Geriatric patients may present to the perioperative environment for urgent or emergent surgery because of the clinical signs and symptoms associated with a life-threatening illness.⁴^,⁹ Common urgent problems include intestinal obstruction, ruptured diverticula, and orthopedic fractures. Vascular incidents such as ruptured aneurysm or bleeding from the gastrointestinal tract necessitate immediate surgery. Sudden arterial occlusion that is unresponsive to chemical treatment is also considered emergent.

The postoperative phase of care is important to the well-being of the geriatric patient. Maintaining or improving the preoperative level of wellness should be considered a primary expected outcome. A preoperative functional assessment is the foundation of the plan of care.³^,¹⁰ Baseline parameters vary to a high degree among individuals, and all patients do not age at the same rate. Some patients are very young at 70 years of age, and some are very old. The difference should be assessed, and optimal outcomes should be identified for each geriatric patient. Influences on the level of functioning include physical ability, psychosocial support and resources, and environmental interactions.

Functional assessment

Functional assessment can serve multiple purposes. In the preoperative phase, the plan of care includes the patient’s unique differences, family involvement, resources, and level of independence. Many of these data are obtained with observation, interview, and lifestyle questionnaires.¹⁰ The information may be obtained from the patient, family, or significant others.

Many aspects of the patient’s unique nature are easily discerned during the preoperative interview. Adequate time should be allowed for the interview (at least 30 minutes) so the patient has time to reflect and respond. Reaction time slows with age. The nurse should listen for subtle modifications or inconsistencies in the patient’s information regarding health status. Sensory deficits should be considered, and the environment should be modified as needed during the interview. The nurse should establish rapport and have respect for the patient’s dignity.

During the intraoperative phase, the functional assessment may allow for anticipation of needed supplies or additional help to accommodate the patient’s needs. The patient’s physical capabilities allow some independence in self-care. Patients tend to regress when they are not permitted to do things for themselves. A self-care deficit takes place when a patient feels the loss of independence while restrained on an operating bed. The freedom to assist with the transfer as able from the transport stretcher to the operating bed gives patients a sense of participation in their own care. Maintaining a high level of self-esteem and value enables patients to prevent emotional regression or loss of control.

Activities of daily living

During the course of a normal day, an individual performs self-maintenance tasks and interacts with the environment. The ability to perform these activities of daily living (ADLs) is influenced by health status, emotions, mental clarity, and mobility. Limitations in performing these activities may be permanent or temporary, and many of the temporary limitations can be eliminated with medical or surgical treatment.

The perioperative nurse should assess the activity level of the geriatric patient. Advance preparations may need to be considered before the patient can undergo a surgical procedure. Because of identified physical limitations, special positioning or additional padding may be needed in combination with some form of communication assistance at the time the surgical procedure is performed. The functional baseline is the patient’s capacity to perform self-care (e.g., feeding, bathing, toileting). Any deviation from the baseline assessment in the postoperative phase should be recorded and reported to the patient’s physician.

Functional activities

The activity patterns of geriatric patients reflect many aspects of their daily lives. Their ability to feed, bathe, and toilet themselves is one way to measure physical and psychological wellness. Basic daily activities such as grooming and dressing may be indicators of the level of the patient’s involvement with his or her own care.

The range of self-care activities depends on various factors, such as whether the patient is active and mobile enough to shop for food and prepare meals or is living in assisted housing where these services are provided. The ability to provide self-care should be assessed preoperatively to evaluate the outcome in the postoperative phase (i.e., resumption of activity level).

Functional capacity

A basic assessment of physical strength and endurance indicates whether the patient will be able to move from the transport stretcher to the operating bed. A patient who is weak or disabled by arthritis will need assistance or a total lift device. A patient who is visually impaired also may need assistance.

Communication through speech and hearing is vital to establishing the cognitive baseline. A hearing deficit or aphasia could be mistaken for a cognitive impairment. The patient who uses a hearing-assist device should be permitted to wear it to the OR and, if possible, throughout the surgical procedure. It should be in place during emergence from anesthesia so the patient can hear requests to deep breathe or move extremities.¹⁵

The patient’s sensory ability should be assessed. Tactile sensation dulls with age, and a patient’s inability to feel external stimuli may lead to an inadvertent injury. Any sensory deficit, including a visual or hearing impairment, should be documented in the plan of care. The administration of a general anesthetic alters the tactile assessment parameter during the intraoperative phase of care.

As the patient emerges from anesthesia, the postanesthesia recovery nurses use the baseline assessment to measure the progress of the patient in the postoperative phase.¹¹^,¹⁶ Because of the interdependent aspects of the central nervous system with other vital physiologic systems, the evaluation of expected outcomes should include a sensory assessment.

Cognitive ability should also be assessed.¹⁵ The patient may be required to comprehend a command that is vital to the perioperative experience. A cognitive deficit may be of organic origin or result from a language barrier. Regardless of the reason, an inability to understand can cause anxiety for the patient and the caregiver. Alertness, short-term memory, capabilities to concentrate and problem solve, and motivation toward self-care are areas of cognition that influence the ability of the geriatric patient to adapt to illness and recovery. A patient who is cognitively impaired experiences disorientation and responds inappropriately to the environment. The impairment may be temporary but often is prolonged after anesthesia. Cognitive impairment also may be a permanent or chronic condition.

The patient’s psychological state should be assessed preoperatively, because a change in mood or temperament may indicate an unexpected outcome caused by an injury or a physical problem resulting from the surgical procedure. Dementia, delirium, and emotional depression are common in older adults. Sudden withdrawal or a change in affect should be investigated promptly.