Transcript lecture 4: chapter 23 The Immune System 2

CHAPTER
23
Lecture Note PowerPoint Presentation
The Immune System
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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LEARNING OUTCOME 1
Explain the importance of the immune
system in the maintenance of health.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Three Biological Defense
Mechanisms That Protect the Body
• First line of defense (anatomic/biochemical
barrier)
– Skin and mucous membranes
• Second line of defense (mechanical
clearance)
– Skin sloughing, respiratory cilia, and urination
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Three Biological Defense
Mechanisms That Protect the Body
• Third line of defense (immune response)
– Long-lasting and sometimes permanent
protection
– Structures
 Thymus
 Red bone marrow
 Spleen
 Lymph nodes, vessels, and tissues
 Skin
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Multiple Factors Affect the
Individual’s Immune System
• Internal characteristics
– Modifiable
 Nutritional status
 Existence of underlying disease
– Nonmodifiable
 Age, gender, and inherited genes
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Multiple Factors Affect the
Individual’s Immune System
• External factors
– Environmental pollutants
– Radiation
– Ultraviolet light
– Drugs
• Intensity and effectiveness
– Combined effort of both internal and external
factors
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Three Major Immune Theories
• Autoimmune theory
– As a person ages, the ability of the immune
system to differentiate between invaders and
normal tissues diminishes → immune cells
begin to attach normal body tissues →
conditions, like arthritis, occur
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Three Major Immune Theories
• Immune deficiency theory
– With increasing age, the immune system is no
longer able to defend the body from foreign
invaders and detrimental changes result
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Three Major Immune Theories
• Immune dysregulation theory
– Multiple changes in immune system → disrupt
regulation between multiple components of
immune process → progressive destruction of
body cells
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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LEARNING OUTCOME 2
Define the three characteristics that are
unique to the immune system.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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Three Characteristics Unique to the
Immune System
• Self-regulation
• Specificity
• Memory
Gerontological Nursing, Second Edition
Patricia A. Tabloski
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Self-Regulation
• The immune system differentiates
between normal and abnormal
constituents
Gerontological Nursing, Second Edition
Patricia A. Tabloski
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Self-Regulation
• Antigens (Ag)
– Nonself substances that stimulate an immune
response
– Located on surfaces of living cells or
environmental substances
Gerontological Nursing, Second Edition
Patricia A. Tabloski
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Self-Regulation
• Antigens (Ag)
– Self-Antigens
 Histocompatibility antigens or human leukocyte
antigens (HLA)
 Do not stimulate an immune response
 Different in all people
 Genetically identical twins will be the same
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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Specificity
• The immune response reacts to only one
antigen
• Different immune response for each
different antigen
• Antigen-specific antibody production
Gerontological Nursing, Second Edition
Patricia A. Tabloski
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Memory
• Immune response develops long-lasting
protection
• Residual set of cells that are specific to an
antigen remain in the body
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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LEARNING OUTCOME 3
Identify factors that affect proper immune
system function.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Types of Immunity
• Natural
– Not produced by the immune response
 Present at birth
– Mother’s antibodies pass across the placenta
to fetus
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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Types of Immunity
• Acquired active
– Naturally acquired
 Result of immune system’s response to foreign
substance
 Most durable if developed during disease
– Artificially acquired
 Immunizations, vaccines, toxoids
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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Types of Immunity
• Acquired passive
– Introduction of serum with antibodies
– Temporary, because no direct stimulation of
person’s immune response
– Gamma globulin to prevent hepatitis A
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Cellular Components of Immune
Response
• Granulocytes
– Ingest and digest debris (remains) and foreign
material throughout the body
– Release chemicals that assist in the
inflammatory process
• Macrophage (mature monocytes)
– Role in inflammatory response
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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Cellular Components of Immune
Response
• Lymphocytes
– Primary cells concerned with the development
of immunity
– Have the ability of self-recognition, specificity,
and memory
– Two types
 B lymphocytes (B cells) (humoral immune
response)
 T lymphocytes (T cells) (cell-mediated immune
response)
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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Humoral Immune Response
• Initiated when an antigen binds with the
antibody receptors on the surface of the
mature B cell
• Triggers a sequence of events that results
in production of plasma cells that secrete
antibodies (immunoglobulin molecules)
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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Humoral Immune Response
• Five classes of immunoglobins (MADGE is
acronym to aid memory)
– IgM
– IgA
– IgD
– IgG
– IgE
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Humoral Immune Response
• Primary
– First exposure to antigen
– Latent period
• Secondary
– Rapid production of large amounts of
antibodies
– Immediate response; may last for several
years
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Cell-Mediated Immune Response
• When presented with an antigen, helper T
cells produce signaling substances such
as interferon, interleukin, and tumor
necrosis factor
• Inflammation and other body activities are
promoted
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Factors Impacting the Immune
Response
• Stress
– Stress “fight-or-flight” response can suppress
the immune system in older adults
– Cumulative effect of stress over time contributes
