CONTINUING EDUCATION

Surgical Risk Factors in GeriatricPerioperative PatientsMARIE BASHAW, MS, RN, NEA-BC, CNOR; DANA N. SCOTT, BSN, RN 2.9

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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.

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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

endorses products mentioned in the activity.

doi: 10.1016/j.aorn.2011.05.025

� AORN, Inc, 2012

P

Surgical Risk Fac

tors in GeriatricPerioperative PatientsMARIE BASHAW, MS, RN, NEA-BC, CNOR; DANA N. SCOTT, BSN, RN 2.9

www.aorn.org/CE

ABSTRACT

The geriatric population is growing in number, and risk factors commonly seen in

this population of patients can seriously affect the outcomes of surgical interven-

tions. Identification of surgical risk factors (eg, hearing and vision loss, inadequate

nutrition, preexisting conditions) and early intervention by the perioperative nurse

to plan for, correct, or accommodate physical limitations often can minimize or

eliminate problems and potential complications. AORN J 96 (July 2012) 59-71. �AORN, Inc, 2012. doi: 10.1016/j.aorn.2011.05.025

Key words: geriatric surgical risk factors, geriatric patients, risk factors.

ersons 65 years of age and older make up

the fastest growing segment of the world’s

population (Figure 1).1 This increase can be

attributed to healthier lifestyles, better preventative

care, and advances in health care.2 In addition, be-

cause of advances in health care, geriatric patients,

once considered poor candidates for surgery because

of complex comorbidities and advancing age, are

now considered appropriate surgical patients.3

Preexisting conditions and normal changes

related to aging, however, can result in perioper-

ative complications in the geriatric patient. The

seriousness of the complication depends on the

patient’s specific preexisting condition or aging

changes. Early intervention, including postponing

the surgical procedure for patients with modifiable

risk factors, may reduce morbidity and mortality

rates in the geriatric surgical patient population.4

CHANGES SPECIFIC TO GERIATRICPATIENTS

Aging affects every body system to some extent,

with some systems more seriously affected than

doi: 10.1016/j.aorn.2011.05.025

� AORN, Inc, 2012

others. In general, aging affects the older adults’

ability to process information and to interpret

and physically navigate their environment. This

in turn affects how older adults experience surgery

and, without careful planning for nursing care

(Table 1), can alter the outcomes of any surgery

the patient undergoes.

Hearing and Vision

Changes in vision occur in older adults and include

decreased visual acuity because of lens thickening

and decreased light sensitivity.2 Aging also changes

the ear and hearing of older adults. This includes

an increase in cerumen accumulation, which can

block the ear canal and reduce hearing, and sensory

hair cell loss and organ of Corti atrophy, which

also affect the ability to hear.2

Hearing and vision losses can prevent geriat-

ric patients from understanding preoperative and

postoperative instructions.5 To ensure that the pa-

tient can understand this information, the nurse

should assess the patient for hearing deficits and

whether he or she uses assistive devices (eg,

July 2012 Vol 96 No 1 � AORN Journal j 59

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

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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

laterality.n Assesses baseline skin condition.n Identifies baseline tissue perfusion.n Identifies baseline musculoskeletal status.n Identifies physical alterations that require additional

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.

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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

leads to an increase in systolic pressure and

peripheral vascular resistance.12 Over time, this

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July 2012 Vol 96 No 1 BASHAWdSCOTT

results in thickened ventricular walls and hyper-

trophy of the ventricles.12 Careful perioperative

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

attributable to aging also can affect anesthesia

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July 2012 Vol 96 No 1 BASHAWdSCOTT

and the patient’s fluid and electrolyte balance.5,6

Anesthesia effects include

n decreased respiratory function,

n disorientation,

n being slow to wake up after the completion of

surgery,

n a slow return of baseline cognitive status, and

n low blood pressure.

The nurse should be aware that older patients may

need to be reoriented to where they are, to breathe

deeply, and to move slowly when getting up to

avoid a drop in blood pressure and that they must

have assistance when getting out of bed because

they may feel light-headed and dizzy and are at

increased risk for a fall. Patients may need to be

repeatedly reminded of these issues.

