Assessment

Assessment of Infection in Older Adults

Signs and Symptoms in Four Body Systems
Mary D. Barakzai, EdD, FNP-C, CNM, CNS; and Dorothy Fraser, MSN, FNP-C
A lthough infection has always
been a major concern in the
older adult population, there is
growing concern in the health care
Abstract community about the rising mor-
Emerging infections and increased antibiotic resistance are growing concerns bidity and mortality associated with
within the health care community. Nurses play an important role in the early rec- emerging infections in patients older
ognition of clinical manifestations of infection in older adults. Atypical presenta- than age 65 (Adedipe & Lowenstein,
2006). The presentation of infection
tion in older adults, the presence of comorbid conditions, and altered immune in this population is often atypical
status all present challenges to both diagnosis and effective treatment in this due to altered immune status, the
population. The purpose of this article is to review common infections seen in presence of comorbid conditions,
older adults, with an emphasis on the integration of the effects of physiological increased functional losses, and
the effects of common physiologi-
changes of aging on patient presentation and nursing assessment. cal changes in aging (Bader, 2006;
Fletcher, 2004). This atypical presen-
tation and the increasing complexity
of care confront nurses in all kinds
of health care environments.
As the Baby Boomer generation
ages, the number of older adults is
expected to double by 2030, and this
growth will be reflected in each age
group as they move through their
60s, 70s, and 80s (Ham, Sloane, &
Warshaw, 2007). These demographic
changes will affect health care
systems, the delivery of care, and
the provision of nursing care within
both community and institutional
settings. As the population ages,
early identification and treatment of

ABOUT THE AUTHORS

Dr. Barakzai is Director, Central
California Center for Excellence in
Nursing, and Ms. Fraser is Lecturer,
California State University, Fresno,
Fresno, California.
© 2007/Charles Smith/Corbis

Address correspondence to Mary D.

Barakzai, EdD, FNP-C, CNM, CNS,
Director, Central California Center for
Excellence in Nursing, California State
University, Fresno, 1780 East Bullard
Avenue, #116, Fresno, CA 93720; e-mail:
Influenza virus at 295,000x magnification. maryb@csufresno.edu.

Journal of Gerontological Nursing • Vol. 34, No. 1, 2008 

infection can significantly influence
both morbidity and maintenance of
functional status (Miller, 2004; Tor-
res et al., 2004).
ATYPICAL PRESENTATION
Presentation of illness in older
adults is often associated with
atypical clinical manifestations
(Fletcher, 2004; Lim & Macfarlane,
2001; Marrie, 2000). Patients de-
scribe their symptoms as subtle or
nonspecific complaints. Decreased
homeostatic control with a lessened
or lengthened febrile response can
Early identification and treatment of infection
can significantly influence both morbidity and
maintenance of functional status.
alter this common objective finding
seen with infection. Although the
majority of health care problems
seen in older adults are not unusual,
an atypical presentation can affect
the diagnosis and implementation
of treatment. Delay in either of
these areas can be associated with
increased morbidity and mortality
(Bader, 2006; Fletcher, 2004; Ham et
al., 2007; Scheinfeld, 2005).
The purpose of this article is to
review common infections seen
in older adults, with an emphasis
on the integration of physiologi-
cal changes in aging and the role of
these changes in the presentation
of infection. In addition, the role
of nurses in the assessment of older
adult patients related to early detec-
tion of infection will be addressed.
integumentary system
Physiological Changes in Aging
The effects of aging on the in-
tegumentary system increases older
adults’ susceptibility to infection in
a number of ways. The thinning of
the epidermis and dermis occurring
in normal aging increases the risk
of injury (Ratliff & Fletcher, 2007).
The decreased moisture content
of the skin results in dryness and
 JOGNonline.com
pruritus, predisposing older adults
to infection secondary to superfi-
cial trauma and loss of the external
barrier protection. Slowing of cell
replacement after injury prolongs
recovery time and increases the risk
of secondary infection (Ham et al.,
2007; Scheinfeld, 2005).
