Download Incorporating Age-Specific Plans of Care to Achieve Optimal

CONTINUING EDUCATION
Incorporating Age-Specific Plans
of Care to Achieve Optimal
Perioperative Outcomes 3.9
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JULIANA MOWER, MSN, RN, CNS, CNS-CP, CNOR
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Purpose/Goal
The behavioral objectives for this program were created by
Helen Starbuck Pashley, MA, BSN, RN, CNOR, clinical editor,
with consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative 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.
To provide the learner with knowledge related to using agespecific plans of care to achieve optimal perioperative outcomes.
Objectives
1. 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.
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AORN recognizes these activities as CE for RNs. This
recognition does not imply that AORN or the American
Nurses Credentialing Center approves or endorses products
mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.07.014
ª AORN, Inc, 2015
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AORN Journal j 369
Incorporating Age-Specific Plans
of Care to Achieve Optimal
Perioperative Outcomes 3.9
www.aorn.org/CE
JULIANA MOWER, MSN, RN, CNS, CNS-CP, CNOR
ABSTRACT
When developing a nursing plan of care, a perioperative nurse identifies nursing diagnoses during
the 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 responsibility of the perioperative RN. Having an individualized plan of care is one of the best ways to
determine whether desired patient outcomes have been successfully attained. Nursing care plans
address intraoperative and postoperative risks and allow for a smooth transfer of care throughout
the perioperative experience. A good nursing care plan also includes education for the patient and
his or her caregiver. Within an overall plan of care, the use of methods such as a concept or mind
map can visually demonstrate the relationships between systems, nursing diagnoses, nursing interventions, 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.
O
ne size does not fit all in developing plans of care
for patients undergoing operative or other
invasive procedures. In addition to identifying
universally applicable outcomes, the perioperative nurse must
identify age-specific outcomes. Two patients undergoing the
same procedure may require very different preparations based
on their ages. Adding to this challenge is the fact that a patient’s physiological age may not accurately reflect his or her
developmental stage. This is particularly true in children and
adolescents, who may not fall neatly into a predetermined,
age-specific category. The perioperative RN’s critical thinking
skills are a valuable asset in identifying a patient’s unique
needs, determining desirable outcomes, and then incorporating this information into an individualized plan of care that
helps ensure safe, efficient, and effective nursing care.
Providing age-specific care requires addressing the typical
changes that occur as a part of the normal aging process. The
purpose of this article is to provide the basic or global components of a care plan and then develop it further by using the
basic components as the foundation for expanding care interventions to all age groups with addendums that address
several of the challenges specific to each age group. A sample
concept map is provided to demonstrate the interrelationship
of systems and desired outcomes for a pediatric patient.
In addition to the aging process, lifestyle factors and chronic
disease processes affect body systems and may enhance or
accelerate changes that are believed to be “normal” parts of
aging, especially in adult and elderly populations. It is beyond
the scope of this discussion to include comorbidities and
http://dx.doi.org/10.1016/j.aorn.2015.07.014
ª AORN, Inc, 2015
370 j AORN Journal
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October 2015, Vol. 102, No. 4
lifestyle choices (eg, sedentary lifestyle; the use of tobacco,
alcohol, or illicit drugs) in the development of an age-specific
plan of care. These effects are well documented in the literature, and perioperative nurses are encouraged to conduct
further exploration as needed to incorporate evidence-based
interventions that are based on identified patient needs specific to comorbidities and lifestyle choices.
CARE PLAN BASICS
A good perioperative nursing plan of care addresses intraoperative and postoperative risks and allows for a smooth
transfer of care as the patient progresses through the perioperative experience. Different methods have been used to
organize and categorize nursing diagnoses and to standardize
terms to be used consistently regardless of the care provider
using them. In the perioperative setting, the Perioperative
Nursing Data Set (PNDS)1 is used to identify the risks or
needs that are affected by nursing interventions for patients
who are undergoing operative or other invasive procedures.
The PNDS is a standardized language recognized by
perioperative nurses and other health care providers; it
provides uniform definitions of diagnostic terms, desired
patient outcomes, and associated perioperative nursing
interventions. Many electronic medical records incorporate
PNDS language into intraoperative charting systems.
Some nursing interventions are applicable regardless of the
patient’s age (eg, preventing wrong patient, wrong site, or
wrong procedure; preventing unintended retention of surgical
items). Others, although universally relevant, vary according to
the patient’s age and developmental stage. For instance,
although every patient is in danger of experiencing intraoperative hypothermia, infants are at increased risk because of
surface area and adipose tissue distribution. Because some
interventions vary according to the patient’s age, this discussion is organized around the basic plan of care developed for
an adult, and subsequent discussion highlights the differences
encountered in other age groups during the perioperative
experience.
Outcomes are the goals or desired end results of nursingsensitive interventions. These should be realistic, relevant to
the patient’s condition, based on available resources, and
written in measurable terms so that the degree to which they
have been met can be measured. The PNDS provides outcomes associated with specific perioperative nursing
interventions.1
Plans of care are developed using the information obtained
during the patient assessment and contain corresponding
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Age-Specific Perioperative Care
nursing diagnoses. The plan of care (Table 1) provides an
excellent opportunity for the nurse to prioritize problems and
corresponding actions. At first glance, every problem may
seem to be of equal importance, but using a standardized
template may be useful for organizing what often can be a
very complex plan of care. For instance, a systems approach
may be used to distinguish normal physiological changes from
comorbidities that the body undergoes, as during aging. It is
important to remember that changes in one system can affect
several others. For instance, hypothermia can affect infection
rates (ie, the immune system) and clotting times (ie, the
circulatory system).2
Many nurses use a focused systems approach to determine the
major areas of concern around which to build a concept map.
Martin3 discussed the use of a concept or mind map as a
method of visually capturing the central topic of interest (in
this case, the surgical patient) and demonstrating the
relationships between systems, nursing diagnoses, nursing
interventions, and desirable outcomes. To help illustrate the
formulation of a care plan, a concept map for the scenario
of a 35-year-old woman with a torn anterior cruciate
ligament highlights the importance of individualizing the
plan of care to account for predictable age-related responses
to surgical stressors (Figure 1). With a little practice, it is
easy to alter the map to account for age-related concerns
encountered 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 ideal
environment for teaching, at a minimum the patient should be
informed about the immediate intraoperative experience and
expectations for postoperative recovery. Involving family
members in the education process is key at this point because
it is likely that the patient may not remember or may misremember what is said by the perioperative team because of
anxiety. Providing information in multiple formats (eg, verbal,
written) facilitates retention of postoperative instructions. If
either the patient or his or her designated support person is
unclear about the purpose of the surgery and the risks, benefits, or alternatives, the nurse should contact the surgeon for
additional counseling of the informed consent process and
should delay the procedure until all questions have been
satisfactorily answered.