Maintaining an older patient’s fluid and elec-

trolyte balance during surgery can be challenging.

Fluid shifts in older adults can lead to impaired

respiratory function and swelling in the extremities.

The nurse should carefully monitor all fluids that

are administered on the field and all fluid output

(eg, blood loss, urine output). The nurse should

report any unusual discrepancies to the anesthesia

care provider and the surgeon and document them

on the OR record.

Nervous System

Normal changes in the central nervous system of

geriatric patients, such as short-term memory loss

and difficulty in processing information and prob-

lem solving, can affect perioperative teaching and

patient care. Geriatric patients also are susceptible

to postoperative problems such as delirium, con-

fusion, and depression.5 As many as 20% of geri-

atric patients experience postoperative delirium,20

which has been associated with increased morbidity

and mortality.20

Delirium manifests as patients not knowing who

they are, where they are, or what the nurses are

doing to help them.20 They become suspicious of

the people around them and believe that caregivers

are trying to harm them. They are not compliant

66 j AORN Journal

with care and are at risk for injuring themselves.

The greater risk of injury increases patients’ overall

morbidity and mortality risk. Patients who are

delirious can become harmful to themselves and

others, whereas confused patients usually are not.

When an older adult patient is confused, the nurse

should be able to reorient the patient and help the

patient comply with what the nurse asks him or

her to do. Nurses must monitor a patient experi-

encing delirium closely and, if necessary, have

someone stay with the patient at all times. As a last

resort, orders for restraints may be required to

keep the patient from harming himself or herself.

The presence of depression and delirium may affect

the patient’s postoperative recovery or ability to

provide self-care.5

Depressed patients are oriented and aware of

their surroundings but do not respond quickly and

sometimes do not respond at all to requests from the

nurse to participate in their own care.20 For example,

a patient may not want to perform deep breathing,

coughing, and turning exercises or sit in a chair or go

for a walk. This can lead to respiratory complica-

tions. Patients who are depressed understand what is

being asked of them but, because of the depression,

do not want to participate in self-care. Delirious

patients, in contrast, do not understand what they

are being asked to do and therefore do not comply.

Failure to comply, regardless of its reasons, can lead

to postoperative complications and increased length

of stay in the hospital.20 The nurse may be able to

prevent postoperative delirium by assessing the

patient for risk factors that include cognitive, hear-

ing, and vision impairments; sleep deprivation;

immobility; and dehydration and planning patient

care to accommodate any deficits.20

Cognitive impairment. Preoperatively, it is

important for the nurse to assess the geriatric

patient for the cognitive ability to “perform [any]

behavior that is essential to the procedure.”7(p37)

The nurse should include family members or

caregivers in patient teaching with the patient’s

permission. If the patient appears unable to follow

RISK FACTORS IN GERIATRIC SURGICAL PATIENTS www.aornjournal.org

directions or is unable to perform self-care tasks

that will be required after surgery, the nurse should

assess family members or caregivers for the ability

to perform these tasks. In instances where the

patient has no support system, the nurse may need

to ask for discharge planning to ensure that the

patient is discharged to an appropriate care facility

until able to care for himself or herself. Nursing

interventions for cognitive impairment include

providing stimulating activities; ensuring frequent

interaction with personnel; and orienting the patient

to time, place, and date.20 Allowing a family mem-

ber to stay with the patient whenever possible also

can be helpful.

Visual and hearing impairments. Auditory

or visual impairments can seriously affect the

patient’s ability to understand what is being said

or see his or her environment. This affects the

patient’s ability to provide self-care and can

contribute to confusion and delirium. If a patient

requires the use of hearing aids or glasses, these

should be available to the patient for as long as

possible in the perioperative setting and should be

working properly.20 If the hearing or visual aids

must be removed, they should handled carefully

and returned to the patient as soon as possible in

the postoperative setting.