A number of other changes that
occur with aging put older adults
at greater risk for infections of
the skin. Diminished cell-medi-
ated immunity decreases older
adults’ response to foreign antigens
(Miller, 2004). Decreased vascular-
ity secondary to disease can impair
the inflammatory response (Fletch-
er, 2004). Infections with both
normal skin flora and pathogenic
organisms increase (Fletcher, 2004;
Scheinfeld, 2005).
Common Infections
Herpes zoster, an infection with
the varicella zoster virus, is a com-
mon, clinically significant infection
in older adults. A primary infection
with the varicella virus in child-
hood increases the risk of a latent
infection that can be reactivated
late in life. An age-related decrease
in cell-mediated immunity, along
with immunosuppression secondary
to malignancy, HIV, malnutrition,
or immunosuppressive therapy,
enhances the risk of reactivation of
the latent virus (Cottam et al., 1999;
Landow, 2000; Stankus, Dlugopol-
ski, & Packer, 2000).
The presence of pain and pares-
thesias in the affected dermatome
can occur any time from 2 days to
4 weeks before the development
of a low-grade fever, malaise, and
an erythematous-based vesicular
rash over the affected dermatome.
The vesicular lesions interrupt the
protective layer of the skin and
increase the opportunity for a sec-
ondary infection, bacteremia, and
sepsis (Landow, 2000; Stankus et al.,
2000). Ocular complications, such as
mucopurulent conjunctivitis, optic
keratitis, and anterior uveitis, can
occur when the ophthalmic branch
of the trigeminal nerve is involved
(Landow, 2000; Scheinfeld, 2005;
Stankus et al., 2000).
Post-herpetic neuralgia is char-
acterized by pain that persists for
at least 30 days after clearing of
the zoster rash. The incidence of
post-herpetic neuralgia increases
with age, with more than 40% of
those older than age 60 reporting
this sequelae (Cottam et al., 1999).
The intractable nature of the pain
of post-herpetic neuralgia can
decrease functional status, which
can lead to decreased mobility,
decreased nutritional intake, and
increased susceptibility to infection
(Bader, 2006).
Cellulitis is an acute bacterial
infection of the connective tissue
of the skin that is most commonly
caused by Staphylococcus aureus or
Streptococcus pyogenes (Stulberg,
Penrod, & Blatney, 2002). In older
adults, the integrity of the skin is
decreased due to thinning of the
epidermis and dermis, which in-
creases the likelihood of superficial
skin tears and abrasions. A break
in the superficial barrier of the skin
increases the opportunity for entry
of bacteria and secondary infection.
In the older adult population, cel-
lulitis can be manifested by malaise,
low-grade fever, decreased appetite,
and changes in mental status.
An underlying decrease in vas-
cular supply can decrease signs and
symptoms such as redness, warmth,
and pain (Cottam et al., 1999). The
increasing incidence of both venous
insufficiency and peripheral arte-
rial disease enhances the risk of the
development of both stasis and
ischemic ulcers. Venous stasis is as-
sociated with dependent edema and
stasis ulcers that heal slowly, provid-
ing ample opportunity for second-
ary infection to occur. An impaired
inflammatory response compounds
the risk of infection in patients with
ischemic ulcers. Impaired circula-
tion will decrease the delivery of
nutrients, oxygen, white blood cells,
and immune system cells to the area
(Scheinfeld, 2005).
The incidence of methicillin-
resistant Staphylococcus aureus
(MRSA) in hospitals and skilled
nursing facilities has increased
rapidly during the past 2 decades
(Graham, Lin, & Larson, 2006).
Risk factors for the development
of health care-associated MRSA
(HA-MRSA) include age, recent
acute care hospitalization, long-term
stay in a skilled nursing facility,
surgery, enteral feedings, prior use
of antibiotic agents, and mechani-
cal ventilation (Graham et al., 2006;
Naimi et al., 2003; Salgado & Farr,
2003; Siegel, Rhinehart, Jackson, &
Chiarello, 2006).
Infection with HA-MRSA can
cause life-threatening skin and
soft tissue infections, endocarditis,
and sepsis. Important risk factors
for HA-MRSA, such as debility,
decreased immune competence, use
of in-dwelling catheters, and prior
use of antibiotic agents, are com-
mon in older adults hospitalized in
acute and chronic care institutions
(Simor, 2001).
