Pressure Ulcers: Prevention, Evaluation, and Direction

ASHKAN JAVAHERI, MD, Stanford University School of Medicine, Stanford, California, and Veterans Affairs Palo, Alto Health Care System, Palo Alto, California

Am Fam Physician. 2008 Nov xv;78(ten):1186-1194.

The online version of this commodity includes supplemental content.

  A more contempo commodity on force per unit area ulcers is available.

Patient information: Come across related handout on preventing bedsores, written by the authors of this article.

Article Sections

  • Abstract
  • Etiology
  • Prevention
  • Assessment
  • Nutritional Evaluation
  • Management
  • Complications
  • References

A pressure ulcer is a localized injury to the peel or underlying tissue, usually over a bony prominence, equally a result of unrelieved pressure. Predisposing factors are classified as intrinsic (e.g., limited mobility, poor nutrition, comorbidities, aging skin) or extrinsic (due east.g., pressure, friction, shear, wet). Prevention includes identifying at-gamble persons and implementing specific prevention measures, such as post-obit a patient repositioning schedule; keeping the head of the bed at the lowest safe height to prevent shear; using pressure level-reducing surfaces; and assessing nutrition and providing supplementation, if needed. When an ulcer occurs, documentation of each ulcer (i.due east., size, location, eschar and granulation tissue, exudate, odor, sinus tracts, undermining, and infection) and appropriate staging (I through IV) are essential to the wound assessment. Handling involves direction of local and afar infections, removal of necrotic tissue, maintenance of a moist surroundings for wound healing, and possibly surgery. Debridement is indicated when necrotic tissue is present. Urgent sharp debridement should be performed if advancing cellulitis or sepsis occurs. Mechanical, enzymatic, and autolytic debridement methods are nonurgent treatments. Wound cleansing, preferably with normal saline and appropriate dressings, is a mainstay of treatment for clean ulcers and later debridement. Bacterial load can be managed with cleansing. Topical antibiotics should be considered if in that location is no improvement in healing after 14 days. Systemic antibiotics are used in patients with advancing cellulitis, osteomyelitis, or systemic infection.

Pressure ulcers, also called decubitus ulcers, bedsores, or pressure sores, range in severity from reddening of the peel to severe, deep craters with exposed muscle or bone. Pressure ulcers significantly threaten the well-being of patients with express mobility. Although 70 percent of ulcers occur in persons older than 65 years,1 younger patients with neurologic impairment or severe illness are also susceptible. Prevalence rates range from 4.7 to 32.i percent in hospital settings2 and from 8.v to 22 per centum in nursing homes.iii

SORT: Key RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Testify rating References

Compared with standard hospital mattresses, pressure-reducing devices subtract the incidence of force per unit area ulcers.

A

10, fourteen

There is no testify to support the routine use of nutritional supplementation (vitamin C, zinc) and a high-protein diet to promote the healing of pressure ulcers.

C

nineteen

Heel ulcers with stable, dry eschar practice not need debridement if there is no edema, erythema, fluctuance, or drainage.

C

viii, 16

Ulcer wounds should non be cleaned with skin cleansers or clarified agents (eastward.thou., povidone-iodine [Betadine], hydrogen peroxide, acerb acrid) because they destroy granulation tissue.

B

8, 27, 28

Etiology

  • Abstract
  • Etiology
  • Prevention
  • Assessment
  • Nutritional Evaluation
  • Management
  • Complications
  • References

Pressure level ulcers are caused by unrelieved force per unit area, practical with great force over a brusk catamenia (or with less force over a longer period), that disrupts claret supply to the capillary network, impeding blood menses and depriving tissues of oxygen and nutrients. This external force per unit area must be greater than arterial capillary pressure to lead to arrival impairment and resultant local ischemia and tissue damage. The most common sites for pressure ulcers are the sacrum, heels, ischial tuberosities, greater trochanters, and lateral malleoli.

