The Gastrointestinal System 2

20
Lecture Note PowerPoint Presentation
The Gastrointestinal
System
23/12/2010
LEARNING OUTCOME 1
Describe age-related changes that affect gastrointestinal
function.
Gerontological Nursing, Second Edition

Patricia A. Tabloski
GASTROINTESTINAL CHANGES
ASSOCIATED WITH AGING
Begin before age 50
23/12/2010
Changes in the mouth

Decreased esophageal motility
Reduced peristalsis
Diminished ability of gastric mucosa to resist damage
Decreased production of intrinsic factor
Reduced intestinal absorption and blood flow
Intrinsic factor (IF) also known as gastric intrinsic factor (GIF) is a glycoprotein
produced by the parietal cells of the stomach. It is necessary for the absorption of vitamin
B12 later on in the terminal ileum

23/12/2010
FIGURE 20-1
NORMAL CONFIGURATION OF THE GI TRACT. 4

GASTROINTESTINAL CHANGES
ASSOCIATED WITH AGING
23/12/2010
Begin before age 50
Decreased pancreas size
Increased incidence of cholelithiasis, decreased
production of bile synthesis
Decreased liver size and blood flow
Decreased thirst and hunger
Increased medication use

23/12/2010
LEARNING OUTCOME 2
Describe the impact of age-related changes of
gastrointestinal function.

AGING AND THE GASTROINTESTINAL
SYSTEM
23/12/2010
Aging has limited impact on system
Aging associated with increased prevalence of
many GI disorders
Evaluate disorders closely

23/12/2010
FIGURE 20-2
NORMAL CHANGES OF AGING RELATED TO THE GASTROINTESTINAL TRACT. 8

DYSPHAGIA
23/12/2010
Number-one esophageal disorder in older people
Impacts oral intake
Seen in 50% of institutionalized persons

DYSPHAGIA
23/12/2010
Causes
Poor tongue control
Poor preparation of food bolus for swallowing
Poor dentition: pertains to the development of teeth
and their arrangement in the mouth
Lack of saliva
10

DYSPHAGIA
23/12/2010
Signs and symptoms
Reports of difficulty swallowing
Difficulty controlling food or saliva in mouth
Facial droop
Dementia, frailty, confusion
Inability to sit upright
11

DYSPHAGIA
23/12/2010
Signs and symptoms
Choking or coughing while eating
Increased oral or nasal congestion after meals
Weak voice or slurred speech
Recurrent upper respiratory infections
Unexplained weight loss
12

DYSPHAGIA
23/12/2010
Risk factors
Incorrect positioning
Inappropriate intake
Rapid feeding
Older persons labeled as difficult
Comorbidities
Neurological disorders
Muscular disorders
Anatomical abnormalities
13

DYSPHAGIA
23/12/2010
Nursing assessment
Observation of individual during eating and drinking
14

DYSPHAGIA
23/12/2010
Nursing assessment
Question patient concerning
Choking
Dry mouth
Excess saliva
Inability to control food in mouth
Spitting up after meals
Need to frequently clear throat
Difficulty sitting up during mealtimes
15

DYSPHAGIA
23/12/2010
Nursing interventions
Minimize distractions while eating
Use consistent feeding techniques
Proper positioning during mealtime
Monitor respirations during feeding
Provide oral hygiene before and after eating
Offer intake consistencies as recommended
Do not forcefully feed
16

GASTROESOPHAGEAL REFLUX DISEASE
23/12/2010
Caused by weakness of esophageal sphincter
Increased incidence of hiatal hernia
Risk factors
Aging
Thyroid disease
Scleroderma or connective tissue disorders
Diabetes
17

23/12/2010
Risk factors
Aging
Thyroid disease
Scleroderma or connective tissue disorders
Diabetes
18

23/12/2010
Signs and symptoms
Heartburn
Indigestion
Belching:(also known as burping, ructus, or eructation) involves
the release of gas from the digestive tract (mainly esophagus and
stomach) through the mouth.
Hiccups
Regurgitation of gastric contents
Voice hoarseness
19