It is important to recognize
that older adults living in the
community may be exposed to
community-acquired MRSA
(CA-MRSA) (Naimi et al., 2003).
CA-MRSA occurs in individuals
who have not been hospitalized or
undergone an invasive procedure
within the past year. CA-MRSA is
more commonly seen as a skin or
soft tissue infection and presents as
an abscess, folliculitis, or cellulitis
(Naimi et al., 2003). The compro-
mised skin of older adults, close
contact of patients in a hospital or
skilled nursing facility, and op-
portunity for exposure to contami-
nated surfaces can all increase the
risk of infection.
Journal of Gerontological Nursing • Vol. 34, No. 1, 2008
Nursing Assessment
Evaluation of older adults’ skin
is an integral part of nursing as-
sessment. Recognizing common
physiological changes that occur
with aging will help identify early
abnormalities associated with infec-
tion. Comorbid conditions such as
diabetes, decreased mobility, and
nutritional deficiencies will increase
the risk of injury and infection. A
careful assessment of all bony, in-
tertriginous, and sun-exposed areas
is important. Loss of sensation and
decreased circulation increases the
chance for untreated skin break-
down. Careful assessment can lead
to early identification and treatment.
Contact isolation with effective
handwashing and environmental
decontamination are interventions
that prevent the spread of both HA-
MRSA and CA-MRSA within facili-
ties (Salgado & Farr, 2003).
RESPIRATORY SYSTEM
Physiological Changes in Aging
Normal aging also affects the
respiratory system. As individu-
als age, the overall effectiveness of
the respiratory reserve decreases.
Reduced mucociliary transport and
diminished strength of the cough
reflex are common. In addition,
reduced pulmonary elasticity, larger
residual volume, and decreased
respiratory strength all predispose
older adults to pulmonary infec-
tions (McCance & Huether, 2005).
Skeletal changes occurring with ky-
phosis and scoliosis can impair chest
wall compliance and reduce ventila-
tory capacity. A progressive decline
in immune competence also occurs
(Marik & Kaplan, 2003). Impaired
nutritional status and the presence
of underlying comorbid conditions
that increase the risk of dysphagia
and aspiration increase the incidence
of pneumonia. The presence of co-
morbid conditions such as chronic
obstructive pulmonary disease,
congestive heart failure, a prior
cerebral vascular accident, and loss
of mobility are all associated with
an increased incidence of infection
(Marik & Kaplan, 2003; Riquelme et
al., 1996).
Common Infections
Pneumonia is the leading cause
of morbidity and mortality among
older adults, with the risk increas-
ing significantly for individuals
older than age 75. The highest rate
of pneumonia is found in resi-
dents of skilled nursing facilities
(Muder, Aghababian, Loed, Solot,
& Higbee, 2004). Streptococcus
pneumoniae remains the most com-
mon cause of community-acquired
pneumonia in older adults (Baik
et al., 2000; Mouton & Bazaldua,
2001). Pneumococcal pneumonia
is commonly manifested by fever,
chills, and rust-colored sputum.
Frail older adults with pneumococ-
cal pneumonia more commonly
experience atypical symptoms. The
initial presentation can be marked
by a change in mental or func-
tional status; weight loss, lethargy,
decreased intake, and delirium also
can occur (Marrie, 2000).
Lim and Macfarlane (2001) found
that skilled nursing facility residents
diagnosed with pneumonia were
most likely to be infected with S.
pneumoniae. Atypical pathogens,
gram-negative bacilli, and S. au-
reus infections were less common.
Outbreaks of viral pneumonias were
also common. Debility, decreased
functional status, and dysphagia in-
creased the risk of infection with S.
aureus and gram-negative pathogens
in patients within institutional set-
tings (Furman, Rayner, & Pelcher-
Tobin, 2004). Residents with
nursing home-acquired pneumonia
were less likely to have a productive
cough, pleuritic pain, or fever. In-
creased confusion and documented
behavior change were found to be
most predictive of infection (Lim &
Macfarlane, 2001).