In the next sections, general information regarding an agerelated population is provided. A case scenario is then presented with a care plan specific to a patient in that population
and his or her condition. The populations discussed are adults,
infants and children, adolescents, and older adult/
geriatric patients.
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Table 1. Basic Nursing Care Plan for a Patient Undergoing Surgery
Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement
The patient’s procedure
Risk for injury related Confirms patient identity
The surgical consent is
is performed on the
to wrong
signed according to facility
Verifies operative procedure, surgical site, and
correct site, side,
patient, site,
policy; the patient and/or
laterality
and level
side, and level
designated support person
Verifies consent for planned procedure
participates in verification of
Implements protective measures prior to the
the procedure, site, and
operative or invasive procedure
laterality with signed
Records devices implanted during the
consent; the time out is
operative or invasive procedure
performed immediately
Evaluates the verification process for correct
before the start of the
patient, site, side, and level of surgery
procedure according to
facility policy
The correct surgical site is
marked before the
procedure according to
facility policy
Risk for
perioperative
positioning
injury
Assesses baseline skin condition
Identifies baseline tissue perfusion
Identifies baseline musculoskeletal status
Identifies physical alterations that require
additional precautions for procedure-specific
positioning
Positions the patient
Implements protective measures to prevent
skin/tissue injury due to mechanical sources
Applies safety devices
Uses supplies and equipment within safe
parameters
Maintains continuous surveillance
Evaluates tissue perfusion
Evaluates musculoskeletal status
Evaluates for signs and symptoms of physical
injury to skin and tissue
The patient has full return of The patient is free from
signs and symptoms
movement of extremities at
of injury related to
the time of discharge from
positioning
the OR or procedure room
The patient is free from pain The patient is free
from signs and
or numbness associated
symptoms of injury
with surgical positioning
caused by
extraneous objects
Acute pain
The patient verbalizes
Assesses pain control
control of pain
Identifies cultural and value components
The patient’s vital signs at
related to pain
discharge from the OR are
Implements pain guidelines
equal to or improved from
Implements alternative methods of pain control
preoperative values
Collaborates in initiating patient-controlled
analgesia
Evaluates response to pain management
interventions
Risk for infection
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Assesses susceptibility to infection
Classifies the surgical wound
Implements aseptic technique
Protects from cross-contamination
Initiates traffic control
Administers prescribed prophylactic
treatments
Administers prescribed medications
Administers prescribed antibiotic therapy as
ordered
Performs skin preparations
Monitors for signs and symptoms of infection
The patient
demonstrates and/
or reports adequate
pain control
The patient’s wound is free The patient is free from
signs and symptoms
from signs or symptoms of
of infection
infection and pain, redness,
swelling, drainage, or
delayed healing at the time
of discharge
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Age-Specific Perioperative Care
Table 1. (continued )
Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement
Minimizes the length of the invasive procedure
by planning care
Maintains continuous surveillance
Administers care to wound sites
Administers care to invasive device sites
Encourages deep breathing and coughing
exercises
Evaluates factors associated with increased risk
for postoperative infection at the completion of
the procedure
Evaluates progress of wound healing
Evaluates for signs and symptoms of infection
through 30 days after the perioperative
procedure
Risk for injury and
delayed surgical
recovery related
to an
unintended
retained foreign
object
Verifies operative procedure, surgical site, and The counts are accurate,
correct, or reconciled
laterality
according to facility policy
Performs required counts
Reports deviation in diagnostic study results
Evaluates results of the surgical count
ADULTS
Physiologically, an adult patient is in the best position to
recover from surgical stressors. Organs have matured but have
not begun to undergo the alterations affecting their function
such as those observed in older adults. Body systems are at
their peak functionality. Laboratory values and diagnostic tests
are well established for this population. Educational materials
pertinent to this age group are widely available; however, as a
result of health literacy concerns, health care providers should
base patient education on a variety of methods, both written
and oral, and should assess the patient for his or her understanding of content using a validation means, such as the
teach-back approach.4
Adult Case Scenario
The perioperative nurse admits Ms R, a 35-year-old
woman, to the preoperative area. Ms R is scheduled to
undergo a left knee arthroscopy and anterior cruciate ligament repair. The preoperative nurse first reviews Ms R’s
medical record, including the history and physical examination and all laboratory and test results. The nurse then
introduces herself to Ms R and completes a preoperative
assessment of the patient. During the preoperative assessment, the nurse notes that Ms R had been preparing for a
marathon during which she fell from a curb, twisted her
knee, and landed on her knee on the concrete. Ms R
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The patient is free from
unintended retained
foreign objects
mentions to the nurse that she is worried because her fiance
is confident that she will recover adequately to run the
marathon the following weekend.
The nurse develops a plan of care (Table 2) specific to Ms R.
She starts by identifying the following nursing diagnoses for
which Ms R is at risk:
impaired physical mobility and
ineffective family therapeutic regimen management.
The nurse selects nursing interventions specific to each diagnosis and identifies desired outcomes and goals from the
implementation of those interventions. Ms R is a healthy,
active adult. Nothing in the nurse’s preoperative assessment
indicates an issue with increased risk for infection, altered
wound healing, or complicated recovery. The nurse selects and
implements nursing-specific interventions related to safe surgery practices (ie, preventing wrong patient, wrong site, or
wrong procedure; managing acute pain) in the typical plan of
care as followed for any patient.
Deficient Knowledge
An area of concern is Ms R’s and her fiance’s disconnect in
their perceptions of the extent of her injury, the proposed
surgical procedure, and the rehabilitation process. Using openended questions, the perioperative nurse obtains additional
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print & web 4C=FPO
Mower
Figure 1. An adult concept map highlights the importance of individualizing the plan of care to account for predictable age-related responses to surgical stressors. The map can be altered to account for age-related concerns
and surgical procedure. This concept map is not all-inclusive for every potential patient problem or outcome. The
Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery is a registered trademark
of The Joint Commission, Oakbrook Terrace, IL.