Prevention

  • Abstract
  • Etiology
  • Prevention
  • Assessment
  • Nutritional Evaluation
  • Management
  • Complications
  • References

RISK Cess

Adventure cess begins past identifying risk factors and inspecting the skin. Risk factors for pressure ulcers are classified every bit intrinsic or extrinsic (Table 1).4 Caregivers should be educated well-nigh risk assessment and prevention and should inspect patients frequently to prevent pressure ulcers or identify them at early stages. Chance assessment scales may further heighten awareness, but have limited predictive power and no proven effect on pressure ulcer prevention.5 The Braden Calibration ( Online Figure A) is the most ordinarily used tool for predicting pressure ulcer risk6 (http://www.bradenscale.com/bradenscale.htm).

Table one

Run a risk Factors for Pressure Ulcers

Intrinsic

Limited mobility

Spinal cord injury

Cerebrovascular accident

Progressive neurologic disorders (Parkinson affliction, Alzheimer affliction, multiple sclerosis)

Hurting

Fractures

Postsurgical procedures

Blackout or sedation

Arthropathies

Poor nutrition

Anorexia

Dehydration

Poor dentition

Dietary restriction

Weak sense of olfactory property or taste

Poverty or lack of access to nutrient

Comorbidities

Diabetes mellitus

Depression or psychosis

Vasculitis or other collagen vascular disorders

Peripheral vascular disease

Decreased hurting sensation

Immunodeficiency or use of corticosteroid therapy

Congestive heart failure

Malignancies

End-stage renal disease

Chronic obstructive pulmonary disease

Dementia

Aging skin

Loss of elasticity

Decreased cutaneous blood catamenia

Changes in dermal pH

Flattening of rete ridges

Loss of subcutaneous fat

Decreased dermal-epidermal blood catamenia

Extrinsic

Force per unit area from any difficult surface (e.g., bed, wheelchair, stretcher)

Friction from patient's inability to move well in bed

Shear from involuntary muscle movements

Wet

Bowel or float incontinence

Excessive perspiration

Wound drainage

INTERVENTIONS

Preventive measures should be used in at-adventure patients. Pressure reduction to preserve microcirculation is a mainstay of preventive therapy. There is no show to decide an optimal patient repositioning schedule, and schedules may need to be determined empirically.7 According to recommendations from the Bureau for Health Intendance Policy and Enquiry, patients who are bedridden should be repositioned every two hours.8 To minimize shear, the head of the bed should not exist elevated more than than xxx degrees and should be maintained at the lowest caste of elevation needed to forestall other medical complications, such as aspiration and worsening congestive heart failure symptoms.7 Some patients tin reduce force per unit area by repositioning themselves using manual aids, such as a trapeze bar.

Pressure-reducing devices can reduce pressure or relieve pressure (i.e., lower tissue pressure to less than the capillary closing pressure of 32 mm Hg) and are classified as static (stationary) or dynamic.9 Static devices include cream, water, gel, and air mattresses or mattress overlays. Dynamic devices, such as alternate force per unit area devices and depression–air-loss and air-fluidized surfaces, use a power source to redistribute localized pressure. Dynamic devices are generally noisy and more than expensive than static devices. Pressure-reducing surfaces lower ulcer incidence past 60 percent compared with standard hospital mattresses, although there is no clear difference amid force per unit area-reducing devices.10,eleven The benefit of dynamic versus static surfaces is unclear. Dynamic surfaces should be considered if a patient cannot reposition him- or herself independently or if the patient has a poorly healing ulcer.7 If there is less than i inch of fabric between the bed and pressure level ulcer when feeling beneath the static surface, the device may not be constructive and an culling should be considered.7 Other pressure-reducing devices include chair cushions and pillows, foam wedges, and materials that are placed between the knees or used to relieve heel force per unit area. Band cushions tin can cause pressure level points and should non be used.

