not all-inclusive for every potential patient problem or outcome. TheUniversal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a registered trademarkof The Joint Commission, Oakbrook Terrace, IL.




information related to Ms R’s knowledge of the surgical pro-cedure and tailors patient education based on that information.The nurse contacts the surgeon and explains the misperceptionregarding recovery from surgery. Before the RN circulatortransports Ms R to the OR, the surgeon reviews the surgicalprocedure, mobility limitations, and physical therapy with MsR to ensure that the desired outcomes of a knowledgeable,prepared patient and designated support person are met.

INFANTS AND CHILDRENInfants and children are not small adults and should not betreated as such. Immature immune and pain responses andundeveloped thermoregulatory, renal, gastrointestinal, andpulmonary systems put younger patients at increased risk

for intraoperative and postoperative complications. Chil-dren at different ages have unique physiological and psy-chosocial characteristics. To better understand these age-based traits, the following discussion is based on threedifferent age groups: birth to two years, two to seven years,and seven to 11 years. Adolescence, the final stage beforeadulthood, is considered to be between 11 and 21 yearsof age.

Immune SystemUnless breastfed, an infant’s total immunoglobulin levels dropimmediately after birth because the maternal source of anti-bodies has been discontinued.5,6 Circulating immunoglobulinsreach their lowest level at six months of age, which accounts

Table 2. Addendum to Basic Nursing Care Plan Specific to an Adult Undergoing Orthopedic Surgery

Diagnosis Nursing InterventionsInterim Outcome

Statement Outcome Statement

Impaired physicalmobility

� Identifies baseline musculoskeletal status� Verifies the presence of prosthetics or correctivedevices

� Identifies physiological status� Reports deviation in diagnostic study results� Transports the patient according to individual needs� Positions the patient� Implements protective measures to prevent skin/tissue injury due to mechanical sources

� Evaluates musculoskeletal status� Evaluates the patient for signs and symptoms ofphysical injury to skin and tissue

� The patient is unable tomove lower extremitiessecondary to spinalanesthesia at time oftransfer to thepostanesthesia care unit

� The patient’s peripheraltissue perfusion isconsistent with orimproved frompreoperative status atdischarge from the OR orprocedure room

The patient’smusculoskeletalstatus is maintainedat or improved frombaseline levels

Ineffective familytherapeuticregimenmanagement

� Identifies the patient’s and designated supportperson’s educational needs

� Identifies expectations of home care� Includes the patient or designated support person inperioperative teaching

� Provides instruction based on age and identifiedneeds

� Evaluates the environment for home care� Evaluates the patient’s response to instructions

� The patient and his orher designated supportperson verbalize realisticexpectations regardingrehabilitation aftersurgery

The patient participatesin the rehabilitationprocess

Deficientknowledge

� Identifies the patient’s and designated supportperson’s educational needs

� Identifies expectations of home care� Includes the patient or designated support person inperioperative teaching

� Provides instruction based on age and identifiedneeds

� Evaluates the environment for home care� Evaluates the patient’s response to instructions

� The patient and his orher designated supportperson verbalize realisticexpectations regardingrehabilitation aftersurgery

� The patient describes theprescribed rehabilitationregimen to followimmediately afterdischarge from thefacility

The patient participatesin the rehabilitationprocess




for the increased numbers of respiratory infections frequentlyseen at this age. When caring for an infant, the nurse shouldhelp ensure strict adherence to standard and respiratory pre-cautions to reduce the risk of exposure to the patient, peri-operative personnel, and other patients whose immune statusmay be compromised.

PainBecause facial expressions, crying, body movements, and theinability of caregivers to console a child are the most consistentevidence of pain in infants and toddlers,5 these are theelements used in pain assessment scales for these age groups.Older children (ie, five to 18 years of age) are better able toverbalize the presence of pain; however, they tend to have alower pain threshold than adults.

Temperature RegulationIn addition to their small body size, infants have difficultymaintaining normal body temperature because of severalphysiological factors. Infants

� have an increased body surface to body weight ratio,� cannot shiver in response to hypothermia, and� have a thinner layer of subcutaneous fat than patients inother age groups.5

In addition to a greater body surface to body weight ratio,children have a more exaggerated response than adults in termsof vasodilation and vasoconstriction when exposed to heat orcold environments.5

Pulmonary FunctionThe airways of children and infants are narrower than those ofadults, and the chest wall is much softer and more pliant.5

These factors put younger patients at increased risk forobstruction and respiratory tract infections. Children alsohave increased oxygen consumption compared with adults,and they tolerate episodes of hypoxia much more poorly.Obstructive sleep apnea should be considered in children,especially in those between the ages of one and three years,who present with hypertrophied tonsils and adenoids.

Renal FunctionThe kidneys are a developing organ during the first severalyears of life. Any corresponding congenital anomalies shouldbe taken into account during review of normal kidneyfunction in infants and children. In infants, ureters areshorter than those of adults. Renal blood flow and glomerularfiltration rate increase immediately after birth, reaching adult

levels at two years of age. Higher blood flow and shorternephrons produce more dilute urine. Limited ability toregulate hydrogen ion, bicarbonate, and potassium meansthat the infant is especially vulnerable to acid-base imbal-ances. Any condition that affects electrolyte balance (eg,diarrhea, infection, NPO status) can rapidly cause acidosisand fluid shifts. By the time the child reaches adolescence,the kidneys have attained adult size.

PsychosocialParents, by acting as surrogate decision makers for infantsand children, assume a vital role as members of the patient/perioperative team.7 Open, clear, and frequent communicationwith the chief decision maker is therefore one of the mostimportant responsibilities of the perioperative nurse, whomust serve as an advocate for not only the patient, but thepatient’s caregivers as well. The nurse should provide clearand age-related expectations of the surgical experience andevaluate comprehension of treatments to maximize theeffectiveness of the intervention.

