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Chapter 10Care of the Older Person Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
?? What are characteristics of      normal aging?? Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of El...
?? As a person ages changes in musculoskeletal system occur.    What can you do to reduce the risk of falls & injury???   ...
Late adulthood ages   Young-old: 65-74   Old: 75-84   Old-old: >85      Mosby items and derived items © 2008 by Mosby, ...
Activity- Think about it?   Divide into groups:       Make a list of psychological & social changes that        occur wi...
PSYCHOLOGICAL AND SOCIAL       CHANGES         Threatens self-esteem & independence.         Social roles change.     Mo...
Psychological changesRetirement:-Age 65-relax-travel-ill/disability-↑ bills- Loss of friends from work- volunteer     Mosb...
Retirement- a reward for a life-time of work.      reduced income.     Social relationships change     Children become c...
Enjoy being with others their own              age   Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of ...
RetirementMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide 10
↓ income   - still have expenses ( rent, insurance, food,    clothing)   - may need to change life style   - some plan ...
Social relationships   -children move out   -grandchildren   -loss of friends   -Lonely   -Hobbies      Mosby items a...
GrandchildrenMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide 13
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide 14
Family timeMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide 15
Children as caregivers   Loss of dignity   - reverse roles   -↑ tension b/t family   -lack of privacy       Mosby item...
Death of spouse   -women live longer   -never prepared   -loss of friend, companion, lover   -grief   -physical &psyc...
Enjoying gardeningMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide 18
RESIDENT RIGHTS-OBRA-rights:    As U.S. citizen    In nsg. homeMust be informed:  •   Orally & in writing  •   @ admission...
Right to communicate privately  Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide...
A nursing center is as home like          as possible  Mosby items and derived items © 2008 by Mosby, Inc., an affiliate o...
Home – like nursing centerMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide 22
Confidential communications that resident                can use    Mosby items and derived items © 2008 by Mosby, Inc., a...
Right to pick clothesMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide 24
Rights    •      To information    •      To refuse treatment    •      To privacy and confidentiality    •      To person...
Nursing Center VolunteersMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide 26
Residents Rights Activity   Create a picture page with each of the residents    rights.   Demonstrate how to create usin...
OMBUDSMAN PROGRAM     - in every state.     -someone who supports residents     -act on behalf of residents. •         pro...
Think about it   Complete residents rights handout      Mosby items and derived items © 2008 by Mosby, Inc., an affiliate...
Gerontology     Aging is normal.     -Normal changes occur in body structure and function.     -Psychological and social ...
Recognizing changes in body        functioning     People live longer     Chronic illness is common     • Disability may...
ActivityCreate a page that shows at least five changes   for each of the following body systems.-Integumentary-Musculoskel...
The integumentary system -Loses elasticity, strength, & fatty tissue . -Decrease secretions from oil & sweat glands -Blood...
-Nails become thick & tough. - Poor circulation. - fewer nerve endings. -White or gray hair -Hair loss - men. -Hair thins ...
The musculoskeletal system -Muscle cells ↓ -Muscles atrophy -↓strength. -Bones lose calcium. -Bones lose strength, become ...
Disorders•   Osteoporosis      Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide 36
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide 37
Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.   Slide 38
The nervous system •      Nerve cells are lost. •      Nerve conduction & reflexes slow. •      Blood flow to brain reduce...
•      Eye             Eyelids thin & wrinkle.             Tear secretion less.             The pupil becomes smaller &...
Circulatory system   • Heart muscle weakens.   • Arteries narrow are less elastic.               Circulatory changes could...
Digestive system   • Salivary glands produce less saliva.   • Dysphagia a risk.   • Taste & smell dull.   • Secretion of d...
Care of digestive disorders   Special diet-low spice, high fiber   Special form of food- soft, pureed   Supplemental fe...
     The urinary system     • Kidney function decreases.     • Kidneys atrophy.     • Blood flow to kidneys reduced.     ...
     The reproductive system     • In men, testosterone decreases.                ↓strength, sperm production, & reprodu...
•      Menopause            Menstruation stops.             Can’t reproduce             Female hormones (estrogen/proges...
Reproductive disorders                                                  BPH ( benign prostateVaginitis                    ...
       HOUSING OPTIONS            Living with family         •        Adult day care centers            Elder cottage h...
   Homesharing   Assisted living residences   Board and care homes   Adult foster care   Continuing care retirement c...
Assignment   In groups review assigned housing option.        Define        What is benefits?        What are concerns?  ...
? An 86 year old man moved to South Shore  Nsg. Home 2 weeks ago. He was living on a  farm alone, 5 miles from the closest...
   Watch video – the Aging Process      Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc...