Other preventive interventions include nutritional and peel intendance assessments. Although poor diet is associated with pressure ulcers, a causal human relationship has not been established.12 I large trial has shown that oral nutritional supplementation reduces risk, just several other trials accept not.13 A Cochrane review concluded that there is bereft evidence on the relationship between nutrition and pressure ulcer prevention.14 A more recent meta-analysis concluded that dietitian consultation and the use of skin moisturizers are reasonable preventive measures.11 Withal, the part of bactericidal and growth factor preparations is unclear. Continence care programs have not proved successful.fifteen Despite proper risk assessment and preventive interventions, some pressure ulcers are unavoidable.

Assessment

  • Abstract
  • Etiology
  • Prevention
  • Cess
  • Nutritional Evaluation
  • Management
  • Complications
  • References

Assessment of an established pressure level ulcer involves a complete medical evaluation of the patient. A comprehensive history includes the onset and elapsing of ulcers, previous wound care, chance factors, and a list of health problems and medications. Other factors such as psychological wellness, behavioral and cognitive status, social and financial resources, and access to caregivers are critical in the initial assessment and may influence treatment plans. The presence of a pressure ulcer may point that the patient does not have access to adequate services or support. The patient may need more intensive support services, or intendance-givers may need more training, respite, or help with lifting and turning the patient. Patients with communication or sensory disorders are particularly vulnerable to pressure ulcers because they may not feel discomfort or may express discomfort in singular ways.

The physician should note the number, location, and size (length, width, and depth) of ulcers and appraise for the presence of exudate, odor, sinus tracts, necrosis or eschar formation, tunneling, undermining, infection, healing (granulation and epithelialization), and wound margins. About importantly, the physician should determine the phase of each ulcer (Figures one through 4).

Effigy 1.

Stage I pressure ulcer. Intact peel with non-blanching redness.

Figure 2.

Stage Ii pressure ulcer. Shallow, open up ulcer with red-pinkish wound bed.

Figure iii.

Stage III pressure ulcer. Total-thickness tissue loss with visible subcutaneous fat.

Effigy iv.

Stage 4 pressure ulcer. Full-thickness tissue loss with exposed musculus and bone.

Table ii presents the National Pressure Ulcer Advisory Panel's staging system for pressure ulcers.16 In a person with dark pare pigmentation, a stage I ulcer may announced as a persistent blood-red, blue, or purple discoloration. The stage of an ulcer cannot be determined until enough slough or eschar is removed to expose the base of the wound. Ulcers do not progress through stages in formation or healing. The Pressure Ulcer Scale for Healing tool (Figure five) can be used to monitor healing progress.17

Tabular array 2

NPUAP Staging System for Pressure level Ulcers

Phase Description

Suspected deep-tissue injury

Majestic or maroon localized area of discolored, intact skin or blood-filled cicatrice caused by damage to underlying soft tissue from pressure or shear; the discoloration may be preceded past tissue that is painful, house, mushy, boggy, or warmer or cooler compared with adjacent tissue

I

Intact skin with nonblanchable redness of a localized area, usually over a bony prominence; dark pigmented pare may not have visible blanching, and the affected expanse may differ from the surrounding expanse; the affected tissue may be painful, firm, soft, or warmer or cooler compared with adjacent tissue

II

Fractional-thickness loss of dermis actualization equally a shallow, open ulcer with a red-pink wound bed, without slough; may too appear equally an intact or open up/ruptured serum-filled blister; this phase should not exist used to describe skin tears, record burns, perineal dermatitis, macerations, or excoriations

Three

Full-thickness tissue loss; subcutaneous fat may be visible, just bone, tendon, or muscle is not exposed; slough may exist nowadays, but does non obscure the depth of tissue loss; may include undermining and tunneling*

IV

Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may exist present on some parts of the wound bed; often includes undermining and tunneling*

Unstageable

Full-thickness tissue loss with the base of the ulcer covered by slough (yellowish, tan, greyness, green, or dark-brown) or eschar (tan, brown, or black) in the wound bed

PUSH Tool

Figure 5.

