Question 1

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 2

An 87-year-old woman 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 1 day earlier by telephone and has documented her preliminary nursing interventions for the intraoperative nurse.Which nursing action by the perioperative nurse will assist the patient to maintain accurate perception and interpretation of environmental and sensory stimuli throughout the perioperative period?

Accepted Answer

Changes in vision,hearing,taste,smell,and touch may influence the patient's response to care.If preadmission communication is done,the perioperative nurse may ask about vision and hearing and remind patients to bring their glasses and hearing aids to the facility.Of importance in the OR is an awareness of the older person's difficulty in adapting to changes in light.Moving patients from a dimly lit holding area to the bright lights of the OR can cause momentary "blindness."

Question 3

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 tachypneic,her tongue and mucous membranes of her mouth are dry,her speech is slurred,and she is confused.Her surgical unit nurse states that the patient's bowel prep the night before was successful.The patient states that she needs to vomit.The anesthesia provider tries to find a good vein for an intravenous (IV)access and asks the perioperative nurse to look for a possible vein on the patient's other arm as the left arm veins are flat.Based on these conditions,what nursing diagnosis is the patient presenting?

Accepted Answer

The patient'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 4

An ethical consideration with older surgical patients centers on the dilemma of do not resuscitate (DNR)orders.When considering the decision to maintain or suspend DNR orders prior to surgery,the guiding principle should be to:

Accepted Answer

The organization's policy must give the patient a voice in the intraoperative area.Even though the patient may have made end-of-life decisions,the fact that the patient has signed the surgical informed consent implies that he or she seeks to improve quality of life,which is incompatible with withholding cardiopulmonary resuscitation (CPR).The guiding principle in the decision to maintain or suspend DNR orders should be respect for the patient's autonomy.Elderly patients have the right to participate in the process for making end-of-life decisions.

Question 5

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.Which 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.

Question 6

Minimally invasive surgeries continue to increase in popularity.It seems logical that older patients would benefit from smaller incisions that produce less postoperative pain,atelectasis,and ileus.However,regardless of age,every surgical procedure possesses a certain amount of risk.Which minimally invasive surgical component can present hemodynamic and pulmonary consequences in patients with severe cardiac or pulmonary disease?

Accepted Answer

Any procedure,even those considered low risk,can have poor outcomes,depending on the patient's overall condition.The extent of hemodynamic and pulmonary consequences of CO₂ pneumoperitoneum is still unclear.In patients with severe cardiac or pulmonary disease,recommendations include invasive monitoring to maintain adequate volume loading and use of alternate gas sources or gasless techniques.

Question 7

A retired perioperative nurse celebrated her 100th birthday with family and friends.Which age group is she now a member of?

Accepted Answer

The retired perioperative nurse is now considered "the elite-old." The aging population is categorized accordingly:
65 to 74 years of age: the young-old
75 to 84 years of age: the middle-old
85 to 99 years of age: the old-old
100 years of age or more: the elite-old

Question 8

There are many important considerations related to the extent of surgical treatment.Therefore,the decision for surgery relies heavily on the patient's physical status at the time of surgery and on the extent of disease progression.When treating patients who are nearing the end of life,attention should promote:

Accepted Answer

When treating patients who are nearing the end of life,attention should shift from solely maximizing survival to maximizing the quality of life and dignity while minimizing suffering.Early identification of problems with aggressive,preventive surgical treatment is considered more appropriate than waiting for problems to develop.

Question 9

Age-related skin changes include a thinning epidermis and decreased subcutaneous fat and elasticity.Which skin-related actions should the perioperative nurse take with regards to the older patient?

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 common.Therefore,review risk factors for intraoperative pressure ulcer development; assess potential pressure areas before anesthesia induction and positioning,noting bruises,sores,skin tears,rashes,lesions,and pressure ulcers; avoid friction and shearing forces by using a four-person lift,a lift sheet,or lifting device when transferring the patient to or from the OR bed and turning the patient to the desired surgical position; prevent wrinkling of linen under the patient or positioning devices; place electrosurgical dispersive pad in the most appropriate area while avoiding bony prominences; avoid pooling of solutions under the patient; apply tape sparingly to prevent skin injury; consider paper tape or a nonadherent dressing on fragile skin; position the patient; and evaluate for signs and symptoms of physical injury to skin and tissue.