23/12/2010
Triggers
Eating large meals
Certain medications
High-fat foods
High caffeine intake
Alcohol and tobacco use
Reclining after eating
Obesity
20

23/12/2010
Consequences for GERD
Nursing assessment of GERD
Diagnostic testing
Barium swallow
Endoscopy
Esophageal contents pH
21

23/12/2010
Goals of treatment
Symptom control
Heal mucosal injury
22

23/12/2010
Lifestyle modifications
Elevate head of bed
Reduce portion size
Avoid trigger foods
Drink 6 to 8 ounces of water with medications
23

23/12/2010
Lifestyle modifications
Report all medications to physician
Avoid tight-fitting clothes and girdles(belt-shaped
textile)
Remain upright after meals for 1 to 3 hours
Avoid right side-lying position
Stop smoking
24

23/12/2010
Medications
Antacids
Aluminum-containing antacids
Histamine 2 receptor agonists
Proton pump inhibitors
Combination drugs
Surgery
25

GASTRIC DISORDERS
23/12/2010
Gastritis
Inflammation of the gastric mucosa
Classification
Severity
Site involvement
Inflammatory cell type
Diagnosis
Endoscopy
26

GASTRIC DISORDERS
23/12/2010
Gastritis
Treatment
Reducing contributing factors
Acid neutralization and suppression
Protection of gastric mucosa
Antibiotic therapy
Transfusions as needed
27

GASTRIC DISORDERS
23/12/2010
Peptic and duodenal ulcer disease
An excoriated area of the gastric mucosa
Signs and symptoms
Bleeding
Positive fecal occult blood test
Pain
Diagnosis
H. pylori breath test
Endoscopy
28

GASTRIC DISORDERS
23/12/2010
Peptic and duodenal ulcer disease
Treatment
Discontinue use of NSAIDs, alcohol, tobacco, and caffeine
Small, frequent meals
Medications
29

GASTRIC DISORDERS
23/12/2010
Zollinger-Ellison syndrome
Caused by a gastrin-producing tumor
Characterized by gastric hypersecretion and peptic
ulceration
Treatment may include tumor removal and surgical
resection
30

GASTRIC DISORDERS
23/12/2010
Gastric volvulus
Turning, twisting, or telescoping of the stomach onto
or into itself
Symptoms
Acute pain
Shock and hypotension
Abdominal distention
Inability to vomit
Dyspnea
31

LOWER GASTROINTESTINAL TRACT
DISORDERS
23/12/2010
Diverticular disease
Saclike mucosal projections protrude through
muscular layer of GI tract
Projections may trap feces resulting in inflammation,
infection, and rupture
Seen most in sigmoid and descending colon
32

DISORDERS
23/12/2010
Diverticular disease
Risk factors
Physical inactivity
Constipation
Obesity
Smoking
NSAID therapy
Management
Increase fiber intake
33

DISORDERS
23/12/2010
Diverticulitis
Normal bowel flora and fecal material becomes
trapped in pouches resulting in inflammation,
infection, and obstruction
Signs and symptoms
Fever
Leukocytosis
Pain or abdominal tenderness
34

DISORDERS
23/12/2010
Assessment of diverticular disease
Physical examination
Questions regarding bowel history
Diagnosis
Abdominal CT scan
Ultrasound
35

DISORDERS
23/12/2010
Goals of treatment
Eliminate bacterial infection
Liquid diet advancing to low fiber to allow colon to
rest
36

INFLAMMATORY BOWEL DISEASE
23/12/2010
Ulcerative colitis
Chronic inflammatory process
Impacts superficial layers of colon walls
Wide spread ulceration of colon walls
Signs and symptoms
Bloody diarrhea
Lower left quadrant abdominal pain
Weight loss
37

23/12/2010
Ulcerative colitis
Diagnosis
Sigmoidoscopy
Colonoscopy
Rectal mucosa biopsy
Stool specimens
Treatment
Oral corticosteroids
5-ASA drugs
Surgery
38