Pressure Ulcer Scale for Healing (PUSH) tool for monitoring the healing of pressure ulcers.

Adapted with permission from Stotts NA, Rodeheaver M, Thomas DR, et al. An musical instrument to measure healing in pressure ulcers: development and validation of the Pressure Ulcer Scale for Healing (Push button). J Gerontol A Biol Sci Med Sci. 2001;56(12):M795.

Nutritional Evaluation

  • Abstract
  • Etiology
  • Prevention
  • Assessment
  • Nutritional Evaluation
  • Management
  • Complications
  • References

Despite the consensus that adequate diet is important in wound healing, documentation of its upshot on ulcer healing is limited; recommendations are based on observational testify and skilful stance. Nutritional screening is part of the full general evaluation of patients with pressure ulcers. Table 3 presents markers for identifying protein-calorie malnutrition.18 In patients who are malnourished, dietary consultation is recommended and a swallowing evaluation should exist considered. Intervention should include encouraging adequate dietary intake using the patient's favorite foods, mealtime assistance, and snacks throughout the mean solar day. High-calorie foods and supplements should exist used to forbid malnutrition. If oral dietary intake is inadequate or impractical, enteral or parenteral feeding should be considered, if compatible with the patient's wishes, to achieve positive nitrogen residuum (approximately 30 to 35 calories per kg per solar day and one.25 to ane.5 g of poly peptide per kg per day). Protein, vitamin C, and zinc supplements should be considered if intake is insufficient and deficiency is present, although data supporting their effectiveness in accelerating healing accept been inconsistent.19

Tabular array 3

Markers for Identifying Protein-Calorie Malnutrition in Patients with Pressure Ulcers

Unintentional weight loss of 5 percent or more in the previous 30 days or of 10 pct or more in the previous 180 days

Weight less than 80 per centum of platonic

Serum albumin level less than three.5 g per dL (35 g per Fifty)*

Prealbumin level less than 15 mg per dL (150 mg per L)*

Transferrin level less than 200 mg per dL (2 yard per L)

Full lymphocyte count less than 1,500 per mm3 (1.l × ten9 per L)

Management

  • Abstract
  • Etiology
  • Prevention
  • Assessment
  • Nutritional Evaluation
  • Direction
  • Complications
  • References

The management of pressure ulcers is interdisciplinary, including principal care physicians, dermatologists, infectious illness consultants, social workers, psychologists, dietitians, podiatrists, home and wound-care nurses, rehabilitation professionals, and surgeons. The basic components of pressure ulcer direction are reducing or relieving pressure level on the skin, debriding necrotic tissue, cleansing the wound, managing bacterial load and colonization, and selecting a wound dressing. Figure vi is a brief overview of these central components.18

Direction of Pressure Ulcers

Figure half-dozen.

Algorithm for the direction of pressure ulcers.

Adapted with permission from Hess CT. Wound Care. 4th ed. Springhouse, Penn.: Springhouse; 2002:54–55.

The pressure-reducing devices used in preventive care also apply to handling. Static devices are useful in a patient who can alter positions independently. A low–air-loss or air-fluidized bed may be necessary for patients with multiple large ulcers or a nonhealing ulcer, after flap surgeries, or when static devices are not effective. No 1 device is preferred.

