Question 1

Changes to the elderly person's skeleton,such as the loss of bone mass,contribute to skeletal instability and make fractures of the hip,rib,distal radius,and vertebrae very common.What special intervention will the perioperative nurse provide,in terms of additional attention and care,in one of the following nursing actions?

Accepted Answer

Extra care in positioning patients in the OR should be taken with the elderly patient,ensuring appropriate padding and joint protection.

Question 2

Martha Boyer,an 82-year-old woman with a displaced intertrochanteric fracture of the upper femur,is scheduled for an open reduction and internal fixation of her right hip.Martha had been scheduled for a total hip replacement for degenerative joint disease before this injury.The perioperative nurse assists with positioning Martha's affected hip and positions the other leg and her arms with equally as much care,using gentle handling,padding,and natural range of motion.In addition to Martha's osteoarthritis,what is the nurse's concern with positioning Martha's other limbs?

Accepted Answer

Osteoporosis is the most obvious skeletal change that occurs with advancing age.Degenerative joint disease (osteoarthritis)and inflammatory polyarticular disease (rheumatoid arthritis)are the primary indications for total joint replacement in the hip and knee.Age-related changes in bone increase the prevalence of displaced femoral and intertrochanteric fractures of the upper femur.Because the usual cause of death in patients with upper femur fracture is pulmonary embolus,surgery is designed to relieve the severe pain,allow movement in and out of bed,and return the patient to his or her former environment as quickly as possible with minimal debilitation.

Question 3

Age-related skin changes include a thinning epidermis and decreased subcutaneous fat and elasticity.What special consideration will the perioperative nurse provide,in terms of additional attention and care,in one of the following nursing actions?

Accepted Answer

The skin loses elasticity and subcutaneous fat and becomes more prone to shear force and pressure injury.Because of the thinness of the skin and small vessel fragility,bruising and hemorrhaging are quite common.

Question 4

Ruth Calaveras is an 87-year-old woman who has been scheduled for a right cataract extraction with intraocular lens implant of her right eye.She also has a cataract in her left eye and is hearing-impaired in both ears.The perioperative nurse conducted a preliminary nursing assessment of Ruth 1 day earlier by telephone,and has documented her preliminary nursing interventions for the intraoperative nurse.What nursing action by the preoperative nurse will assist Ruth to maintain accurate perception and interpretation of environmental and sensory stimuli throughout the perioperative period?

Accepted Answer

Disturbed sensory perception (visual or auditory)is related to removal of eyeglasses or hearing aid in the OR secondary to age-associated changes in sensory organs.If the patient uses an assistive sensory device (e.g.,hearing aid,eyeglasses),leave it in place as long as possible.Provide necessary information before removing assistive device.Speak slowly and distinctly in a low-pitched,clear voice,frequently rephrasing and verifying communication.Prepare the patient for changes in light intensity,and allow time to adapt to lighting changes.

Question 5

Impaired nutritional status is highly prevalent among the elderly;as many as 12% of men and 8% of women in the healthy geriatric population are considered undernourished.During the preoperative assessment and interview,what information will the perioperative nurse review,in addition to a thorough assessment including body mass index and Mini Nutritional Assessment?

Accepted Answer

Higher rates of surgical complications and increased postoperative mortality have been observed in patients with poor nutritional status,as determined by a low body mass index,weight loss,a low preoperative serum albumin level,or a low Mini Nutritional Assessment score.

Question 6

Hyperthyroidism is the great masquerader in the elderly population and can easily be missed in patients older than 60 years.It can be severe and even life-threatening.An important assessment point during the preoperative interview,that could influence the positioning for the surgical procedure,is based on which true statement?

Accepted Answer

Hyperthyroidism may also cause osteoporosis.Almost any condition that can make a person ill can cause euthyroid syndrome;therefore elders are more susceptible because of their co-morbid conditions.Medication to suppress hormone secretion by the gland,surgery to remove the hyperfunctioning tissue,and use of radioactive iodine (RAI)to destroy the gland are the three treatment options.Following surgery,the perioperative nurse must be aware of the possibility of a hyperthyroid storm that can be precipitated by the stress of the procedure,systemic infections,and anesthesia induction.

Question 7

Elderly patients have an increased tendency for slower metabolism,multiple chronic diseases,and a decreased reserve capacity of their organs to respond to stress,when compared to younger patients.When considering the decision for surgery,the risk of surgery should be measured against the risk of not operating,and the expected postoperative quality of life.What important factors should be evaluated in the decision-making? Select all that apply.

Accepted Answer

A frequent mistake is to compare the risk in elderly patients with that of younger patients.Surgical intervention and management should be tailored to the patient's symptoms,overall functional and health status,and the predicted advantage of palliative intervention.Important factors that need to be evaluated are disease course versus life expectancy,state of independence,personal motivation,and surgical risk versus nonoperative management.