to the physical aging of the immune system
– Increase in stress can lead to poorer cellular
immunity
– Coping skills impacts stress response
 Active coping skills can have a positive effect
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Factors Impacting the Immune
Response
• Chronic illness
– CNS, immune system, endocrine, and psyche
all interact
– Mood, stress, depression, and mental illness
can all influence immunity
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Factors Impacting the Immune
Response
• Exercise
– May prevent or slow the age-related decline in
the immune response
– Long-term, moderate exercise benefits
 Reduced infectious disease risk
 Increased rates of vaccine efficacy
 Reduced inappropriate inflammation
 Increased wound healing
 Improved physical and psychosocial aspects of
daily living
– Tai chi benefits
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Factors Impacting the Immune
Response
• Increased IgG and IgM
• Nutrients
– Adequate intake of vitamins and trace
elements are required for the immune system
to function effectively
– Vitamins A, C, D, E, B6, folate, B12, iron
copper, selenium, and zinc all contribute to
cellular immune response
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Factors Impacting the Immune
Response
• Nutrients
– Mild zinc deficiency is common in the older adult
– Ginseng is thought to boost the immune system
– Yogurt drinks with L. casei immunitas cultures
claim to strengthen the body’s defense
 No established body of evidence to support this claim
 Lactobacillus casei is a species of genus Lactobacillus found
in the human intestine and mouth. As a lactic acid producer,
it has been found to assist in the propagation of desirable
bacteria.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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LEARNING OUTCOME 4
Identify the similarities, differences, and
interactions between the humoral immune
response and the cellular immune response.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Humoral Immune Response
• Comprised of B cells
– Assisted in the beginning by Th cells
• Plasma cells are produced and secrete
antigen-specific antibodies
• Memory cells
– Long lives
– React swiftly to specific antibodies
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Cell-Mediated Immune Response
• Comprised of a variety of T cells
• Th (helper T)
– Exhibits TCR receptors
– CD (clusters of differentiation) markers
– Interacts with macrophage antigen-presenting
cell (APC)
– Causes binding of entire Th to antigen
– Produces signaling substances
 Interleukins, interferon, and tumor necrosis factor
– Tc and B cells (and others) stimulated
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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LEARNING OUTCOME 5
Explain the pathology that underlies
illnesses associated with both excessive and
deficient immune responses.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Excessive Responses
• Hypersensitivity
– Excessive response to antigen stimulation
– Normal response that is inappropriate
• Autoimmunity:is the failure of an organism to recognize its own
constituent parts as self, which allows an immune response against its own
cells and tissues.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Type I Hypersensitivity
• Reaction of the humoral response system
• Responses are immediate and may be life
threatening
• Reactions may occur within 15 to 30
minutes of exposure
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Type I Hypersensitivity
• Severities vary
– Hives (skin complaint)
– Localized swelling
– Throat tightening
– Shortness of breath
– Wheezing
– Tachycardia
– Hypotension
• Example: asthma
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Type II Hypersensitivity
• Reaction of the humoral response system
• Occur within 15 to 30 minutes of exposure
• Examples
– Transfusion reactions
– Drug reactions
– Myasthenia gravis (is an autoimmune neuromuscular disease
leading to fluctuating muscle weakness and fatiguability)
– Thyroiditis
– Autoimmune hemolytic anemia: is a type of hemolytic anemia where the
body's immune system attacks its own red blood cells (RBCs), leading to their destruction (hemolysis)
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Type III Hypersensitivity
• Reaction of the humoral response system
• Failure to remove antigen–antibody
complexes from the circulation and tissues
• Longer response time
• Examples
– Glomerulonephritis
– Systemic lupus erythematosus: is a systemic
autoimmune disease that can affect any part of the body
– Rheumatoid arthritis
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Type IV Hypersensitivity
• Delayed hypersensitivity
• Cell-mediated response
• Tissue is damaged as a result of a
delayed T-cell reaction to an antigen
• Normally occurs within 1 to 14 days after
exposure
• Examples
– Contact dermatitis from a latex allergy
– Tuberculin reactions
– Transplant rejections
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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LEARNING OUTCOME 6
Relate the care of the patient with a
rheumatoid disorder to the pathology
involved.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Pain and RA
• Control or alleviation of symptoms created
by inflammatory response
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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Activity Intolerance and Fatigue are
Associated With RA
• Nutrition, energy-saving techniques, and
treatment to diminish the disease process
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Exercise and Assistive Devices
• Prevent the loss of motion and joint
function caused by infiltrating T cells which
cause destruction of the articular cartilage
and bone erosion
• Prolonged inactivity increases stiffness
and swelling
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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Depression and Body Image
Disturbances
• Out-of-control inflammatory response
leads to chronic pain, diminished joint
function, and deformities
• As the disease progresses, proper
functioning of the joints becomes
impossible and crippling deformities occur
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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LEARNING OUTCOME 7
Describe the susceptibility of the older
person to infections.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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A Typical Presentation of Infection
• Febrile response may be blunted
• Lower baseline temperature → lower rise
with infections
– Temperature of 100o F (37.7) may indicate an
infection
• Other classic signs such as redness,
swelling, and pain may be altered
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Pneumonia
• Leading cause of death in persons over 65
• Most common hospital-associated
infection
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Pneumonia
• Why?
