General Surgical Care of the Older Adult   33  

Larry Z. Slater and Fidelindo Lim

OVERVIEW

Older adult surgical patients offer unique challenges for the multidisciplinary team from the postoperative period to discharge. Physiological changes of aging (e.g., decreased cardiac and respiratory reserve, impaired kidney and liver function, and loss of muscle mass) can significantly affect the recovery time of older adult surgical patients and put them at greater risk of postoperative complications (Leung & Dzankic, 2001; Makary et al., 2010). In addition, older adults often present for elective and nonelective or emergent surgeries with a number of medical comorbidities that place them at further risk of postoperative morbidity and mortality (Dasgupta, Rolfson, Stolee, Borrie, & Speechley, 2009). The risk of complications and mortality continues to increase with advancing age, with those aged 90 years and older experiencing twice the rate of mortality at less than 48 hours postsurgery as compared to those younger than 65 years (Deiner, Westlake, & Dutton, 2014).

As the number of surgeries for older adults continues to rise, with adults aged 65 years and older currently accounting for 34% of all surgeries (Deiner et al., 2014), it is imperative that nurses in intensive care, step-down, and medical–surgical units develop competencies in working with a multidisciplinary team to provide patient-centered care for older adult surgical patients. Such care can help maximize recovery, facilitate a return to baseline functioning, and decrease the time to discharge. Longer lengths of stay have been consistently linked to increased postoperative adverse outcomes (Leung & Dzankic, 2001; Makary et al., 2010). Blegen, Goode, Park, Vaughn, and Spetz (2013) found that surgical patients at hospitals with a higher percentage of nurses with a baccalaureate or higher degree experienced shorter lengths of stay and less postoperative complications. Similarly, Aiken et al. (2014) demonstrated that a higher education level for nursing staff decreased mortality risk among surgical patients. These studies underscore the importance of nurses receiving initial and ongoing education and training in providing evidence-based care to older adult surgical patients.

BACKGROUND AND STATEMENT OF PROBLEM

In 2010, older adults (aged 65 years and older) had a total of 19.2 million operative procedures performed in acute care settings (Centers for Disease Control and Prevention [CDC], 2010). In addition, they accounted for more than 37% of all procedures and 45% of total hospital days of care (CDC, 2010). As the population continues to age, comprising an estimated 16.8% of the total population by 2020 and 20.3% by 2030 (Ortman, Velkoff, & Hogan, 2014), the number of operative procedures and hospital stays for older adults will only increase. Hospital stays that involve surgical procedures have been shown to be more costly, require longer lengths of stay, and result in higher morbidity and mortality (Weiss & Elixhauser, 2014), so it is imperative that nurses address the specific needs of older adult surgical patients.

The American Geriatrics Society (AGS, 2007) developed quality indicators related to care of vulnerable elders (Assessing Care of Vulnerable Elders [ACOVE]), which include sections on hospital care, surgery, and perioperative care. The indicators address several key areas that fall under the purview of nurses providing general surgical care of the older adult: venous thromboembolism (VTE) prophylaxis, infection prevention, delirium screening and prevention, mobilization, fall prevention, and discharge assessment (AGS, 2007). An expert panel, with funding from the National Institute of Aging (NIA), also developed a list of process-based quality indicators for older adult surgical patients, applicable across disciplines, to improve surgical care and outcomes (McGory et al., 2009). The panel rated 91 indicators as valid for surgical management of the older adult, which direct the assessment and management of critical areas in order to prevent postoperative complications, decrease lengths of stay, and facilitate discharge transitions (McGory et al., 2009). The report highlighted the need for comprehensive baseline status assessment and the use of an interdisciplinary team with surgical and geriatric expertise to follow the patient from preop to discharge, facilitating as quick a return as possible to presurgery functioning (McGory et al., 2009). The indicators were similar to the ACOVE indicators: nutrition, hydration, pain management, delirium, respiratory function, infection prevention, mobility/ambulation, functional status, fall prevention, skin integrity, and restraint use (McGory et al., 2009).

This chapter provides the latest evidence and guidelines for the management of the stable older surgical patient in each of these key areas outlined by the ACOVE (AGS, 2007) and NIA Expert Panel (McGory et al., 2009) quality indicators. In addition, the nurse’s responsibilities related to discharge planning will be highlighted. The discussion also provides, where applicable, the identification of applicable Joint Commission (TJC) National Patient Safety Goals (TJC, 2015) and National Quality Forum (NQF) National Database of Nursing Quality Indicators (NDNQI; Montalvo, 2007). For a discussion on the comprehensive management of critically ill, older patients, please refer to Chapter 29, “Comprehensive Assessment and Management of the Critically Ill.”

ASSESSMENT OF THE PROBLEM AND NURSING CARE STRATEGIES

The Patient Safety Indicators (PSIs) espoused by the Agency for Healthcare Research and Quality (AHRQ) guide assessment and screening for adverse events that patients experience as a result of exposure to the health care system (AHRQ, 2014). PSIs that are directly related to postsurgical care include:

These high-risk and high-impact events are deemed amenable to prevention by changes at the system or provider level (AHRQ, 2014). Nurses play a pivotal role in the prevention and management of these events. In the next section, specific care topics directly or indirectly related to the PSIs are explored.

Postoperative Delirium and Cognitive and Sensory Function

Postoperative delirium can occur in up to 50% of high-risk older adult surgical patients, leading to prolonged and more costly hospitalizations, functional decline, and death (AGS, 2014). Older adult surgical patients are at a high risk of delirium for a number of causes, including medication side effects; immobility; infection; inadequate pain management; and cardiac, renal, and respiratory complications (Hughes, Leary, Zweizig, & Cain, 2013). In addition, routine hospital care may contribute to delirium resulting from effects on the patient’s sleep–wake cycle and sleep deprivation, often related to routine procedures and hospital noise, and inattention to visual and hearing deficits, including lack of appropriate corrective lenses and hearing aids (Hughes et al., 2013).

The management of postoperative delirium begins presurgery. The ACOVE and NIA Expert Panel recommend that this assessment be performed 8 weeks before surgery (AGS, 2007; McGory et al., 2009). The AGS Expert Panel on Postoperative Delirium in Older Adults (2014) emphasizes the assessment of risk factors for postoperative delirium, with the presence of two or more factors placing the patient at a greater risk of delirium after surgery. Moreover, patients should receive a comprehensive evaluation of cognitive and sensory (vision/hearing) function 8 weeks before surgery (McGory et al., 2009). Chapter 6, “Assessing Cognitive Function,” discusses the assessment of cognitive function and Chapter 5, “Sensory Changes,” outlines sensory changes in older adults. For more on preoperative (as well as intraoperative) management of delirium in surgical patients, see Chapter 32, “Perioperative Care of the Older Adult.”

