Nurses dispense comfort, compassion and caring without even a prescription.
The focus of postoperative nursing care of geriatric surgical patients is mainly to prevent complications and restore them to optimal health by involving them and their families in the care process. Everything illustrated below has to be planned, applied and assessed in close cooperation with the entire multiprofessional team, which is key to making the pathway effective and giving added value to professional expertise. Furthermore, the perioperative nurse’s duty is to learn as much as possible about the geriatric patient upon admission, as highlighted in Chapter 16. Indeed, purposeful, consistent communication about the geriatric postoperative plan of care that integrates pertinent assessment information, special needs and a dynamic nursing plan to manage actual or potential problems across the continuum of care is vital to an uneventful surgical experience and successful perioperative outcomes. The benefits of using a holistic, individualized approach during the surgical continuum are essential to optimal nursing care (Mamaril 2006).
To facilitate reading, the text is divided into three main topics of intervention, which in turn can be broken down into several sub-topics, although their rationales and themes are closely interconnected. The first point of focus concerns ensuring “effective immediate postoperative monitoring,” the second can be summarized as “prevention of complications during hospitalization: nursing-sensitive outcomes” and the third includes all nursing actions aimed at “creating an environment for the elderly in relation to their physical and social needs.”
Upon leaving the operating room, the patient’s vital signs should be monitored (body temperature, pulse rate, respiration rate, blood pressure) to detect the onset of complications. Furthermore, blood loss, oxygen saturation, pain and hydro-electrolytic balance should be monitored, together with cognitive assessment, which is very important in the elderly. In cooperation with other professionals it is also important to monitor nutritional intake, in terms of both quantity and quality.
Concerning the monitoring of vital signs, reassessment times are very important in the first 24 hours, which represent the most critical period. In low-risk patients there is no evidence with regards to predetermined times (Fernandez and Griffiths 2005). Therefore, reassessment times of vital signs should take into consideration the patient’s general clinical conditions and the type of operation.
A modern conception of nursing assigns to pain the role of “fifth vital sign,” after blood pressure, heart rate, respiratory rate and temperature. Assessing pain and treating it is a paramount duty for the care team in surgery. Pain often represents an unmet need; in the elderly it is frequently undertreated by the care team and under-reported by the patients. Active search for pain is then essential. In cognitively compromised patients, instead of traditional pain scores such as the Visual Analogic Scale or Faces Pain Scale, dedicated pain scores such as PAINAD or NOPPAIN should be used (see Chapter 32). Pain assessment should be made together with the other vital signs, and scores reported in the record. If pain is not relieved by the assigned antalgic protocol or the rescue dose specifically prescribed to cover the limits of the protocol, the operator in charge of pain relief (usually the anesthetist) should be alerted.
Special attention should be placed on monitoring body temperature (BT), both in the immediate postoperative period and in the following days. Elderly patients have difficulties in maintaining normothermia and, mostly in the early postoperative hours, are prone to develop hypothermia, a condition that may increase the risk of surgical infection and prolonged hospital stay, and cause discomfort. Active rewarming should be done carefully, to avoid skin lesions in case of peripheral sensitivity deficits. Hyperthermia is often a sign of infection, however it is frequent in the elderly that complications present atypically and that infections are not accompanied by hyperthermia.
Although the act of taking BT seems easy, the accuracy of various thermometers should be taken into account. A recent systematic review (Niven et al. 2015) showed that peripheral thermometers (tympanic, temporal, axillary or oral) are not sufficiently accurate and their use should be restricted to screening, whereas for accurate monitoring of the BT, central thermometers (pulmonary artery catheter, urinary bladder, esophageal, or rectal) are preferred.
Postoperative delirium (POD) is a very common postoperative complication in the elderly (see Chapters 14 and 38). Its origin is multifactorial and it may present in various settings; however, its frequency is high, especially after invasive and prolonged surgeries. In a well-organized facility, patients should be preoperatively evaluated for their POD risk and those presenting multiple risk factors (advanced age, dementia, comorbidity, impaired functional status or frailty) should be “labelled” and assigned to careful proactive observation. Nurses should try to admit them to quiet rooms, avoid unnecessary sensory stimulation (noises, lights) and respect as much as possible the circadian rhythm.
It is important to assess the patients for cognitive status and use tools to identify patients whose status is changing, so that swift, targeted action can be taken. Several tools are described in the literature that enable a patient with delirium to be identified. One simple screening method is the Confusion Assessment Method (CAM), which is especially recommended in the elderly patient. In consists of a series of questions that the nurse asks. If one of the answers is affirmative, a state of delirium may be suspected.
The Confusion Assessment Method – Intensive Care Unit (CAM-ICU) is a variant of the CAM scale, specific for a patient in a critical state; a systematic review showed that when the result of this scale was positive no further assessment was necessary to confirm the diagnosis of delirium (Gusmao-Flores et al. 2012). Therefore, it is not only a screening tool, but also an accurate tool for diagnosis.
In the postoperative care of the elderly an important aim to achieve is recovery of motor activity, according to the physical status of the patient, to prevent deconditioning. An extended period in bed can lead to several complications that can weigh heavily on the prognosis of the elderly patient, including pulmonary infection, deep vein thrombosis, muscle wasting, reduced peristalsis with subsequent loss of appetite, urinary incontinence, altered cognitive state or mood changes, and last but not least increased risk of pressure sores (PS). Therefore, it is useful to adopt a care plan, shared with other health professionals, especially physiotherapists and doctors, with the aim of minimizing bed rest and favoring early recovery of the ability to move independently. Guerra et al. (2015) showed that a program of early mobilization can effectively reduce hospitalization time. This also promotes contacts among patients and socialization, with positive psychological effects.