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  • Physical reminders of aging include graying hair, wrinkles, and slow movements. Adjusting to the death of a partner, family members, and friends is common. The person faces his or her own death.
  • Many people enjoy retirement. Others must retire because of illness or disability. Most older people have regular contact with children, grandchildren, family, and friends. Some older people are lonely. Review the Focus on Communication: Social Changes Box on p. 128 in the textbook. Review the Caring About Culture: Foreign-Born Persons Box on p. 128 in the textbook. Sometimes parents and children change roles. This helps some older persons feel more secure. Others feel unwanted, in the way, and useless. When the death of a partner occurs, the loss is crushing. The person loses a lover, friend, companion, and confidant. Review the contents of Box 10-2 on p. 129 in the textbook.
  • Nursing centers must provide care in a manner and in a setting that maintains or improves each person’s quality of life, health, and safety. If a resident is incompetent, a responsible party or legal representative exercises his or her rights. Resident rights are posted throughout the center.
  • A person who does not give consent or who refuses treatment cannot be given the treatment. Report any treatment refusal to the nurse. The person’s body is not exposed unnecessarily. No one can punish the person in any way for voicing a grievance. The person does not work for care, care items, or other things or privileges. Nursing centers must investigate suspected or reported cases of abuse. Centers cannot employ persons who were convicted of abusing, neglecting, or mistreating others. Restraints are not used for staff convenience or to discipline a person. Review the contents of Box 10-6 on p. 139 in the textbook.
  • Nursing centers must post where residents can easily see them the names, addresses, and phone numbers of local and state ombudsmen. You must know state and center policies and procedures for contacting an ombudsman. Ombudsman services are useful when: There is concern about a person’s care or treatment Someone interferes with a person’s rights, health, safety, or welfare Review the Focus on Ethics and Laws: Freedom from Abuse, Mistreatment, and Neglect Box on p. 138 in the textbook.
  • Aging is not a disease. The changes that occur in body structure and function increase the risk for illness, injury, and disability. Most people adjust well to these changes. To provide good care, you need to know the facts about older persons and aging. Review the contents of Box 10-1 on p. 126 in the textbook.
  • Older people are healthier and more active than ever before. Widow-hood is more common in older women than in older men. Disabilities increase and become more severe with aging. Disabilities can interfere with many activities of daily living and leisure and recreational activities.
  • Skin breakdown, skin tears, and pressure ulcers are risks. Bruising and delayed healing are risks. You need to protect the person from drafts and cold. A shower or a bath twice a week is enough. Partial baths are taken at other times. Lotions, oils, and creams prevent drying and itching.
  • A nick or a cut can lead to a serious infection. Burns are great risks. Hot water bottles and heating pads are not used. Brushing hair promotes circulation and oil production. Shampoo frequency depends on personal choice. The risk of skin cancer increases with age. Skin changes can affect self-esteem and body image.
  • Walking is good exercise. Exercise groups and range-of-motion exercises are helpful. A diet high in protein, calcium, and vitamins is needed. You need to: Protect the person from injury and prevent falls. Turn and move the person gently and carefully. Help and support the person getting out of bed as needed. Help the person with walking as needed.
  • Dizziness may occur. It increases the risk for falls. Practice measures to prevent falls. Remind the person to get up slowly from a bed or chair. Changes may affect personality and mental function. Memory is shorter. Forgetfulness increases. Responses slow. Confusion, dizziness, and fatigue may occur. The person may not notice painful injuries or diseases. You need to: Protect older persons from injury. Follow safety measures for heat and cold. Check for signs of skin breakdown. Give good skin care. Prevent pressure ulcers.
  • Vision is poor at night or in dark rooms. The eyes take longer to adjust to lighting changes. It is harder for the eye to shift from far to near vision and from near to far vision. Changes in the eye increase the risks of falls and accidents. Eyeglasses are worn as needed. Keep rooms well lit. Night-lights help at night. High-pitched sounds are hard to hear. A hearing aid may be needed. It must be clean and correctly placed in the ear. Earwax wedged in the ear can cause hearing loss. A doctor or nurse removes the wax.
  • The heart pumps blood with less force. A weak heart must work harder to pump blood through narrowed vessels. Exercise helps maintain health and well-being. Older persons need to be as active as possible. Persons who stay in bed need range-of-motion exercises. Doctors may order certain exercises and activity limits. Difficult, labored, or painful breathing (dyspnea) may occur with activity. Respiratory infections and diseases may develop. Normal breathing is promoted. The person should be as active as possible.
  • Flatulence and constipation can occur. Oral hygiene and denture care improve taste. High-fiber foods help prevent constipation. Persons with chewing problems or constipation often need foods that provide soft bulk. Foods are needed to prevent constipation and bone changes. High-protein foods are needed for tissue growth and repair.