Birth to two years of ageThe principle psychosocial stressor related to this age group isseparation anxiety.8 Allowing a parent to stay with the child asmuch as possible throughout the perioperative experience isthe most effective nursing intervention, which includesbeing present in the OR for induction of anesthesia. Whenthe parent cannot be present, using distraction or holdingthe child can be effective strategies to minimize the anxietyassociated with separation from the primary caregiver.

Two to seven years of ageChildren in this age group are very concrete thinkers. Usingterms such as “going to sleep” may be associated with thedisappearance of a beloved pet. Surgery may be associated withpunishment for a perceived misdeed. Because of their healthyimaginations, it is best to limit preoperative teaching to lessthan 24 hours before the surgical procedure.8

Seven to 11 years of ageChildren in this age group are developing a world view frommultiple perspectives. In addition to viewing surgery as somesort of punishment, fear of pain, fear of mutilation (especiallyfor boys), and separation anxiety are coupled with beliefs thatthe problem requiring surgical intervention was caused byeating or touching something. Clearing up misconceptions is amajor focus of preoperative education and is best accom-plished within a week of the surgical procedure.8




Child Case ScenarioThe intensive care unit (ICU) nurse admits Haley, a three-day-old newborn girl, to the pediatric ICU. Haley has ahistory of choking on the first feeding and an inability toswallow secretions. The neonatologist is unable to pass anasogastric tube. Diagnostic tests show esophageal atresia.Haley has been scheduled for a repair of the esophagealatresia. The preoperative nurse goes to the ICU to reviewHaley’s medical record, including the history and physicalexamination and all laboratory and test results. The nursethen introduces herself to Haley’s family and completes apreoperative assessment. During the preoperative assessment,the perioperative nurse develops a plan of care (Table 3)specific to Haley. She starts by identifying the followingnursing diagnoses for which Haley is at risk:

� imbalanced body temperature,� postoperative nausea, and� imbalanced nutrition: less than body requirements.

The perioperative nurse selects nursing-specific interventionsfor each diagnosis and identifies desired outcomes as goalsfrom the implementation of those interventions.

Temperature regulationThe perioperative nurse knows that because of Haley’s smallsize, she is particularly vulnerable to the cold temperatures inthe OR and that extra measures are required to meet thedesired outcome of normothermia. The nurse ensures that awarming device (eg, forced-air warming blanket, circulatingwarming garment, energy transfer pad, head covering), ameans to deliver warmed IV and irrigation fluids, and amethod to monitor Haley’s temperature are available for Haleyon arrival in the OR. The nurse should prewarm the room andmaintain the temperature at 26� C (78.8� F). Because of theanticipated length of time for the surgical procedure, the nurseverifies that the anesthesia professional and the postanesthesiacare unit nurse have the equipment needed to monitor Haley’score body temperature throughout her perioperativeexperience.2

Gastrointestinal systemAny procedure performed on the esophagus will affect thepatient’s nutritional status. Coupled with the adverse effects ofnausea and vomiting associated with many general anestheticagents, Haley has the potential for decreased nutritionalintake. Her tiny size means that she has fewer reserves tocounter the effects of a reduction in calories. The perioperativeRN initiates a consult with the hospital dietician, the surgeon,and the intensive care hospitalist to ensure that Haley receives

nourishment via the appropriate route to maximize woundhealing and meet bodily requirements.

ADOLESCENTSAlthough physically adolescents, many patients in this agegroup (ie, 11 to 21 years) may resemble adults. Emotionallyand psychosocially, this age group has its own unique set ofcharacteristics, which differ markedly from both older andyounger age groups. Often, signs and symptoms related to thefight-or-flight response are exhibited as a response to thestresses encountered in surgery.9 Increased heart andrespiratory rates, sweating, vasoconstriction, and anxiety canaffect anesthesia induction and the response to postoperativepain. Providing a calm environment and adequate time toaddress the patient’s concerns are key to a successful outcome.

The patient’s developing sense of identity, heightened self-consciousness, and desire for autonomy9 mean that theperioperative nurse should include the patient in discussionsrelated to the surgical experience. Although the patient maynot be old enough to consent to the surgery, every effortshould be made to obtain assent. Normal risk-takingbehaviors that are a part of transitioning to adulthood maymanifest as teenage pregnancy or substance abuse,10 addingan additional level of complexity to the development of aplan of care. Interviewing the patient alone on such sensitivesubjects as substance and alcohol use and sexual activity mayelicit a more accurate response.

In a qualitative study by Rullander et al,11 anxiety related tothe surgical procedure, loss of control related to painmanagement, and lost contact with friends during theextended recovery period were considered the most difficultelements of the surgical experience for adolescent patients.These findings correspond with typical behaviors manifestedby this age group, and nursing interventions to address themshould be incorporated into the plan of care.

Adolescent Case ScenarioThe perioperative nurse admits Ben, a 16-year-old boy, to thepreoperative area. Ben is scheduled for a surgery to correctscoliosis. The preoperative nurse first reviews Ben’s medicalrecord, including the history and physical examination and alllaboratory and test results. The nurse then introduces herselfor himself to Ben and his family and completes a preoperativeassessment of the patient. During the preoperative assessment,the perioperative nurse determines that Ben’s major concernsare that he is missing the remainder of the basketball seasonand that he fears how his girlfriend will react to the surgicalscar. The nurse develops a plan of care (Table 4) specific to




Ben. The nurse starts by identifying the following nursingdiagnoses for which Ben is at risk:

� decisional conflict and� situational low self-esteem.

The perioperative nurse selects nursing interventions specif-ically for each diagnosis and identifies desired outcomes asgoals from the implementation of those interventions.

