Chapter 33 Acute Care

Introduction Acute care and the older adult population Higher rates of hospitalization Longer length of stay (LOS) Significant consumers of outpatient hospital services Age-related changes increase the risk of injuries, infections, and complications Older adults have unique care needs while hospitalized

Risks Associated with Hospitalization of Older Adults Decreased functional status Nosocomial infections Iatrogenic complications Delirium, falls, pressure ulcers, dehydration, incontinence, constipation, and loss of functional independence

Question Is the following statement true or false? Many older adults who have lived independently in their homes prior to hospitalization are not discharged with the same level of function and may require nursing home transfer.

Answer True Rationale: Many older adults who have lived independently prior to hospitalization are discharged with a significant decrease in functional status. This decline is related to effects of aging, risk for nosocomial infections, and iatrogenic complications. Rather than being discharged to home, they may require transfer to a nursing home.

Nursing Interventions to Minimize Risk and Promote Optimal Function Assessment to identify problems and risks Early discharge planning Encouragement of independence Monitoring of medications Prevention of complications Environmental safety protections Education

Surgical Care More adults of advanced age are undergoing surgical procedures Independent functional status and quality of life (QOL) can be improved Age-related changes alter normal surgical procedures in this population

Surgical Care (cont.) Special risks for older adults Smaller margin of physiologic reserve Less ability to adapt to physiologic changes Age changes can cause greater risk of complications Proactive strengthening of capacities Nursing diagnoses

Surgical Care (cont.) Preoperative considerations Sensitivity to fears of older adults Understanding of how surgical procedures have advanced Reassurance and support Patient education regarding what to expect before, during, and after the procedure Review of medications Preoperative screening completed

Question Which of the following herbal medications may have an effect on blood clotting and must be documented in the medical record prior to any surgical procedure? Garlic Ginkgo biloba Black cohosh Rose hips

Answer B. Gingko biloba Rationale: Because cardiac and pulmonary functions can be altered by certain drugs, it is important to make sure this information is communicated to the physician. It is important to know about herbal medications that the patient may be using because some—such as ginseng and gingko biloba—can affect clotting.

Surgical Care (cont.) Operative and postoperative care considerations Use of anesthetics in older adults Prolonged surgery discouraged Careful positioning Close monitoring of body temperature Infection control measures

Surgical Care (cont.) Operative and postoperative care considerations (cont.) Close observation and monitoring of vital signs Evaluation of the potential for shock and hemorrhage including blood loss Assessment for hypoxia, urinary output, fluid and electrolyte balance, and infection Strict documentation of intake and output Relief of pain is essential

Surgical Care (cont.) Operative and postoperative care considerations (cont.) Attention to nutritional status Maintaining regular bowel and bladder elimination Keeping joints mobile Interventions to promote mobilization and prevent postoperative complications

Question Is the following statement true or false? Older adults may demonstrate restlessness as the primary symptom of hypoxia after surgery.

Answer True Rationale: Although not fully conscious after surgery, the older person may demonstrate restlessness as the primary symptom of hypoxia. It is important that this restlessness not be mistaken for pain; administration of a narcotic could deplete the body’s oxygen supply even more.

Emergency Care Occurrence is often because of age-related changes that lower resistance and increase the risk of injury and illness Atypical presentation of disease that complicates diagnosis More difficult to treat and stabilize Greater risk of complications and death

Emergency Care (cont.) Goals guiding nursing actions Err on the side of safety Obtain necessary diagnostic tests Emergency conditions Nursing interventions

Infections Factors responsible for the high risk of infection in older adults Atypical presentation of symptoms Abrupt, unexplained change in physical or mental function Leading causes of infection-related deaths Urinary tract infection (UTI) Bacterial pneumonia Measures that prevent infections

Question Is the following statement true or false? Gerontological nurses should suspect an infection when there is any abrupt, unexplained change in physical or mental function in the older adult.

Answer True Rationale: Infections in older adults develop more easily and are more difficult to identify early because of altered symptomatology. Gerontological nurses should suspect an infection when there is any abrupt, unexplained change in physical or mental function in the older adult.

Discharge Planning for Older Adults Early and competent discharge planning is essential Goals: prevent complications, reduce risk for re- hospitalization, and minimize stress Factors influencing postdischarge outcomes Interdisciplinary geriatric team function Discharge plans must address family and caregiving needs