374 j AORN Journal
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Age-Specific Perioperative Care
Table 2. Addendum to Basic Nursing Care Plan Specific to an Adult Undergoing Orthopedic Surgery
Diagnosis
Interim Outcome
Statement
Nursing Interventions
Outcome Statement
Impaired physical
mobility
The patient is unable to The patient’s
Identifies baseline musculoskeletal status
musculoskeletal
move lower extremities
Verifies the presence of prosthetics or corrective
status is maintained
secondary to spinal
devices
at or improved from
anesthesia at time of
Identifies physiological status
baseline levels
transfer to the
Reports deviation in diagnostic study results
Transports the patient according to individual needs postanesthesia care unit
The patient’s peripheral
Positions the patient
tissue perfusion is
Implements protective measures to prevent skin/
consistent with or
tissue injury due to mechanical sources
improved from
Evaluates musculoskeletal status
preoperative status at
Evaluates the patient for signs and symptoms of
discharge from the OR or
physical injury to skin and tissue
procedure room
Ineffective family
therapeutic
regimen
management
Identifies the patient’s and designated support
person’s educational needs
Identifies expectations of home care
Includes the patient or designated support person in
perioperative teaching
Provides instruction based on age and identified
needs
Evaluates the environment for home care
Evaluates the patient’s response to instructions
Deficient
knowledge
The patient participates
Identifies the patient’s and designated support
The patient and his or
in the rehabilitation
person’s educational needs
her designated support
process
Identifies expectations of home care
person verbalize realistic
Includes the patient or designated support person in expectations regarding
rehabilitation after
perioperative teaching
surgery
Provides instruction based on age and identified
The patient describes the
needs
prescribed rehabilitation
Evaluates the environment for home care
regimen to follow
Evaluates the patient’s response to instructions
immediately after
discharge from the
facility
The patient participates
The patient and his or
in the rehabilitation
her designated support
process
person verbalize realistic
expectations regarding
rehabilitation after
surgery
information related to Ms R’s knowledge of the surgical procedure and tailors patient education based on that information.
The nurse contacts the surgeon and explains the misperception
regarding recovery from surgery. Before the RN circulator
transports Ms R to the OR, the surgeon reviews the surgical
procedure, mobility limitations, and physical therapy with Ms
R to ensure that the desired outcomes of a knowledgeable,
prepared patient and designated support person are met.
for intraoperative and postoperative complications. Children at different ages have unique physiological and psychosocial characteristics. To better understand these agebased traits, the following discussion is based on three
different age groups: birth to two years, two to seven years,
and seven to 11 years. Adolescence, the final stage before
adulthood, is considered to be between 11 and 21 years
of age.
INFANTS AND CHILDREN
Immune System
Infants and children are not small adults and should not be
treated as such. Immature immune and pain responses and
undeveloped thermoregulatory, renal, gastrointestinal, and
pulmonary systems put younger patients at increased risk
Unless breastfed, an infant’s total immunoglobulin levels drop
immediately after birth because the maternal source of antibodies has been discontinued.5,6 Circulating immunoglobulins
reach their lowest level at six months of age, which accounts
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for the increased numbers of respiratory infections frequently
seen at this age. When caring for an infant, the nurse should
help ensure strict adherence to standard and respiratory precautions to reduce the risk of exposure to the patient, perioperative personnel, and other patients whose immune status
may be compromised.
Pain
Because facial expressions, crying, body movements, and the
inability of caregivers to console a child are the most consistent
evidence of pain in infants and toddlers,5 these are the
elements used in pain assessment scales for these age groups.
Older children (ie, five to 18 years of age) are better able to
verbalize the presence of pain; however, they tend to have a
lower pain threshold than adults.
Temperature Regulation
In addition to their small body size, infants have difficulty
maintaining normal body temperature because of several
physiological 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 in
other age groups.5
In addition to a greater body surface to body weight ratio,
children have a more exaggerated response than adults in terms
of vasodilation and vasoconstriction when exposed to heat or
cold environments.5
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levels at two years of age. Higher blood flow and shorter
nephrons produce more dilute urine. Limited ability to
regulate hydrogen ion, bicarbonate, and potassium means
that the infant is especially vulnerable to acid-base imbalances. Any condition that affects electrolyte balance (eg,
diarrhea, infection, NPO status) can rapidly cause acidosis
and fluid shifts. By the time the child reaches adolescence,
the kidneys have attained adult size.
Psychosocial
Parents, by acting as surrogate decision makers for infants
and children, assume a vital role as members of the patient/
perioperative team.7 Open, clear, and frequent communication
with the chief decision maker is therefore one of the most
important responsibilities of the perioperative nurse, who
must serve as an advocate for not only the patient, but the
patient’s caregivers as well. The nurse should provide clear
and age-related expectations of the surgical experience and
evaluate comprehension of treatments to maximize the
effectiveness of the intervention.
Birth to two years of age
The principle psychosocial stressor related to this age group is
separation anxiety.8 Allowing a parent to stay with the child as
much as possible throughout the perioperative experience is
the most effective nursing intervention, which includes
being present in the OR for induction of anesthesia. When
the parent cannot be present, using distraction or holding
the child can be effective strategies to minimize the anxiety
associated with separation from the primary caregiver.
Pulmonary Function
The airways of children and infants are narrower than those of
adults, and the chest wall is much softer and more pliant.5
These factors put younger patients at increased risk for
obstruction and respiratory tract infections. Children also
have 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 Function
The kidneys are a developing organ during the first several
years of life. Any corresponding congenital anomalies should
be taken into account during review of normal kidney
function in infants and children. In infants, ureters are
shorter than those of adults. Renal blood flow and glomerular
filtration rate increase immediately after birth, reaching adult
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Two to seven years of age
Children in this age group are very concrete thinkers. Using
terms such as “going to sleep” may be associated with the
disappearance of a beloved pet. Surgery may be associated with
punishment for a perceived misdeed. Because of their healthy
imaginations, it is best to limit preoperative teaching to less
than 24 hours before the surgical procedure.8
Seven to 11 years of age
Children in this age group are developing a world view from
multiple perspectives. In addition to viewing surgery as some
sort of punishment, fear of pain, fear of mutilation (especially
for boys), and separation anxiety are coupled with beliefs that
the problem requiring surgical intervention was caused by
eating or touching something. Clearing up misconceptions is a
major focus of preoperative education and is best accomplished within a week of the surgical procedure.8
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Child Case Scenario
The intensive care unit (ICU) nurse admits Haley, a threeday-old newborn girl, to the pediatric ICU. Haley has a
history of choking on the first feeding and an inability to
swallow secretions. The neonatologist is unable to pass a
nasogastric tube. Diagnostic tests show esophageal atresia.
Haley has been scheduled for a repair of the esophageal
atresia. The preoperative nurse goes to the ICU to review
Haley’s medical record, including the history and physical
examination and all laboratory and test results. The nurse
then introduces herself to Haley’s family and completes a
preoperative assessment. During the preoperative assessment,
the perioperative nurse develops a plan of care (Table 3)
specific to Haley. She starts by identifying the following
nursing 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 interventions
for each diagnosis and identifies desired outcomes as goals
from the implementation of those interventions.
