Journal of Gerontological Nursing

Medicating the Postoperative Elderly: How Do Nurses Make Their Decisions?

Lois M Short, RN, MS, MN; Mary Lynn Burnett, RN, MS; Anne Marsh Egbert, MD; Leland H Parks, PhD

Abstract

Many analgesic medication orders by physicians give a wide dosage and frequency range. Therefore, nurses make critical decisions for the amount of narcotic administered. The safe administration of narcotic analgesics is a consideration for all patients, but as the population of elderly continues to rise, the frequency of decisions for these persons will also increase. In the absence of appropriate tools or explicit guidelines, clinical nursing judgment is predominantly used to determine these medication needs. A conservative approach to managing acute postoperative pain has led to concerns of undertreatrnent in the elderly population.

RELEVANT LITERATURE

Conservative approaches to pain management often result in significantly undertreated pain. Marks and Sachar1 reported that 73% of hospitalized medical patients receiving parenteral narcotic analgesics continued to experience moderate to severe distress despite their analgesic regimen. Results of other studies indicate that 4 1 % to 75% of hospitalized post-surgical patients experienced moderate to severe pain distress with their postoperative pain management regimens.2"5

If the adult postoperative patient continues to describe pain of sufficient intensity to be disturbing, while receiving up to 70% of the maximum prescribed dose in the first 24 hours postoperatively, then there is reason for concern about how the postoperative elderly patient is being managed.5 Faherty and Grier found that smaller doses of narcotics were ordered for the elderly postoperative patient than for the younger patient and that there was a significant correlation in the amount of medication prescribed with that administered.6 This is consistent with the findings of Barth, who reported that elderly patients receive even less of the prescribed narcotic analgesic than younger patients.7

Reluctance to administer narcotics to the elderly may occur as a result of concern for patient safety. Little is known about the pharmacokinetics of medications in the elderly, although it is possible to speculate on what might occur based on knowledge of the physiological changes of the normal aging process. Both renal and liver function decrease with age. Because opiates are detoxified in the liver and active metabolites of meperidine are excreted by the kidney, increasing age is associated with a longer half-life for both morphine sulphate and meperidine.8,9 Decreased protein binding also affects drug distribution in the elderly, which may increase the fraction of unbound drug, such as meperidine, in the plasma.

Fot patients over age 60, as compared with the younger adult population, there seems to be an increase in the analgesic response to narcotic drugs.10 Kaiko reported that the greatest difference in analgesic effects was age-related, with elderly patients responding as though they had received four times the dose given to younger adult patients11. Age, then, appears to be a better predictor of patient response than height, weight, or other characteristics of the older age group.6,9,10

No difference was found when the incidence of side effects from narcotic analgesics in postoperative patients over the age of 58 were compared with those under this age. ,0 It has been suggested, however, that elderly patients need smaller doses of morphine to reduce the risk of opiate-induced respiratory depression.12 Although there is strong concern for respiratory depression as a consequence of narcotic administration, few nurses acknowledge that inadequate pain relief may actually play a role in depressed respirations.2,5,13

The medication decisions of both physicians and nurses have played a part in the undertreatrnent of postoperative pain. The complicating factor is that no absolute way to make appropriate medication decisions for the elderly has been identified. Analgesic medication administration decisions are based on an assessment, which is then used to make an objective and safe judgment. Nurses consider a variety of factors, such as vital signs,…

Many analgesic medication orders by physicians give a wide dosage and frequency range. Therefore, nurses make critical decisions for the amount of narcotic administered. The safe administration of narcotic analgesics is a consideration for all patients, but as the population of elderly continues to rise, the frequency of decisions for these persons will also increase. In the absence of appropriate tools or explicit guidelines, clinical nursing judgment is predominantly used to determine these medication needs. A conservative approach to managing acute postoperative pain has led to concerns of undertreatrnent in the elderly population.