23/12/2010
Crohns disease
Chronic inflammatory disorder of the terminal ileum or
colon
Characterized by inflammation, linear ulcerations, and
granulomas
Signs and symptoms
Diarrhea
Fever
Abdominal pain
Weight loss
39

23/12/2010
Crohns disease
Diagnosis
Abdominal CT scan
Complete blood cell count
Barium enema colonoscopy
Treatment
Oral corticosteroids
Surgery
40

BENIGN AND MALIGNANT TUMORS
23/12/2010
Benign tumors or polyps seen in 75% of persons
over age 50
Predisposing factors
Age
Diet
Family history
Prior diagnosis polyps
41

23/12/2010
Malignant tumor
2nd most common malignancy in the United States
Increase incidence with age
Family history
Inflammatory bowel disease
History of colorectal tumors
42

23/12/2010
Malignant tumor
Signs and symptoms
Change in bowel habits
Abdominal pain
Abdominal mass
Anemia
Rectal bleeding
Weight loss
43

23/12/2010
Malignant tumor
Diagnostic testing
Colonoscopy
Carcinoembryonic antigen levels
Sigmoidoscopy
Fecal occult blood testing
Treatment
Surgical resection
44

ANTIBIOTIC THERAPY ASSOCIATED
DIARRHEA AND COLITIS
23/12/2010
Occurs during or shortly after administration of
antibiotics
Caused by Clostridium difficile cytoxin, causing
bowel inflammation and epithelial necrosis
resulting in diarrhea and postmembranous colitis
45

23/12/2010
Signs and symptoms
Watery, nonbloody diarrhea
Low abdominal pain
Fever
Potential complications
Dehydration
Hypotension
Colonic perforation
46

23/12/2010
Diagnosis
Stool perforation
Treatment
Metronidazole
Vancomycin
47

CONSTIPATION
23/12/2010
Definitions
Infrequent defecation
Hardened or reduced caliber of stool
Sensation of incomplete evacuation or need to strain
with stools
Three bowel movements or less per week
48

CONSTIPATION
23/12/2010
Aging
Certain medications
Metabolic and endocrine disorders
Muscular dystrophy
Neurologic disorders
Recent abdominal surgery
Obstructive disorders
49

CONSTIPATION
23/12/2010
Complications
Abdominal discomfort
Loss of appetite
Nausea and vomiting
Excessive straining
Hemorrhoids, anal fissures, and rectal prolapse
Intestinal obstruction
Colonic ulceration
Overflow incontinence with stool leakage
50

CONSTIPATION
23/12/2010
Assessment
Evaluate complaint
Management
Education
Hydration
Increased mobility
Fiber supplementation
51

CONSTIPATION
23/12/2010
Assessment
Management
Medication
Bulk laxative
Stool softeners
Osmotic laxatives
Magnesium containing laxatives
Senna
Suppositories and enema
52

DIARRHEA
23/12/2010
Defined as abnormally loose stool accompanied
by change in frequency or volume
53

DIARRHEA
23/12/2010
Causes
Virus
Food poisoning
Food contamination
Medications
Lactose intolerance
54

DIARRHEA
23/12/2010
Symptoms
Urgency
Cramping
Bloating
Incontinence
Pain on defecation
Presence of blood in stool
55

DIARRHEA
23/12/2010
Assessment
Interview
Physical examination
Management
Antidiarrheal agents
Soluble fiber
56

FECAL INCONTINENCE
23/12/2010
Seen in 50% of institutionalized elderly
Cause
Mobility problems
Severe depression
Cognitive impairment
57

HEMORRHOIDS AND RECTAL BLEEDING
23/12/2010
Hemorrhoids and colorectal cancer most common
causes of rectal bleeding
Hemorrhoids are varicose of anorectal junction
Treatment based upon size
58

LIVER AND BILIARY DISORDERS
23/12/2010
Signs and symptoms
Older adults often present with vague, ambiguous
symptoms
Fatigue
Weight loss
Anorexia
Malaise
59