  • Waste removal is less efficient. Urine is more concentrated. Urinary frequency or urgency may occur. Many older persons have to urinate during the night. Urinary incontinence (inability to control the passage of urine from the bladder) may occur. An enlarged prostate can cause difficult or frequent urination. Adequate fluids are needed. Most fluids should be taken before 5:00 PM. Persons with incontinence may need bladder training programs. Sometimes catheters are needed.
  • Older men may need the penis stimulated for arousal. Fatigue, overeating, and drinking too much alcohol affect erections.
  • Menopause occurs between 45 and 55 years of age. Thinning of vaginal walls and vaginal dryness may make intercourse uncomfortable or painful.
  • Most older people live in their own homes. Many function without help. In-home and community-based services assist older persons with activities of daily living. Review the contents of Box 10-3 on p. 132 in the textbook. Leaving a home is often very hard. Moving brings many losses. A new home setting could maintain or improve the person’s quality of life. Review the Focus on Long-Term Care and Home Care: Housing Options Box on p. 133 in the textbook. Living with an adult child is a social change. Everyone in the home must adjust.
  • Assisted living residences are for persons who need help with daily living. Health care and 24-hour oversight are provided. Nursing centers are options for older persons who cannot care for themselves. Some people stay in nursing centers until death. Some stay until they can return home. Review the contents of Box 10-4 on p. 136 in the textbook. Most nursing centers receive Medicare or Medicaid funds. They must meet OBRA (Omnibus Budget and Reconciliation Act of 1987) requirements. Review the contents of Box 10-5 on p. 136 in the textbook. Many hospitals have long-term care units for persons who still need skilled care but not at the level once required.
  • Transcript of "Ch10 care of the older pt.."

    1. 1. Chapter 10Care of the Older Person Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc.
    2. 2. ?? What are characteristics of normal aging?? Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2
    3. 3. ?? As a person ages changes in musculoskeletal system occur. What can you do to reduce the risk of falls & injury??? Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3
    4. 4. Late adulthood ages Young-old: 65-74 Old: 75-84 Old-old: >85 Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4
    5. 5. Activity- Think about it? Divide into groups:  Make a list of psychological & social changes that occur with aging  5 minutes to discuss  Present to class  Share any personal experiences with change and loss • How did you adjust to the change or loss? • What support systems helped you? Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5
    6. 6. PSYCHOLOGICAL AND SOCIAL CHANGES  Threatens self-esteem & independence.  Social roles change. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6
    7. 7. Psychological changesRetirement:-Age 65-relax-travel-ill/disability-↑ bills- Loss of friends from work- volunteer Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7
    8. 8. Retirement- a reward for a life-time of work. reduced income. Social relationships change Children become caregivers. Death of a partner is common. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8
    9. 9. Enjoy being with others their own age Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9
    10. 10. RetirementMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10
    11. 11. ↓ income - still have expenses ( rent, insurance, food, clothing) - may need to change life style - some plan for retirement, some don’t Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11
    12. 12. Social relationships -children move out -grandchildren -loss of friends -Lonely -Hobbies Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12
    13. 13. GrandchildrenMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13
    14. 14. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14
    15. 15. Family timeMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15
    16. 16. Children as caregivers Loss of dignity - reverse roles -↑ tension b/t family -lack of privacy Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16
    17. 17. Death of spouse -women live longer -never prepared -loss of friend, companion, lover -grief -physical &psychosocial changes can occur Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 17
    18. 18. Enjoying gardeningMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 18
    19. 19. RESIDENT RIGHTS-OBRA-rights: As U.S. citizen In nsg. homeMust be informed: • Orally & in writing • @ admission to the center • In language the person uses Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19
    20. 20. Right to communicate privately Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20
    21. 21. A nursing center is as home like as possible Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 21
    22. 22. Home – like nursing centerMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 22
    23. 23. Confidential communications that resident can use Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23
    24. 24. Right to pick clothesMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 24
    25. 25. Rights • To information • To refuse treatment • To privacy and confidentiality • To personal choice • To voice disputes and grievances • Not to work • To take part in resident and family groups • To care and security of personal items • To freedom from abuse, mistreatment, and neglect • To freedom from restraint • To quality of lifeMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25
    26. 26. Nursing Center VolunteersMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 26
    27. 27. Residents Rights Activity Create a picture page with each of the residents rights. Demonstrate how to create using power point Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 27