Postoperatively, health care professionals with adequate training in the assessment and diagnosis of delirium should screen patients using validated screening instruments, at least daily or as clinically indicated, to diagnose postoperative delirium and institute early interventions (AGS, 2014). ACOVE recommends screening to occur for at least the first 3 days after surgery (AGS, 2007). Table 33.1 provides more specific medical evaluations, which include both nursing and collaborative assessments, as listed by the AGS Expert Panel on Postoperative Delirium. These evaluations are also highlighted in the British Geriatric Society (BGS, 2006) guidelines for management of delirium and the NIA Expert Panel quality indicators (McGory et al., 2009) for older surgical patients. Lagoo-Deenadayalan, Newell, and Pofahl (2011) also provide a useful mnemonic, I’m Confused, to summarize etiologies of delirium in surgical older adult patients. This mnemonic is provided in Table 33.2.

Chapter 17, “Delirium: Prevention, Early Recognition, and Treatment,” outlines in greater detail the prevention, recognition, and treatment of delirium in the older adult population. For the older surgical patient, however, there are some specific management dos and don’ts that need to be highlighted here. Given the breadth of factors that may lead to postoperative delirium, adequate nursing care, as emphasized in the rest of this chapter, that addresses the general surgical care of the older adult may help prevent delirium; it will also be essential in the management of delirium, should it occur. Although evidence has not demonstrated that specific units designed for older adult surgical patients or those with delirium improve patient outcomes, environmental adjustments remain an important component of care (AGS, 2014). These may include continuity of care (familiar residents, nurses, and care technicians), continuous environmental and personal orientation, availability of working hearing and vision aids, minimization of noise and interruptions to promote adequate sleep, and involvement of family and caregivers (BGS, 2006). In addition, the AGS (2014) and BGS (2006) emphasize the following pharmacologic and nonpharmacological interventions.

TABLE 33.1

Evaluation of Precipitating Factors for Postoperative Delirium

Adapted from the American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults Best Practices Statement (2014).

TABLE 33.2

Mnemonic for Etiology of Postoperative Delirium in Older Adult Surgical Patients

Adapted from Lagoo-Deenadayalan, Newell, and Pofahl, (2011).

Pharmacologic

  Adequate pain management, preferably with nonopioid pain medications

  Avoidance of delirium-inducing medications such as benzodiazepines, anticholinergics, diphenhydramine, histamine₂-receptor antagonists, sedative-hypnotics, and meperidine (see also the AGS Beers Criteria [AGS, 2012])

  Avoidance of routine sedation or prophylactic antipsychotics

Nonpharmacologic

  Use of nonpharmacologic pain management strategies

  Adequate fluid and nutrition intake

  Promotion of early ambulation/mobility, physical and occupational therapy

  Initiation of plans to prevent pressure ulcers, falls, and infection

  Prevention of complications (respiratory, cardiac, gastrointestinal, and renal)

  Avoidance of unnecessary catheterization and restraint use

Pain Management

A large majority of hospitalized older adults experience pain or discomfort, but they are consistently less likely to receive adequate pain management than their younger counterparts (Schofield, 2014). Pain may be postoperative, but could also include the patient’s chronic pain issues, which may be exacerbated as a result of the stress of surgery and/or hospitalization. A study in the United Kingdom found that although 81% of older adults were being treated in a hospital that had an acute pain service, only a small minority of them actually had a pain assessment chart (National Confidential Enquiry into Perioperative Deaths [NCEPOD], 1999). One reason may be the misconception that older adults have a higher pain threshold (Doerflinger, 2009). This may be compounded by the fact that older adults may be more hesitant to report pain, feeling that it is just a fact of life or possibly not wanting to be a bother to the nursing staff (Panprese & Johnson, 2014), or they may be concerned about becoming dependent on pain medications (Hughes et al., 2013). Pain management is further complicated if the older adult has cognitive or communication issues.

Adequate assessment and management of pain are the nurse’s imperative for the older surgical patient, as a lack of pain control can lead to a host of complications, including delirium, depression, fluid imbalances, atelectasis, and fatigue (AGS, 2014; Bashaw & Scott, 2012). Pain assessments should be performed with each set of vital signs, at a minimum (McGory et al., 2009; Schofield, 2014), but are most effective when performed as part of hourly rounding. Assessments should include a rating of intensity (using numeric, verbal, or visual scales), a pain description (to address sensory and affective dimensions as well as the impact of pain on function), and observations of signs of pain, which are especially important for patients with cognitive or communication issues (Royal College of Physicians, British Geriatrics Society, & British Pain Society, 2007). For patients with dementia, a rating scale, such as Patient Assessment in Advanced Dementia (PAINAD), may be used to systematically gather pain data (Warden, Hurley, & Volicer, 2003). In addition, a family member or caregiver may be able to assist in identifying signs of pain in the person with dementia as they are often more experienced in recognizing subtle clues (Hughes et al., 2013).

Although pain assessment is a critical component of TJC Hospital Accreditation Standards (2014b), and pain has been assessed as the fifth vital sign since the Veterans Health Administration launched its initiative in 1999, there has been little improvement in the overall quality of pain management (Mularski et al., 2006). The NIA Expert Panel recommends that a comprehensive pain management plan should be offered to any patient with a pain score greater than 5 (McGory et al., 2009). However, it is best to set pain management plans and goals according to the individualized needs of the patient and the plans must take into account any chronic pain-related conditions that already exist. ACOVE states that for complaints of moderate to severe pain, an intervention should be performed, reassessment of pain should occur within 4 hours, and documentation of the intervention and reassessment should be placed in the medical chart (AGS, 2007). In practice, pain reassessment often occurs within 15 minutes for intravenous (IV) medications and 1 hour for oral (PO) medications.

Chapter 18, “Pain Management,” provides specific protocols for management of pain in older adult populations. When applying these protocols to the surgical patient, the nurse must also take into account medication side effects that can contribute to postoperative complications (e.g., morphine and constipation). ACOVE specifically recommends interventions to address constipation when the older adult surgical patient is on opioid therapy (AGS, 2007). These are described in greater detail in the following section on Nutrition and Gastrointestinal Complications. TJC (2014a) provided a clarification to their pain management standard to express the many nonpharmacologic strategies, such as massage, acupuncture, and cognitive behavioral therapy, which may be used as part of the pain management arsenal. These methods may be preferred over the use of nonsteroidal anti-inflammatory drugs (NSAIDs) because of the potential gastrointestinal (GI) and renal complications associated with these medications (Griffiths et al., 2014).