23/12/2010
Risk of disease increases with aging
Hepatitis A
Hepatitis B
Hepatitis B and C
Hepatic cysts
Common in older adults
Typically benign
60

23/12/2010
Hepatic cysts
Common in older adults
Typically benign
61

23/12/2010
Metastatic carcinoma
Most common liver cancer
Highest rates in those aged 5070
Associated with alcohol and tobacco use
62

23/12/2010
Signs and symptoms
Jaundice
Variceal bleeding
Ascites
Right upper quadrant pain
Weight loss
Enlarged liver
63

23/12/2010
Diagnostic tests
Liver function tests
Abdominal ultrasound
CT scan
Liver biopsy
Treatment based upon tumor stage and patients

health status
64

23/12/2010
Gallstones
Increased incidence with age
1:3 people over age 70 have gallstones
Symptoms
Right upper quadrant pain
Gas
Distention
Nausea and vomiting
65

23/12/2010
Gallstones
Diagnostic testing
Abdominal CT scan
Ultrasound
Treatment
Laparoscopic cholecystectomy
Pharmacological dissolution
Extracorporeal shock wave lithotripsy
Dietary modifications
66

23/12/2010
Pancreatitis
Acute pancreatitis
Symptoms
Epigastric pain
Nausea and vomiting
Elevated serum liver function studies
Amylase
Lipase
Bilirubin
Alkaline phosphatase
67

23/12/2010
Pancreatitis
Acute pancreatitis
Treatment
Nasogastric suction
Pain management
Hyperalimentation
Fluid replacement
68

23/12/2010
Pancreatitis
Chronic pancreatitis
Symptoms
Weight loss
Diarrhea
Diabetes
Persistent pain
Treatment
Behavior modification
Surgery
69

23/12/2010
LEARNING OUTCOME 3
Identify risk factors to health for the older person with
gastrointestinal problems.
70

MEDICATIONS WITH POTENTIAL TO
AFFECT THE GASTROINTESTINAL TRACT
23/12/2010
Anticholinergics
Antidepressants
Neuroleptics
Antihistamines
Antiparkinsonian agents
71

MEDICATIONS WITH POTENTIAL TO
AFFECT THE GASTROINTESTINAL TRACT
23/12/2010
Antihypertensives
Calcium channel blockers
ACE inhibitors
Diuretics
Iron and calcium supplements

Opiates
Laxatives
72

MEDICATIONS AS RISK FACTORS FOR
ESOPHAGEAL INJURY
23/12/2010
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Potassium chloride
Tetracycline
Quinidine
Alendronate
Ferrous sulfate
Theophylline
73

RISK FACTORS FOR DYSPHAGIA IN
INSTITUTIONALIZED OLDER PERSONS
23/12/2010
Inappropriate positioning for mealtimes
Inappropriate feeding of foods and liquids
Thin food and liquids difficult to swallow
Thickened liquids slow the swallow process
Too-rapid feeding of at-risk patients

Residents labeled as difficult or uncooperative
74

GERD RISK FACTORS
23/12/2010
Primary
Length and frequency of esophageal acid exposure
Others
Thyroid disease
Diabetes
Scleroderma
Connective tissue disorders
75

RISK FACTORS FOR LARGER ULCERS
23/12/2010
Higher doses of NSAIDs
History of peptic ulcer disease
Concurrent use of anticoagulants
76

LIFESTYLE FACTORS CONTRIBUTE TO RISK
OF DIVERTICULOSIS
23/12/2010
Inadequate dietary fiber intake
77

PREDISPOSING FACTORS FOR BENIGN
TUMORS
23/12/2010
Age
Diet
Family history
Prior diagnosis of polyps
78

C. DIFFICILE-INDUCED DIARRHEA AND
COLITIS
23/12/2010
Recent surgery
Nasogastric or gastric intubation
Antibiotics
Common in older persons receiving treatment in

hospitals or residing in nursing homes
79

DRUGS COMMONLY ASSOCIATED WITH
DIARRHEA
23/12/2010
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Magnesium-containing antacids
Antiarrhythmics
Beta-blockers
Quindine
Colchicines
Digoxin
80