RELEVANT LITERATURE

Conservative approaches to pain management often result in significantly undertreated pain. Marks and Sachar1 reported that 73% of hospitalized medical patients receiving parenteral narcotic analgesics continued to experience moderate to severe distress despite their analgesic regimen. Results of other studies indicate that 4 1 % to 75% of hospitalized post-surgical patients experienced moderate to severe pain distress with their postoperative pain management regimens.2"5

If the adult postoperative patient continues to describe pain of sufficient intensity to be disturbing, while receiving up to 70% of the maximum prescribed dose in the first 24 hours postoperatively, then there is reason for concern about how the postoperative elderly patient is being managed.5 Faherty and Grier found that smaller doses of narcotics were ordered for the elderly postoperative patient than for the younger patient and that there was a significant correlation in the amount of medication prescribed with that administered.6 This is consistent with the findings of Barth, who reported that elderly patients receive even less of the prescribed narcotic analgesic than younger patients.7

Reluctance to administer narcotics to the elderly may occur as a result of concern for patient safety. Little is known about the pharmacokinetics of medications in the elderly, although it is possible to speculate on what might occur based on knowledge of the physiological changes of the normal aging process. Both renal and liver function decrease with age. Because opiates are detoxified in the liver and active metabolites of meperidine are excreted by the kidney, increasing age is associated with a longer half-life for both morphine sulphate and meperidine.8,9 Decreased protein binding also affects drug distribution in the elderly, which may increase the fraction of unbound drug, such as meperidine, in the plasma.

Fot patients over age 60, as compared with the younger adult population, there seems to be an increase in the analgesic response to narcotic drugs.10 Kaiko reported that the greatest difference in analgesic effects was age-related, with elderly patients responding as though they had received four times the dose given to younger adult patients11. Age, then, appears to be a better predictor of patient response than height, weight, or other characteristics of the older age group.6,9,10

No difference was found when the incidence of side effects from narcotic analgesics in postoperative patients over the age of 58 were compared with those under this age. ,0 It has been suggested, however, that elderly patients need smaller doses of morphine to reduce the risk of opiate-induced respiratory depression.12 Although there is strong concern for respiratory depression as a consequence of narcotic administration, few nurses acknowledge that inadequate pain relief may actually play a role in depressed respirations.2,5,13

The medication decisions of both physicians and nurses have played a part in the undertreatrnent of postoperative pain. The complicating factor is that no absolute way to make appropriate medication decisions for the elderly has been identified. Analgesic medication administration decisions are based on an assessment, which is then used to make an objective and safe judgment. Nurses consider a variety of factors, such as vital signs, type of surgery, severity of pain, nonverbal patient behaviors, age, and weight, as influences. 2,14,15 Faherty and Grier found age, more than weight, to be the influencing variable in analgesic medication administration.6 The extremes of pain distress and the presence or absence of side effects have also been reported as most important to nurses in choosing among doses of analgesic medication.16

Perceptions may also influence the decision to medicate. Davitz and Pendleton reported that nurses perceived that younger patients suffer more than the aged.17 Nurses may not offer analgesics to the elderly based on this perception, and the elderly often do not request postoperative medications.18 Patients and nurses seem to have different perceptions about who should initiate the request for pain relief.'9

Undertreatrnent of postoperative pain in the elderly occurs for a number of reasons: lack of communication; inadequate pharmacological knowledge; unreasonable concern for narcotic dependence; and obvious concern for complications.2,19 Thus, the nurse's role in pain assessment and intervention for the elderly is important. The factors on which the nurse bases the decision to medicate need to be further examined to provide for both patient safety and comfort.

The purpose of this study was to compare the quantity of narcotic ordered to that actually received by the elderly postoperative patient on the surgical nursing units; and to identify the factors that nurses on these surgical units consider in determining when and how much analgesic to administer to the postoperative patient over age 60.

METHOD

This descriptive study was unique in that the charts of elderly patients who had been on the surgical nursing units were examined retrospectively to determine the amount of prescribed narcotic pain medication they received after surgery, and the nurses who made those medication decisions and administered the narcotics on the surgical nursing units were surveyed to determine which factors influenced their decisions.

Sample and Procedure

The charts of 56 men age 60 and over were reviewed retrospectively. This sample represented 76% of all patients undergoing major elective surgery over a 12-month period in a midwestern Veteran's Administration Medical Center. The predominance of men reflects the population of the institution; women were not excluded as subjects. The mean age of the patients was 67.5 years (SD = 6.09). Ibrty-three (77%) of the patients were located on surgical units and 13 (23%) were in the surgical intensive care unit (SICU). The prescribed versus administered parenteral analgesic was tabulated through the first postoperative day (8:00 AM postoperative day 1 to 8:00 AM postoperative day 2). Accuracy of the recordings was assumed since medication documentation is a legal requirement.