Question 10

When considering surgery for an elderly patient,the risk of surgery should be measured against the risk of not operating,and the expected postoperative quality of life.Which important factors should be evaluated in the decision making?

Accepted Answer

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 11

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.Which of the following would be appropriate questions for the perioperative nurse to ask during the preoperative interview and assessment?

Accepted Answer

The common use of nonsteroidal anti-inflammatory 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 12

Hyperthyroidism is the great masquerader in the elderly population and can easily be missed in patients older than 60 years.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.Following surgery,the perioperative nurse must also be aware of the possibility of a hyperthyroid storm that can be precipitated by the stress of the procedure,and anesthesia induction.

Question 13

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.Which interventions will the perioperative nurse provide in positioning older patients in the OR?

Accepted Answer

The nurse takes extra care in positioning elderly patients in the OR,ensuring appropriate padding and joint protection.Actions include assessing pain and skeletal/range-of-motion limitations before anesthesia induction and positioning; assessing potential pressure areas before anesthesia induction and positioning; placing safety strap above the knees and preventing undue pressure on the popliteal space and heels; ensuring that arm boards are maintained at less than a 90-degree angle; providing adequate padding to protect potential pressure areas; maintaining body alignment within restrictions imposed by chronic pain and musculoskeletal age-related changes; using gentleness during positioning and turning; and keeping the head and neck in a comfortable position that limits hyperextension.

Question 14

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 common digestive condition may result from delayed stomach emptying?

Accepted Answer

Esophageal mobility is reduced as a person gets older,and a more relaxed cardiac sphincter slows emptying in the esophagus,increasing the prevalence of esophageal reflux.

Question 15

Factors in the evaluation of the older surgical patient are assessing cognitive ability and capacity,risk for postoperative delirium,screening for alcohol and substance abuse,documentation of functional status including falls,nutritional status,and understanding of treatment goals and expectations and their family/social support system.The Mini-Cog test can be used as a tool for:

Accepted Answer

Key factors in the evaluation of the older surgical patient are assessing cognitive ability and capacity,existence of depression,risk for postoperative delirium,screen for alcohol and substance abuse,cardiac and pulmonary evaluations,documentation of functional status including falls,baseline frailty score,nutritional status,medication history,diagnostic tests,and understanding of treatment goals and expectations and their family/social support system.The Mini-Cog test can be used as a tool for assessing cognitive impairment and indications for postoperative depression or delirium.

Question 16

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

Accepted Answer

As part of history taking,the nurse should determine if symptoms such as dysuria (painful urination),micturition (straining at urination),and hematuria (blood in the urine)exist.

Question 17

Which 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: try not to startle the person when starting a communication; approach them from the front,knock,or announce your presence by calling the person's name; approach patients who have a left-sided hemiparesis from the right side and vice versa; identify yourself.

Question 18

Age-related changes cause decreased blood flow to the kidneys with a resultant decrease in nephron function.Which 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 19

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 the American Geriatrics Society,the occurrence of perioperative mortality in geriatric surgical patients is influenced by three factors-emergency surgery,the site of the surgery,and the presence of coexisting disease.Presence of coexisting disease is quantified according to the 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.Surgical risk in elders increases dramatically when the surgery is of an emergent nature.Major vascular,intrathoracic,and intra-abdominal procedures are reported to have a higher surgical risk than other surgical procedures in elders.

Question 20

The perioperative nurse assigns the patient scheduled for cataract surgery the following nursing diagnosis: Ineffective Breathing Pattern attributable to the patient's chronic lung disease.The nurse also documents a secondary nursing diagnosis: Risk for Injury related to increased intraocular pressure.Which 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.

Quiz 27: Geriatric Surgery

An ethical consideration with older surgical patients centers on the dilemma of do not resuscitate (DNR) orders.When considering the decision to maintain or suspend DNR orders prior to surgery,the guiding principle should be to: