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Geriatrics > Common infections in the elderly > Flashcards

Common infections in the elderly Flashcards

1
Q

UTI

A
  • Very Common among female residents
  • Don’t treat dirty urine, wait for culture
  • Only treat if >100k colonies on culture
  • Cultures often contaminated, don’t treat
  • Male UTI’s are always complicated
  • UTI with dsyuria/fever is symptomatic, +SPT usually not enough in SNF
  • Don’t always treat if colonized, eg, recurrent and asymptomatic, esp if have chronic indwelling foley
  • Weaker UTI hes much more likely to treat with microstatic anx (nitrofurantoin, Macrobid)
  • Levaquin, levofloxacin for the stronger UTIs
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2
Q

hospital acquired pneumonia tx vs outpatient

A
  • levaquin - hospital

- z-pack - outpatient

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3
Q

managing PNA

A
  • Bronchitis: Zpack: Azithromycin 500mg po x 1 then 250mg po x 4 d, can’t call it bronchitis anymore, call it atypical PNA
  • HAP: Levofloxacin 500mg po qd x 7 d
  • Aspiration: Augmentin 870mg po bid x 10 d, Often Levofloxacin with addition of Flagyl 40mg po qid x 7d
  • Augmentin is great for mouth infections
  • If they have penicillin allergy, CLINDAMYCIN (Tx for oral problems, ENT, aspiration PNA)
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4
Q

rales vs rhonchi

A
  • Rhonchi MEANS PNA!!! (There is a fluid in the larger tubes in the bronchi, You can hear air going through a tube and you can hear a little water on the edges, Inspiratory AND expiratory, “course breaths” means you think its rhonchi, but it might not be)
  • Rales = crackles (INSPIRATORY ONLY, END of inspiration – why?? The alveoli are popping open!, Sound like rice crispies at the end of inspiration, RALE = atelectasis, CHF, PNA; RALE IS NOT VERY USEFUL!! If they have a rale, your ddx is CHF vs PNA vs atelectasis)
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5
Q

Stridor vs wheeze

A
  • Stridor = inspiratory – bronchiolitis – need to be on duoneb within 5 minutes
  • Wheeze = expiratory
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6
Q

TB and the elderly

A
  • Common, especially in long-term care
  • Seek history of prior disease and
  • immune limitations
  • Screening (PPD x Two, Blood: Quantiferon Gold)
  • CXR
  • Check for weight loss, fever, nightsweats
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7
Q

Tb and the elderly

A
  • Common, especially in long-term care
  • Seek history of prior disease and immune limitations
  • Screening (PPD x Two, Blood: Quantiferon Gold)
  • CXR
  • Check for weight loss, fever, nightsweat
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8
Q

CXR

A
  • Morbidly obese

- Demented

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9
Q

Incidence of pressure ulcers

A
  • High as 38% in acute care settings
  • Hospitals 2.8-9%, SNF 3.6-59%, home 4.5-6.3%
  • Very litigious: Medicare have stooped reimbursing facilities for the treatment of PU developed in house
  • Pressure ulcers and hospice: pain of turning a patient may exceed potential pain of pressure ulcers
  • Once they reach hospice we don’t really treat them anymore
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10
Q

Physical signs of neglect

A
  • Pressure sores
  • Malnutrition
  • Dehydration
  • Poor hygiene
  • Disheveled appearance
  • Failure to seek care in a timely fashion
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11
Q

Pressure ulcer synonyms

A
  • Bed sores
  • Decubitus ulcers
  • Decubiti
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12
Q

Pressure ulcers ca be a complication of which disease states

A
  • Strokes
  • Parkinson’s
  • Cancer with pain
  • Advanced dementia with impaired mobility
  • ALS
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13
Q

How do pressure ulcers develop

A

-When pressure forces exceed capillary flow causing ischemia and subsequent tissue necrosis

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14
Q

Common pressure sore locations

A
  • Occiput
  • Spine
  • Sacrum
  • Ischium
  • Heels
  • Trochanter
  • Knee
  • Ankle
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15
Q

Pressure ulcers intrinsic risk factors

A
  • Nutritional status
  • Age
  • Immobility or limited activity
  • Sensory impairment
  • Incontinence (fecal > urinary)
  • Dry skin
  • Body temp, blood pressure
  • PRESSURE
  • Shearing forces
  • Moisture
  • Friction
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16
Q

Pressure ulcer medical risk factors

A
  • Diabetes
  • Kidney failure
  • PVD
  • Diseases that require chronic prednisone: rheumatoid arthritis and COPD
17
Q

Norton scale

A

-1-5 scoring in five domains

  • General physical conditioning
  • Mental state
  • Activity
  • Incontinence
  • Mobility

-Validated, though no randomized trials to measure impact on incidence

18
Q

Braden scale

A

-six domains, 1-4 for first 5, <18 high risk

  • sensory perception
  • activity
  • mobility
  • skin moisture
  • friction
  • dietary intake 1-3