Among residents of skilled nurs-
ing facilities admitted to the hospital
with a diagnosis of pneumonia,
Marrie (2000) documented increased

morbidity and mortality in those
with the following characteristics:
l Bedridden.
l Documented history of dyspha-
gia.
l Inability to take oral medica-
tions.
l History of prior aspiration.
l Temperature <37° Celsius on
admission to the hospital.
l Three or more areas of con-
solidation on admission chest
X ray.
Aspiration pneumonia is un-
derdiagnosed in the older adult
population. Although more than
50% of healthy adults aspirate a
small amount of oral pharyngeal
secretions during the night, the
development of disease is prevented
by the ability to forcefully cough,
the presence of an active mucocili-
ary defense mechanism, and normal
cell-mediated and humoral immu-
nity (Mouton & Bazaldua, 2001).
Impaired swallowing with aspira-
tion of oropharyngeal secretions
already colonized with S. pneu-
moniae or Haemophilus influenzae
is a common cause of pneumonia in
this population (Marik, 2001). Older
adults living in both the community
and institutional settings who have
a history of stroke or degenerative
neurological disease are at increased
risk for significant aspiration. It has
been estimated that 50% to 75% of
older adults in skilled nursing facili-
ties have dysphagia, which plays a
role in the high incidence of aspira-
tion pneumonia in this population
(Marik & Kaplan, 2003). Older
adults with Parkinson’s disease, Al-
zheimer’s disease, cerebral vascular
disease, and other neurodegenerative
diseases can have dysphagia early in
the disease. The presence of dyspha-
gia also increases the risk of a larger
volume of aspirate with an increased
exposure to bacterial colonization.
Nursing Assessment
Nurses need to identify atypical
presentations of pneumonia in frail
older adults to ensure early recogni-
10
tion and treatment of the disease.
The presence of dementia, inability
to relate current symptoms, and
decreased ability to participate in
the physical examination can limit
history and physical findings. Early
changes in behavior are often the
most important clues. Patients with
difficulty swallowing bear careful
watching and a high degree of suspi-
cion of aspiration pneumonia.
Although examination of the
respiratory system in older adults
can be challenging, it is important
to document increased respira-
tory rate; presence of adventitious
sounds, such as crackles, wheezing,
or decreased breath sounds; color;
and signs of respiratory distress.
Changes in mental or functional
status, anorexia, decreased mobil-
ity, and changes in behavior are also
important clinical manifestations
that warrant a careful respiratory
assessment for signs of infection.
RENAL SYSTEM
Physiological Changes in Aging
Age-related changes in the uri-
nary tract system also increase the
risk of infection. In older adults,
peak bladder capacity is reduced,
and residual volume is increased.
In addition, renal blood flow is de-
creased, and the ability to concen-
trate urine is impaired. Glomerular
filtration decreases and may be
further impaired by dehydration
or the effect of renal-toxic drugs.
In postmenopausal women, a de-
crease in estrogen levels can lead to
vaginal atrophy, decreased lactoba-
cilli, increased pH, and increased
colonization with pathogenic
bacteria.
Urinary obstruction with urinary
stasis increases the risk of infection.
Obstruction can occur with benign
prostatic hypertrophy, pelvic floor
weakness, fecal impaction, or cysto-
cele, or as a result of anticholinergic
side effects from antidepressant,
antihistamine, and antipsychotic
medications (Ham et al., 2007; Mc-
Cance & Huether, 2005).
Common Infections
Asymptomatic bacteriuria is
increased in individuals older than
age 65. It has been estimated that
20% to 25% of older women and
approximately 10% of older men
have asymptomatic bacteriuria
(Gomolin & McCue, 2000; Midt-
hun, 2004). This incidence increases
to more than 50% in women older
than age 80 or individuals who live
in skilled nursing facilities (Gomolin
& McCue, 2000). Asymptomatic
bacteriuria is defined as the presence
of bacteriuria without the signs of
symptomatic infection.
Risk factors for the development
of a urinary tract infection (UTI)
are recent diagnostic evaluation of
the urinary tract, diabetes, urinary
obstruction, and debility. Older
women are four to five times more
likely than are men to develop UTIs
(Gomolin & McCue, 2000). The
lack of a febrile response early in the
infection can delay the differentia-
tion of early pyelonephritis from a
more localized infection in the blad-
der. A complete history and physi-
cal examination to rule out other
associated diseases is important.