Temperature regulation
The perioperative nurse knows that because of Haley’s small
size, she is particularly vulnerable to the cold temperatures in
the OR and that extra measures are required to meet the
desired outcome of normothermia. The nurse ensures that a
warming device (eg, forced-air warming blanket, circulating
warming garment, energy transfer pad, head covering), a
means to deliver warmed IV and irrigation fluids, and a
method to monitor Haley’s temperature are available for Haley
on arrival in the OR. The nurse should prewarm the room and
maintain the temperature at 26 C (78.8 F). Because of the
anticipated length of time for the surgical procedure, the nurse
verifies that the anesthesia professional and the postanesthesia
care unit nurse have the equipment needed to monitor Haley’s
core body temperature throughout her perioperative
experience.2
Gastrointestinal system
Any procedure performed on the esophagus will affect the
patient’s nutritional status. Coupled with the adverse effects of
nausea and vomiting associated with many general anesthetic
agents, Haley has the potential for decreased nutritional
intake. Her tiny size means that she has fewer reserves to
counter the effects of a reduction in calories. The perioperative
RN initiates a consult with the hospital dietician, the surgeon,
and the intensive care hospitalist to ensure that Haley receives
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nourishment via the appropriate route to maximize wound
healing and meet bodily requirements.
ADOLESCENTS
Although physically adolescents, many patients in this age
group (ie, 11 to 21 years) may resemble adults. Emotionally
and psychosocially, this age group has its own unique set of
characteristics, which differ markedly from both older and
younger age groups. Often, signs and symptoms related to the
fight-or-flight response are exhibited as a response to the
stresses encountered in surgery.9 Increased heart and
respiratory rates, sweating, vasoconstriction, and anxiety can
affect anesthesia induction and the response to postoperative
pain. Providing a calm environment and adequate time to
address the patient’s concerns are key to a successful outcome.
The patient’s developing sense of identity, heightened selfconsciousness, and desire for autonomy9 mean that the
perioperative nurse should include the patient in discussions
related to the surgical experience. Although the patient may
not be old enough to consent to the surgery, every effort
should be made to obtain assent. Normal risk-taking
behaviors that are a part of transitioning to adulthood may
manifest as teenage pregnancy or substance abuse,10 adding
an additional level of complexity to the development of a
plan of care. Interviewing the patient alone on such sensitive
subjects as substance and alcohol use and sexual activity may
elicit a more accurate response.
In a qualitative study by Rullander et al,11 anxiety related to
the surgical procedure, loss of control related to pain
management, and lost contact with friends during the
extended recovery period were considered the most difficult
elements of the surgical experience for adolescent patients.
These findings correspond with typical behaviors manifested
by this age group, and nursing interventions to address them
should be incorporated into the plan of care.
Adolescent Case Scenario
The perioperative nurse admits Ben, a 16-year-old boy, to the
preoperative area. Ben is scheduled for a surgery to correct
scoliosis. The preoperative nurse first reviews Ben’s medical
record, including the history and physical examination and all
laboratory and test results. The nurse then introduces herself
or himself to Ben and his family and completes a preoperative
assessment of the patient. During the preoperative assessment,
the perioperative nurse determines that Ben’s major concerns
are that he is missing the remainder of the basketball season
and that he fears how his girlfriend will react to the surgical
scar. The nurse develops a plan of care (Table 4) specific to
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Table 3. Addendum to Basic Nursing Care Plan Specific for an Infant or Child Undergoing Gastrointestinal Surgery
Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement
The patient’s temperature is The patient is at or
Assesses the risk for normothermia regulation
returning to
greater than 36 C (96.8 F)
Assesses the risk for inadvertent hypothermia
normothermia
Assesses the risk for inadvertent hyperthermia
at the time of discharge
at the conclusion
Identifies physiological status
from the OR or procedure
of the immediate
Reports deviation in diagnostic study results
room
postoperative
Implements thermoregulation measures
period
o Provides a stocking cap and socks to prevent
heat loss from the scalp
o Applies temperature-regulating devices to the
patient according to the plan of care, facility
practice guidelines, and manufacturers’ written
instructions
o Operates temperature-monitoring and regulation devices according to the manufacturers’
written instructions
Monitors body temperature
Monitors physiological parameters
Evaluates response to thermoregulation measures
Risk for
imbalanced
body
temperature
Potential for
postoperative
nausea
Imbalanced
nutrition:
more than
body
requirements
Identifies baseline gastrointestinal status
Assesses nutritional habits and patterns
Assesses psychosocial issues specific to the
patient’s nutritional status
Includes the patient and designated support
person in perioperative teaching
Provides instruction regarding dietary needs
Evaluates response to nutritional instruction
The patient, family member, The patient, family
member,
designated support person,
designated support
or legal guardian describes
person, or legal
the appropriate home
guardian
management of symptoms
demonstrates
that affect nutritional intake
knowledge of
(eg, sore throat, nausea,
nutritional
vomiting) at the time of
management
discharge
related to the
The patient or designated
operative or other
support person describes
invasive procedure
the recommended
postoperative nutritional
intake regimen for the
recovery period at the time
of discharge
Imbalanced
Includes the patient, family member, designated The patient, family member,
nutrition:
designated support person,
support person, or legal guardian in perioperative
more than
teaching
or legal guardian describes
body
the recommended
Provides instruction regarding dietary needs
requirements Evaluates response to nutritional instruction
postoperative nutritional
intake regimen for the
recovery period at the time
of discharge
Ben. The nurse starts by identifying the following nursing
diagnoses for which Ben is at risk:
decisional conflict and
situational low self-esteem.
The perioperative nurse selects nursing interventions specifically for each diagnosis and identifies desired outcomes as
goals from the implementation of those interventions.