Nutrition and Gastrointestinal Complications

Poor preoperative nutritional status can put the older adult surgical client at risk of serious postoperative complications, including impaired skin integrity, delayed wound healing, wound or other infections, sepsis, and death (Lagoo-Deenadayalan et al., 2011; Scandrett, Zuckerbraun, & Peitzman, 2015). As older adults may have several factors that put them at risk of malnutrition, such as financial constraints, social isolation, poor oral health, depression, alcohol use, or difficulties with meal preparation (Volkert, 2002), nutritional screening before surgery is of vital importance. In the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and AGS Best Practice Guidelines on preoperative assessment, Chow, Rosenthal, Merkow, Ko, and Esnaola (2012) list a body mass index (BMI) less than 18.5 kg/m², a serum albumin less than 3.0 g/dL, and unintentional weight loss greater than 10% to 15% within 6 months as placing the surgical patient at severe nutritional risk; they advise that a comprehensive nutritional plan be developed to address deficits through the postoperative period. As approximately 86% of older hospitalized adults are malnourished or are at risk of malnutrition (Kaiser et al., 2010), early nutritional intervention is imperative in preventing complications, decreasing length of stay, and promoting a quick return to baseline functioning.

Chapter 10, “Nutrition,” provides a detailed discussion of nutrition assessment and nursing care strategies for older adults and Chapter 25, “Mealtime Difficulties in Dementia,” discusses mealtime difficulties. Nutritional care requires collaboration with the multidisciplinary health care team, including the nurse, surgical resident, and dietitian, as well as the speech therapist and occupational therapist. The goal is to provide early and adequate nutritional intake, preferably by mouth, which may be enhanced through the use of nutritional supplements (e.g., Ensure^®). If oral intake is not possible, the team may consider the use of other forms of enteral nutrition (e.g., percutaneous endoscopic gastrostomy [PEG] tube and Dobhoff tube) or parenteral nutrition. Although parenteral nutrition may temporarily be the only option for some postsurgical older adults, especially those with a prolonged postoperative ileus (POI), it is important to note that enteral nutrition offers better outcomes than parenteral, as the former is associated with shorter hospital stays, lower incidence of infection, and lower severity of complications (Wheble, Knight, & Khan, 2012).

Several issues could possibly prevent early postsurgical nutrition intake, including postoperative nausea and vomiting (PONV) and dysphagia. PONV affects about one third of surgical patients (Apfel, Kranke, & Eberhart, 2004). Not only does PONV affect nutritional status, but it can also lead to further complications for the older surgical patient, including aspiration, wound dehiscence, and prolonged length of stay (American Society of PeriAnesthesia Nurses [ASPAN], 2006). The risk of PONV increases with age and duration of surgery (ASPAN, 2006). PONV should be continually monitored, especially within the first 24 hours of arrival to the unit. If PONV is present, it should be quantified using a descriptive or visual scale and then rescue interventions should be implemented, including the administration of antiemetic agents, verification of adequate hydration, and use of aromatherapy (ASPAN, 2006). For older adults, however, it is important to steer clear of metoclopramide, which can lead to extrapyramidal effects (AGS, 2012).

Older adults may experience age-related decreases in swallowing function (Scandrett et al., 2015). Additionally, swallowing difficulties take longer to resolve following extubation for older adults, particularly after long surgeries (El Solh, Okada, Bhat, & Peitrantoni, 2003), predisposing the older adult patient to postoperative dysphagia. As such, swallowing ability should be assessed early to address the need for fluid and caloric intake and to lower the risk of aspiration and debilitating aspiration pneumonia (Lagoo-Deenadayalan et al., 2011). If the swallowing assessment shows signs of aspiration, modification of the diet, including alterations in food consistency, upright positioning during and up to 1 hour after feeding, speech therapy, and aggressive oral care should be implemented to improve intake (Marik & Kaplan, 2003; McGory et al., 2009). For patients who may need to receive tube feedings because of swallowing difficulties or other postoperative complications, a documented plan to reduce the risk of aspiration should be incorporated into the medical record (AGS, 2007).

Constipation or diarrhea can also complicate postsurgical nutritional interventions and may signify more serious complications. Constipation can occur postoperatively as a result of immobility, altered (or lack of) diet, and excessive use of opioid pain medications (Doerflinger, 2009). In addition, the use of anticholinergics, particularly first-generation antihistamines (e.g., diphenhydramine), may initiate or exacerbate constipation and should be avoided in the older postsurgical patient (AGS, 2012). Preventive methods for constipation should be instituted for older adult surgical patients on opioid pain management regimens. This typically includes the use of bowel stimulants (senna and bisacodyl) and osmotic agents (polyethylene glycol); however, bulk-forming agents (psyllium) should be avoided as they are ineffective and may worsen symptoms, especially in a patient without adequate fluid intake (AGS, 2007; Malec & Shega, 2015). Quick transitioning from opioid medications to acetaminophen for mild to moderate pain may help reduce the risk of constipation.

The presence of diarrhea might trigger assessment for fecal impaction (following unaddressed constipation) or a more serious complication, such as Clostridium dificile infection (Doerflinger, 2009). A study by Zerey et al. (2008) showed that C. dificile infection occurs in about 1% of older adults undergoing a general surgical procedure. The occurrence of C. dificile infection can increase length of stay by 16 days and triple the mortality risk (Zerey et al., 2008). Universal precautions and proper handwashing are essential in reducing the risk of C. difficile infection. If C. difficile infection is suspected, then stool samples should be taken and prompt treatment initiated if samples test positive (Doerflinger, 2009).

Special Consideration: POI Following Gastrointestinal Surgery

Older adult surgical patients have a higher incidence of POI following surgeries involving manipulation of the bowel (Hamel, Henderson, Khuri, & Daley, 2005). Prolonged POI (lasting more than 5 days) occurs in 40% of patients and leads to prolonged hospital stays and increased medical costs (Delaney, 2004; Schuster et al., 2006). Management for POI has routinely included bowel rest and bowel decompression (through placement of a nasogastric [NG] tube (Lagoo-Deenadayalan et al., 2011). However, evidence has shown that early enteral feeding is often well tolerated and may decrease POI, whereas NG decompression has not been shown to reduce incidence of POI and may actually place the patient at risk of aspiration and other postoperative pulmonary complications (Lubawski & Saclarides, 2008). In addition to early return to feeding, early mobilization and avoiding unnecessary use of opioids can reduce incidence of prolonged POI (Lagoo-Deenadayalan et al., 2011, Lubawski & Saclarides, 2008).

Hydration and Renal Complications

Older adults are at greater risk of fluid and electrolyte imbalances caused by physiological changes that lead to decreased total body water and poorer kidney function (lower glomerular filtration rate [GFR] and decreased ability to concentrate urine; Luckey & Parsa, 2003). Older adults are more susceptible to experiencing dehydration resulting from changes in thirst response, functional disability leading to decreased intake, and polypharmacy, including the overuse of diuretics (El-Sharkaway, Sahota, Maughan, & Lobo, 2014). However, surgical stress and excessive fluid resuscitation during the perioperative period could have the opposite effect, leading to water, sodium, and chloride excess, all of which have been shown to be independent risk factors for mortality, postoperative renal injury, and increased lengths of stay (El-Sharkaway et al., 2014).