Sleep deprivation. To prevent sleep depriva-

tion, health care providers should schedule surgery,

medications, testing, and care activities so that they

do not interrupt the patient’s sleep and should

provide nonpharmacological sleep aids such as

warm milk, relaxation activities, soothing music,

and noise reduction if needed.20 The perioperative

nurse should be aware that the anxiety of an ap-

proaching surgery may have altered the patient’s

sleep pattern and may pose a risk for postoperative

delirium. The perioperative nurse can provide

a calm, soothing environment in the preoperative

holding area. Allowing family members to remain

with the patient until the time of surgery and

providing a hand massage, soft music, or a dark-

ened environment can help the patient relax.

Immobility. Prolonged bedrest can cause pres-

sure on the nerves and atrophy of the muscles.

When patients do attempt to get up, their extremi-

ties do not respond as rapidly as before, which

increases the risk of falling. If a patient believes

he or she is going to fall and becomes afraid to try,

this initiates a downward spiral.

In surgery, prolonged positioning can result in

nerve and tissue damage, and because of the effects

of the surgery or prolonged hospitalization, the

same types of immobility problems can result.

Reassurance by the nurse and one or two persons

who can assist the patient with ambulating can

decrease his or her fears and facilitate postoperative

recovery. The nurse should help the patient ambu-

late as soon as possible. The use of devices such

as indwelling urinary catheters that could restrict

a patient’s ability to move should be avoided.20

Dehydration. Preoperative fasting will have

altered the patient’s normal intake and output. The

nurse should assess the patient’s regular intake and

output patterns, assess his or her current NPO

status, and review the patient’s blood urea nitrogen

levels and creatinine ratios for signs of dehydration

and closely monitor them during surgery.20 Any

apparent deficits should be reported to the anes-

thesia care provider, the surgeon, and postoperative

caregivers.

Nerve injury. Injury to nerves can occur when

there is pressure caused by incorrect positioning.10

The brachial plexus, radial nerves, sciatic nerves,

and popliteal nerves are prone to pressure injury

in geriatric patients. Being aware of a patient’s

particular risks helps caregivers determine when

and where to provide extra protection.10 The nurse

should assess the patient for numbness or tingling

of the extremities10 as well as mobility issues and

any areas of skin breakdown or bruising. These

should be documented and discussed with the

surgical team. Because of limitations in mobility

associated with aging, the surgical team may need

to modify positioning and should take particular

care not to hyperextend joints or use undue force

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July 2012 Vol 96 No 1 BASHAWdSCOTT

when positioning the patient for surgery.21 When

placing the patient in the supine position, the

patient’s arms should be positioned on arm boards

at less than a 90-degree angle from the body, and

the patient’s palms should face up to prevent ul-

nar nerve damage.21 When tucking the patient’s

arms at his or her sides is required, the nurse

should place the patient’s palms facing inward and

support the elbows to avoid compression on the

ulnar nerve; the patient’s fingertips should be

checked to ensure that any repositioning of the

OR bed does not trap them.21 Bony prominences

should be carefully padded, and heels should be

elevated off the mattress if possible to avoid un-

due pressure.20 The patient’s head should be in

a neutral position.21

Pain. Contrary to popular belief, older adults

do not have higher pain thresholds than younger

adults,6 and pain is not a natural outcome of

aging.22 Elderly patients, however, may appear to

have less pain because they may be reluctant to

report it to the nurse or will underreport the in-

tensity of their pain. Older adults often believe

that pain must be endured or that if they report

having pain, they will be “labeled as a ‘bad’

patient.”14(p1160) Elderly patients often use words

such as aching, soreness, or discomfort to describe

what they are feeling.22 These words are considered

“softening” words and may poorly describe the

magnitude of the pain the patient is experiencing,

resulting in unrelieved or poorly relieved pain.22

Unrelieved pain can cause many postoperative

complications, including hypertension, tachy-

cardia, depression, anxiety, sleep disturbances,

immune dysfunction, weight loss, urinary reten-

tion, atelectasis, fluid imbalance, constipation,

weakness, fatigue, confusion, glucose intolerance,

and fluid overload.16 “Pain may actually hasten

death by increasing physiological stress, decreas-

ing mobility, and contributing to pneumonia and

thromboemboli.”23(p79)