PsychosocialThe perioperative nurse understands that Ben is at avulnerable stage in his ability to make his own decisions, andshe addresses the issues related to his upcoming surgery fromBen’s point of view. He is not of legal age to give informedconsent for surgery, yet he is already making increasinglyindependent choices as he nears adulthood. His relationshipwith his peers is at least as important as his association with

Table 3. Addendum to Basic Nursing Care Plan Specific for an Infant or Child Undergoing Gastrointestinal Surgery


Risk forimbalancedbodytemperature

� Assesses the risk for normothermia regulation� Assesses the risk for inadvertent hypothermia� Assesses the risk for inadvertent hyperthermia� Identifies physiological status� Reports deviation in diagnostic study results� Implements thermoregulation measures

o Provides a stocking cap and socks to preventheat loss from the scalp

o Applies temperature-regulating devices to thepatient according to the plan of care, facilitypractice guidelines, and manufacturers’ writteninstructions

o Operates temperature-monitoring and regula-tion devices according to the manufacturers’written instructions

� Monitors body temperature� Monitors physiological parameters� Evaluates response to thermoregulation measures

� The patient’s temperature isgreater than 36� C (96.8� F)at the time of dischargefrom the OR or procedureroom

The patient is at orreturning tonormothermiaat the conclusionof the immediatepostoperativeperiod

Potential forpostoperativenausea

Imbalancednutrition:more thanbodyrequirements

� Identifies baseline gastrointestinal status� Assesses nutritional habits and patterns� Assesses psychosocial issues specific to thepatient’s nutritional status

� Includes the patient and designated supportperson in perioperative teaching

� Provides instruction regarding dietary needs� Evaluates response to nutritional instruction

� The patient, family member,designated support person,or legal guardian describesthe appropriate homemanagement of symptomsthat affect nutritional intake(eg, sore throat, nausea,vomiting) at the time ofdischarge

� The patient or designatedsupport person describesthe recommendedpostoperative nutritionalintake regimen for therecovery period at the timeof discharge

The patient, familymember,designated supportperson, or legalguardiandemonstratesknowledge ofnutritionalmanagementrelated to theoperative or otherinvasive procedure

Imbalancednutrition:more thanbodyrequirements

� Includes the patient, family member, designatedsupport person, or legal guardian in perioperativeteaching

� Provides instruction regarding dietary needs� Evaluates response to nutritional instruction

� The patient, family member,designated support person,or legal guardian describesthe recommendedpostoperative nutritionalintake regimen for therecovery period at the timeof discharge




claytonk001

Rectangle

COMP: shading needs to be closed up

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Leslie: Is this correct? Breakdown was not clear.

his parents. However, his friends’ reactions to his surgery,including visible changes in body image and altered physicalactivity, may not take into account the long-term benefits ofthe proposed procedure. The preoperative nurse understandsthat Ben is feeling confused and helpless about the upcomingexperience.

The perioperative nurse includes Ben in all discussions ofthe procedure and the rehabilitation process. The nurseengages Ben in a frank discussion on the length of the scarand methods to minimize its appearance to help Ben feel incontrol. The nurse makes special effort to respect Ben’sneed for privacy, although he may wish to have peer sup-port in the form of a trusted friend to stay with himbefore surgery.

The perioperative nurses assess Ben and his parents atregular intervals for psychosocial reactions to his procedure.The nurses identify and support appropriate copingmechanisms and incorporate Ben’s reliance on the use oftechnology into the plan of care. The nurses use appropriatevideos, social media, and online age-specific support groupsto help validate the choices being made. Thirteen- to

17-year-olds average three and a half hours per day ondigital media, including e-mail and instant messaging.12 Inaddition to socializing, adolescents use the Internet toaccess information. Discussion groups, blogs, and chatrooms are ways to allow these “Net Gens” to remainconnected while providing and receiving support fromtheir peers.12

AGED ADULT/GERIATRIC POPULATIONOlder adults (aged 65 years and older) have a decreasedphysiological reserve in which to respond to and recover fromsurgical stressors. A thorough, individualized, age-appropriateassessment helps ensure positive outcomes. As with infantsand children, a caregiver or family member may play a vitalrole in providing valuable information when nurses are eval-uating the health status of an aged patient.

Immune SystemAntibody activity and production begin to diminish after 60years of age, putting elderly patients at risk for infections andincreasing their recovery time when an infection occurs.5 Theincreased numbers of surgeries being performed on this age

Table 4. Addendum to Basic Nursing Care Plan Specific an Adolescent Patient Undergoing Spine Surgery


Decisional conflict � Verifies the operative procedure, surgicalsite, and laterality

� Verifies consent for the planned procedure� Identifies psychosocial status� Identifies individual values and wishesconcerning care

� Identifies the patient’s and his or herdesignated support person’s educationalneeds

� Provides information and explains thePatient Self-Determination Act

� Includes the patient and designatedsupport person in perioperative teaching

� Includes the patient and designatedsupport person in discharge planning

� Evaluates psychosocial response to the planof care

� The patient verbalizessatisfaction with the decision-making process and level ofinvolvement concerning theperioperative plan throughoutthe perioperative experience

� The patient, family member,designated support person, orlegal guardian asks questionsregarding care optionsthroughout the perioperativeexperience

� The patient, family member,designated support person, orlegal guardian voicespreferences in care throughoutthe perioperative experience

The patient, familymember,designated supportperson, or legalguardianparticipates indecisions affectingthe perioperativeplan of care

Risk for situationallow self-esteem

� Identifies psychosocial status� Maintains patient’s dignity and privacy� Secures patient’s records, belongings, andvaluables

� Maintains patient confidentiality� Shares patient information only with thosedirectly involved in care

� Evaluates psychosocial response to the planof care

� The patient verbalizessatisfaction with the level ofprivacy provided throughoutthe surgical experience

The patient’s rightto privacy ismaintained




group requires strict attention to aseptic technique, as well asstandard and transmission-based precautions to prevent healthcare-associated infections.