Pain cess should be completed, especially during repositioning, dressing changes, and debridement. Patients at the highest risk of pressure ulcers may not have full sensation or may require alternate hurting assessment tools to aid in advice. The goal is to eliminate hurting by covering the wound, adjusting force per unit area-reducing surfaces, repositioning the patient, and providing topical or systemic analgesia. Small randomized controlled trials show that topical opioid (diamorphine gel; not available in the U.s.a.) and nonopioid (lidocaine/prilocaine [EMLA]) preparations reduce hurting during dressing changes and debridement.20,21

Necrotic tissue promotes bacterial growth and impairs wound healing, and it should be debrided until eschar is removed and granulation tissue is nowadays. Debridement, however, is not recommended for heel ulcers that have stable, dry eschar without edema, erythema, fluctuance, or drainage.8,16 Debridement methods include precipitous, mechanical, enzymatic, and autolytic. Precipitous debridement using a sterile scalpel or pair of scissors may be performed at bedside, although more all-encompassing debridement should be performed in the operating room. Sharp debridement is needed if infection occurs or to remove thick and extensive eschar. Healing after sharp debridement requires adequate vascularization; thus, vascular cess for lower extremity ulcers is recommended.22 Anticoagulation is a relative contraindication for precipitous debridement.

Mechanical debridement includes wet-to-dry out dressings, hydrotherapy, wound irrigation, and whirlpool bath debridement.23 Wet-to-dry out dressings adhere to devitalized tissue, which is removed with dressing changes (dry dressings should not be moistened before removal). However, viable tissue may also be removed and the process may exist painful.24 Hydrotherapy via whirlpool bathroom debridement or irrigation may loosen debris. Enzymatic debridement is useful in the long-term intendance of patients who cannot tolerate sharp debridement; however, it takes longer to be effective and should not be used when infection is present.25,26

Wounds should exist cleansed initially and with each dressing change. Use of a 35-mL syringe and 19-gauge angiocatheter provides a degree of strength that is effective nevertheless condom; utilise of normal saline is preferred. Wound cleansing with antiseptic agents (e.thou., povidone-iodine [Betadine], hydrogen peroxide, acetic acid) should exist avoided considering they destroy granulation tissue.27

Dressings that maintain a moist wound environment facilitate healing and tin can exist used for autolytic debridement.28  Synthetic dressings (Table 4) reduce caregiver time, crusade less discomfort, and potentially provide more consequent moisture.18 These dressings include transparent films, hydrogels, alginates, foams, and hydrocolloids. Transparent films effectively retain moisture, and may be used alone for fractional-thickness ulcers or combined with hydrogels or hydrocolloids for full-thickness wounds. Hydrogels can be used for deep wounds with light exudate. Alginates and foams are highly absorbent and are useful for wounds with moderate to heavy exudate. Hydrocolloids retain wet and are useful for promoting autolytic debridement. Dressing selection is dictated past clinical judgment and wound characteristics; no moist dressing (including saline-moistened gauze) is superior.29 A wet-to-dry dressing should only be used for debridement and is not a substitute for a wound dressing. Because at that place are numerous dressing options, physicians should exist familiar with one or 2 products in each category or should obtain recommendations from a wound care consultant.

Table 4

Overview of Different Dressings for Force per unit area Ulcers

Dressing type Clarification Indication Advantages Disadvantages Instance (brand names)

Transparent film

Agglutinative, semipermeable, polyurethane membrane that allows h2o to vaporize and cross the barrier

Management of stage I and Ii pressure ulcers with lite or no exudates May be used with hydrogel or hydrocolloid dressings for total-thickness wounds

Retains moisture Impermeable to leaner and other contaminants Facilitates autolytic debridement Allows for wound observation Does non crave secondary dressing (due east.g., tape, wrap)

Non recommended for infected wounds or wounds with drainage Requires border of intact peel for adhesion May dislodge in high-friction areas Not recommended on fragile skin

Bioclusive, Carrafilm, Dermaview, Mefilm, Opsite, Polyskin, Suresite, 3M Tegaderm, Uniflex

Hydrogel

Water- or glycerin-based amorphous gels, impregnated gauze, or canvass dressings Amorphous and impregnated gauze fill the dead space tissue and tin can exist used for deep wounds

Management of stages II, 3, and 4 ulcers; deep wounds; and wounds with necrosis or slough