Given this dichotomy, fluid management during the perioperative period is of vital importance. However, fluid orders are often delegated to the most junior member of the medical team who may lack an understanding of the importance of maintaining fluid balance for the older adult surgical patient (El-Sharkaway et al., 2014). In a report by the NCEPOD in the United Kingdom (1999), the authors noted that fluid management in older adult surgical patients was poor and contributed to serious postoperative morbidity and mortality. After conducting chart reviews, the report cited both doctors and nurses as being remiss in providing accurate documentation in fluid balance charts and recommended that working practices be developed, including elevating fluid management to the same importance as drug prescribing, to address the problem (NCEPOD, 1999).

During the postoperative period, the older adult is most at risk of dehydration and acute renal failure. Gajdos et al. (2013) reported that approximately 1.5% of adults older than 60 years undergoing nonemergent surgery developed postoperative renal insufficiency and, of those, the mortality rate was more than 31%. The nurse plays a vital role in the assessment of fluid status, monitoring for signs and symptoms of fluid volume deficit and providing accurate documentation of fluid balance. The NIA Expert Panel recommends that fluid status be monitored for at least the first 5 days after surgery using daily weights and/or daily intake and output (McGory et al., 2009). However, Sullivan (2011) notes that because fluid volume shifts may take up to twice as long to resolve in the older surgical patient, urine output alone may not be enough to determine whether the patient has low blood volume leading to poor perfusion. The nurse should also be on the lookout for drops in blood pressure, changes in mental status, and new-onset atrial fibrillation, all of which could signify poor perfusion (Sullivan, 2011). Hughes et al. (2013) stress the importance of routine screening of serum electrolytes, urea nitrogen, and creatinine, although in older adults creatinine levels may not change even with significant drops in GFR.

As with nutrition, oral hydration should begin as soon as feasibly possible. Similarly, PONV and dysphagia must be addressed in order for the postoperative older adult to maintain adequate fluid balance. Chapter 9, “Managing Oral Hydration,” addresses the management of oral hydration in the older adult, much of which is applicable to the older postsurgical patient. However, if the patient is unable to maintain adequate oral intake, IV fluids or adequate hydration through tube feeding may be required (with appropriate aspiration precautions instituted).

Respiratory Complications

Age-related changes in respiratory function include weakened swallowing and cough responses, chest wall stiffness, a weakened diaphragm, and decreased vital capacity and forced expiratory volume in 1 second (Bashaw & Scott, 2012; Hughes et al., 2013). These changes predispose the older adult surgical patient to respiratory complications. For patients with preexisting respiratory conditions, such as chronic obstructive pulmonary disease or asthma or for those who are smokers, the risk of complications is even greater (Lagoo-Deenadayalan et al., 2011). Preoperative assessment of pulmonary function is vital to delineating postoperative risk and the promotion of preoperative smoking cessation, even just 24 to 48 hours before surgery, may help lessen postoperative sequelae (AGS, 2007; Hughes et al., 2013).

Pulmonary complications occur in approximately 10% of older adult surgical patients and account for up to 40% of postoperative complications and nearly 20% of preventable deaths (Lagoo-Deenadayalan et al., 2011). Magill et al. (2014) estimated that there were approximately 157,500 cases of hospital-acquired pneumonia (HAP) in the United States in 2011, of which 39% were ventilator-associated pneumonia (VAP). Gajdos et al. (2013) found that pulmonary complications, including pneumonia, failure to wean from a ventilator, and unplanned intubation, occurred in 7% of patients aged 60 years and older undergoing nonemergent surgery, with a mortality rate of 23% among those that had such complications.

Nursing interventions are essential in the prevention of respiratory complications through implementation of an aggressive pulmonary toilet regimen (Lagoo-Deenadayalan et al., 2011). In order to promote lung expansion and prevent postoperative atelectasis, the nurse should promote the use of an incentive spirometer (with adequate education and reinforcement on use) at least 10 times per hour; turning, coughing, and deep breathing every 2 hours; and chest percussion or other chest physiotherapy as needed (Doerflinger, 2009; McGory et al., 2009). Early ambulation should also be encouraged, as should proper positioning when in bed with the head of the bed elevated (Bashaw & Scott, 2012; Doerflinger, 2009). Adequate pain control is imperative as pain may reduce respiratory effort and may limit coughing to clear secretions (Lagoo-Deenadayalan et al., 2011). The health care team should also avoid the excessive use of narcotics and sedatives that could lead to respiratory depression (Lagoo-Deenadayalan et al., 2011).

VAP is a key nursing-sensitive indicator listed by the NDQNI and also endorsed by the NQF as the nurse plays a pivotal role in its prevention (Montalvo, 2007). For patients who are mechanically ventilated, the Institute of Healthcare Improvement (IHI; 2012c) lists five components of care (a ventilator bundle) to be instituted in order to prevent VAP. These components include (a) elevation of the head of the bed between 30° and 45°, (b) daily sedative interruptions and assessment of readiness to extubate, (c) peptic ulcer disease prophylaxis, (d) deep vein thrombosis (DVT) prophylaxis, and (e) daily oral care with chlorhexidine (IHI, 2012c). Despite the evidence, Munaco, Dumas, and Edlund (2014) noted that lack of staff education and limitations of the electronic medical record (EMR) affected overall compliance with a VAP bundle. AGS (2007) emphasizes the need of a documented care plan to reduce VAP. Therefore, facilities must address EMR limitations and provide ongoing education and training of nurses and nursing assistants to adequately implement VAP prevention.

Infection Prevention

Older adults are at increased infection risk postsurgery because of immune system changes and delayed wound healing (Panprese & Johnson, 2014). In 2011, it was estimated that approximately 4% of hospitalized patients had at least one hospital-acquired infection (HAI; Magill et al., 2014). In addition to pneumonia (22% of HAI) and GI infection (17%), the remaining common HAI included surgical site infection (SSI; 22%), urinary tract infection (UTI; 13%), and primary blood stream infection (10%; Magill et al., 2014). Older age and increased length of stay were related to increased risk of HAI (Magill et al., 2014). One of the most consistently cited ways to reduce HAI is through improving hand hygiene in the hospital setting. TJC (2015) specifies that current CDC or World Health Organization (WHO) guidelines should be used as a basis for hand-hygiene programs.