The cardinal symptoms of
dysuria—frequency, urgency, or
incontinence—are often exhibited
by community-dwelling older
adults with UTIs. Older adults
who are more debilitated and who
live at home or in an assisted living
environment can experience more
atypical presentations. Changes in
mental or functional status, restless-
ness, loss of appetite, and weight
loss are common (Gomolin & Mc-
Cue, 2000). Increased confusion,
new onset of falls or incontinence,
and changes in behavior are also
more common in institutional set-
tings (Midthun, 2004).
Older adults who have comor-
bid conditions that may interfere
with cognitive function, speech, or
attention can present a challenge to
nurses. Cognitive or communica-
tion losses can impair older adults’
ability to describe their symptoms.
JOGNonline.com
Decreased febrile response may also
affect assessment. All patients with
a catheter, whether Foley or supra-
pubic, will have bacteriuria within 5
days (Gomolin & McCue, 2000), es-
pecially if urinary retention second-
ary to obstruction of the catheter,
dehydration, or fecal soiling occurs.
Although it is commonly
believed that the presence of a
single organism of greater than 105
colony-forming units per mL is the
diagnostic criteria for a UTI, it is
important to note that contamina-
tion may be the cause of polymi-
crobial bacteriuria in community-
dwelling older adults (Midthun,
2004). Difficulty obtaining a mid-
stream urine specimen secondary to
arthritis, decreased functional status,
or decreased cognitive status can in-
crease the chance for contamination
and polymicrobial bacteriuria.
Nursing Assessment
UTIs can pose a challenge to
nurses. Atypical signs and symp-
toms such as lethargy, confusion,
decreased appetite, and change in
behavior can be misleading. The
presence of chronic asymptomatic
bacteriuria can also increase the diffi-
culty. A complete nursing assessment
is essential when a change in condi-
tion occurs. Documentation of the
characteristics of the urine is impor-
tant. Reduced use of Foley catheters,
assessment and early treatment of
urinary retention, and prevention of
fecal soiling can all decrease the risk
of infection and the possible develop-
ment of sepsis in older adults.
GASTROINTESTINAL system
Physiological Changes in Aging
Normal physiological changes
in aging seen in the gastrointestinal
tract of older adults are largely
characterized by diminished
peristalsis and secretion of gastro-
intestinal enzymes. The size of the
pancreas and liver also decreases.
These changes are not significant
alone but can increase the risk of
constipation, fecal incontinence,
Journal of Gerontological Nursing • Vol. 34, No. 1, 2008
and infection when associated with
other comorbid conditions, such
as dehydration and medication
use (Ham et al, 2007; McCance &
Huether, 2005).
Common Infections
Increased use of antibiotic agents
has increased the incidence of Clos-
tridium difficile. Current research
Increased vulnerability and subtle, often atypical
presentation of infection place older adults
at increased risk for delayed diagnosis and
development of complications.
points to the development of a more
virulent strain that is associated with
outbreaks of clinically severe disease
(Sunenshine & McDonald, 2006).
Risk factors identified for Clos-
tridium difficile-associated disease
(CDAD) are age older than 65,
severe underlying disease, nasogas-
tric intubation, antiulcer medica-
tion, long hospital stay, and broad
spectrum antibiotic use.
In long-term care settings, pa-
tient age, increased use of antibiot-
ic therapy, and increased use of an-
tiulcer medications make CDAD
the most common infectious cause
of diarrheal illness (Sunenshine
& McDonald, 2006). The clinical
manifestations of this infection can
range from mild abdominal cramp-
ing with small-volume diarrhea to
significant abdominal pain, fever,
large-volume diarrhea, and volume
depletion. The normal changes
of aging within the renal system
decrease the kidneys’ ability to
concentrate urine; this, along with
decreased intake, can increase the
risk of dehydration with diarrheal
illness. In turn, dehydration in-
creases postural hypotension, falls,
and azotemia (Cherifi et al., 2006;
Sunenshine & McDonald, 2006).