RISK FACTORS FOR CONSTIPATION
23/12/2010
Dehydration
Side effects of medications
Anticholinergic side effects
Antidepressants
Neuroleptics
Antihistamines
Antiparkinsonian agents
81

23/12/2010
Selected antihypertensive agents
Calcium channel blockers
ACE inhibitors
Diuretics
82

23/12/2010
Iron supplements
Calcium supplements
Benzodiazepines
Antiarrhythmics
Opiates
83

23/12/2010
Insufficient fiber intake
Cognitive impairment and immobility
Physical illness
Metabolic/endocrine disorders
Muscular dystrophy
Neurological disorders
Recent abdominal surgery
Obstructive disorders
84

RISK FACTORS FOR FECAL INCONTINENCE
23/12/2010
Dementia
Depression
Chronic pain
Lack of mobility
Lack of sensation
85

FACTORS THAT INCREASE RISK FOR
PANCREATITIS
23/12/2010
Gallstones
Hyperlipidemia
Hypercalcemia
86

FACTORS THAT INCREASE RISK FOR
PANCREATITIS
23/12/2010
Medications
Estrogen
Furosemide
ACE inhibitors
Mesalamine
Alcohol abuse
Cancer
87

23/12/2010
LEARNING OUTCOME 4
Describe unique presentations of gastrointestinal
problems in the older person.
88

PRESENTATION OF GI DISORDERS IN THE
OLDER ADULT
23/12/2010
Present with different symptoms than the
younger adult
Peptic ulcer disease
Impaired visceral pain perception
Longer to recognize and report pain
Symptoms for gastric disorders tend to be vague
Symptoms may be attributed as a normal age-
related change
89

OTHER DISORDERS RESULTING IN GI
SYSTEM CHANGES
23/12/2010
Diabetes
Neurological illness
Vascular disorders
90

23/12/2010
LEARNING OUTCOME 5
Define appropriate nursing interventions directed
toward assisting the older adult with gastrointestinal
problems to develop self-care abilities.
91

PATIENT EDUCATION NEEDS
23/12/2010
Presentation and reporting of symptoms of GI
problems in the older adult
Impact of select medications on the GI system
Safe and appropriate use of prescribed

mediations
Recommended health screenings for the GI
system
92

LIFESTYLE MODIFICATION FOR GERD
23/12/2010
Lose weight as appropriate
Avoid tight clothing
Remain in upright position after eating
Reduce alcohol, caffeine, and fat intake
93

NURSING DIAGNOSES FOR PATIENTS WITH
GERD
23/12/2010
Impaired swallowing
Impaired skin integrity
Impaired social interaction (if appropriate)
Sleep pattern disturbance (if appropriate)
Acute or chronic pain
94

LIFESTYLE MODIFICATION FOR
PEPTIC/DUODENAL ULCER DISEASE
23/12/2010
Discontinue use of all NSAIDs
Discontinue use of alcohol, tobacco, and caffeine
Avoid offending foods
95

LIFESTYLE MODIFICATIONS TO
PREVENT DIVERTICULITIS AND
MANAGE DIVERTICULAR DISEASE
23/12/2010
Increase dietary fiber
Drink at least 8 full glasses of water per day
(unless contraindicated by other medical
condition)
Do not ignore the urge to have a bowel movement
Exercise regularly
Avoid foods that precipitate painful attacks
96

EARLY DETECTION AND PREVENTION OF
COLON CANCER
23/12/2010
Annual fecal occult blood testing
Colonoscopy and sigmoidoscopy screenings
Initially begin with sigmoidoscopy
Colonoscopy screening should begin at age 50
97

NURSING MANAGEMENT OF
CONSTIPATION
23/12/2010
Patient education
Dietary intake of fluid and fiber
Exercise
Awareness in bowel habits
Understanding of potential impact of selected
medications
98