The nurse should assess the patient’s pain level

and treat it. Ideally, pain medication should be

68 j AORN Journal

administered regularly in the immediate postoperative

period to prevent the patient’s pain from recur-

ring.2,6 If the patient is unable to report pain be-

cause of delirium or dementia, the nurse should

observe him or her for other indications of pain,

including

n restlessness,

n facial expressions (eg grimacing, frowning),

n posturing,

n guarding,

n aggression,

n withdrawal,

n appetite changes, or

n mental status changes (eg, increased confusion,

crying, irritability).2

If these symptoms of pain are observed, the nurse

should administer pain medication as symptoms

present to reduce potential complications. The

nurse can also institute complementary and alter-

native therapies for pain treatment, including

n therapeutic touch,

n massage therapy,

n distraction,

n guided imagery,

n aromatherapy, and

n the use of hot or cold packs if ordered by the

physician.2

Thermoregulation. During surgery, any patient

can experience hypothermia. Heat can be lost be-

cause of the use of cool IV and irrigation fluids,

lower ambient room temperature in the OR, and

mechanical ventilation and through radiation, con-

vection, conduction, and evaporation.14 Hypo-

thermia can lead to increased postoperative pain

and bleeding, immune system compromise, medi-

cation metabolism delay, and impaired wound

healing. The normal physiologic response to hy-

pothermia is shivering and vasoconstriction.14

Shivering increases oxygen consumption, cardiac

output, and carbon dioxide production.16 Vaso-

constriction shunts blood from the extremities to

the core body organs in an attempt to conserve

PATIENT EDUCATION

Surgery and the Older Adult

OverviewPreexisting conditions and normal aging can cause

complications in the older adult patient who requires

surgery. The seriousness of the complication de-

pends on your specific preexisting conditions and

the planned surgery. Please let your caregivers know

about any preexisting conditions you may have and

any problems you may have had with surgery in

the past.

Hearing and eyesight problemsIf you are hard of hearing or require the use of

hearing aids or glasses, remember to bring them

with you to the hospital and let caregivers know that

you need them to see or hear well. This will help

ensure that you get the information you need for

a successful outcome to your surgery. If you have

a hard time hearing what a caregiver is saying, ask

him or her to speak up or repeat the information.

Ask the caregiver to explain anything you do not

understand. If you cannot read the postoperative

instructions that are given to you, ask your caregiver

to read them to you. If a caregiver is speaking too

rapidly or using words you do not understand, ask

him or her to slow down or further explain the in-

formation. Caregivers may ask you to demonstrate

that you can follow postoperative instructions.

When you are away from familiar surroundings,

you may feel confused or disoriented. If possible,

have a family member come with you to help you

adjust to the hospital environment. If you become

confused, remember that this is not unusual and ask

caregivers or family members to help orient you.

PainPain is a normal result of surgery; however, it can be

relieved by medication and other treatments. Pro-

viding pain relief is important to prevent other

complications. It is important for you to tell your

caregivers if you are experiencing pain and whether

medications or other treatments to relieve it have

been successful. Do not minimize what you are

experiencing or worry that you are bothering your

caregivers. Do not wait until you are in a lot of pain

to ask for relief.

MedicationsTell your caregivers about any medications you are

taking and why; this includes over-the-counter med-

ications, herbs, or vitamins. If it is hard for you to

remember, bring a written medication list with you to

the hospital. Let caregivers know if there are any

medications that you cannot take and why.

Skin, muscles, and jointsLet your caregivers know if you have any bruising,

cuts, or other skin damage so that they can take

precautions to protect these areas. Also let your

caregivers know if you have problems with arthritis,

stiffness, or other mobility issues. Your caregiver

may ask you to move these joints so that any move-

ment restrictions can be identified and caregivers can

take extra care to prevent injury during surgery.