Question 8

The occurrence of perioperative mortality in geriatric surgical patients is influenced by several evidence-based factors.Select the patient most at risk for perioperative mortality.

Accepted Answer

According to Kim and Zenilman (2007),the occurrence of perioperative mortality in geriatric surgical patients is influenced by the presence of co-existing disease,emergency surgery,and site of surgery.Presence of co-existing disease:This is quantified according to the American Society of Anesthesiologists (ASA)Physical Status Classification.Patients with an ASA status of IV or V are consistently found to have greater mortality than those with a physical status of I or II.Emergency surgery:Surgical risk in elders increases dramatically when the surgery is of an emergent nature.Site of surgery:Major vascular,intrathoracic,and intraabdominal procedures are reported to have a higher surgical risk than other surgical procedures in elders.

Question 9

Age-related changes cause decreased blood flow to the kidneys with a resultant decrease in nephron function.What condition is created from the cumulative effect of the multiple drugs that the elderly patient will receive during the perioperative phase?

Accepted Answer

During the perioperative phase of the patient's hospital stay,the greatest number and variety of drugs are given;the cumulative effect increases the chances for adverse and consequential results.

Question 10

Wilbur Jenkins,a 92-year-old man,is scheduled for emergency surgery for a strangulated scrotal hernia.He is thin and frail with a preoperative body temperature of 97.2° F.His skin is pink and he is not shivering even though he states that he is cold.The perioperative nurse and the anesthesia provider have planned for Wilbur's hypothermia before he was transferred to the OR.What therapeutic measures will they implement to raise and maintain his core body temperature?

Accepted Answer

Use active warming intraoperatively by applying a forced air-warming system.Devices such as warmed blankets or forced air-warming blankets are highly recommended,particularly when a lengthy surgical procedure is expected.Increasing the ambient OR temperature will help stabilize the effects of heat loss.Warm blankets,room temperature,and warm fluids will maintain normothermia once established.

Question 11

As a person ages digestive secretions decrease,mucus becomes thicker (causing dysphagia),and saliva becomes more alkaline.Decreased peristalsis and gastric motility,resulting in muscle tone loss,will cause delayed stomach emptying.What perioperative concern may be influenced by this age-related digestive condition?

Accepted Answer

These factors are of particular importance for assessing the patient's response to preoperative,anesthetic,and postoperative medications:relaxation of esophageal muscle tone,increasing the prevalence of esophageal reflux,decreased saliva production and gastric secretions,and bowel dysfunction from decreased peristalsis.

Question 12

During the preoperative assessment and interview with a patient scheduled for a transurethral resection of the prostate (TURP),the perioperative nurse notes that the patient has an inguinal hernia.What would be an appropriate statement that the nurse might make to the patient?

Accepted Answer

The elective repair of inguinal and femoral hernias is strongly advised because of the risk of incarceration with subsequent emergency surgery.When elective,the operation may be performed as an ambulatory procedure.Laparoscopic techniques for hernia repair make this approach one that may not be advisable in elders because of the necessity for general anesthesia.In elderly men the co-existence of inguinal hernia and prostatism is fairly common.Depending on the size of the prostate,the hernia repair should be postponed until after the prostate surgery.

Question 13

Anita Gergen,an 83-year-old woman admitted for an abdominal perineal resection for early sigmoid cancer,has a recent history of a 4% weight loss.On admission to the OR she is tachy-pneic,her tongue and mucous membranes of her mouth are dry,her speech is slurred,and she is confused.Her surgical unit nurse states that Anita's bowel prep the night before was successful.Anita states that she has to vomit.The anesthesia provider tries to find a good vein for an intravenous access and asks the perioperative nurse to look for a possible vein on Anita's other arm as the left arm veins are flat.Based on these conditions,what would be Anita's presenting nursing diagnosis?

Accepted Answer

Martha's fluid volume deficit is due to her NPO status and bowel prep in addition to other age-related factors and possibly her primary surgical diagnosis.Since her surgery has not yet begun,her deficit is not related to intraoperative causes.

Question 14

The most common causes of acute abdominal complaints in older patients are biliary tract disease,intestinal obstruction,GI hemorrhage,hernia,diverticulitis,and appendicitis.Common abdominal procedures in people older than 65 years include cholecystectomy,lysis of adhesions,appendectomy,and partial excision of the small bowel.Many important clinical signs of abdominal disease may be less obvious in the elderly patient.What would be an appropriate question for the perioperative nurse to ask during the preoperative interview and assessment?

Accepted Answer

The common use of nonsteroidal antiinflammatory drugs (NSAIDs)may mask symptoms or even predispose elderly patients to acute abdominal disease.The age-group older than 65 years has seen an increase of ulcer disease.Many believe that the higher incidence of Helicobacter pylori infection,prevalent use of NSAIDs,and the prevalence of cigarette smoking in elders account for the age-related differences.Up to 80% of peptic ulcer-related deaths occur in patients older than 65 years.