– Less effective airway clearance
– Loss of both alveolar ducts and surrounding
elastic tissue
– Decreased effective of the respiratory
musculature
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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Pneumonia
• Atypical sign and symptoms
– Classic signs often muted
– General deterioration
– Lethargy
– Falls
– Changes in mental status and orientation
– Anorexia
– GI symptoms
– Tachycardia
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Pneumonia
• Prevention
– Pneumococcal vaccine 65 or older
• Revaccinate every 5 to 10 years
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Urinary Tract Infections (UTIs)
• Older women > men
• Incidence increases with age
• Why?
– Bladder dysfunction
– Hypertrophied prostate gland
– Relaxation of the pelvic musculature
– Other coexisting illnesses
– Indwelling catheters
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Urinary Tract Infections (UTIs)
• Atypical symptoms
– Typical signs: urinary frequency, urgency,
suprapubic or flank pain
– Mental status changes
– Falls
– Decline in activities of daily living
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Urinary Tract Infections (UTIs)
• Treatment
– Antibiotics
– Hospitalization because of
 Hypotension
 Dehydration
 Sign of sepsis
 May require IV antibiotics
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Bacteremia
• Microorganisms may be introduced into
the bloodstream via
– Indwelling catheters
– Dental, GI, GU procedures
– Pneumonia
– UTI (most common)
– Skin/soft tissue infections
– Perirectal abscess
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Bacteremia
• Once in bloodstream, disseminated to
other organs
• Symptoms
– Confusion
– Agitation
– Decreased LOC
– Fever (may be low grade)
– Septic shock is a serious complication
• Treatment
– IV antibiotics
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Tuberculosis
• Highest in 65 or older
• Causes
– Exposure to mycobacterium tuberculosis
– Reactivation of dormant infection not properly
treated in the past
• Atypical symptoms
– Confusion and altered mental status
– Pleural effusion
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Tuberculosis
• Two-step Mantoux method
• Treatment
– Latent infection: daily isoniazid (INH) for 6 to
12 months
– Active infection: combination of drugs over a
long period of time
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Skin Infections
• Older person more susceptible due to
– Thinner and less elastic skin
– Decreased sensation related to peripheral
neuropathy
– Decreased activity or immobilization
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Skin Infections
• Normal flora are typical organisms
• Eryipelas
– Superficial cellulitis
– Group A streptococcus
– Associated with DM and alcohol abuse
– Lower extremities and face
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Skin Infections
• Bright red, well-defined borders
• Herpes zoster (varicella)
– Reactivation of chicken pox infection in nerve
tissue (After you get chickenpox, the virus falls asleep (becomes dormant) in certain nerves in the
body. Shingles (herpes) occurs after the virus becomes reactive in these nerves after many years. The
reason the virus suddenly become active again is not clear. Often only one attack occurs. If an adult or child
is exposed to the herpes zoster virus and has not had chickenpox as a child or received the chickenpox
vaccine, a severe case of chickenpox may develop, rather than shingles
– Common condition among those over 60
– Vesicular lesions among spinal nerves
– Treatment
 Analgesics
 Acyclovir or other antiviral medication
 Topical cleansing
 Prevent: zoster vaccine
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Nosocomial or Care-Acquired
Infections
• Overuse of antibiotics
• Increasing levels of frailty in older persons
• Several pathogens
– Vancomycin-resistant enterococci (VRE)
– Methicillin-resistant Staphylococcus aureus
(MRSA)
– Clostridium difficile–associated disease
(CDAC)
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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Nosocomial or Care-Acquired
Infections
• Prevention is vital
• Monitor infection rates
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
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LEARNING OUTCOME 8
Identify nursing interventions that can be
effective in improving immune status in the
older person.
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Health History and Physical
Examination: Key Assessments
•
•
•
•
•
Age
Nutrition
Recent infections
Immunization status
Allergies
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Health History and Physical
Examination: Key Assessments
• Disorders and diseases
– Autoimmune disease
– Neoplastic disease
– Chronic illness
– Surgery
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Health History and Physical
Examination: Key Assessments
•
•
•
•
Pain
Medication
Blood transfusions
Lifestyle, stress, and other factors
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Nursing Interventions to Improve
Immune Status
• Consider older people who are under
substantial stress at high risk for
conditions associated with decreased
immune status
• Encourage evaluation of stress levels and
biological markers of stress such as
hypertension, insomnia, and anxiety to
identify older people at high risk
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Nursing Interventions to Improve
Immune Status
• Assist people in identifying active, positive
coping strategies, especially following
stressful events
• Educate the person, family, and friends
about the effects of stress
• Administer pneumococcal vaccine at age
65 or revaccinate after the age of 65 if
indicated as recommended by the primary
care provider
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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Nursing Interventions to Improve
Immune Status
• Stress the importance of obtaining yearly
influenza immunizations
• Encourage daily vitamin and mineral
supplementation and discourage
megadosing leading to possible toxicity
• Encourage all older persons to develop an
exercise plan appropriate for their physical
status
Gerontological Nursing, Second Edition
Patricia A. Tabloski
Copyright ©2010 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.