PolypharmacyIn addition to the normal physiological changes attributed tothe aging process, the elderly patient often brings a host ofcomorbidities and resulting polypharmacy to the perioperativesetting. According to Oster and Oster,13

Polypharmacy, literally meaning “many pharmacies,” . . .13(p448)

is characterized by

� use of multiple medications,� multiple prescribers,� use of several filling pharmacies,� too many forms of medication,� use of over-the-counter medications,� multiple dosing schedules, and� prescriptions for appropriate medications of which the pa-tient must take too many pills.14-16

As a result of the multiple comorbidities associated withaging, the geriatric population is most susceptible to theassociated adverse health outcomes of polypharmacy.17

Older adult patients can exhibit either increased ordecreased response to medications compared with youngerpatients. Polypharmacy increases the likelihood ofexperiencing medication-to-medication interactions.18,19

Adverse medication interactions occur when two or moremedications interact in a way that the effectiveness ortoxicity of one or more medications is altered.20 Thenumber of potential interactions increases as the numberof medications increases.

PainThe perception of pain is variable in the older patient. Neu-ropathies and cognitive impairment may contribute to theview that the pain threshold increases in some older adults;however, the pain threshold seems to decrease in some olderadults and women in general.5 These inconclusive resultsreinforce the need for accurate and personalized painassessment and treatment, regardless of age. Elderly patientsare especially vulnerable to both the action and excretion ofany pain medications as a result of changes in liver andrenal function; therefore, their response to medicationsshould be carefully monitored. Elderly patients may havepreconceptions about the risk for narcotic dependency or alack of knowledge about the benefit of pain control forsurgical recovery.

Temperature RegulationOlder adults are especially vulnerable to changes in environ-mental temperatures. Slowed blood circulation may maskperceptions of heat or cold and may manifest as

� delayed vasoconstrictive or vasodilatory responses,� skin changes and peripheral neuropathies, and� delayed shivering and sweating responses.

These factors and the presence of comorbidities (eg, diabetes,congestive heart failure, chronic obstructive pulmonary dis-ease) all have a negative effect on the body’s ability to react tochanges in temperature. The colder temperature commonlyencountered in the perioperative suite, besides being a comfortissue, decreases what is often an already compromised coro-nary perfusion system in the older adult. The relationshipbetween infection and hypothermia is already well docu-mented.2 Efforts to maintain normothermia (eg, forced-airwarming devices, fluid warmers) should be consideredstandard protocols in this population.

Pulmonary FunctionNormal aging alterations of the pulmonary system include lossof elastic recoil, stiffening of the chest wall, changes in gasexchange, and increases in flow resistance. Up to a 20% loss inrespiratory muscle strength and endurance is seen in patientsolder than 70 years.5 The concurrent loss of elasticity of boththe chest wall and alveoli account for the reduced ventilatorycapacity (eg, decreased vital capacity, increased residualvolume) seen in older adults. However, these changes aregradual and usually are well tolerated by the healthyindividual. On the other hand, the loss of muscle strengthimpairs gas exchange and the ability to cough, putting theindividual at increased risk for acquiring pneumonia andexperiencing exercise intolerance.21 Dewan et al22

recommend that patients older than 60 years undergo arespiratory risk assessment. The perioperative nurse mayrecommend that the patient use an incentive spirometer andmay provide additional perioperative patient education ondeep breathing exercises to address potential or actualpostoperative pulmonary complications.

Onset, length of action, and sensitivity to anesthetic agentsand medications are altered in older adults. In general, in-duction and emergence are prolonged.23 The RN circulatorshould factor this into the intraoperative plan of carebecause the anesthesia professional may need assistance for alonger period during emergence.

Changes in positioning and the administration of medicationsthat alter respiratory drive have a more pronounced effect on




older adults. Patients in this age group have a decreasedresponse to hypercapnia and hypoxemia. Therefore, the use ofregional anesthetics and positions that mimic normalanatomical alignment are more likely to have the least adverseeffect on the patient’s pulmonary system. However, the res-piratory benefit of a spinal anesthetic needs to be weighedagainst its effect on peripheral vascular resistance and sympa-thetic block, which can result in profound hypotension andbradycardia.22 The surgical team’s baseline assessment of thepatient’s activity level should account for age-related changesand be incorporated into patient education regarding realisticexpectations for postoperative rehabilitation and recovery.

Renal FunctionOne of the most dramatic alterations of all age-related physi-ological changes occurs in the renal system, and these changesaffect virtually every other body system. Renal blood flowdecreases, in part because of the aging cardiovascular system.This manifests as a decreased glomerular filtration rate (ie,20% to 50%), which in turns affects excretion of medica-tions.23 This longer excretion time means that the action ofthe medication, along with its concurrent adverse effects,will be prolonged.

The number of renal nephrons is reduced by 30% to 50% bythe age of 75 years. The glomeruli become sclerotic and maydisappear entirely, leading to a decreased ability to concentrateurine. This may be noted in the specific gravity laboratoryvalue, which will be on the low side of normal.5 Clinically, thisputs the elderly patient at increased risk for

� both hypovolemia and hypotension as a result of thedecreased ability to concentrate urine and

� fluid overload caused by decreased glomerular filtration rates.

Perioperative nurses should monitor urine output carefullyand consider the potential for accumulation of medicationsthat are excreted by the kidneys.

Adaptation to the stress of surgery is more difficult for theelderly patient. Chemicals that help maintain a normal acid-base balance (eg, bicarbonate, potassium) are not as readilyabsorbed. Sodium shifts can contribute to either hypervolemiaor hypovolemia, necessitating close monitoring of fluidsadministered intravenously and those used for irrigation. Thereabsorption of glucose decreases with age, contributing to agreater amount of glucose in the urine. Perioperative nursesshould take this normal age-related phenomenon into accountwhen using urinary analyses for diabetic screening. Renalactivation of vitamin D (necessary for intestinal absorption of

calcium) decreases with age and contributes to osteoporosis,bone fractures, and delayed wound healing.5

Neurogenic and myogenic changes to the bladder contribute tofeelings of frequency and urgency. In addition, prostatic hyper-trophy will affect stream flow and urinary retention.5 Although itmay be viewed as a convenient way to address these commonmanifestations of aging, the routine use of urinary catheters inthis population should be avoided because these patients are atincreased risk for urinary tract infections. The placement ofcatheters should be carefully considered, and catheters shouldbe removed as soon as possible after surgery.