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Psychosocial
The perioperative nurse understands that Ben is at a
vulnerable stage in his ability to make his own decisions, and
she addresses the issues related to his upcoming surgery from
Ben’s point of view. He is not of legal age to give informed
consent for surgery, yet he is already making increasingly
independent choices as he nears adulthood. His relationship
with his peers is at least as important as his association with
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Age-Specific Perioperative Care
Table 4. Addendum to Basic Nursing Care Plan Specific an Adolescent Patient Undergoing Spine Surgery
Diagnosis
Nursing Interventions
Interim Outcome Statement
Outcome Statement
Decisional conflict
The patient, family
The patient verbalizes
Verifies the operative procedure, surgical
member,
satisfaction with the decisionsite, and laterality
designated support
making process and level of
Verifies consent for the planned procedure
person, or legal
involvement concerning the
Identifies psychosocial status
guardian
perioperative plan throughout
Identifies individual values and wishes
participates in
the perioperative experience
concerning care
decisions affecting
The patient, family member,
Identifies the patient’s and his or her
the perioperative
designated support person, or
designated support person’s educational
plan of care
legal guardian asks questions
needs
regarding care options
Provides information and explains the
throughout the perioperative
Patient Self-Determination Act
experience
Includes the patient and designated
The patient, family member,
support person in perioperative teaching
designated support person, or
Includes the patient and designated
legal guardian voices
support person in discharge planning
preferences in care throughout
Evaluates psychosocial response to the plan
the perioperative experience
of care
Risk for situational
low self-esteem
The patient verbalizes
Identifies psychosocial status
satisfaction with the level of
Maintains patient’s dignity and privacy
privacy provided throughout
Secures patient’s records, belongings, and
the surgical experience
valuables
Maintains patient confidentiality
Shares patient information only with those
directly involved in care
Evaluates psychosocial response to the plan
of care
his parents. However, his friends’ reactions to his surgery,
including visible changes in body image and altered physical
activity, may not take into account the long-term benefits of
the proposed procedure. The preoperative nurse understands
that Ben is feeling confused and helpless about the upcoming
experience.
The perioperative nurse includes Ben in all discussions of
the procedure and the rehabilitation process. The nurse
engages Ben in a frank discussion on the length of the scar
and methods to minimize its appearance to help Ben feel in
control. The nurse makes special effort to respect Ben’s
need for privacy, although he may wish to have peer support in the form of a trusted friend to stay with him
before surgery.
The perioperative nurses assess Ben and his parents at
regular intervals for psychosocial reactions to his procedure.
The nurses identify and support appropriate coping
mechanisms and incorporate Ben’s reliance on the use of
technology into the plan of care. The nurses use appropriate
videos, social media, and online age-specific support groups
to help validate the choices being made. Thirteen- to
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The patient’s right
to privacy is
maintained
17-year-olds average three and a half hours per day on
digital media, including e-mail and instant messaging.12 In
addition to socializing, adolescents use the Internet to
access information. Discussion groups, blogs, and chat
rooms are ways to allow these “Net Gens” to remain
connected while providing and receiving support from
their peers.12
AGED ADULT/GERIATRIC POPULATION
Older adults (aged 65 years and older) have a decreased
physiological reserve in which to respond to and recover from
surgical stressors. A thorough, individualized, age-appropriate
assessment helps ensure positive outcomes. As with infants
and children, a caregiver or family member may play a vital
role in providing valuable information when nurses are evaluating the health status of an aged patient.
Immune System
Antibody activity and production begin to diminish after 60
years of age, putting elderly patients at risk for infections and
increasing their recovery time when an infection occurs.5 The
increased numbers of surgeries being performed on this age
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group requires strict attention to aseptic technique, as well as
standard and transmission-based precautions to prevent health
care-associated infections.
Temperature Regulation
Polypharmacy
delayed vasoconstrictive or vasodilatory responses,
skin changes and peripheral neuropathies, and
delayed shivering and sweating responses.
In addition to the normal physiological changes attributed to
the aging process, the elderly patient often brings a host of
comorbidities and resulting polypharmacy to the perioperative
setting. 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 patient must take too many pills.14-16
As a result of the multiple comorbidities associated with
aging, the geriatric population is most susceptible to the
associated adverse health outcomes of polypharmacy.17
Older adult patients can exhibit either increased or
decreased response to medications compared with younger
patients. Polypharmacy increases the likelihood of
experiencing medication-to-medication interactions.18,19
Adverse medication interactions occur when two or more
medications interact in a way that the effectiveness or
toxicity of one or more medications is altered.20 The
number of potential interactions increases as the number
of medications increases.
Pain
The perception of pain is variable in the older patient. Neuropathies and cognitive impairment may contribute to the
view that the pain threshold increases in some older adults;
however, the pain threshold seems to decrease in some older
adults and women in general.5 These inconclusive results
reinforce the need for accurate and personalized pain
assessment and treatment, regardless of age. Elderly patients
are especially vulnerable to both the action and excretion of
any pain medications as a result of changes in liver and
renal function; therefore, their response to medications
should be carefully monitored. Elderly patients may have
preconceptions about the risk for narcotic dependency or a
lack of knowledge about the benefit of pain control for
surgical recovery.
380 j AORN Journal
Older adults are especially vulnerable to changes in environmental temperatures. Slowed blood circulation may mask
perceptions of heat or cold and may manifest as
These factors and the presence of comorbidities (eg, diabetes,
congestive heart failure, chronic obstructive pulmonary disease) all have a negative effect on the body’s ability to react to
changes in temperature. The colder temperature commonly
encountered in the perioperative suite, besides being a comfort
issue, decreases what is often an already compromised coronary perfusion system in the older adult. The relationship
between infection and hypothermia is already well documented.2 Efforts to maintain normothermia (eg, forced-air
warming devices, fluid warmers) should be considered
standard protocols in this population.
Pulmonary Function
Normal aging alterations of the pulmonary system include loss
of elastic recoil, stiffening of the chest wall, changes in gas
exchange, and increases in flow resistance. Up to a 20% loss in
respiratory muscle strength and endurance is seen in patients
older than 70 years.5 The concurrent loss of elasticity of both
the chest wall and alveoli account for the reduced ventilatory
capacity (eg, decreased vital capacity, increased residual
volume) seen in older adults. However, these changes are
gradual and usually are well tolerated by the healthy
individual. On the other hand, the loss of muscle strength
impairs gas exchange and the ability to cough, putting the
individual at increased risk for acquiring pneumonia and
experiencing exercise intolerance.21 Dewan et al22
recommend that patients older than 60 years undergo a
respiratory risk assessment. The perioperative nurse may
recommend that the patient use an incentive spirometer and
may provide additional perioperative patient education on
deep breathing exercises to address potential or actual
postoperative pulmonary complications.
Onset, length of action, and sensitivity to anesthetic agents
and medications are altered in older adults. In general, induction and emergence are prolonged.23 The RN circulator
should factor this into the intraoperative plan of care
because the anesthesia professional may need assistance for a
longer period during emergence.
Changes in positioning and the administration of medications
that alter respiratory drive have a more pronounced effect on
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older adults. Patients in this age group have a decreased
response to hypercapnia and hypoxemia. Therefore, the use of
regional anesthetics and positions that mimic normal
anatomical alignment are more likely to have the least adverse
effect on the patient’s pulmonary system. However, the respiratory benefit of a spinal anesthetic needs to be weighed
against its effect on peripheral vascular resistance and sympathetic block, which can result in profound hypotension and
bradycardia.22 The surgical team’s baseline assessment of the
patient’s activity level should account for age-related changes
and be incorporated into patient education regarding realistic
expectations for postoperative rehabilitation and recovery.