Question 15

What action is considered a best practice when communicating with geriatric patients with cognitive impairments?

Accepted Answer

When communicating with elderly adults who have cognitive impairments,perioperative nurses and surgical technologists should consider the following strategies:approach from the front,knock on the door,or announce your presence by calling the person's name;identify yourself;pay attention to the emotional context of conversation;treat the person as normally as possible.

Question 16

A number of screening tools have been developed to accurately establish biologic age.One tool,the Comprehensive Geriatric Assessment (CGA),is a multidimensional evaluation that scrutinizes medications,functional ability,co-morbid conditions,cognitive ability,mental function,nutritional status,and socioenvironmental factors.In geriatric medical studies,the CGA has been valuable in providing a metric for describing healthy aging and:

Accepted Answer

The CGA may be used both to identify at-risk individuals and to guide interventions.In geriatric medical studies the CGA has been found to be potentially beneficial in reducing the incidence of hospitalization,falls,delirium,and readmission.It is predictive of both morbidity and mortality in older patients.When evaluated as a screening tool in the geriatric community,it has been shown to detect new and unsuspected problems in 76% of elderly persons living at home.

Question 17

The predominant reason for urologic surgery in elderly men is benign prostatic hypertrophy (BPH).What appropriate assessment question would the perioperative nurse ask the patient scheduled for a TURP during the preoperative interview?

Accepted Answer

As part of history taking,the nurse should determine if symptoms such as dysuria,straining at micturition,and hematuria exist.

Question 18

The perioperative nurse,Lynne,assigns the patient scheduled for cataract surgery the following nursing diagnosis:Ineffective Breathing Patterns attributable to the patient's chronic lung disease.Lynne also documents a secondary nursing diagnosis:High Risk for Injury related to increased intraocular pressure.What potential event can result in this secondary nursing diagnosis?

Accepted Answer

Patients with chronic lung disease who are lying in the supine position may experience coughing,which can increase intraocular pressure and jeopardize the outcome of the surgery.Because elderly patients may have concurrent systemic disease,even a low-stress procedure should not be treated lightly.Age-related changes,such as hearing loss and musculoskeletal disease,may pose a challenge during ophthalmic surgery because the patient must lie still for long periods and be able to follow verbal instructions.

Question 19

Gregorio Halverson is an 82-year-old diabetic patient with several other co-morbidities in addition to recent withdrawal from alcohol after he was admitted for emergency bowel obstruction surgery.He is both hearing-impaired and visually-impaired.His wife states that Gregorio has only an eighth-grade education and has occasional bouts of depression.The anesthesia provider classified Gregorio as an ASA IV for his surgery.He is now postoperative day 1,in the ICU,and exhibits confusion and delirium.His presentation suggests disorganized thinking,pain,and an acute onset of change in mental status.What risk reduction strategy before Gregorio's surgery might have provided substantial information for the care team to proceed with implementing corrective measures?

Accepted Answer

It is of pivotal importance to determine the patient's interpretation of pain in the assessment phase.The following mnemonic can be used for assessing pain in demented and nonverbal elders:
B:What Behaviors did you see?
O:How Often did the behaviors occur?
D:What was the Duration of behaviors?
I:How Intense were the behaviors?
E:How Effective was the treatment,if given?
S:What made the behaviors Start or Stop?
Recognize that older adults are at great risk for undertreated pain.

Question 20

Perioperative nurses caring for older adults must consider factors that affect the choice of medications and the effects of those medications on this population.Physiologic changes may affect the absorption,distribution,metabolism,and excretion of medications.What statement about medication metabolism is true?

Accepted Answer

Changes in metabolism include decreased liver size,decreased hepatic blood flow,decreased liver enzyme activity,decreased renal blood flow,and reduced glomerular filtration rate,leading to slower excretion times for medications and allowing serum drug levels to rise.

Quiz 26: Geriatric Surgery

Age-related skin changes include a thinning epidermis and decreased subcutaneous fat and elasticity.What special consideration will the perioperative nurse provide,in terms of additional attention and care,in one of the following nursing actions?

The occurrence of perioperative mortality in geriatric surgical patients is influenced by several evidence-based factors.Select the patient most at risk for perioperative mortality.

Age-related changes cause decreased blood flow to the kidneys with a resultant decrease in nephron function.What condition is created from the cumulative effect of the multiple drugs that the elderly patient will receive during the perioperative phase?

During the preoperative assessment and interview with a patient scheduled for a transurethral resection of the prostate (TURP) ,the perioperative nurse notes that the patient has an inguinal hernia.What would be an appropriate statement that the nurse might make to the patient?

What action is considered a best practice when communicating with geriatric patients with cognitive impairments?

The predominant reason for urologic surgery in elderly men is benign prostatic hypertrophy (BPH) .What appropriate assessment question would the perioperative nurse ask the patient scheduled for a TURP during the preoperative interview?