Treatment of CDAD includes
stopping the antibiotic agent, in-
creasing fluid intake, and avoiding
antiperistaltic agents.
Nursing Assessment
Complete assessment of older
adults with suspected CDAD
is important. Paralytic ileus and
toxic megacolon are associated
with severe disease (Sunenshine &
McDonald, 2006). Assessment of
the abdomen with special atten-
tion to bowel sounds, evidence of
abdominal distension, or signs of
dehydration secondary to fluid loss
is essential. Nurses play an impor-
tant role in early recognition of
CDAD. Cohorting infected patient
groups, instituting contact isolation,
and ensuring stringent handwash-
ing measures are recommended to
prevent spread of infection (Boyce
& Pittet, 2002).
CONCLUSION
Current concerns about antibi-
otic resistance, infectious disease,
and the growing numbers of older
adults all point to an increasing need
for nurses to develop expertise in
the care of this population. Knowl-
edge of how physiological changes
in aging can affect both the presen-
tation and response to infection in
older adults is essential. Increased
vulnerability and subtle, often atypi-
cal presentation of infection place
older adults at increased risk for
delayed diagnosis and development
of complications. Early and frequent
assessment is necessary. Early iden-
tification of infection with initia-
tion of early treatment can improve
morbidity.
Nurses are instrumental in early
identification and prevention of the
spread of infection. Careful atten-
tion to infection control policies
and handwashing can decrease the
spread of infection within both in-
stitutional and home care settings.
11
References
Adedipe, A., & Lowenstein, R. (2006). Infec-
tious emergencies in the elderly. Emergen-
cy Medicine Clinics of North America, 24,
433-448.
Bader, M.S. (2006). Staphylococcus aureus
bacteremia in older adults: Predictors of 7
day mortality and infection with methicil-
lin-resistant strains. Infection Control and
Hospital Epidemiology, 27, 1219-1225.
Baik, I., Curhan, G.C., Rimm, E.B., Bendich,
A., Willett, W.C., & Fawi, W.W. (2000). A
prospective study of age and lifestyle fac-
tors in relation to community-acquired
pneumonia in US men and women. Ar-
chives of Internal Medicine, 160, 3082-
3088.
Boyce, J., & Pittet, D. (2002). Guidelines for
hand hygiene in health care settings: Rec-
ommendations of the HealthCare Infec-
tion Control Practices Advisory Commit-
tee and the HICPAC/SHEA/APIC/IDSA
Hand Hygiene Task Force. Infection
Control and Hospital Epidemiology, 23(12
Suppl.), S3-S40.
Cherifi, S., Delmee, M., Van Broeck, J., Beyer,
I., Byl, B., & Mascart, G. (2006). Manage-
ment of an outbreak of Clostridium dif-
ficile associated diseases among geriatric
patients. Infection Control and Hospital
Epidemiology, 27, 1200-1205.
Cottam, J., Shenefelt, P., Sinnott, J., Stevens,
G., Cancio, M., & Sakalosky, P. (1999).
Common skin infections in the elderly. In-
fection in Medicine, 16, 280-290.
Fletcher, K. (2004). Geriatric emergencies
part 1: Vulnerability and primary preven-
tion. Topics in Advanced Practice Nursing
eJournal, 4(2). Retrieved November 1,
2007, from http://www.medscape.com/
viewarticle/477731
Furman, C.D., Rayner, A.V., & Pelcher-Tobin,
E. (2004). Pneumonia in older residents of
long term care facilities. American Family
Physician, 70, 1495-1500.
Gomolin, I.H., & McCue, J.D. (2000). Uri-
nary tract infections in the elderly patient.
Infections in Urology, 13(5a). Retrieved
November 1, 2007, from http://www.
medscape.com/viewarticle/412692
12
Graham, P.L., 3rd, Lin, S.X., & Larson, E.L.
(2006). A U.S. population-based survey of
Staphylococcus aureus colonization. An-
nals of Internal Medicine, 144, 318-326.
Ham, R., Sloane, P., & Warshaw, G. (2007).
Primary care geriatrics: A case-based ap-
proach. St. Louis: Mosby.
Landow, K. (2000). Acute and chronic her-
pes zoster. Postgraduate Medicine, 107(7),
107-118.