PsychosocialAlthough age is no longer a contraindication for surgery per se,the ability of the aged patient to cope with stress is diminished.Patients in this age group vary widely in physiological statusand comorbidities, and overall health may have little to dowith chronological age. Important predictors of surgical out-comes include functional status, the presence of coexistingchronic diseases, the level of cognitive and emotional func-tioning, and nutritional status.23 The older patient may viewan operative or other invasive procedure much differentlythan a younger person. If the surgery signifies a loss offunction, mobility, physical ability, or independence, theadditional psychosocial implications of the procedure mustbe incorporated into the plan of care. This population oftenneeds additional assistance in meeting optimal outcomesduring and after surgery.

Neurological ChangesChanges in brain structure and neurotransmitter function ac-count for some of the functional changes seen with aging. As abenchmark for subsequent changes in mental status or func-tioning, the perioperative nurse should perform a baselineassessment before administration of any medications that couldalter mood or consciousness.24 Cognitive impairment is stronglyassociated with the development of postoperative delirium.23

The elderly population is at increased risk for falling because of

� skeletal muscle atrophy,� deterioration in vision,� loss of neuromuscular control,� administration of certain medications during surgery, and� altered mobility as a side effect of a surgical procedure.5

According to Dewan et al,22 frailty is a major risk factorinfluencing postoperative recovery for elderly patients. Theperioperative nurse should perform a social assessment on




which he or she can base postoperative discharge planning toensure that the elderly patient has appropriate resources tosafely recover from the planned surgical event.

Cognitive changes as a result of comorbidities may influencethe patient’s ability to understand instructions and giveinformed consent. A designated representative who has med-ical power of attorney may be needed if the patient lacks thecognitive ability to understand and give informed consent.

Age-related sleep disturbances coupled with what is often adramatic change in routine activities of daily living can exac-erbate a typical level of confusion. It is important to perform abaseline preoperative neurological assessment to accuratelyassess the presence of postoperative delirium or other changesin mental status not exhibited before the procedure. For rea-sons that are poorly understood, benzodiazepines and anti-cholinergic medications increase the risk for postoperativedelirium and should be avoided if possible.21 Vision andhearing loss as a result of disease or as a part of the agingprocess can affect the elderly patient’s ability tocommunicate with his or her caregivers. Table 5 providessome tips on improving communication with patients whohave sensory impairments.

Cardiovascular ChangesNormal aging effects on the cardiovascular system are difficult toseparate from lifestyle factors such as activity level. The mostrelevant age-associated physiological changes include myocardialand blood vessel wall stiffening, changes in neurogenic controlthat affect vascular tone, and left ventricular hypertrophy.5

These changes are compounded by comorbidities and surgicalstress. Changes in position required by the procedure caninfluence cardiac output and vascular resistance; theperioperative nurse should incorporate measures into the planof care to alleviate the effects of these changes.

Gastrointestinal TractTypically, assessing a patient’s nutritional status is not a highpriority for the perioperative nurse because most often patientshave fasted before a procedure. However, nutrition, especiallyprotein intake, has a direct effect on wound healing and im-mune function.

Altered nutritional status as a result of tooth loss, as well assensory changes (ie, decline in number of taste buds, decreasedsense of smell, decreased salivary production), can affect boththe quality and quantity of food intake. Decreased esophageal,gastric, and intestinal motility can impair nutrient absorption.5

Decreased motility means that food may be in the stomach fora longer time, posing an increased aspiration risk.

The nurse should assess the patient preoperatively for loose ormissing teeth, which may make intubation more challenging.Although liver function test results can remain in a relativelynormal range, blood flow and enzyme activity decrease withage. This normal physiological change can directly affectmedication metabolism. It should be noted that alterations inliver, pancreas, or gallbladder function can usually be attrib-uted to a disease process, not aging.

Musculoskeletal FunctionThe loss of bone tissue in women, especially after the start ofmenopause, is well documented. Women have lost 50% oftheir cortical bone mass by the time they reach their 70s,putting them at increased risk for fractures and pain. Men alsoexperience bone loss, but at a later age and at a much slowerrate than women.5 Fragile bones demand careful positioningand fall-prevention strategies.

Table 5. Tips for Communicating With Patients WhoHave Sensory Impairments1

Sight Impairment Hearing Impairment

Provide large-typeeducational materials.

Remove your mask,whenever possible, whenspeaking to the patient.

Move overhead lights out ofthe patient’s face until thelights are ready for use.

Speak in a normal tone intothe patient’s better ear.

Alert the patient beforetouching him or her.

Do not shout.

Treat the patient as being athigh risk for falls.

Maintain eye contact.

Explain any procedure orintervention ahead oftime to compensate for alack of visual prompts.

Use short sentences andshort words.

Allow the patient to keep hisor her glasses for as longas possible and keep theglasses in a safe place forprompt return aftersurgery.

Allow the patient to keep hisor her hearing aiddevices for as long aspossible and keep thedevices in a safe placefor prompt return aftersurgery.

Reference1. Smith SC, Neely S. Nursing management: visual and auditory

problems. In: Lewis SL, Dirksen SR, Heitkemper MM, Bucher L,Harding MM, eds. Medical-Surgical Nursing: Assessment andManagement of Clinical Problems. St Louis, MO: ElsevierMosby; 2014:407, 432.