-validated, though no randomized trials to measure impact on incidence

19
Q

pressure ulcer staging

A
  • Stage I (47%) – erythema that does not blanche
  • Stage II (33%)- Partial thickness, involving epidermal and dermal layers
  • Stage III – Full thickness loss involving all layers of the skin
  • Stage IV – Full thickness involving muscle and bone
  • Suspected DTI Deep tissue Injury: Purple or maroon area, blood filled blister 2/2 underlying tissue, progresses or resolves (You look at it and the skin is intact!! But its bruised in an obvious place which suggests massive necrosis under the skin, Will go from skin intact to stage 4 in a week, If you see a bruise on bony prominence with no falls, it’s a DTI until proven otherwise)
  • Unstageable: base covered by slough or eshar
  • IF THERES SLOUGH ON THE TOP, IT IS UNSTAGABLE!!! YOU HAVE TO SCRAPE THE SLOUGH OFF TO STAGE IT!!
  • When you describe it, you have to note that there is “70% slough, unstageable” (If there is no slough, you say “well epithelialized, beefy red bottom”, Very rarely do you see a stage 4 without slough)
20
Q

implications of staging pressure ulcers

A
  • increasing stage implies increasing difficulty and time in healing
  • increasing stage implies increased risk of recurrence throughout life
21
Q

mortality

A
  • Patients admitted to nursing homes (With Pressure Ulcers 50% in one year, Without Pressure Ulcers 27% in one year)
  • Patients who develop pressure ulcers within three months of admission (35% mortality, Versus 25% without pressure ulcers)
22
Q

wounds and infeciton

A
  • as a rule, we do not culture wounds (because we cover for MRSA anyway)
  • Colonization: all wounds are
  • Superficial infection: appears clean (Topical ABTs: iodine, Medihoney, ionized silver, Dakins and betadine short term.)
  • Cellulitis: erythema, pain, drainage, odor, fever, leukocytosis (Topical Abts and PO rx (clinda and Bactrim to cover MRSA unless mild, keflex for Strep), It has a clearly and well demarcated border)
  • Sepsis
23
Q

wounds and sepsis

A
  • Sepsis: Infection throughout the body
  • Signs of Sepsis (Fever OR Hypothermia, Chills, Rapid respiratory rate, HR, Low blood pressure)
  • Mortality: 40-60%
  • Treatment: Pressors, IVF, IV ABT
24
Q

prevention of pressure ulcers

A
  • Turn the patient every 2 hours!!! – this is the standard of care!!
  • Although bed rails are a form of restraint, benefits may exceed the risks of restraint injuries
  • Keep the patient dry
  • Use special beds to prevent pressure ulcers
25
Q

treatment of pressure sores

A
  • REMOVE PRESSURE
  • Medical Treatment (Nutrition: High Protein, Vitamin C, Zinc, Monitor albumin and prealbumin/ nutritional consult, Treat primary medical condition/comorbidity)
  • Manage incontinence
  • Specialized beds and mattresses (air loss and air fluidized mattresses), doughnut cushion
  • Local wound care
  • Surgery
  • Pain management
26
Q

healing of pressure ulcers

A
  • Long treatment
  • In acute care setting only 12% heal
  • Nursing home setting:
  • Stage II – 25 – 42 % healed after 4 weeks of treatment
  • Stage III – IV – None are healed at 4 weeks (Best healing rate – 59% at 6 months, YOU NEVER REGRESS FROM A STAGE 4!!!! – regardless of what surgery has been done to fix it!!)
27
Q

differentiating wounds

A
  • Location
  • Comorbidities
  • Location
  • Quality of Care
  • Recent medical Hx
28
Q

DDX and cause

A
  • MASD: most common misdiagnosis, moisture associated skin damage/ abrasion
  • Diabetes: neuropathy
  • PVD: poor pulses or venous stasis
  • Generalized skin changes at the end of life
  • People will call pressure ulcers MASDs to avoid getting fined
29
Q

peripheral vascular dz: dx

A
  • Noninvasive imaging has replaced angiography for detection
  • Angiography primarily for confirmation during endovascular intervention
  • Examples of location: Carotid stenosis, AAA, LE arterial dz
30
Q

LE arterial dz

A
  • 15-20% incidence >70yo
  • Presentation: Claudication/cramping in calves, buttocks, aching relieved with 10 min of cessation of activity
  • Only 10% proceed to severe pain gangrene or amputation
31
Q

PVD

A
  • Similar to CAD, smoking, males, +family hx
  • PE: monitor pulses!, Trophic changes: loss of hair
  • Dx: DUS (doppler ultrasound), angiography, CT, MRI, ABI
  • Treatment: 90% have CAD, eg. get a Cards consult, PT (incr walking), Endovascular angioplasty vs open repair
32
Q

diabetes and wounds

A
  • Diabetic Neuropathy: Microvascular complication, affects up to 50% of DM2 pts
  • Foot ulcerations common, Amputations common
  • Highest risk: DM>10 years, males, poor glycemic control
  • Prevention: Monitor Feet! Test sensation, Achilles reflex, treat neuropathic pain, podiatry consults
  • IF YOU HAVENT LOOKED AT THEIR FEET, THE NOTE IS NOT COMPLETE

Geriatrics (7 decks)

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