For standard comparison, the meperidine dosages were converted to equianalgesic doses of morphine sulfate with the ratio of meperidine, 75 mg equal to morphine sulfate, 10 mg.20 The maximum amount of narcotic prescribed was determined by multiplying the greatest number of times the dose could be administered by the largest amount ordered during this 24-hour period. Additional data collected in the chart review included demographics, co-existing medical illnesses, anesthetic risk class, type of surgery performed, and patient location (SICU versus surgical ward).

The subjects for the nurse survey were 40 nurses employed on the surgical nursing units where the patients whose charts were reviewed had recovered postoperatively. All 65 nurses who practiced on these surgical nursing units were asked to participate in the survey; 60% responded. Of those who responded, 60% (n = 24) of the subjects were from the surgical units and 40% (n = 16) from the SICU. The median age group was 40 to 49 years. Whereas 85% (n = 35) had practiced at least 2 years in a surgical setting, 28% (n = 1 1 ) of the subjects had more than 10 years of surgical nursing experience.

Consent was obtained from the nurse subjects as they came to the announced location for the investigators' administration of a two-part written survey. The following open-ended question was presented in the first part of the survey and was designed to elicit spontaneous responses (nurse-generated factors):

Table

TABLE 1AMOUNT AND TYPE OF PRESCRIBED AND ADMINISTERED NARCOTIC FOR PATIENT GROUP FIRST POSTOPERATIVE DAY

TABLE 1

AMOUNT AND TYPE OF PRESCRIBED AND ADMINISTERED NARCOTIC FOR PATIENT GROUP FIRST POSTOPERATIVE DAY

Table

TABLE 2TYPE OF SURGERY BY MEAN PERCENT OF PRESCRIBED NARCOTIC RECEIVED AND PERCENT PERFORMED

TABLE 2

TYPE OF SURGERY BY MEAN PERCENT OF PRESCRIBED NARCOTIC RECEIVED AND PERCENT PERFORMED

If given a dosage range such as meperidine (Demerol), 50 to 100 mg, intramuscularly, every 4 hours as needed for pain, what factors do you use to determine when and how much as needed parenteral narcotic to give to postoperative patients over the age of 60? List all factors.

After the nurses' responses were collected, the second part of the survey was administered. This section consisted of a list of 30 factors that have been associated with narcotic administration in the literature. The nurses were instructed to indicate the importance of each factor in determining when and how much narcotic to administer to postoperative patients over the age of 60 when a dosage and frequency range is prescribed. Possible responses ranged from "very important; crucial" to "not important at all" on a 5-point scale. They were then asked to rank the factors they had selected as "very important; crucial" (rank-ordered factors).

ANALYSIS AND RESULTS

Amount of Medication Prescribed and Administered

During the first postoperative day, the mean amount of prescribed parenteral narcotic that the nurses administered to the patients was 24.3% (SD = 21.59) (Table 1). The patients received from 0% to 100% of the prescribed dose of narcotic analgesic. One patient received 100% of the prescribed dose, whereas the next highest percentage of prescribed dose administered was 62.5%. No parenteral analgesic was administered to 29% (n = 16) of the subjects.

The data were further explored using one-way analyses of variance with anesthetic risk class, type of surgery, co-existing illness, and location after surgery entered as dependent variables, and the amount of narcotic analgesic administered, in mean milligrams percent, as the independent variable. The amount of narcotic administered was significantly related to the type of surgery experienced by the patient (F (9,46) = 3.253, P = .003) and his location on the first postoperative day. The mean percentage of the prescribed milligrams of narcotic administered to the patient varied from 0% for patients with limb amputations to 53% for patients with abdominal aortic aneurysm repairs (Table 2). Patients in the SICU received significantly more of the prescribed narcotic than did the patients on the surgical ward (F (1,54) = 13.719, P = .0005), yet there was no significant difference in the amount of narcotic ordered by physicians nor in the types of surgeries that went to the two locations. Pearson product-moment correlation revealed no significant relationship between the percent milligrams of administered narcotic and the patient's age (r = -.20) or weight (r = .11). Using chi square with Fisher exact correction factor, location was the only significant difference between the 16 patients who received no parenteral postoperative analgesic and the other patients, with all 16 patients having been located on the surgical ward (x2 = 5.072, d/= 1,P= .006).