Cartilage calcification and muscle stiffness are commonlyattributed to “old age,” and there is a physiological basis behindthese common signs and symptoms of aging. It is important to

remember that the range of motion of a joint while the patientis anesthetized may be dramatically increased; any excessivestretching or stress on joints during positioning will cause

Table 6. Addendum to Basic Nursing Care Plan Specific to an Elderly Adult Undergoing Coronary Artery BypassSurgery

Diagnosis Nursing InterventionsInterim Outcome

Statement Outcome Statement

Risk for injury related tothe potential forpolypharmacy

� Confirms the patient’s identity� Verifies allergies� Prescribes medications within the scope of practice(eg, RN first assistant)

� Establishes IV access� Administers prescribed solutions� Administers prescribed medications� Administers electrolyte therapy as prescribed� Administers prescribed antibiotic therapy as ordered� Administers immunizing agents as ordered� Administers prescribed medications based on arterialblood gas results

� Administers prescribed prophylactic treatments� Works with the patient and his or her designatedsupport person to complete a thorough medicationreconciliation form identifying all medications to takeafter discharge, including resumption of allpreoperative medications as applicable

� Evaluates response to medications

� The patient receivescorrect medication(s)in accurate doses atthe correct time andvia the correct routethroughout thesurgical experience

� Medicationreconciliation recordsare completed

The patient receivesappropriatelyadministeredmedication(s)

Decreased cardiacoutput

� Identifies physiological status� Identifies baseline cardiac status� Reports the presence of implantable cardiac devices� Reports deviation in diagnostic study results� Monitors physiological parameters� Monitors changes in cardiac status� Uses monitoring equipment to assess cardiac status� Evaluates cardiac status

� The patient’shemodynamic statusis within the expectedrange at transfer tothe postanesthesiacare unit

The patient’scardiovascularstatus ismaintained at orimproved frombaseline levels

Anxiety; ineffectivecoping

� Identifies psychosocial status� Screens for elder abuse� Screens for substance abuse� Assesses coping mechanisms� Assesses psychosocial issues specific to the patient’smedication management

� Assesses baseline neurological status� Identifies sensory impairments� Identifies barriers to communication� Identifies the patient’s and his or her designatedsupport person’s educational needs

� Identifies expectations of home care� Implements measures to provide psychological support� Includes the patient or designated support person inperioperative teaching

� Explains the expected sequence of events� Provides status reports to the designated supportperson

� Evaluates psychosocial response to the plan of care� Evaluates the patient’s response to instructions

� The patient ordesignated supportperson states realisticexpectationsregarding recoveryfrom the procedure

� The patient ordesignated supportperson identifies signsand symptoms toreport to the surgeonor health careprovider

� The patient ordesignated supportperson describesthe prescribedpostoperativeregimen accurately

The patient ordesignatedsupport persondemonstratesknowledge ofthe expectedpsychosocialresponses tothe procedure




additional postoperative pain. Range of motion should beassessed preoperatively to prevent intraoperative nerve damageand excessive stretching of muscles, tendons, and ligaments.

Age-related loss of muscle strength results in age-related loss ofskeletalmuscle. This decline in strength begins after the age of 50years; as much as 30% to 40% of muscle strength and mass maybe lost between the third and ninth decades of life.5 Loss ofstrength is manifested in decreased mobility, which can affectlength and quality of rehabilitation and postoperative recovery.As mentioned previously, degree of frailty is one of the chiefindicators influencing successful recovery after surgery. Fragilepatients may need placement in an intermediate rehabilitationcenter to regain optimal function after surgery, especially iftheir primary caregiver is another aged person. Eliciting thisinformation during the preoperative interview can help ensurethat the continuum of care accommodates this special needand helps decrease the rate of readmission to the facility as aresult of pain or other postoperative complications.

Integumentary SystemNormal skin changes that are associated with the aging processinclude loss of turgor, dryness, thinning, and increased skinfragility.21 Elderly patients are especially at risk for shearing (ie,removal of layers of skin) injuries caused during transfer fromone surface to another. Decreased subcutaneous fat increasesthe risk for pressure ulcers and hypothermia. Depending onthe surgical procedure, the perioperative nurse should consideradditional padding and warming devices for the patient’s planof care. Team members should take extra care whentransferring and positioning the elderly patient. Any movementor positioning of the patient should be undertaken as part of acollaborative team effort. Shearing can occur during the pullingor sliding of the patient. Adequate personnel and appropriatetransfer devices (eg, air transfer systems, low-friction slideboards, memory foam mattresses, gel positioning aids) helpreduce the risk for tissue injury during transfer.

Geriatric Case ScenarioThe perioperative nurse admits Mr T, a 74-year-old man, tothe preoperative area. Mr T is scheduled to undergo coronaryartery bypass graft surgery. The preoperative nurse first reviewsMr T’s medical record, including the history and physicalexamination and all laboratory and test results. The nurse thenintroduces herself to Mr T and completes a preoperativeassessment. During the preoperative assessment, the periop-erative nurse notes that Mr T is taking several medications totreat congestive heart failure, myocardial infarction, hyper-tension, and non-insulin-dependent diabetes mellitus. Thenurse develops a plan of care (Table 6) specific to Mr T. The

nurse starts by identifying the following nursing diagnoses forwhich Mr T is at risk:

� injury related to the potential for polypharmacy,� decreased cardiac output, and� anxiety and ineffective coping.

The perioperative nurse selects nursing interventions specif-ically for each diagnosis and identifies desired outcomes asgoals from the implementation of those interventions.

PainMr T’s risk for adverse outcomes related to polypharmacy isexacerbated by normal changes found in the aging kidney andby the pathophysiological effect of his non-insulin-dependentdiabetes mellitus. This can be particularly important in regardto pain medications. The preoperative nurse identifies all themedications that Mr T has been taking preoperatively, spe-cifically pain medications.

Sensory systemsNormal age-related changes in hearing may make it moredifficult for Mr T to understand verbal communications. Thishas a direct effect on his level of anxiety and ability to un-derstand postoperative instructions. The perioperative nurseplaces Mr T in a quiet area during preoperative preparation, aswell as postoperative recovery.

Cardiovascular systemThe perioperative nurse assists with monitoring of cardiacoutput and vital signs. Along with evaluating adequate tissueperfusion, vital signs are one means of assessing patient re-sponses to anxiety-relieving interventions.

