The population of the United States is getting older. That is no secret to anyone, especially to the orthopaedic nurse. Older adults utilize a large percentage of the resources in the healthcare system. However, our knowledge base for dealing with geriatric nursing care issues is frequently inadequate. These journal club articles deal with some topics that can have major implications for the older client.
Mentes, J. (2006). Oral hydration in older adults.American Journal of Nursing, 106(6), 40-49, quiz 50.
Fluid balance is essential for healthy living no matter what the age of the individual. Body fluid levels are a balance between intake and output. However, physiological changes that are a normal part of aging can predispose the older adult to dehydration, where the phenomena progress quickly and may result in dangerous effects if not recognized and treated. Older adults undergoing diagnostic procedures, those having prolonged diarrhea or constipation for a variety of reasons, and hospitalized patients with multiple co-morbid conditions are at great risk. Disease processes such as pneumonia can lead to emergency situations of dehydration for an older adult.
In this article, Mentes cites research that proposes that community-dwelling elders are no different than younger adults in their need for and consumption of fluids. On the contrary, she cites one study that indicates that older adults admitted to the emergency room had a 48% rate of dehydration; 88% of these older adults were living independently at home.
With the progression of aging, multiple processes occur that increase the risk of dehydration for the older client, including (a) a decreased appreciation of thirst as a sign of fluid need; (b) changing ratios of body fat and muscle, where decreased muscle mass means decreased intracellular fluid volume; (c) declining kidney function resulting in diminished ability to concentrate urine with a greater loss of fluid than in younger adults; (d) medication use that affects fluid level balance; (e) changes in mobility and independence that hamper procurement of fluids when needed; and (f) cognitive changes that alter the ability to remember to take fluids.
Nurses need to be aware of the changes that occur with the aging process and proactively include remedies and treatments for dehydration in nursing care plans. Mentes offers many strategies for preventing dehydration for nursing home patients who are extremely vulnerable to dehydration. Orthopaedic nurses need to be very cognizant of dehydration needs of patients who undergo surgery, especially if delays are encountered for surgical procedures. Careful monitoring of intake and output, assessing urine color, checking blood urea nitrogen and creatinine levels, looking for distended neck veins, and monitoring shortness of breath and confusion should be part of daily routines for checking fluid balance. This author provides a simple suggestion for nursing care-put fluids where older patients can see and reach them. Dehydration, which can lead to increased falls in older orthopaedic patients, may be averted with a glass of fluid within easy reach of the patient.
Jacoby, S.F., Ackerson, T.H., & Richmond, T.S. (2006). Outcome from serious injury in older adults.Journal of Nursing Scholarship, 38(2), 133-140. PMID: 16773916.
There is little geriatric or nursing research about older adults who have serious injuries resulting from trauma. These authors reviewed the published peer-reviewed literature between 1996 and 2005, which yielded only 27 articles that focused on the physical outcomes of traumatic injuries with older adults. The most common areas of injury for older adults include (a) falls after the age of 75; (b) pedestrian-vehicle accidents; and (c) motor vehicle accidents for those less than 75 years of age. All of these injuries have implications for orthopaedic nurses who are caring for an increasing number of older adults. The review of the published studies indicated a major gap in research to assist nurses in planning care for these patients in the posttraumatic phase. The care of the older adult, which may differ due to such complex areas as decreased physiological resilience, frailty, decreased compensatory mechanisms, increased number of comorbid conditions, or polypharmacy, will contribute to poorer outcomes for these older orthopaedic patients.
What was enlightening were the mortality rates of older adults in the short-term and the long-term phases of care. Short-term survival after a traumatic injury ranged from 4 to 38.8%, with larger sample size studies demonstrating 10% mortality. As can be expected, older adults had poorer outcomes than younger adults with similar injuries. However, one limitation of the studies was the inconsistent definition of "older adults." As a result, the ages of patients included in the studies had a wide range, making comparisons between and among the studies difficult. Because the majority of these studies were conducted after the patients had been discharged (retrospective), no information was available about the patients preinjury assessment, making it difficult to look at postinjury quality of life and functional status.
How can this information be applied to clinical nursing for orthopaedic patients? Because there is very little research available on this topic, the whole area of postinjury outcomes of geriatric clients is rich for study. As the authors state, older adults are at greater risk for mortality both during and after hospitalization than younger adults. This review noted that long-term mortality occurred at about two years. Why is this the case? Is there a relationship between the frailty of older adults and their ability to respond to the frailty cycle and physiological needs during a time of dramatic stress? Because nurses are an integral part of continuing care for older adults after serious injury, interventions designed to mobilize these patients and prevent complications of the aged should be a targeted area of research, and something we probably do every day. What is the difference in nursing care that we implement with older adults and the younger clients? In addition, orthopaedic nurses must begin to learn more about the needs of geriatric clients in order to be attuned to the special needs of this older cohort.
Olofsson, B., Lundstrom, M., Borssen, B., Nyberg, L., & Gustafson, Y. (2005). Delirium is associated with poor rehabilitation outcome in elderly patients treated for femoral neck fractures.Scandinavian Journal of Caring Sciences, 19(2), 119-127.
As orthopaedic nurses, many of us work with patients with hip fracture who experience delirium. By definition, delirium is "an acute state of confusion" making it difficult for the patient to focus his or her attention, leading to memory loss, disorientation, and difficulty in executive functions of daily life (p. 119). Delirium is usually a temporary state that comes on slowly and may last for a short time or even until after discharge from the hospital. As a result, delirium can compromise the hospital course for a patient after a hip fracture by making rehabilitation difficult. Patients are often unable to participate fully in physical therapy or other activities that are essential for recuperation.