Renal Function
One of the most dramatic alterations of all age-related physiological changes occurs in the renal system, and these changes
affect virtually every other body system. Renal blood flow
decreases, 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 medications.23 This longer excretion time means that the action of
the medication, along with its concurrent adverse effects,
will be prolonged.
The number of renal nephrons is reduced by 30% to 50% by
the age of 75 years. The glomeruli become sclerotic and may
disappear entirely, leading to a decreased ability to concentrate
urine. This may be noted in the specific gravity laboratory
value, which will be on the low side of normal.5 Clinically, this
puts the elderly patient at increased risk for
both hypovolemia and hypotension as a result of the
decreased ability to concentrate urine and
fluid overload caused by decreased glomerular filtration rates.
Perioperative nurses should monitor urine output carefully
and consider the potential for accumulation of medications
that are excreted by the kidneys.
Adaptation to the stress of surgery is more difficult for the
elderly patient. Chemicals that help maintain a normal acidbase balance (eg, bicarbonate, potassium) are not as readily
absorbed. Sodium shifts can contribute to either hypervolemia
or hypovolemia, necessitating close monitoring of fluids
administered intravenously and those used for irrigation. The
reabsorption of glucose decreases with age, contributing to a
greater amount of glucose in the urine. Perioperative nurses
should take this normal age-related phenomenon into account
when using urinary analyses for diabetic screening. Renal
activation of vitamin D (necessary for intestinal absorption of
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Age-Specific Perioperative Care
calcium) decreases with age and contributes to osteoporosis,
bone fractures, and delayed wound healing.5
Neurogenic and myogenic changes to the bladder contribute to
feelings of frequency and urgency. In addition, prostatic hypertrophy will affect stream flow and urinary retention.5 Although it
may be viewed as a convenient way to address these common
manifestations of aging, the routine use of urinary catheters in
this population should be avoided because these patients are at
increased risk for urinary tract infections. The placement of
catheters should be carefully considered, and catheters should
be removed as soon as possible after surgery.
Psychosocial
Although 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 status
and comorbidities, and overall health may have little to do
with chronological age. Important predictors of surgical outcomes include functional status, the presence of coexisting
chronic diseases, the level of cognitive and emotional functioning, and nutritional status.23 The older patient may view
an operative or other invasive procedure much differently
than a younger person. If the surgery signifies a loss of
function, mobility, physical ability, or independence, the
additional psychosocial implications of the procedure must
be incorporated into the plan of care. This population often
needs additional assistance in meeting optimal outcomes
during and after surgery.
Neurological Changes
Changes in brain structure and neurotransmitter function account for some of the functional changes seen with aging. As a
benchmark for subsequent changes in mental status or functioning, the perioperative nurse should perform a baseline
assessment before administration of any medications that could
alter mood or consciousness.24 Cognitive impairment is strongly
associated 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 factor
influencing postoperative recovery for elderly patients. The
perioperative nurse should perform a social assessment on
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which he or she can base postoperative discharge planning to
ensure that the elderly patient has appropriate resources to
safely recover from the planned surgical event.
Cognitive changes as a result of comorbidities may influence
the patient’s ability to understand instructions and give
informed consent. A designated representative who has medical power of attorney may be needed if the patient lacks the
cognitive ability to understand and give informed consent.
Age-related sleep disturbances coupled with what is often a
dramatic change in routine activities of daily living can exacerbate a typical level of confusion. It is important to perform a
baseline preoperative neurological assessment to accurately
assess the presence of postoperative delirium or other changes
in mental status not exhibited before the procedure. For reasons that are poorly understood, benzodiazepines and anticholinergic medications increase the risk for postoperative
delirium and should be avoided if possible.21 Vision and
hearing loss as a result of disease or as a part of the aging
process can affect the elderly patient’s ability to
communicate with his or her caregivers. Table 5 provides
some tips on improving communication with patients who
have sensory impairments.
Cardiovascular Changes
Normal aging effects on the cardiovascular system are difficult to
separate from lifestyle factors such as activity level. The most
relevant age-associated physiological changes include myocardial
and blood vessel wall stiffening, changes in neurogenic control
that affect vascular tone, and left ventricular hypertrophy.5
These changes are compounded by comorbidities and surgical
stress. Changes in position required by the procedure can
influence cardiac output and vascular resistance; the
perioperative nurse should incorporate measures into the plan
of care to alleviate the effects of these changes.
Gastrointestinal Tract
Typically, assessing a patient’s nutritional status is not a high
priority for the perioperative nurse because most often patients
have fasted before a procedure. However, nutrition, especially
protein intake, has a direct effect on wound healing and immune function.
Altered nutritional status as a result of tooth loss, as well as
sensory changes (ie, decline in number of taste buds, decreased
sense of smell, decreased salivary production), can affect both
the quality and quantity of food intake. Decreased esophageal,
gastric, and intestinal motility can impair nutrient absorption.5
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Table 5. Tips for Communicating With Patients Who
1
Have Sensory Impairments
Sight Impairment
Provide large-type
educational materials.
Hearing Impairment
Remove your mask,
whenever possible, when
speaking to the patient.
Move overhead lights out of Speak in a normal tone into
the patient’s better ear.
the patient’s face until the
lights are ready for use.
Alert the patient before
touching him or her.
Do not shout.
Treat the patient as being at Maintain eye contact.
high risk for falls.
Explain any procedure or
Use short sentences and
intervention ahead of
short words.
time to compensate for a
lack of visual prompts.
Allow the patient to keep his Allow the patient to keep his
or her hearing aid
or her glasses for as long
devices for as long as
as possible and keep the
possible and keep the
glasses in a safe place for
devices in a safe place
prompt return after
for prompt return after
surgery.
surgery.
Reference
1. 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 and
Management of Clinical Problems. St Louis, MO: Elsevier
Mosby; 2014:407, 432.
Decreased motility means that food may be in the stomach for
a longer time, posing an increased aspiration risk.
The nurse should assess the patient preoperatively for loose or
missing teeth, which may make intubation more challenging.
Although liver function test results can remain in a relatively
normal range, blood flow and enzyme activity decrease with
age. This normal physiological change can directly affect
medication metabolism. It should be noted that alterations in
liver, pancreas, or gallbladder function can usually be attributed to a disease process, not aging.
Musculoskeletal Function
The loss of bone tissue in women, especially after the start of
menopause, is well documented. Women have lost 50% of
their cortical bone mass by the time they reach their 70s,
putting them at increased risk for fractures and pain. Men also
experience bone loss, but at a later age and at a much slower
rate than women.5 Fragile bones demand careful positioning
and fall-prevention strategies.