23/12/2010
LEARNING OUTCOME 6
Identify and implement appropriate nursing
interventions to care for the older person with
gastrointestinal problems.
99

INTERVENTIONS TO PREVENT ASPIRATION
23/12/2010
Minimize distractions during eating
Provide a pleasant mealtime environment
Use consistent feeding techniques
Document patient food preferences and

consumption patterns
Position patient upright during and 1 hour
following mealtime
Allow time for swallowing
100

23/12/2010
Monitor respirations
Provide oral hygiene before and after mealtimes
Provide meals when patient is rested
Provide food and fluid of appropriate

consistencies
101

23/12/2010
Never force-feed
Monitor weight, function status, and patient
satisfaction during meals
Evaluate swallowing capacity every 6 months
and prn
Avoid nasogastric tubes
102

NURSING DIAGNOSES FOR PATIENTS WITH
DYSPHAGIA
23/12/2010
Impaired Swallowing
Feeding Self-Care Deficit
Risk for Fluid Volume Imbalance (Deficit)
Ineffective Airway Clearance
Risk for Aspiration
Altered Dentition (if appropriate)
103

RELATED FACTORS IDENTIFIED BY
NANDA IN 2003
23/12/2010
Neuromuscular impairment
Decreased strength or excursion of muscles
involved in mastication
Perceptual impairment
104

RELATED FACTORS IDENTIFIED BY
NANDA IN 2003
23/12/2010
Mechanical obstruction (edema, tracheostomy
tube, tumor)
Fatigue
Limited awareness
Reddened, irritated oropharyngeal cavity
105

AGGRESSIVE NURSING INTERVENTIONS TO
PREVENT DEHYDRATION
23/12/2010
Frequently assess pulse and blood pressure
Establish schedule to offer fluids every 15 to 30
minutes
Measure intake and output
Assess skin turgor
Notify primary care provider if dehydration is

imminent
106

NURSING INTERVENTIONS FOR FECAL
INCONTINENCE
23/12/2010
Regular toileting program
Administration of high-fiber diet
Elimination of medications associated with

diarrhea
Treatment of infections
107

ENDOSCOPIC GASTROINTESTINAL
PROCEDURES
23/12/2010
Esophagogastroduodenoscopy
Restrict intake prior to procedure
Strong laxative
Antibiotics for patients at high risk for infection
Oxygen during tube insertion
Sigmoidoscopy
Sedation not required
Phosphate enemas
108

ENDOSCOPIC GASTROINTESTINAL
PROCEDURES
23/12/2010
Colonoscopy
1 to 2 days of liquid diet
Cathartic evening prior
Monitor patients with cardiovascular or renal
instability
109

NURSING DIAGNOSES ASSOCIATED WITH
GASTROINTESTINAL TRACT PROBLEMS
23/12/2010
Imbalanced Nutrition: Less Than Body
Requirements for those with anorexia
Risk for Infection, for those undergoing
endoscopic examination and needing antibiotic
prophylaxis
Constipation and Perceived Constipation
Diarrhea
Bowel Incontinence
110

23/12/2010
Risk for Constipation
Ineffective Tissue perfusion: Gastrointestinal
Tract
Risk for Aspiration
Impaired Oral Mucous Membrane
Social Isolation (if appropriate)
Noncompliance (if appropriate)
111

23/12/2010
Ineffective Breath Maintenance
Toileting Self-Care Deficit
Acute or Chronic Pain Disturbance
Nausea
112


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20

Lecture Note PowerPoint Presentation

Gerontological Nursing, Second Edition

Changes in the mouth

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Seen in 50% of institutionalized persons

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Inability to control food in mouth

Spitting up after meals

Need to frequently clear throat

Difficulty sitting up during mealtimes

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Inflammatory cell type

Gerontological Nursing, Second Edition

Protection of gastric mucosa

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Pain or abdominal tenderness

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Rectal mucosa biopsy

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Barium enema colonoscopy

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

History of colorectal tumors

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Fecal occult blood testing

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition

Gerontological Nursing, Second Edition