The aim of this study was to describe risk factors of delirium and the impact delirium had on rehabilitation outcomes for patients with femoral neck fractures. Several instruments were used to assess the patients 3 to 5 days after surgery, including the Mini-mental state examination (MMSE), the Organic Brain Syndrome (OBS) scale, and the Geriatric Depression Scale (GDS). The study included 61 patients who had been physically inactive with hip fractures, multiple diseases, and polypharmacy. The mean age of the patients was 82.6 years, with two-thirds of the patients being women and one-third having dementia and depression.
The outcomes of the study indicated that patients with delirium suffer from many complications, such as urinary tract infections and nutritional deficits. It was postulated that many of these conditions exacerbate the delirium, resulting in additional complications and extended length of hospitalization. These patients were more dependent in activities of daily living, making rehabilitation slower and return to an independent life style more difficult. Recommendations were to use the capabilities the patients possessed related to feeding, bathing, and mobility rather than to do these activities for them. Encouraging involvement in one's own care was important, and engaging patients in group activities helped to improve outcomes and shorten hospital stays. As orthopaedic nurses, we are busy nurses. We may need to remember to take that extra moment to let the patient feed himself or herself in order to encourage the resolution of delirium. Nursing care patterned with geriatric principles in mind helps to improve psychological well-being and quality of life. Unfortunately, a large number of the patients with delirium did not regain their previous level of activity, thus necessitating placement in a new living arrangement.
Hsieh, C. (2005). Treatment of constipation in older adults.American Family Physician, 72(11), 2277-2284.
Orthopaedic nurses see constipation with all of our patients. However, for the older adult who experiences the physiological changes of aging, the problem becomes more acute when combined with co-morbid conditions and the need for pain medication after surgery. Not assessing for bowel movements after surgery, which eventually leads to unrecognized constipation, can be manifested in such ways as temperature elevations, lack of appetite (disadvantageous for a healing wound), acute delirium, possible bowel obstruction, and delayed rehabilitation and discharge.
Constipation is not a physiological result of aging, but many age-related problems (decreased mobility) may predispose the patient to constipation. It is estimated that 2.5 million annual physician office visits are for the complaint of constipation. Functional constipation is the diagnosis when no other causes are noted (p. 2277). Constipation is classified as primary and secondary. With primary constipation, the movement of stool through the colon may be slowed or prolonged. Patients will complain of abdominal bloating and fewer bowel movements. The reasons for slow constipation are unclear. Anorectal dysfunction, an incomplete evacuation of the colon, a part of primary constipation, is a learned behavior from childhood. Secondary constipation, on the other hand, may potentially be caused by medications and psychiatric conditions. The orthopaedic nurse needs to be very cognizant of this type of constipation, because many medications interfere with the nerve conduction and smooth muscle function of the colon. Combined with the age-related changes that older adults face, constipation can pose a medical emergency for some patients. This article provides a good list of medications that cause constipation and may even be taken over the counter by older adults. Irritable bowel syndrome is also a common cause of constipation, with alternated periods of diarrhea.
Many physicians prescribe morphine for orthopaedic patients postoperatively. This author quotes one study that found fentanyl (Duragesic) less likely to cause constipation than oral morphine (p. 2279). In addition, this article has a comprehensive review of nonpharmacological and pharmacological treatments for constipation, with a chart listing adult dosage recommendations and costs of each agent.
The author notes that if constipation is not improved with treatment, further diagnostic evaluation should be warranted. Alternative methods of biofeedback may be considered for some patients. However, only patients with proven slow colonic transit constipation (prolonged passage of stool through the colon) benefit from surgery that involves a subtotal colectomy and ileorectostomy. It is essential that knowledge of the changes occurring with aging are reviewed when caring for older adults. Promotion of normal bowel evacuation is crucial for the care of older adults. A bowel program should be addressed with older adults on admission to the hospital.
Forman, T.A., Forman, S.K., & Rose, N.E. (2005). A clinical approach to diagnosing wrist pain.American Family Physician, 72(9), 1753-1758.
With the advent of the computer age, the economic impact of wrist injuries has led to accelerated workman's compensation claims. The average cost of a claim is $7500, with the average direct cost for carpal tunnel syndrome being $1 billion annually (p. 1755). Because the economic impact of wrist injuries is so great, accurate diagnosis is important for the patient.
Wrist pain can be divided into three categories, namely mechanical, neurological, and systemic. A thorough history that characterizes the exact mechanism of injury, described in the patient's own words, will aid in the diagnosis. The noting of precise pain, quality, movement-induced symptoms, radiation, and relief should be solicited from the patient. Mechanical injury is often the result of specific trauma, such as a fall on the hand with an outstretched wrist. If the patient has not had a direct injury, a complete assessment should include consideration of vocational or leisure activity that could produce injury. Patients with excessive extension and ulnar or radial deviation could have a ligament injury if a clicking or popping sound is present (p. 1756).
The wrist may be the first site of a systemic response such as gout or rheumatoid arthritis. An examination of the wrist should be preceded by a comprehensive examination of the neck and upper extremity to rule out other causes of pain, such as a herniated disc. Then the hand should be palpated to identify the specific area of tenderness and/or injury. This article gives an excellent summary of specific maneuvers for assessment of wrist pain. Psychosocial factors must also be considered with the evaluation, especially if the patient has been injured on the job. Self-injury should also be thought of if psychosocial factors are present.
Radiography is the first-line imaging for a wrist injury, although it is not always necessary. Posterior and anterior views of the wrist are essential to provide view of the bone anatomical structure. If a diagnosis is not reached after radiography, further diagnostic imaging may be needed.