TemperatureLet your caregivers know if you are cold or would

like more blankets. This will help them ensure that

you do not have complications from being cold.

ResourcesHow to prepare for surgery. Women to Women.

http://www.womentowomen.com/womenshealth/

howtoprepareforsurgery.aspx. Accessed April 4,

2012.

Preparing the older adult for surgery and anesthesia.

Mosby’s NursingConsult. http://www.nursingconsu

lt.com/nursing/journals/10899472/full-text?issn¼10899472&full_text¼html&article_id¼483748&

spid¼15433640&iphub_return¼http%3A%2F%

2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%

2FS1089947204002941%3Fshowall%3Dtrue. Ac-

cessed April 4, 2012.

AORN Journal j 69

RISK FACTORS IN GERIATRIC SURGICAL PATIENTS www.aornjournal.org

July 2012 Vol 96 No 1 BASHAWdSCOTT

heat.14 Older patients, however, havemore difficulty

regulating their body temperature and surgical

procedures place them at increased risk for hypo-

thermia because of their decreased ability to vaso-

constrict and shiver.14

The nurse can increase the ambient room

temperature of the OR to reduce radiant heat loss

and use temperature regulating blankets and head

coverings to reduce the risk of heat loss from

radiation and convection.6,14 Warmed irrigation

fluids should be used on the sterile field and the

circulating nurse should use warmed prep solutions

(if the manufacturer supports this) to reduce heat

loss and ensure that the patient is not lying in prep

solution or on wet linen, which could increase heat

loss. Anesthesia care providers should use fluid

warmers for IV solutions. The patient’s feet should

be kept warm with socks if possible.14

SURGICAL RISK

Age alone is not a contraindication for surgery;

however, certain situations and conditions increase

surgical risk for the geriatric population. For ex-

ample, surgery performed on an emergent basis or

surgery involving the heart, chest, or abdominal

cavity and that lasts more than 3.5 hours increases

the risk of complications significantly.14 The

American Society of Anesthesiologists Physical

Status Classification System24 helps to categorize

a patient’s anesthetic risk. A patient with a classi-

fication of III, IV, or V (ie, presence of preexisting

disease of increasing severity) and who is older

than 75 years is at an increased level of surgical

and anesthetic risk and requires careful assessment

and planning to prevent complications.14,24

CONCLUSION

Perioperative nurses must be aware of the surgi-

cal risk factors for geriatric patients and the phys-

iologic and cognitive changes associated with

aging and how they affect patients undergoing

surgery. Careful patient assessment, addressing and

correcting issues perioperatively when possible,

70 j AORN Journal

and planning for care can provide a safer, more

successful surgical experience for the geriatric

patient.

References1. Projected future growth of the older population. 2010.

Department of Health and Human Services Administra-

tion on Aging. http://www.aoa.gov/AoARoot/Aging_

Statistics/future_growth/future_growth.aspx#age. Ac-

cessed November 21, 2011.

2. Tabloski PA. Gerontological Nursing. 2nd ed. Upper

Saddle River, NJ: Pearson Education, Inc; 2010.

3. Swann J. Fall prevention is everyone’s responsibility.

Nurs Resid Care. 2008;10(6):294-297.

4. Harari D, Martin F, Buttery A, O’Neill S, Hopper A.

The older persons’ assessment and liaison team “OPAL”:

evaluation of comprehensive geriatric assessment in

acute medical inpatients. Age Ageing. 2007;36(6):

670-675.

5. Dunn D. Preventing perioperative complications in an

older adult. Nursing. 2004;34(11):36-42.

6. Doerflinger D. Older adult surgical patients: presentation

and challenges. AORN J. 2009;90(2):223-244.

7. Westhead C. Perioperative nursing management of the

elderly patient. Can Oper Room Nurs J. 2007;25(3):34.

8. Bergman SA, Coletti D. Perioperative management of the

geriatric patient. Part I: respiratory system. Oral Surg

Oral Med Oral Pathol Oral Radiol Endod. 2006;102(3):

e1-e6.