Responses of the Nurses

Responses of the nurses to the openended question provided in the first part of the survey were categorized and coded independently by three investigators. Inter-rater reliability was determined on two random subjects and found to be 90.6% and 87.5% for one and 93.7% and 96.8% for the other. Specific responses, such as vital signs, respiratory status, and blood pressure, were listed separately because of their possible correlation to effects of the narcotics.

Nurse-Generated Factors

The frequency of each of the nursegenerated factors was tabulated and the percentage of nurses who listed each factor was determined (Table 3). The following three factors were identified by 50% or more of the nurses as being important in their narcotic medication administration decisions: type of surgery (57.5%), vital signs (57.5%), and patient's weight (50%). Factors with the next highest frequencies were effectiveness of previous dose (45%) and patient confusion (42.5%). Thirty percent of the subjects listed "no age difference," whereas 20% identified the age of patient as a factor. Verbal communication of pain by the patient was reflected as an influence in two of the factors reported: severity of pain according to the patient (30%) and verbal complaints of pain (12.5%).

No significant difference was found between the nursing unit (SICU or surgical ward) and the factors identified by the nurses from those units (P = .21). Thus, although the SICU nurses gave more narcotics, the factors used when making narcotic analgesic administration decisions for the elderly after surgery were not different.

Rank-Ordered Factors

Results of the frequency and percentage tabulations for the rankordered literature-derived factors are reported in Table 4. Factors most frequently ranked as first in importance were respiratory rate (18%), type of surgery, patient's overall condition, age, and time since last medication (each 10%). The factor of age was also ranked third by 8% of the subjects.

DISCUSSION

The findings indicate that the amount of narcotic analgesic the elderly patients received on the first postoperative day was substantially less than the amount prescribed. Important in the amount of pain medication received was the patient's location (SICU or surgical ward) following his surgery and the type of surgery he experienced. Significantly, type of surgery was one of the factors that most nurses identified as important in their medication decisions. The other factor most frequently identified by the nurses was vital signs.

Table

TABLE 3NURSE-GENERATED FACTORS FOR NARCOTIC ADMINISTRATION DECISIONS IN ELDERLY POSTOPERATIVE PATIENTS*

TABLE 3

NURSE-GENERATED FACTORS FOR NARCOTIC ADMINISTRATION DECISIONS IN ELDERLY POSTOPERATIVE PATIENTS*

Table

TABLE 4FACTORS RANK-ORDERED BY NURSES AS TO IMPORTANCE IN NARCOTIC ADMINISTRATION TO POSTOPERATIVE ELDERLY

TABLE 4

FACTORS RANK-ORDERED BY NURSES AS TO IMPORTANCE IN NARCOTIC ADMINISTRATION TO POSTOPERATIVE ELDERLY

Patients in this study received an even smaller percentage of the prescribed narcotic (24%) than was reported by Faherty and Grier, who found that subjects age 55 and older received less than 50% of the prescribed medication.6 Although die percentage of patients in this study who received no parenteral narcotic analgesic during the first postoperative day obviously influenced these findings, no specific factors, other than location, were suggested. The amount of parenteral pain medication that was received by the patients in this study gives rise to a concern for undertreatrnent of pain in the elderly.

Patients who went to the SICU postoperatively received more narcotic analgesic than did those on the surgical ward. These nursing decisions may have been affected by the lower nursepatient ratio, continuous monitoring devices, and routine detailed nursing assessments common to the SICU.

It is not surprising that the type of surgery experienced by the patient was also an important factor in the amount of narcotic analgesic received by the patients whose charts were reviewed. The type of illness or injury, has been found to influence nurses' assessment of pain in adult patients.21 Nurses have identified this factor as important in their medication decisions for both pediatric and adult patients.2,14 Although the type of surgery may be a valid factor, these decisions must also be made with a sensitivity to individual perceptions and responses to pain.

Neither weight nor age were found to be significantly related to the amount of medication the nurses actually administered to the patients, although 50% of the nurses identified weight as an important consideration in their narcotic administration decisions. Age was listed by only 20% of the nurses, whereas 30% indicated age made no difference. When the factors provided by the investigators were ranked by the nurses, only 10% selected age as the factor most important to consider. Although more nurses considered me patient's weight than age in their narcotic administration decisions in both this and a previous study,2 age actually has a more significant effect on the patient's response to the medication.9,10

The factors identified on the two lists from the survey of the nurses -nurse-generated and rank-ordered -could not be directly compared because no ranking of factors was requested for the nurse-generated list. However, the type of surgery and vital signs (eg, blood pressure, respiratory rate) appeared with the highest frequency on both responses. These two factors appear to be commonly used by nurses in making decisions to medicate patients postoperatively.