Lim, W.S., & Macfarlane, J.T. (2001). A pro-
spective comparison of nursing home
acquired pneumonia with community ac-
quired pneumonia. European Respiratory
Journal, 18, 362-368.
Marik, P.E. (2001). Aspiration pneumonitis
and aspiration pneumonia. New England
Journal of Medicine, 344, 665-671.
Marik, P.E., & Kaplan, D. (2003). Aspiration
pneumonia and dysphagia in the elderly.
Chest, 124, 328-336.
Marrie, T.J. (2000). Community-acquired
pneumonia in the elderly. Clinical Infec-
tious Disease, 31, 1066-1078.
McCance, K.L., & Huether, S.E. (2005). Patho-
physiology: The biologic basis of disease in
adults and children. St. Louis: Mosby.
Midthun, S. (2004). Criteria for urinary tract
infection in the elderly: Variables that
challenge nursing assessment. Urological
Nursing, 24, 157-162.
Miller, C. (2004). Nursing for wellness in older
adults: Theory and practice. Philadelphia:
Lippincott, Williams & Wilkins.
Mouton, C., & Bazaldua, O. (2001). Common
infections in older adults. American Fam-
ily Physician, 63, 257-268.
Muder, R.R., Aghababian, R.V., Loed,
M.B., Solot, J.A., & Higbee, M. (2004).
Nursing home acquired pneumonia: An
emergency department algorithm. Cur-
rent Medical Research and Opinion, 20,
309-320.
Naimi, T.M., LeDell, K., Como-Sabetti, K.,
Borchardt, S., Boxrud, D., Etienne, J., et
al. (2003). Comparison of community and
health care associated methicillin resistant
Staphylococcus aureus infection. Journal
of the American Medical Association, 290,
2976-2985.
Ratliff, C.R., & Fletcher, K.R. (2007). Skin
tears: A review of the evidence to sup-
port prevention and treatment. Ostomy/
Wound Management, 53(3), 32-34, 36,
38-40 passim.
Riquelme, R., Torres, A., El-Ebiary, M., del
la Bellacasa, J.P., Estruch, R., Mensa,
J., et al. (1996). Community-acquired
pneumonia in the elderly: A multivariate
analysis of risk and prognostic factors.
American Journal of Respiratory and
Critical Care Medicine, 154, 1450-1455.
Salgado, C., & Farr, B. (2003). MRSA and
VRE: Preventing patient-to-patient
spread. Infections in Medicine, 20(4). Re-
trieved November 1, 2007, from http://
www.medscape.com/viewarticle/452426
Scheinfeld, N. (2005). Infections in the el-
derly. Dermatology Online Journal,
11(3). Retrieved November 1, 2007,
from http://dermatology.cdlib.org/113/
reviews/elderly/scheinfeld.html
Siegel, J., Rhinehart, E., Jackson, M., & Chi-
arello, L. (2006). Management of multi-
drug-resistant organisms in healthcare
settings, 2006. Retrieved April 7, 2007,
from http://www.cdc.gov/ncidod/dhqp/
pdf/ar/mdroGuideline2006.pdf
Simor, A. (2001). Containing methicillin re-
sistant S. aureus. Postgraduate Medicine,
110(4), 43-48.
Stankus, S., Dlugopolski, M., & Packer, D.
(2000). Management of herpes zoster (shin-
gles) and postherpetic neuralgia. American
Family Physician, 61, 2437-2447.
Stulberg, D., Penrod, M., & Blatney, R.
(2002). Common bacterial skin infec-
tions. American Family Physician, 66,
119-224.
Sunenshine, R.H., & McDonald, L.C.
(2006). Clostridium difficile-associated
disease: New challenges from an estab-
lished pathogen. Cleveland Clinic Jour-
nal of Medicine, 73, 187-197.
Torres, O.H., Munoz, J., Ruiz, J., Ris, J.,
Gich, I., Coma, E., et al. (2004). Out-
come predictors of pneumonia in elderly
patients: Importance of functional as-
sessment. Journal of the American Geri-
atrics Society, 52, 1603-1609.
JOGNonline.com
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.