9. Ekstein M, Gavish D, Ezri T, Weinbroum A. Monitored

anaesthesia care in the elderly: guidelines and recom-

mendations. Drugs Aging. 2008;25(6):477-500.

10. Millsaps C. Pay attention to patient positioning! RN.

2006;69(1):59-63.

11. Turrentine F, Wang H, Simpson V, Jones R. Surgical risk

factors, morbidity, and mortality in elderly patients. J Am

Coll Surg. 2006;203(6):865-877.

12. Bergman SA, Coletti D. Perioperative management of the

geriatric patient. Part II: cardiovascular system. Oral

Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;

102(3):e7-e12.

13. Recommended practices for the prevention of deep vein

thrombosis. In: Perioperative Standards and Recom-

mended Practices. Denver, CO: AORN, Inc; 2012:

353-363.

14. Allen SA. Geriatric surgery. In: Rothrock JC, ed. Alex-

ander’s Care of the Patient in Surgery. 14th ed. St Louis,

MO: Mosby Elsevier; 2011:1157-1181.

15. Millar E. Reducing the impact of pre-operative fasting

on patients. Kai Tiaki Nurs New Zealand. 2009;15(5):

16-18.

16. Lewis S, Heitkemper M, Dirksen S, O’Brian P, Bucher L.

Medical-Surgical Nursing: Assessment and Management

of Clinical Problems. 7th ed. St Louis, MO: Mosby

Elsevier; 2007.

17. Lindgren M, Unosson M, Krantz A, Ek A. Pressure ulcer

risk factors in patients undergoing surgery. J Adv Nurs.

2005;50(6):605-612.

18. Sewchuk D, Padula C, Osborne E. Prevention and early

detection of pressure ulcers in patients undergoing

cardiac surgery. AORN J. 2006;84(1):75-96.

RISK FACTORS IN GERIATRIC SURGICAL PATIENTS www.aornjournal.org

19. Feuchtinger J, de Bie R, Dassen T, Halfen RA. 4-cm

thermoactive viscoelastic foam pad on the operating

room table to prevent pressure ulcer during cardiac

surgery. J Clin Nurs. 2006;15(2):162-167.

20. Bergman SA, Coletti D. Perioperative management of

the geriatric patient. Part III: delirium. Oral Surg Oral

Med Oral Pathol Oral Radiol Endod. 2006;102(3):

e13-e16.

21. Recommended practices for positioning the patient in the

perioperative setting. In: Perioperative Standards and

Recommended Practices. Denver, CO: AORN, Inc; 2012:

421-443.

22. Mauk KL. Gerontological Nursing: Competencies

for Care. Boston, MA: Jones and Bartlett Publishers;

2010.

23. Paice JA, Fine PG. Pain at the end of life. In: Ferrell B,

Coyle N, eds. Textbook of Palliative Nursing. New York,

NY: Oxford University Press; 2001:76-90.

24. ASA Physical Status Classification System. American

Society of Anesthesiologists. http://www.asahq

.org/clinical/physicalstatus.htm. Accessed November

18, 2011.

Marie Bashaw, MS, RN, NEA-BC, CNOR, is

a clinical assistant professor and associate di-

rector of the Master’s in Nursing Administration

Program at Wright State University, Dayton, OH.

Ms Bashaw has no declared affiliation that could

be perceived as posing a potential conflict of

interest in the publication of this article.

Dana N. Scott, BSN, RN, is a recent bachelor

of science in nursing graduate and is currently

enrolled in a master’s degree program at Wright

State University, Dayton, OH. Ms Scott has no

declared affiliation that could be perceived as

posing a potential conflict of interest in the

publication of this article.

AORN Journal j 71

EXAMINATION

CONTINUING EDUCATION PROGRAM

2.9

www.aorn.org/CESurgical Risk Factors in Geriatric

Perioperative Patients

PURPOSE/GOAL

72

To educate perioperative nurses about surgical risk factors in older adults under-

going surgical interventions.