A localized infection could potentially become systemic, putting the patient at risk of increased morbidity/mortality resulting from sepsis, which can occur in up to 2% of postoperative older adults (Lagoo-Deenadayalan et al., 2011). The NIA Expert Panel on quality indicators for older adult surgical patients recommends the following for any patient who has a fever greater than 38.0°C after postoperative (postop) day 2: urinalysis and urine culture, examination of wound, blood culture from central venous line (if one is in place), peripheral vein blood culture, and chest radiograph (McGory et al., 2009). Older adults, however, may not necessarily mount a febrile response to systemic infection (Norman, 2000). Therefore, it is also important to monitor for other manifestations of sepsis, including altered mental status, agitation, respiratory distress, tachycardia, and hypotension (Lee, Chen, Chang, Chen, & Wu, 2007). If the older adult does have a significant febrile response, it often indicates severe infection with increased morbidity and mortality (Norman, 2000).

The Centers for Medicare & Medicaid Services (CMS) list several HAI as hospital-acquired conditions for which hospitals will receive no reimbursement (CMS, 2014). The HAI include SSIs following coronary artery bypass graft, bariatric surgery, and orthopedic procedures; catheter-associated urinary tract infections (CAUTI); and vascular catheter-associated infections (CMS, 2014). As reimbursement will not be provided for HAI, it is imperative that the multidisciplinary health care team works to prevent HAI from occurring in the hospital.

Zingg et al. (2015) performed a comprehensive systematic literature review and identified 10 key components that can impact HAI prevention. Some of the components addressed system issues, such as availability and ease of access to equipment (poorer access is related to higher risk); bed occupancy, staffing, and workload (high occupancy, low staffing levels, and high workload correlated with increased risk); and modeling a culture of infection control at the organizational level (Zingg et al., 2015). The study group also noted that adequate education and training on the appropriate use of guidelines, as well as proper auditing, surveillance, and feedback, reduced HAI risk (Zingg et al., 2015). In reviewing HAI programs from a national collaborative, Welsh, Flanagan, Hoke, Doebbeling, and Herwaldt (2012) had similar findings. They highlighted the importance of engaging front-line staff by involving them in projects and enlisting champions to further complement the education, surveillance, and feedback required to succeed in reduction of HAI (Welsh et al., 2012). In sum, a system-wide, multidisciplinary, collaborative effort is required to reduce HAI and thus reduce morbidity and mortality in older adult surgical patients.

Surgical Site Infection

Approximately 2% to 5% of surgical patients develop an SSI (Anderson et al., 2014). Among older surgical patients (aged 60 years and older), SSI occurred in 8%, with a 7% mortality rate for those developing an SSI (Gajdos et al., 2013). The occurrence of an SSI, of which approximately 60% are preventable, can lead to an additional 11 days of postoperative hospital days and two to 11 times the mortality rate of those who do not acquire an SSI (Anderson et al., 2014). SSI, which are typically defined as those that occur within 30 days of surgery but may occur up to 90 days after, are classified into three categories: superficial incisional SSI, which affects only the skin or subcutaneous tissue; deep incisional SSI, which involves deep soft tissues such as fascia or muscle; and organ/space SSI, which involves any other part of the body that was manipulated during surgery (Anderson et al., 2014).

The Surgical Care Improvement Project (SCIP) was developed to decrease SSI and develop performance measures to improve outcomes (Fry, 2008). SCIP built on previous work by the Surgical Infection Prevention Project (SIP) that identified three quality-performance measures, which related to use of prophylactic antibiotics (Fry, 2008). SCIP added three additional measures: glucose control in cardiac patients, proper hair removal before incision, and maintenance of normothermia in colorectal surgery patients (Fry, 2008). The ACOVE quality indicators also identified prophylactic antibiotics for the prevention of SSI (AGS, 2007).

These measures relate more specifically to the perioperative phase, which is discussed in Chapter 32, with the exception of glucose monitoring, which should occur for each of the first two postoperative days, with an attempt to maintain serum glucose levels below 200 mg/dL (IHI, 2012b). Compliance to appropriate antibiotic selection and administration within 60 minutes of time of incision has been associated with lower SSI rate (Cataife, Weinberg, Wong, & Kahn, 2014).

A majority of TJC (2015) National Patient Safety Goals for SSI, as well as the TJC (2013) Implementation Guide for SSI, relate to implementation of education and training of health care providers and patients/families on SSI and how to prevent them, as well as ongoing monitoring and reporting of SSI occurrences. However, other than hand hygiene, TJC provides no clear postoperative procedures for prevention of SSI. For hand hygiene, the WHO identified five key moments that require adequate hand hygiene: (a) before touching a patient, (b) before clean and aseptic procedures (which would include clean and sterile dressing changes), (c) after contact with bodily fluids, (d) after touching a patient, and (e) after touching a patient’s surroundings (Tsai & Caterson, 2014). Hand hygiene should include hand rubbing with alcohol-based products or, if hands are visibly soiled, then scrubbing with soap and water (Tsai & Caterson, 2014).

For incisional care, the CDC recommends that closed incisions, those with approximated edges after surgery, be covered with a sterile dressing for 24 to 48 hours and that dressing changes be done using a sterile technique (Mangram, Horan, Pearson, Silver, & Jarvis, 1999). Beyond 48 hours, the CDC did not provide any guidance on continued use of sterile dressings or the effects of bathing/showering (Mangram et al., 1999). For open surgical incisions, the CDC recommended that the wound should be packed with sterile moist gauze and covered with a sterile dressing (Mangram et al., 1999). Some conventional wound care regimens have specified dressing changes up to 7 days postoperatively, which could also require patient education if the patient was discharged before that time (Akagi et al., 2012). In a study by Akagi et al. (2012), the authors found that the CDC recommendation of dressing changes up to 48 hours showed no increased risk of SSI compared with a standard 7-day regimen. A Cochrane Review also found no difference in SSI risk for early dressing removal (48 hours) when compared with delayed removal (after 48 hours; Toon, Ramamoorthy, Davidson, & Gurusamy, 2013). Furthermore, early removal could result in shorter hospital stays and decreased costs (Akagi et al., 2012; Toon et al., 2013).

In addition to wound care and dressing changes, the nurse must be vigilant in assessing for signs of infection, including redness around the wound edges, warmth, tenderness to palpation, and purulent drainage from the site (Lagoo-Deenadayalan et al., 2011). If an SSI occurs, treatment may include reopening of the incision to allow for drainage and frequent monitoring for signs of systemic infection; antibiotic use is typically discouraged unless the infection becomes systemic (Lagoo-Deenadayalan et al., 2011). A wound culture will identify any infection with multi-drug-resistant organisms (MDRO). If an MDRO is the infectious agent, contact isolation precautions will be instituted along with adequate cleaning and disinfecting of equipment and the patient’s environment (TJC, 2015).