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Age-Specific Perioperative Care
Table 6. Addendum to Basic Nursing Care Plan Specific to an Elderly Adult Undergoing Coronary Artery Bypass
Surgery
Diagnosis
Interim Outcome
Statement
Nursing Interventions
Outcome Statement
Risk for injury related to Confirms the patient’s identity
The patient receives The patient receives
appropriately
the potential for
correct medication(s)
Verifies allergies
administered
polypharmacy
in accurate doses at
Prescribes medications within the scope of practice
medication(s)
the correct time and
(eg, RN first assistant)
via the correct route
Establishes IV access
throughout the
Administers prescribed solutions
surgical experience
Administers prescribed medications
Medication
Administers electrolyte therapy as prescribed
reconciliation records
Administers prescribed antibiotic therapy as ordered
are completed
Administers immunizing agents as ordered
Administers prescribed medications based on arterial
blood gas results
Administers prescribed prophylactic treatments
Works with the patient and his or her designated
support person to complete a thorough medication
reconciliation form identifying all medications to take
after discharge, including resumption of all
preoperative medications as applicable
Evaluates response to medications
The patient’s
The patient’s
cardiovascular
hemodynamic status
status is
is within the expected
maintained at or
range at transfer to
improved from
the postanesthesia
baseline levels
care unit
Decreased cardiac
output
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
Anxiety; ineffective
coping
Identifies psychosocial status
Screens for elder abuse
Screens for substance abuse
Assesses coping mechanisms
Assesses psychosocial issues specific to the patient’s
medication management
Assesses baseline neurological status
Identifies sensory impairments
Identifies barriers to communication
Identifies the patient’s and his or her designated
support person’s educational needs
Identifies expectations of home care
Implements measures to provide psychological support
Includes the patient or designated support person in perioperative teaching
Explains the expected sequence of events
Provides status reports to the designated support
person
Evaluates psychosocial response to the plan of care
Evaluates the patient’s response to instructions
Cartilage calcification and muscle stiffness are commonly
attributed to “old age,” and there is a physiological basis behind
these common signs and symptoms of aging. It is important to
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The patient or
The patient or
designated
designated support
support person
person states realistic
demonstrates
expectations
knowledge of
regarding recovery
the expected
from the procedure
psychosocial
The patient or
responses to
designated support
the procedure
person identifies signs
and symptoms to
report to the surgeon
or health care
provider
The patient or
designated support
person describes
the prescribed
postoperative
regimen accurately
remember that the range of motion of a joint while the patient
is anesthetized may be dramatically increased; any excessive
stretching or stress on joints during positioning will cause
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additional postoperative pain. Range of motion should be
assessed preoperatively to prevent intraoperative nerve damage
and excessive stretching of muscles, tendons, and ligaments.
Age-related loss of muscle strength results in age-related loss of
skeletal muscle. This decline in strength begins after the age of 50
years; as much as 30% to 40% of muscle strength and mass may
be lost between the third and ninth decades of life.5 Loss of
strength is manifested in decreased mobility, which can affect
length and quality of rehabilitation and postoperative recovery.
As mentioned previously, degree of frailty is one of the chief
indicators influencing successful recovery after surgery. Fragile
patients may need placement in an intermediate rehabilitation
center to regain optimal function after surgery, especially if
their primary caregiver is another aged person. Eliciting this
information during the preoperative interview can help ensure
that the continuum of care accommodates this special need
and helps decrease the rate of readmission to the facility as a
result of pain or other postoperative complications.
Integumentary System
Normal skin changes that are associated with the aging process
include loss of turgor, dryness, thinning, and increased skin
fragility.21 Elderly patients are especially at risk for shearing (ie,
removal of layers of skin) injuries caused during transfer from
one surface to another. Decreased subcutaneous fat increases
the risk for pressure ulcers and hypothermia. Depending on
the surgical procedure, the perioperative nurse should consider
additional padding and warming devices for the patient’s plan
of care. Team members should take extra care when
transferring and positioning the elderly patient. Any movement
or positioning of the patient should be undertaken as part of a
collaborative team effort. Shearing can occur during the pulling
or sliding of the patient. Adequate personnel and appropriate
transfer devices (eg, air transfer systems, low-friction slide
boards, memory foam mattresses, gel positioning aids) help
reduce the risk for tissue injury during transfer.
Geriatric Case Scenario
The perioperative nurse admits Mr T, a 74-year-old man, to
the preoperative area. Mr T is scheduled to undergo coronary
artery bypass graft surgery. The preoperative nurse first reviews
Mr T’s medical record, including the history and physical
examination and all laboratory and test results. The nurse then
introduces herself to Mr T and completes a preoperative
assessment. During the preoperative assessment, the perioperative nurse notes that Mr T is taking several medications to
treat congestive heart failure, myocardial infarction, hypertension, and non-insulin-dependent diabetes mellitus. The
nurse develops a plan of care (Table 6) specific to Mr T. The
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nurse starts by identifying the following nursing diagnoses for
which 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 specifically for each diagnosis and identifies desired outcomes as
goals from the implementation of those interventions.
Pain
Mr T’s risk for adverse outcomes related to polypharmacy is
exacerbated by normal changes found in the aging kidney and
by the pathophysiological effect of his non-insulin-dependent
diabetes mellitus. This can be particularly important in regard
to pain medications. The preoperative nurse identifies all the
medications that Mr T has been taking preoperatively, specifically pain medications.
Sensory systems
Normal age-related changes in hearing may make it more
difficult for Mr T to understand verbal communications. This
has a direct effect on his level of anxiety and ability to understand postoperative instructions. The perioperative nurse
places Mr T in a quiet area during preoperative preparation, as
well as postoperative recovery.
Cardiovascular system
The perioperative nurse assists with monitoring of cardiac
output and vital signs. Along with evaluating adequate tissue
perfusion, vital signs are one means of assessing patient responses to anxiety-relieving interventions.
CONCLUSION
Incorporating age-specific factors into the nursing plan of care
guides preoperative, intraoperative, and postoperative care of
the patient. Normal aging milestones, in conjunction with any
presenting comorbidities, can have a huge influence on attaining positive outcomes. The perioperative nurse is responsible for
reducing risks for every patient, regardless of age.
References
1. Perioperative Nursing Data Set: The Perioperative Nursing Vocabulary. 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 innovative
group didactic activity. Nurse Educ. 2009;34(6):238-240.
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4. National Action Plan to Improve Health Literacy. Washington, DC:
US Department of Health and Human Services, Office of Disease
Prevention 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 for
Disease in Adults and Children. 7th ed. St Louis, MO: Elsevier; 2014.