OBJECTIVES

1. Describe the changes associated with aging.

2. Discuss the nurse’s role in caring for geriatric patients in the OR.

The Examination and Learner Evaluation are printed here for your conven-

ience. To receive continuing education credit, you must complete the Exami-

nation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS

1. Hearing and vision losses that occur in the geri-

atric patient include

1. lens thickening.

2. increased light sensitivity.

3. increased cerumen production.

4. sensory hair cell loss.

5. organ of Corti atrophy.

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

j AORN Journal

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

2. To help a patient understand preoperative

and postoperative instructions, the nurse

should

1. make sure that a patient who uses hearing

aids and glasses is able to use them as long as

possible.

2. increase speech volume, if necessary, and

face the patient when speaking.

3. limit the amount of information given at one

time.

� July 2012 Vol 96 No 1

4. provide written materials printed in light ink

on a dark background.

a. 1 and 2 b. 3 and 4

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

3. Respiratory system changes seen in older adult

patients include

1. loss of pharyngeal support.

2. decreased risk of aspiration.

3. weakened diaphragm function.

4. weakening or loss of swallowing and

coughing reflexes.

a. 1 and 3 b. 2 and 4

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

4. Acute and chronic cardiovascular conditions that

place older patients at risk for negative surgical

outcomes include

1. heart block.

2. changes in stroke volume and cardiac

conduction.

3. degeneration of heart valves.

� AORN, Inc, 2012

CE EXAMINATION www.aornjournal.org

4. stiffening of the walls of large arteries.

5. increases in systolic pressure and peripheral

vascular resistance.

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

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

5. Surgical fasting can lead to increased risk of

pressure ulcers and wound healing.

a. true b. false

6. Renal changes caused by aging affect how

___________ are processed by geriatric patients.

a. foods b. blood products

c. medications d. instructions

7. The nurse can help prevent postoperative delirium

by planning perioperative care after assessing

1. cognitive impairment.

2. hearing and vision impairments.

3. sleep deprivation.

4. immobility.

5. dehydration.

a. 1 and 2 b. 4 and 5

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

8. The nurse should help the patient ambulate as

soon as possible and avoid the use of devices such

as indwelling urinary catheters that could restrict

the patient’s ability to move.

a. true b. false

9. Older patients require careful nursing assessment

and may appear to have less pain because they

a. have difficulty feeling pain because of age-

related changes.

b. are reluctant to report pain or underreport it.

c. have higher pain thresholds.

d. are used to pain.

10. Surgical procedures place older patients at

increased risk for hypothermia because of their

bodies’ decreased abilities to vasoconstrict and

shiver.

a. true b. false

AORN Journal j 73

LEARNER EVALUATION

CONTINUING EDUCATION PROGRAM

2.9

www.aorn.org/CESurgical Risk Factors in Geriatric

Perioperative Patients

This evaluation is used to determine the extent to

which this continuing education program met

your learning needs. Rate the items as described

below. The Learner Evaluation is printed here for your

convenience. To receive continuing education credit,

you must complete the Learner Evaluation online at

http://www.aorn.org/CE.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Describe the changes associated with

aging. Low 1. 2. 3. 4. 5. High

2. Discuss the nurse’s role in caring for geriatric

patients in the OR.

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

CONTENT

3. To what extent did this article increase your

knowledge of the subject matter?

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

4. To what extent were your individual objectives

met? Low 1. 2. 3. 4. 5. High

5. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

6. Will you change your practice as a result of reading

this article? (If yes, answer question #6A. If no,

answer question #6B.)

74 j AORN Journal � July 2012 Vol 96 No 1

6A. 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 informational meeting with

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 is incorporated as best practice.

5. Other: ______________________________

6B. If you will not change your practice as a result

of reading 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: ______________________________

7. Our accrediting body requires that we verify

the time you needed to complete the 2.9 continuing

education contact hour (174-minute) program:

_________________________________

� AORN, Inc, 2012