Catheter-Associated Urinary Tract Infections

Up to 25% of all hospitalized patients receive urinary catheterization (IHI, 2011a). However, studies have shown that approximately 21% of patients with urinary catheters lacked a proper indication for insertion and up to 58% of catheters that were in place were subsequently found to be unnecessary (IHI, 2011a). The risk of developing a CAUTI increases as the length of catheterization increases, with a daily UTI risk of 5% (Bhardwaj, Pickard, Carrick-Sen, & Brittain, 2012; IHI, 2011a). Magill et al. (2014) noted that 68% of all UTIs in 2011 were CAUTI. In a survey of postoperative complications following nonemergent surgery, Gajdos et al. (2013) found that UTI occurred in 4% of adults aged 60 years and older, with a 5% mortality rate for those experiencing a UTI. The occurrence of a postoperative CAUTI can result in longer lengths of stay, increased hospital costs, and increased morbidity/mortality for the older adult surgical patient (Gajdos et al., 2013; Lagoo-Deenadayalan et al., 2011). CAUTI is listed as a nursing-sensitive indicator by NDNQI (Montalvo, 2007) and is a target for TJC National Patient Safety Goals (2015).

The IHI (2011a) provides four components of care to prevent or reduce the risk of CAUTI. They include (a) avoidance of unnecessary catheterizations, (b) insertion of catheters using an aseptic technique, (c) maintenance of catheters based on recommended guidelines, and (d) daily review of catheter necessity and prompt removal. TJC’s National Patient Safety Goals (2015) address these same components. Hospitals should have specific protocols outlining the criteria for appropriate catheter insertion. For the older adult surgical client, catheterization will most likely occur in the perioperative period. However, catheters should be removed as soon as possible postsurgery to prevent infection risk. IHI (2011a) recommends developing protocols that allow nurses to remove catheters if criteria for necessity are no longer met and if there are no contraindications to removal. Additionally, automatic stop orders can be used in the EMR to promote removal within 48 to 72 hours after surgery (IHI, 2011a). The NIA Expert Panel also specified that the catheter should be removed by post-op day 3 (McGory et al., 2009). If the catheter remains in place, documentation should be provided to indicate the need for continued catheterization (IHI, 2011a). ACOVE quality indicators recommend documentation at least every 3 days indicating the continued need for use until the catheter is removed (AGS, 2007).

Involving the patient in catheter-related decision making could also lead to decreased length of catheterization. Bhardwaj et al. (2012) found that patients who underwent short-term catheterization for surgery lacked knowledge about the reason for catheterization, often did not provide consent, and were not included in the decision to remove the catheter. Patients also felt that their catheter remained in longer than was necessary because of a lack of easily accessible toileting options, even though they would have preferred to use a bedpan or bedside commode over continued catheterization (Bhardwaj et al., 2012). Therefore, the nurse should advocate for patient participation in the decision-making process for catheter removal as part of CAUTI-prevention practices.

Chapter 22, “Prevention of Catheter-Associated Urinary Tract Infection,” provides further protocols on the prevention of CAUTI in older adults. The chapter discusses proper insertion using an aseptic technique as well as evidence-based maintenance of catheters that are in place. Guidelines for proper insertion include adequate hand hygiene, use of sterile equipment and an aseptic technique, and use of as small a catheter as possible that still allows for proper drainage (IHI, 2011a). Routine maintenance should include, at a minimum, maintaining a closed, sterile drainage system; properly securing the catheter and collection bag, which should be below the level of the bladder at all times; maintaining unobstructed urine flow; and emptying the collection bag regularly, using a separate container for each patient and not allowing the nozzle to touch the collection device (IHI, 2011a).

Central Line–Associated Bloodstream Infections

Approximately 84% of the estimated 72,000 primary bloodstream infections in the United States in 2011 were central line–associated bloodstream infections (CLABSI; Magill et al., 2014). For older adults, CLABSI is associated with more than twice the mortality risk, longer lengths of stay (up to 10 additional hospital days), and increased health care costs (Kaye et al., 2014). Most CVC days, approximately 15 million in the United States, occur in the intensive care setting (CDC, 2011). However, some older adult surgical patients on step-down or medical–surgical floors may have peripherally inserted central catheters (PICC) or other tunneled lines that can also place them at risk of CLABSI. As with other HAI, nurses play an integral role in the prevention of CLABSI, which is listed as an NDNQI nursing-sensitive indicator (Montalvo, 2007) and specified as a National Patient Safety Goal by TJC (2015).

The IHI (2012a) describes five key components of its central line bundle aimed at preventing CLABSI. The components include: (a) hand hygiene; (b) maximal barrier precautions, which includes sterile operator procedures and equipment and sterile patient draping from head to toe; (c) chlorhexidine skin antisepsis before insertion; (d) optimal catheter site selection, avoiding the use of the femoral vein; and (e) daily review of line necessity and prompt removal when indicated. The CDC, in its 2011 guidelines, also recommended implementing bundle strategies, which incorporate hand hygiene and aseptic, appropriate catheter and site selection, and maximum barrier precautions. The guidelines also highlight the need for adequate education, training, and staffing in the prevention of CLABSI. The ACOVE quality indicators for vulnerable elders include documentation in the EMR of the use of maximal barrier protection.

For nursing care, the CDC (2011) specifies dressing-change regimens, which include the following:

The nurse should also replace IV administration sets at the appropriate intervals: no less than 96-hour intervals but at least every 7 days for continuous or secondary infusion tubing; within 24 hours for tubing involving blood, blood products, or fat emulsions; or every 6 to 12 hours for propofol infusion tubing (CDC, 2011). When accessing catheter hubs, needleless injectors, and injection ports, the nurse should disinfect (scrub) using an appropriate antiseptic and access the site using only sterile devices/equipment (CDC, 2011).

Other important nursing functions are to ensure that the patient is not showering or submerging the CVC site in water (adequate patient education and monitoring) and to palpate the site through an intact dressing regularly to assess for tenderness (CDC, 2011). If tenderness is noted, the dressing should be removed for full visual inspection and, if indicated, provider notification made to address possible CLABSI (CDC, 2011). ACOVE indicators specify daily documentation of examination of the site for signs of infection as well as documentation of the continued need for use (AGS, 2007). The NIA Expert Panel offers the same quality indicators as ACOVE, but also adds daily examination for swelling in the extremity on the side of line placement (McGory et al., 2009).

Mobility, Function, and Frailty

Older adults experience loss of muscle mass, muscle strength, and bone mass as they age (Bashaw & Scott, 2012). Further deconditioning can occur following periods of inactivity, such as prolonged immobility during surgical procedures and bed rest during the immediate postoperative period (Lagoo-Deenadayalan et al., 2011). Postsurgical deconditioning can slow recovery in older adults, including restoration of activities of daily living (ADL), and put the patient at increased risk of DVT, delirium, incontinence, constipation, pressure ulcers, and falls (Lagoo-Deenadayalan et al., 2011). Early mobilization has been shown to combat deconditioning, decrease length of stay, and increase discharges to home (Engel, Tatebe, Alonzo, Mustille, & Rivera, 2013).