Soothing, reduces hurting Rehydrates wound bed Facilitates autolytic debridement Fills dead tissue space Easy to apply and remove Can exist used in infected wounds or to pack deep wounds

Not recommended for wounds with heavy exudate Dehydrates easily if non covered Difficult to secure (amorphous and impregnated gauze demand secondary dressing) May cause maceration

Acryderm, Aquaflo, Aquagauze, Carradres, Carraguaze, Carrasmart, Carrasyn, Dermagauze, Dermasyn, Felxigel, SAF-Gel, Solosite, 3M Tegagel, Transigel

Alginate

Derived from brown seaweed; composed of soft, nonwoven fibers shaped into ropes or pads

May exist used as principal dressing for stages III and IV ulcers, wounds with moderate to heavy exudate or tunneling, and infected or noninfected wounds

Absorbs upwardly to 20 times its weight Forms a gel inside the wound Conforms to the shape of the wound Facilitates autolytic debridement Fills in dead tissue space Easy to apply and remove

Non recommended with light exudate or dry out scarring or for superficial wounds May dehydrate the wound bed Requires secondary dressing

Algicell, Algisite 1000, Carboflex, Carraginate, Dermaginate, Kalginate, Kaltostat, Melgisorb, Restore Calcicare, Sorbsan, 3M Tegagen

Foam

Provides a moist environment and thermal insulation; bachelor every bit pads, sheets, and pillow dressings

May be used equally primary dressing (to provide absorption and Insulation) or as secondary dressing (for wounds with packing) for stages 2 to Iv ulcers with variable drainage

Nonadherent, although some take adherent borders Repels contaminants Easy to use and remove Absorbs lite to heavy exudate May exist used under compression Recommended for fragile skin

Not effective for wounds with dry out eschar May crave a secondary dressing

Allevyn, Biatain, Carrasmart, Curafoam, Dermalevin, Epigard, Hydrocell, Lyofoam, Mepilex, Optifoam, Polyderm, Polymem, SOF-foam, Tielle, Vigifoam

Hydrocolloid

Occlusive or semiocclusive dressings equanimous of materials such as gelatin and pectin; available in various forms (e.g., wafers, pastes, powders)

May be used equally primary or secondary dressing for stages Ii to Iv ulcers, wounds with slough and necrosis, or wounds with light to moderate exudates Some may be used for stage I ulcers

Impermeable to bacteria and other contaminants Facilitates autolytic debridement Self-adherent, molds well Allows observation, if transparent May exist used nether compression products (pinch stockings, wraps, Unna kick) May be applied over alginate dressing to control drainage

Not recommended for wounds with heavy exudate, sinus tracts, or infection May curl at edges May injure fragile pare upon removal Contraindicated for wounds with packing

Carrasmart, Combiderm, Comfeel, Dermafilm, Duoderm, Exuderm, Hyperion, MPM Excel, Nuderm, Primacol, RepliCare, Restore, Sorbex, 3M Tegaderm, Ultec

Moistened gauze

2 × two- or four × 4-inch foursquare of gauze soaked in saline for packing

May be used for stages 3 and IV ulcers and for deep wounds, especially those with tunneling or undermining

Accessible

Must exist remoistened oftentimes Time-consuming to apply

Fluffed Kerlix, Patently Nugauze

Urinary catheters or rectal tubes may be needed to prevent bacterial infection from carrion or urine. Pressure ulcers are invariably colonized with leaner; however, wound cleansing and debridement minimize bacterial load. A trial of topical antibiotics, such every bit silver sulfadiazine cream (Silvadene), should exist used for upwardly to two weeks for clean ulcers that are not healing properly later on two to iv weeks of optimal wound intendance. Quantitative leaner tissue cultures should be performed for nonhealing ulcers later on a trial of topical antibiotics or if at that place are signs of infection (e.g., increased drainage, odor, surrounding erythema, pain, warmth). A superficial swab specimen may be used; notwithstanding, a needle aspiration or ulcer biopsy (preferred) is more clinically significant.30 Systemic antibiotics are not recommended unless at that place is evidence of advancing cellulitis, osteomyelitis, and bacteremia.