CONCLUSIONIncorporating age-specific factors into the nursing plan of careguides preoperative, intraoperative, and postoperative care ofthe patient. Normal aging milestones, in conjunction with anypresenting comorbidities, can have a huge influence on attain-ing positive outcomes. The perioperative nurse is responsible forreducing risks for every patient, regardless of age. �References1. Perioperative Nursing Data Set: The Perioperative Nursing Vo-

cabulary. 3rd ed. Denver, CO: AORN, Inc; 2011.2. Guideline for prevention of unplanned perioperative hypothermia.

In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc;2015:479-490.

3. Martin KE. Computer-generated concept maps: an innovativegroup didactic activity. Nurse Educ. 2009;34(6):238-240.



http://refhub.elsevier.com/S0001-2092(15)00667-5/sref1








4. National Action Plan to Improve Health Literacy. Washington, DC:US Department of Health and Human Services, Office of DiseasePrevention and Health Promotion; 2010. http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf.Accessed March 25, 2015.

5. McCance KL, Huether SE. Pathophysiology: The Biologic Basis forDisease in Adults and Children. 7th ed. St Louis, MO: Elsevier; 2014.

6. Breastfeeding benefits your baby’s immune system. Healthychildren.Org. American Academy of Pediatrics. https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Breastfeeding-Benefits-Your-Baby’s-Immune-System.aspx. AccessedJuly 17, 2015.

7. Hazebroek FW, Tibboel D, Wijnen RMH. Ethical aspects of care inthe newborn surgical patient. Semin Pediatr Surg. 2014;23(5):309-313.

8. Harris TB, Sibley A, Rodriguez C, Brandt ML. Teaching the psy-chosocial aspects of pediatric surgery. Semin Pediatr Surg. 2013;22(3):161-166.

9. Monahan JC. Using an age-specific nursing model to tailor care tothe adolescent surgical patient. AORN J. 2014;99(6):734-749.

10. Grisby S, Miller M, Dunn JC, et al. Variations in pre-operativemanagement of adolescents undergoing elective surgery. Int JPediatr Otorhinolaryngol. 2013;77(5):770-775.

11. Rullander AC, Isberg S, Karling M, Jonsson H, Lindh V. Adoles-cents’ experience with scoliosis surgery: a qualitative study. PainManag Nurs. 2013;14(1):50-59.

12. Oblinger D, Oblinger J. Is it age or IT: first steps toward under-standing the net generation. Educause.edu. http://www.educause.edu/research-and-publications/books/educating-net-generation/it-age-or-it-first-steps-toward-understanding-net-generation. Ac-cessed July 17, 2015.

13. Oster KA, Oster CA. Care of the geriatric patient population in theperioperative setting. AORN J. 2015;101(4):443-456.

14. Fulton MM, Allen ER. Polypharmacy in the elderly: a literaturereview. J Am Acad Nurse Pract. 2005;17(4):123-132.

15. Haque R. ARMOR: a tool to evaluate polypharmacy in elderlyperson. Ann Longterm Care. 2009;17(6):26-30.

16. Zarowitz BJ, Stebelsky LA, Muma BK, Romain TM, Peterson EL.Reduction of high-risk polypharmacy drug combinations in patientsin a managed care setting. Pharmacotherapy. 2005;25(11):1636-1645.

17. Bushardt RL, Massey EB, Simpson TW, Ariail JC, Simpson KN.Polypharmacy: misleading, but manageable. Clin Interv Aging.2008;3(2):383-389.

18. Wyles H, Rehman HU. Inappropriate polypharmacy in the elderly.Eur J Intern Med. 2005;16(5):311-313.

19. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergencyhospitalizations for adverse drug events in older Americans. N EnglJ Med. 2011;365(21):2002-2012.

20. Kaufman G. Polypharmacy in older adults. Nurs Stand. 2001;25(38):49-55.

21. Smith CS, Neely S. Nursing management: visual and auditoryproblems. In: Lewis SL, Dirksen SR, Heitkemper MM, Bucher L,eds. Medical-Surgical Nursing: Assessment and Management ofClinical Problems. 9th ed. St Louis, MO: Elsevier; 2014:403-435.

22. Dewan SK, Zheng SB, Xia SJ. Preoperative geriatric assessment:comprehensive, multidisciplinary and proactive. Eur J Intern Med.2012;23(6):487-494.

23. Kristjansson SR, Spies C, Veering BTH, et al. Perioperative care ofthe elderly oncology patient: a report of the SIOG task force on theperioperative care of older patients with cancer. J Geriatr Oncol.2012;3(2):147-162.

24. Nelson JM, Carrington JM. Transitioning the older adult in theambulatory care setting. AORN J. 2011;94(4):348-358.

ResourcesChow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF; AmericanCollege of Surgeons National Surgical Quality Improvement Program;the American Geriatrics Society. Optimal preoperative assessment ofthe geriatric surgical patient: a best practices guideline from theAmerican College of Surgeons National Surgical Quality ImprovementProgram and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466.

Health literacy resources. American Medical Association. http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/our-programs/public-health/health-literacy-program/health-literacy-kit.page. AccessedMarch 16, 2015. Note: The continuing medical education creditsassociated with this resource have expired but the content is still currentand relevant. The video can be downloaded at no charge from http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/our-programs/public-health/health-literacy-program/health-literacy-video.page.

Juliana Mower, MSN, RN, CNS, CNS-CP, CNOR,is the nurse manager of Credentialing and EducationDevelopment at Competency & Credentialing Institute,Denver, CO. Ms Mower has no declared affiliation thatcould be perceived as posing a potential conflict ofinterest in the publication of this article.



http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf

http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf



https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Breastfeeding-Benefits-Your-Baby%27s-Immune-System.aspx

















http://Educause.edu

http://www.educause.edu/research-and-publications/books/educating-net-generation/it-age-or-it-first-steps-toward-understanding-net-generation











































http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/our-programs/public-health/health-literacy-program/health-literacy-kit.page



http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/our-programs/public-health/health-literacy-program/health-literacy-video.page




EXAMINATION

Continuing Education:Incorporating Age-Specific Plansof Care to Achieve OptimalPerioperative Outcomes 3.9 www.aorn.org/CE

PURPOSE/GOALTo provide the learner with knowledge related to using age-specific plans of care to achieve optimalperioperative outcomes.