Frailty is defined as having decreased physiological and functional reserve (Scandrett et al., 2015). Frailty has been shown to be an independent risk factor for postoperative complications, increased length of hospital stay, and discharge to a skilled or assisted-living facility after previously living at home (Dasgupta et al., 2009; Makary et al., 2010). Chapter 27, “The Frail Hospitalized Older Adult,” provides a more thorough discussion of frailty in older adult populations.

To address postoperative risks for issues with mobility and functional decline, it is imperative to develop a preoperative baseline assessment. The ACS NSQIP/AGS Best Practice Guidelines specifically address assessment of functional/performance status and frailty risk (Chow et al., 2012). If the patient is unable to perform any ADL, a full screening of ADL and instrumental ADL (IADL) should be performed (Chow et al., 2012). Performance is assessed using the Timed Up and Go Test (TUGT) and also includes inquiring about a history of falls (see the following section on Fall Prevention; Chow et al., 2012). The TUGT is performed by the patient using normal walking aids and without any assistance in the following manner (Chow et al., 2012). The patient:

If the patient takes longer than 15 seconds to complete the exercise, the patient is considered to have a high risk of falls and a more detailed gait assessment should be completed (Chow et al., 2012).

Frailty can be measured using a number of validated tools. ACS NSQIP/AGS (Chow et al., 2012) recommend the use of the Frailty Phenotype, which assesses five domains: weight loss, weakness, exhaustion, low physical activity, and slowness (Makaray et al., 2010). Each domain is scored 0 to 1 and then scores are totaled; scores of 2 to 3 indicate prefrailty and 4 to 5 indicate frailty (Chow et al., 2012). Panprese and Johnson (2014) recommend using the Braden Scale because, although it is typically used for pressure ulcer risk, its six domains of sensory perception, moisture, mobility, nutrition, activity, and skin friction and shearing characterize frailty vulnerabilities. Another reason for its use is that nurses are familiar with the tool and it is already incorporated into many EMR systems (Panprese & Johnson, 2014).

The NAI Expert Panel recommends that function and mobility screening be performed 8 weeks before surgery (McGory et al., 2009). The assessment should include the TUGT with a comprehensive assessment of mobility if it is abnormal, and assessment of hearing/visual impairment, ADL, and IADL (McGory et al., 2009). For any abnormalities, including with the TUGT, the panel recommends that a written plan be developed for postoperative care before surgery (McGory et al., 2009). Chapter 7, “Assessment of Physical Function,” provides further discussion about the assessment of physical function in older adults.

Re-enablement after surgery describes the process of returning the patient to presurgery functioning (Griffiths et al., 2014). During the postoperative period, the nurse participates with a multidisciplinary team to prevent functional decline and the development of frailty and allow for re-enablement before discharge. The team includes the nurse, nursing assistant, physician resident, physical therapist, and occupational therapist. It is imperative that each member of the team understands his or her role in patient re-enablement, as confusion has been shown to be a significant barrier to mobility and activity program implementation (Markey & Brown, 2002). Other potential caregiver and patient barriers must also be addressed. Some patient barriers include dependent behavior and daytime sleepiness; the nurse and nursing assistant as well as family members should encourage independence and discourage daytime sleeping (Markey & Brown, 2002). For further information on excessive sleepiness in older adults, refer to Chapter 26, “Excessive Sleepiness.” Caregiver barriers include scheduling conflicts and the use of equipment (i.e., IV poles and tubing, urinary catheters, and sequential compression devices [SCDs]) that make ambulation and mobility activities more complex (Markey & Brown, 2002).

A physical therapy consult should provide an early assessment of the patient to develop a mobility and strengthening plan, including the potential need for assistive devices (Hughes et al., 2013). ACOVE and the NIA Expert Panel stress that ambulation should occur by post-op day 2 and, if not, documentation should be provided in the EMR about why ambulation could not occur (AGS, 2007; McGory et al., 2009). The NIA Expert Panel further specifies that if the patient cannot ambulate, mobilization (e.g., range-of-motion [ROM] exercises) should be performed by postop day 2 and, if not, documentation should be provided about why it could not be done (McGory et al., 2009).

The nurse, nursing assistant, and occupational therapist will address the patient’s ADL and IADL. Independent performance of ADL should be encouraged, but if the patient needs assistance, the level of assistance should be documented, relayed to the occupational therapist, and communicated during handoff (Markey & Brown, 2002). If the level of assistance indicates a change from baseline functioning, a plan should be developed and documented in the EMR to facilitate re-enablement (McGory et al., 2009). A final assessment of ambulation, mobility, ADL, and IADL should also be completed and documented at discharge, with appropriate documentation provided to the skilled or assisted-living facility, home health agency, or family/caregivers, depending on the discharge destination (McGory et al., 2009). Chapter 14, “Preventing Functional Decline in the Acute Care Setting,” provides further information on preventing functional decline in the acute care setting.

Fall Prevention

In the acute care setting, up to 20% of patients fall at least once over the course of their hospitalization (IHI, 2012d). Falls are the most frequently reported adverse event in hospitals, reaching approximately 1 million per year, with 90,000 serious injuries and 11,000 deaths occurring as a result (Currie, 2008). Falls can lead to head injuries, hip fracture, reduced mobility (caused by pain or added fear of falling), longer length of stay, unplanned discharge to assisted-living facilities, and increased medical costs (IHI, 2012d). Studies have consistently identified unsteady gait, confusion, increased need for toileting, use of sedative-hypnotics, and history of falling as key risk factors for falling in an acute care setting (Currie, 2008). Although it is inconclusive whether older age is a risk factor for falls, it does place the surgical patient at greater risk of injury from a fall (Currie, 2008). NQF (2011) placed falls resulting in serious injury on its list of serious reportable events (SRE). NDNQI lists falls and falls with injury as key nursing-sensitive indicators (Montalvo, 2007). CMS (2014) lists trauma related to falls as a nonreimbursable hospital-acquired condition.

Similar to mobility and function, preoperative fall-risk assessment is critical to identifying those who may be at risk for falls and developing a multidisciplinary plan to prevent falls postoperatively. The NIA Expert Panel specifies that an assessment should be performed 8 weeks before surgery on an older adult and, if the patient has reported two or more falls in the past year or one fall with injury, referral should be made for a comprehensive preoperative fall evaluation as well as inpatient physical therapy (McGory et al., 2009). There are a number of tools that have been developed to assess fall risk, including the Morse Falls Risk Assessment Tool, the Hendrich Falls Risk Model II, or the STRATIFY instrument (Currie, 2008). Although research has demonstrated that the Hendrich Falls Risk Model II may be more robust, it is more important that assessment remains consistent from preoperative screening through discharge (Currie, 2008).