Early mobilization and nutrition are part of ERAS (Enhanced Recovery After Surgery), an innovative concept for postoperative recovery (see Chapter 34) that promotes the active participation of patients in the healing process.
These are defined as localized damage to the skin and/or underlying tissue, which generally arise near a bony prominence, as a result of pressure or pressure combined with shear and strain forces (NPUAP 2014). They are an important complication because of the severe impact they can have on the patient’s prognosis, and marked social cost. One of the main objectives the nurse should achieve when treating an elderly patient undergoing surgery is thus to prevent PS. Because they are closely connected to nursing care, the ability to prevent them is an indicator of the good quality care provided. Several studies have shown that old age is a chief risk factor. A good plan to prevent PS should therefore also include appropriate mobilization of the patient, at least one postural change every 4 hours, which, if the patient is at very high risk, should be increased to every 2 hours, and the use of suitable support surfaces and daily monitoring of the skin status. A prevention care bundle was recently reported to be positively perceived and well accepted by older hospitalized patients (Roberts et al. 2017).
Topical products such as moisturizing creams and polyurethane film can also be used to reduce strain and shear forces as well as friction forces. Special care should be taken when choosing the mattress; using standard mattresses for elderly patients is not recommended. Pressure-relieving mattresses can be static or dynamic. Static mattresses may be sufficient, but over time they can deteriorate and lose their efficacy. For high-risk patients it is always preferable to use dynamic mattresses, which can change pressure points by a motorized mechanism.
Another key aspect of nursing care is hygiene. According to the patient’s clinical status, focus should be on restoring autonomy. Even when patients are completely dependent, they should be involved in choices about their hygiene. Providing patients with assistance in hygiene matters is not simply a question of helping them to wash themselves. Besides being a time for building a relationship of trust with the patient, it is also a useful time to assess different aspects related to achieving the aims of nursing care. In particular it is a time to make an accurate “inspection of the skin” in order to detect any early signs of damage or sores and also a time to assess the patient’s ability to move. Therefore, performing hygiene care may be interpreted as a moment to make a full assessment of the patient.
A fundamental way to prevent complications and facilitate the postoperative recovery of the elderly patient is to manage devices that often become instruments of restraint. The most commonly used devices are oxygen tubing, intravenous lines, indwelling catheters, pulse oximeters and wound drains. These devices can become a network of restraints that leads to the immobilization of the patient. Furthermore, for a patient with limited vision, hearing and cognitive status, this situation can cause fear and insecurity and even increase the risk of delirium (Sanguineti et al. 2014). Therefore, a daily assessment of all the devices is recommended and when possible they should be removed.
Particularly in the elderly, urinary catheters are frequently associated with perioperative urinary tract infection, and a targeted indication for their use is an important preventive measure (Folbert et al. 2017). If they must be inserted, urinary catheters should preferably be removed within 48 hours to reduce the risk of urinary tract infection (UTI) (Ksycki and Namias 2009). Should there be problems in recovering autonomy in urination, there is evidence that it is preferable to perform intermittent drainage rather than leave the catheter in situ, even if it is more expensive (Kidd et al. 2015). Using antimicrobial-impregnated bladder catheters does not seem to provide any advantages in terms of preventing UTI (Lam et al. 2014), nor is there evidence supporting strategies to favor early recovery of autonomy by bladder drainage (Griffiths and Fernandez 2009). The use of closed urinary drainage systems is recommended, thus avoiding unnecessary disconnections. Make sure the urethral meatus is cleaned with soap and water and anchored to avoid tension, to the abdomen if the patient is male and to the leg if the patient is female (Kidd et al. 2015).
The skin of an elderly patient is fragile, with a thin dermis layer, low elasticity, and less collagen, muscle and adipose tissue, thus creating a high potential for bruising and skin tears. Therefore hypoallergenic plasters should be used and removed with care, paying particular attention to blisters caused by medication of the surgical wound. Blisters are quite common in patients undergoing surgery (13–35%). They cause pain and increase the risk of wound infection. They are common in orthopedics and in other types of surgery. It has also been shown that they can delay mobilization and therefore increase the risk of complications. Hypoallergenic medications should always be preferred, with isometric elasticity associated with flexibility and, if blisters occur, it is important not to burst them (Eastburn et al. 2015).
Postoperative ileus is a common complication due to the prevalence of constipation and its prevention in the elderly requires special attention. The best preventive strategy is to assess the patient upon admission with regards to chronic incontinence and constipation (RNAO, 2011) and the use of medication associated with increased risk of ileus, such as, among others, the chronic use of laxatives, anticholinergics and diuretics. Finally, malnutrition, reduced mobility and cognitive impairment contribute to increasing the risk of postoperative ileus. There is evidence that administering preoperative mechanical bowel preparation also increases the risk of ileus. Preoperative fasting should be limited in accordance with the ASA preoperative fasting guidelines (ASA 2011). There is now solid evidence that to favor the early movement of feces and gas in the bowel it is useful to administer carbohydrate-rich liquid in the hours prior to surgery. Early postoperative feeding has also been shown to help restore bowel movement, as has the use of chewing gum, which is rarely adopted in the elderly patient. From a nursing point of view, it is useful to implement the above-mentioned strategies in a combined and targeted way, especially in patients shown to be at high risk during preoperative screening (Story and Chamberlain 2009).