6. Breastfeeding benefits your baby’s immune system. Healthy
children.Org. American Academy of Pediatrics. https://www.healthy
children.org/English/ages-stages/baby/breastfeeding/Pages/Breast
feeding-Benefits-Your-Baby’s-Immune-System.aspx.
Accessed
July 17, 2015.
7. Hazebroek FW, Tibboel D, Wijnen RMH. Ethical aspects of care in
the newborn surgical patient. Semin Pediatr Surg. 2014;23(5):
309-313.
8. Harris TB, Sibley A, Rodriguez C, Brandt ML. Teaching the psychosocial aspects of pediatric surgery. Semin Pediatr Surg. 2013;
22(3):161-166.
9. Monahan JC. Using an age-specific nursing model to tailor care to
the adolescent surgical patient. AORN J. 2014;99(6):734-749.
10. Grisby S, Miller M, Dunn JC, et al. Variations in pre-operative
management of adolescents undergoing elective surgery. Int J
Pediatr Otorhinolaryngol. 2013;77(5):770-775.
11. Rullander AC, Isberg S, Karling M, Jonsson H, Lindh V. Adolescents’ experience with scoliosis surgery: a qualitative study. Pain
Manag Nurs. 2013;14(1):50-59.
12. Oblinger D, Oblinger J. Is it age or IT: first steps toward understanding 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. Accessed July 17, 2015.
13. Oster KA, Oster CA. Care of the geriatric patient population in the
perioperative setting. AORN J. 2015;101(4):443-456.
14. Fulton MM, Allen ER. Polypharmacy in the elderly: a literature
review. J Am Acad Nurse Pract. 2005;17(4):123-132.
15. Haque R. ARMOR: a tool to evaluate polypharmacy in elderly
person. 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 patients
in 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.
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19. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency
hospitalizations for adverse drug events in older Americans. N Engl
J 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 auditory
problems. In: Lewis SL, Dirksen SR, Heitkemper MM, Bucher L,
eds. Medical-Surgical Nursing: Assessment and Management of
Clinical 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 of
the elderly oncology patient: a report of the SIOG task force on the
perioperative care of older patients with cancer. J Geriatr Oncol.
2012;3(2):147-162.
24. Nelson JM, Carrington JM. Transitioning the older adult in the
ambulatory care setting. AORN J. 2011;94(4):348-358.
Resources
Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF; American
College of Surgeons National Surgical Quality Improvement Program;
the American Geriatrics Society. Optimal preoperative assessment of
the geriatric surgical patient: a best practices guideline from the
American College of Surgeons National Surgical Quality Improvement
Program 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. Accessed
March 16, 2015. Note: The continuing medical education credits
associated with this resource have expired but the content is still current
and 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 Education
Development at Competency & Credentialing Institute,
Denver, CO. Ms Mower has no declared affiliation that
could be perceived as posing a potential conflict of
interest in the publication of this article.
AORN Journal j 385
EXAMINATION
Continuing Education:
Incorporating Age-Specific Plans
of Care to Achieve Optimal
Perioperative Outcomes 3.9
www.aorn.org/CE
PURPOSE/GOAL
To provide the learner with knowledge related to using age-specific plans of care to achieve optimal
perioperative outcomes.
OBJECTIVES
1.
2.
3.
4.
5.
Describe how to develop an age-specific nursing care plan for a surgical patient.
Explain the purpose of a concept map.
Identify age-related characteristics pertinent to providing perioperative care.
Define polypharmacy.
Identify methods for improving communication with patients who have sensory impairments.
The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aorn.org/CE.
QUESTIONS
1. To develop an individualized plan of care, the perioperative RN must
1. 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 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
2. The _______________ is used to identify the risks or
needs that are affected by nursing interventions for patients who are undergoing operative or other invasive
procedures.
a. American Nurses Association (ANA) Nursing Interventions Classification System
386 j AORN Journal
b. North American Nursing Diagnosis Association Diagnoses and Nursing Interventions System
c. Perioperative Nursing Data Set
d. ANA Nursing Outcomes Classification
3. Outcomes
1. 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.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
4. A method of visually demonstrating the relationships
between systems, nursing diagnoses, nursing interventions, and desirable outcomes is called
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October 2015, Vol. 102, No. 4
a. an object-role modeling graph.
c. a circuit diagram.
Age-Specific Perioperative Care
b. a concept map.
d. a Venn diagram.
5. Physiologically, _____________ patients are in the best
position to recover from surgical stressors.
a. adult
b. pediatric
c. adolescent
d. elderly
6. In the adult case scenario, the nurse developing a plan of
care specific to Ms R identifies nursing diagnoses for
which Ms R is at risk, including
1. 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 5
c. 1, 2, 3, and 4
d. 1, 2, 3, 4, and 5
7. In addition to their small body size, infants have difficulty
maintaining normal body temperature because they
1. 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.
a. 1 and 3
b. 2 and 4
c. 1, 3, and 4
d. 1, 2, 3, and 4
8. According to a qualitative study, the most difficult elements of the surgical experience for an adolescent are
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1.
2.
3.
4.
anxiety related to the surgical procedure.
loss of control related to pain management.
loss of function, mobility, or independence.
lost contact with friends during the extended recovery
period.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
9. Polypharmacy is characterized by
1. 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 3
c. 1, 2, 3, and 4
d. 1, 2, 3, 4, and 5
10. Tips for improving communication with sight-impaired
patients include
1. 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 5
c. 2, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6
AORN Journal j 387
LEARNER EVALUATION
Continuing Education:
Incorporating Age-Specific Plans
of Care to Achieve Optimal
Perioperative Outcomes 3.9
www.aorn.org/CE
T
his evaluation is used to determine the extent to
which this continuing education program met your
learning needs. The evaluation is printed here for
your convenience. To receive continuing education credit, you
must complete the online Examination and Learner Evaluation
at http://www.aorn.org/CE. Rate the items as described below.
8.
Will you be able to use the information from this article
in your work setting?
1.
Yes
2.
No
9.
Will you change your practice as a result of reading this
article? (If yes, answer question #9A. If no, answer
question #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 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: __________________________________
9B.
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: __________________________________
10.
Our accrediting body requires that we verify the time
you needed to complete the 3.9 continuing education
contact hour (234-minute) program: ______________
OBJECTIVES
To what extent were the following objectives of this
continuing 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 providing
perioperative care.
Low
1.
2.
3.
4.
5.
High
4.
Define polypharmacy.
Low
1.
2.
3.
5.
4.
5.
High
Identify methods for improving communication with
patients who have sensory impairments.
Low
1.
2.
3.
4.
5.
High
CONTENT
6. 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
388 j AORN Journal
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