Chapter 19, “Preventing Falls in Acute Care,” provides a comprehensive discussion on preventing falls in acute care settings. A number of intervention strategies have been examined, including staff education, armband identification, bed alarms, exercise and toileting regimens, and vitamin D supplementation (Cameron et al., 2012). Although some have shown to be effective, multifaceted prevention strategies have been shown to be more effective (Cameron et al., 2012). IHI (2012d) highlights six key areas to address in its guide on preventing falls: fall risk screening on admission, injury and injury risk factors screening on admission, in-depth admission screening for any positive findings, communication and education about the patient’s fall risk, standardized interventions for those at risk for falls, and customized interventions for those at highest risk. The final three areas address postoperative care and may incorporate such interventions as signage to identify those at risk; teach-back education to patients and family members about fall risk; and rounding every hour or 2 to address the patient’s need for pain relief, toileting, and positioning (IHI, 2012d). TJC and the AHRQ have similar guidelines and also provide educational and training materials for preventing falls on their websites. If a fall does occur, ACOVE recommends that an inpatient fall evaluation should occur within 24 hours to include the presence or absence of any signs/symptoms of injury and a review of medications that could potentially contribute to a fall.

Skin Integrity

With advancing age, older adults experience thinning of the dermis, loss of collagen and adipose tissue, and decreased skin elasticity (Bashaw & Scott, 2012). As the skin becomes more friable, older adults are at increased risk for bruising, tearing, shearing, and infection, especially over bony prominences (Panprese & Johnson, 2014). If the older adult is malnourished or dehydrated, the risk of skin breakdown and pressure ulcer development increases (Bashaw & Scott, 2012). Approximately 2.5 million patients are treated for pressure ulcers each year, and about 15% of patients in hospitals at any given time have a pressure ulcer (IHI, 2011b). Pressure ulcers lead to increased morbidity (pain, delayed functional recovery, infection, and sepsis), increased length of stay, and increased hospital costs (IHI, 2011b). It is estimated that 60,000 patients die in hospitals each year as a result of complications from pressure ulcers (IHI, 2011b). Because of the nurse’s specific role in assessing and maintaining skin integrity, pressure ulcers are listed by NDQNI as a nursing-sensitive quality indicator (Montalvo, 2007). Additionally, CMS (2014) lists stage 3 and 4 pressure ulcers as nonreimbursable hospital-acquired conditions.

The IHI (2011b) identifies six essential elements for pressure ulcer prevention: (a) pressure ulcer admission assessment, (b) daily reassessment of pressure ulcer risk, (c) daily skin inspection, (d) moisture management, (e) adequate nutrition and hydration, and (f) minimization of pressure. The NIA Expert Panel dictates admission screening for pressure ulcer risk using the Braden or Norton Scales (McGory et al., 2009). This is in line with admission assessments as recommended by TJC and NQF (IHI, 2011b). The remaining five elements fall under the nurse’s purview during postoperative care. Chapter 24, “Preventing Pressure Ulcers and Skin Tears, outlines nursing protocols for preventing pressure ulcers and skin tears in older adults. Daily risk assessment should be completed using the same tool as was used on admission and should be documented in the EMR along with the visual skin inspection (IHI, 2011b). Some other key interventions include the following (IHI, 2011b):

Additional care should be focused on pressure caused by medical devices as well as caution when removing dressings, pads, tape, or leads in order to prevent skin tears (Bashaw & Scott, 2012).

The NIA Expert Panel recommends daily screening and repositioning/pressure reduction at least until the patient is ambulatory (McGory et al., 2009). Additionally, if the surgical patient has an existing stage 2, stage 3, or stage 4 pressure ulcer, a treatment plan should be outlined and documented before surgery (McGory et al., 2009). For patients undergoing cardiac surgery, it is recommended to continue skin assessment and interventions up until the postop day 5 (Pokorny, Koldjeski, & Swanson, 2003).

Prevention of VTE

Older adult surgical patients may have many factors, including age, that place them at risk of VTE, including obesity, prolonged immobility, lengthy surgery (longer than 2 hours), presence of varicose veins, and smoking history (Bashaw & Scott, 2012). VTE occurs in approximately 1 million patients each year (Dobesh, 2009). In a study of nonemergent surgeries, Gajdos et al. (2013) found that 2% of adults aged 60 years and older experienced VTE, and 10% of those with VTE died. The occurrence of VTE leads to increased length and cost of stay, and also puts the patient at risk of other potentially life-threatening complications (Dobesh, 2009). In addition, there may be significant long-term complications and related costs, often caused by recurrent VTE, postthrombotic syndrome, or pulmonary hypertension (Dobesh, 2009). According to the CMS (2014), the occurrence of VTE following certain orthopedic surgeries (e.g., total knee replacement and hip replacement) is a nonreimbursable hospital-acquired condition.

The AHRQ (2012) guidelines for VTE prophylaxis list four interventions and practices to consider: (a) assessment of VTE risk factors, (b) patient education and early ambulation, (c) mechanical prophylaxis, and (d) pharmacologic prophylaxis (AHRQ, 2012). The guidelines also address special situations, such as prophylaxis for patients with hip/knee arthroplasty and hip fracture (see Chapter 34, “Care of the Older Adult With Fragility Hip Fracture”). For VTE screening of surgical patients, AHRQ (2012) recommends the use of the Caprini Risk Assessment Model. The Caprini Model uses a checklist of factors scored as 1 point (e.g., swollen legs and acute myocardial infarction), 2 points (e.g., age 61–74 years and central venous access), 3 points (e.g., age 75 years or more and history of DVT), or 5 points (e.g., stroke within the past month); the scores for the checked boxes are then summed for an overall Caprini score (Caprini, 2009).

Mechanical prophylaxis measures include early ambulation and the use of SCDs (AHRQ, 2012). Compression stockings have been shown to reduce VTE risk when used effectively, but are not necessarily recommended because tight fit can impair circulation and lead to additional complications (Bashaw & Scott, 2012). The BGS cautions against the use of compression stockings in older adults but if they are used, skin integrity needs to be regularly and carefully monitored (Donald, 2010). ROM exercises can also be effective if the patient is unable to ambulate (Bashaw & Scott, 2012). Inferior vena cava (IVC) filters may be placed in critically ill adults to prevent pulmonary embolism related to DVT; however, AHRQ (2012) does not recommend their use. Pharmacologic prophylaxis measures include the use of low-molecular-weight heparin (LMWH) or low-dose unfractionated heparin (LDUH). However, the BGS purports that major bleeding risk may outweigh VTE risk in older adults, thus use of LMWH or LDUH may not be the best choice for prophylaxis (Donald, 2010).

TABLE 33.3

VTE Prophylaxis

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