The nurses used valid subjective and objective data in determining their narcotic dosage administration. Vital signs, the effectiveness of previous doses, and the patient's overall condition were frequently considered. The patient's verbal responses and such pharmacokinetic parameters as liver function, respiratory disease, and age were considered less frequently.

Nurses must encourage and respond to verbal responses of elderly patients regarding their pain. According to McCaffery, the definition of pain most relevant to nursing practice is, "pain is whatever the experiencing person says it is and exists whenever he says it does."20 Yet, in an earlier study, 43% of the patients in severe pain could not recall a nurse discussing their pain with them.22 It is possible that the elderly received less pain medication partly because of their altered response to pain or their reluctance to request medication. Barth found that patients over age 60 reported less severe pain in the first 48 hours postoperatively than younger patients, but they were also less inclined to express pain or request increases in the amount of pain medication received.7 In this study, however, 43% of the nurses identified the patient's verbal reports of pain as important in their medication decisions while giving less than one quarter of the possible dosage of pain medication.

Limitations of the study include the retrospective nature of the chart review for the patient group and lack of documentation of the effectiveness of the administered doses of narcotic analgesic in the patient's record.

The results of this study suggest that for the elderly patients who received less than one fourth of the prescribed narcotic analgesic postoperatively, the potential for undertreatrnent of pain is greater than forovertreatment. Responsibility for the amount of prescribed medication that the patient actually receives is shared by the patient and the nurse. Greater emphasis is needed on promoting the elderly patients' verbal communication of pain and assessing their individualized response to pain medication. The use of objective measures of pain should be encouraged.

Further study is needed to determine both the effectiveness of the administered amount of narcotic to the elderly and the attitudes and knowledge of nurses concerning this type of narcotic administration. As nurses make medication decisions for pain management in the growing elderly population, the comfort as well as the safety of these persons must be high priorities.

REFERENCES

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  • 3. Weis OF, Sriwatanakul K, Alloza JL. Weintraub M. Lasagna L. Attitudes of patients, housestaff, and nurses toward postoperative analgesic care. Anesth Analg. 1983; 62(l):70-74.
  • 4. Kerri-Szanto M, Heaman S. Postoperative demand analgesia. Surg Gynecol Obstet. 1971; 134(4):647-651.
  • 5. Sriwatanakul K, Weis OF. Alloza JL, Kelvie W, Weintraub M, Lasagna L. Analysis of narcotic analgesic usage in the treatment of postoperative pain. JAMA. 1983; 250(7): 926-929.
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  • 15. Saxey S. The nurse's response to postoperative pain. Nursing (London). 1986; 3(10):377-381.
  • 16. Grier MR, Howard M, Cohen F. Beliefs and \itlues Associated with Administering Narcotic Analgesics to Terminally III Patients. Kansas City , Mo: American Nurses' Association; 1979:21 1-222. Publication No. NP-59.
  • 17. Davitz U, Pendleton SH, Members of the Class of TN 4600, Fall 1967. Nurses' inferences of suffering. Nurs Res. 1969; 18(2): 100- 107.
  • 18. Steinberg FU, ed. Care of the Geriatric Patient. 6th ed. St Louis: CV Mosby Co; 1983.
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TABLE 1

AMOUNT AND TYPE OF PRESCRIBED AND ADMINISTERED NARCOTIC FOR PATIENT GROUP FIRST POSTOPERATIVE DAY

TABLE 2

TYPE OF SURGERY BY MEAN PERCENT OF PRESCRIBED NARCOTIC RECEIVED AND PERCENT PERFORMED

TABLE 3

NURSE-GENERATED FACTORS FOR NARCOTIC ADMINISTRATION DECISIONS IN ELDERLY POSTOPERATIVE PATIENTS*

TABLE 4

FACTORS RANK-ORDERED BY NURSES AS TO IMPORTANCE IN NARCOTIC ADMINISTRATION TO POSTOPERATIVE ELDERLY

10.3928/0098-9134-19900701-05

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