OBJECTIVES1. Describe how to develop an age-specific nursing care plan for a surgical patient.2. Explain the purpose of a concept map.3. Identify age-related characteristics pertinent to providing perioperative care.4. Define polypharmacy.5. Identify methods for improving communication with patients who have sensory impairments.

The Examination and Learner Evaluation are printed here for your convenience. To receivecontinuing education credit, you must complete the online Examination and Learner Evaluationat http://www.aorn.org/CE.

QUESTIONS1. To develop an individualized plan of care, the perioper-

ative RN must1. consider the patient’s developmental stage.2. identify age-specific outcomes.3. identify the patient’s unique needs.4. identify universally applicable outcomes.

a. 1 and 2 b. 3 and 4c. 1, 2, and 4 d. 1, 2, 3, and 4

2. The _______________ is used to identify the risks orneeds that are affected by nursing interventions for pa-tients who are undergoing operative or other invasiveprocedures.a. American Nurses Association (ANA) Nursing In-

terventions Classification System

b. North American Nursing Diagnosis Association Di-agnoses and Nursing Interventions System

c. Perioperative Nursing Data Setd. ANA Nursing Outcomes Classification

3. Outcomes1. are the goals or desired end results of nursing-sensitive

interventions.2. should be based on available resources.3. should be realistic and relevant to the patient’s condition.4. should be written in measurable terms.


4. A method of visually demonstrating the relationshipsbetween systems, nursing diagnoses, nursing in-terventions, and desirable outcomes is called





a. an object-role modeling graph. b. a concept map.c. a circuit diagram. d. a Venn diagram.

5. Physiologically, _____________ patients are in the bestposition to recover from surgical stressors.a. adult b. pediatricc. adolescent d. elderly

6. In the adult case scenario, the nurse developing a plan ofcare specific to Ms R identifies nursing diagnoses forwhich Ms R is at risk, including1. decreased cardiac output.2. imbalanced nutrition: less than body requirements.3. impaired physical mobility.4. ineffective family therapeutic regimen management.5. situational low self-esteem.

a. 3 and 4 b. 1, 2, and 5c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

7. In addition to their small body size, infants have difficultymaintaining normal body temperature because they1. have an increased body surface to body weight ratio.2. cannot sweat as a means of thermoregulation.3. have a thinner layer of subcutaneous fat than patients

in other age groups.4. cannot shiver in response to hypothermia.


8. According to a qualitative study, the most difficult ele-ments of the surgical experience for an adolescent are

1. anxiety related to the surgical procedure.2. loss of control related to pain management.3. loss of function, mobility, or independence.4. lost contact with friends during the extended recovery

period.a. 1 and 3 b. 2 and 4c. 1, 2, and 4 d. 1, 2, 3, and 4

9. Polypharmacy is characterized by1. multiple dosing schedules.2. prescriptions for appropriate medications of which

the patient must take too many pills.3. use of multiple medications.4. use of over-the-counter medications.5. use of several filling pharmacies.

a. 4 and 5 b. 1, 2, and 3c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 5

10. Tips for improving communication with sight-impairedpatients include1. alerting the patient before touching him or her.2. allowing the patient to keep his or her glasses for as

long as possible.3. maintaining eye contact.4. moving overhead lights out of the patient’s face until

the lights are ready for use.5. providing large-type educational materials.6. using short sentences and short words.

a. 1, 3, and 6 b. 1, 2, 4, and 5c. 2, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6




LEARNER EVALUATION

Continuing Education:Incorporating Age-Specific Plansof Care to Achieve OptimalPerioperative Outcomes 3.9 www.aorn.org/CE

This evaluation is used to determine the extent towhich this continuing education programmet yourlearning needs. The evaluation is printed here for

your convenience. To receive continuing education credit, youmust complete the online Examination and Learner Evaluationat http://www.aorn.org/CE. Rate the items as described below.

OBJECTIVESTo what extent were the following objectives of thiscontinuing education program achieved?1. Describe how to develop an age-specific nursing care plan

for a surgical patient.Low 1. 2. 3. 4. 5. High

2. Explain the purpose of a concept map.Low 1. 2. 3. 4. 5. High

3. Identify age-related characteristics pertinent to providingperioperative care.Low 1. 2. 3. 4. 5. High

4. Define polypharmacy.Low 1. 2. 3. 4. 5. High

5. Identify methods for improving communication withpatients who have sensory impairments.Low 1. 2. 3. 4. 5. High

CONTENT6. To what extent did this article increase your knowledge of

the subject matter?Low 1. 2. 3. 4. 5. High

7. To what extent were your individual objectives met?Low 1. 2. 3. 4. 5. High

8. Will you be able to use the information from this articlein your work setting?1. Yes 2. No

9. Will you change your practice as a result of reading thisarticle? (If yes, answer question #9A. If no, answerquestion #9B.)

9A. How will you change your practice? (Select all that apply)1. I will provide education to my team regarding why

change is needed.2. I will work with management to change/implement

a policy and procedure.3. I will plan an informationalmeetingwith physicians to

seek their input and acceptance of the need for change.4. I will implement change and evaluate the effect of

the change at regular intervals until the change isincorporated as best practice.

5. Other: __________________________________

9B. If you will not change your practice as a result ofreading this article, why? (Select all that apply)1. The content of the article is not relevant to my

practice.2. I do not have enough time to teach others about the

purpose of the needed change.3. I do not have management support to make a

change.4. Other: __________________________________

10. Our accrediting body requires that we verify the timeyou needed to complete the 3.9 continuing educationcontact hour (234-minute) program: ______________





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Incorporating Age-Specific Plans of Care to Achieve Optimal