Ulcers are difficult to resolve. Although more 70 per centum of stage Two ulcers heal after six months of appropriate handling, merely 50 percent of stage Three ulcers and 30 percent of stage IV ulcers heal within this period. Surgical consultation should be obtained for patients with clean stage III or IV ulcers that do not respond to optimal patient care or when quality of life would be improved with rapid wound closure. Surgical approaches include straight closure; peel grafts; and skin, musculocutaneous, and free flaps. However, randomized controlled trials of surgical repair are lacking and recurrence rates are high.

Growth factors (e.g., platelet-derived growth factor becaplermin [Regranex])31,32 and vacuum-assisted closure for recalcitrant stage 3 and 4 ulcers are emerging management options.33 The role of electromagnetic therapy,34 ultrasound,35 and hyperbaric oxygen therapy is unclear.36

Complications

  • Abstract
  • Etiology
  • Prevention
  • Assessment
  • Nutritional Evaluation
  • Management
  • Complications
  • References

Although noninfectious complications of force per unit area ulcers occur, systemic infections are the about prevalent. Noninfectious complications include amyloidosis, heterotopic bone formation, perinealurethral fistula, pseudoaneurysm, Marjolin ulcer, and systemic complications of topical handling. Infectious complications include bacteremia and sepsis, cellulitis, endocarditis, meningitis, osteomyelitis, septic arthritis, and sinus tracts or abscesses.8 Osteomyelitis has been reported in 17 to 32 percent of infected ulcers and may atomic number 82 to nonhealing ulcers with or without systemic manifestations.37 Manifestly radiographs and bone scans are often unreliable. Magnetic resonance imaging has a 98 percent sensitivity and 89 per centum specificity for osteomyelitis in patients with pressure ulcers38; however, needle biopsy of the bone (via orthopedic consultation) is recommended and can guide antibiotic therapy. Bacteremia may occur with or without osteomyelitis, causing unexplained fever, tachycardia, hypotension, or altered mental condition.39 Overall mortality is loftier with both weather,40 and empirical antibiotics awaiting culture results should cover methicillin-resistant Staphylococcus aureus, anaerobes, enterococci, and gram-negative organisms, such equally Pseudomonas, Proteus, and Providencia species.41

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The Authors

evidence all author info

DANIEL BLUESTEIN, Md, MS, CMD, AGSF, is a professor in the Department of Family and Customs Medicine at Eastern Virginia Medical School, Norfolk, and is director of the section's Geriatrics Division. He received his medical degree from the University of Massachusetts Medical School, Worcester, and completed a family medicine residency at the Academy of Maryland Schoolhouse of Medicine, Baltimore. Dr. Bluestein holds a certificate of added qualification in geriatrics and is a fellow of the American Geriatrics Society....

ASHKAN JAVAHERI, Dr., is a geriatric medicine swain at Stanford (Calif.) University School of Medicine. He received his medical degree from Shahid Beheshti University of Medical Sciences, Tehran, Iran, and completed a family and customs medicine residency at Eastern Virginia Medical Schoolhouse.

Address correspondence to Daniel Bluestein, Md, MS, CMD, AGSF, Dept. of Family and Community Medicine, Eastern Virginia Medical School, 825 Fairfax Ave., Norfolk, VA 23507 (e-mail: bluestda@evms.edu). Reprints are not bachelor from the authors.

Author disclosure: Nothing to disclose.

The authors thank Cathy Flynn, BA; Sherry Allen, LPN, CPS; and Corrine Alvey, RN, BSN, CWOCN, for their assistance in the preparation of the manuscript.

The views expressed in this article are those of the authors and do not necessarily correspond the views of the Department of Veterans Affairs.

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