    28. 28. OMBUDSMAN PROGRAM - in every state. -someone who supports residents -act on behalf of residents. • protect the health, safety, welfare, & rights of residents.Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 28
    29. 29. Think about it Complete residents rights handout Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 29
    30. 30. Gerontology Aging is normal. -Normal changes occur in body structure and function. -Psychological and social changes also occur. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 30
    31. 31. Recognizing changes in body functioning People live longer Chronic illness is common • Disability may occur Most elderly have at least one disability. Most older people live in a family setting. Some live :alone or with friends. nursing centers. Need for nsg. homes increase with age. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 31
    32. 32. ActivityCreate a page that shows at least five changes for each of the following body systems.-Integumentary-Musculoskeletal-NervousCirculatory-Respiratory-DigestiveUrinaryReproductive- male© & female an affiliate of Elsevier Inc. Mosby items and derived items 2008 by Mosby, Inc., Slide 32
    33. 33. The integumentary system -Loses elasticity, strength, & fatty tissue . -Decrease secretions from oil & sweat glands -Blood vessels decrease -Brown spots appear -Lose fatty tissue -more sensitive to cold. -Dry skin itchy -Easily damaged.Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 33
    34. 34. -Nails become thick & tough. - Poor circulation. - fewer nerve endings. -White or gray hair -Hair loss - men. -Hair thins –men /women. -Facial hair - women. -Hair is drier -Skin disordersMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 34
    35. 35. The musculoskeletal system -Muscle cells ↓ -Muscles atrophy -↓strength. -Bones lose calcium. -Bones lose strength, become brittle-break easily. -Vertebrae shorten. -Joints become stiff & painful. -Mobility decreasesMosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 35
    36. 36. Disorders• Osteoporosis Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 36
    37. 37. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37
    38. 38. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 38
    39. 39. The nervous system • Nerve cells are lost. • Nerve conduction & reflexes slow. • Blood flow to brain reduced. • Changes in brain cells. • Sleep patterns change. • Touch & sensitivity to pain/pressure reduced. • Sensing heat & cold reduced. • Taste & smell dull.Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 39
    40. 40. • Eye  Eyelids thin & wrinkle.  Tear secretion less.  The pupil becomes smaller & responds less to light.  Clear vision reduced.  The lens yellows.  Farsighted (presbyopia). • Ear.  Changes in auditory nerve.  Eardrums atrophy.  Wax secretion decreases.  Wax becomes harder & thicker.Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 40
    41. 41. Circulatory system • Heart muscle weakens. • Arteries narrow are less elastic. Circulatory changes could be severe.  Increase restRespiratory system • Respiratory muscles weaken. • Lung tissue less elastic. • May lack strength to cough & clear the airway of secretions. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 41
    42. 42. Digestive system • Salivary glands produce less saliva. • Dysphagia a risk. • Taste & smell dull. • Secretion of digestive juices decreases.-Flatulence, poor digestion • Loss of teeth & ill-fitting dentures cause chewing problems. • Peristalsis decreases. • Fewer calories needed. • Loss of sphincter control Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42
    43. 43. Care of digestive disorders Special diet-low spice, high fiber Special form of food- soft, pureed Supplemental feeding Long time to eat Wgt. Position when eating Hydration Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43
    44. 44.  The urinary system • Kidney function decreases. • Kidneys atrophy. • Blood flow to kidneys reduced. • Ureters, bladder, & urethra lose tone & elasticity. • Bladder muscles weaken. • Bladder size decreases. • In men, prostate gland enlarges. • Urinary tract infections a risk. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 44
    45. 45.  The reproductive system • In men, testosterone decreases.  ↓strength, sperm production, & reproductive tissues.  Erection takes longer.  phase between erection/orgasm longer.  Orgasm less forceful .  Erections lost quickly.  Time between erections longer. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 45
    46. 46. • Menopause  Menstruation stops.  Can’t reproduce Female hormones (estrogen/progesterone) ↓.  uterus, vagina, & genitalia atrophy.  Vaginal walls thin  Vaginal dryness.  Arousal takes longer.  Orgasm less intense.  Pre-excitement state returns more quickly.Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 46
    47. 47. Reproductive disorders BPH ( benign prostateVaginitis hypertrophy) Inflamed vaginal lining  Enlarged prostate -foul odor  -trouble urinating -drainage  -trouble starting flow -irritation Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 47
    48. 48.  HOUSING OPTIONS  Living with family • Adult day care centers  Elder cottage housing opportunity (ECHO)  Apartments  Residential hotels  Congregate housing • Senior citizen housing Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 48
    49. 49.  Homesharing Assisted living residences Board and care homes Adult foster care Continuing care retirement communities (CCRCs) Nursing centers • Hospital long-term care units Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 49
    50. 50. Assignment In groups review assigned housing option. Define What is benefits? What are concerns?  Share with class Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 50
    51. 51. ? An 86 year old man moved to South Shore Nsg. Home 2 weeks ago. He was living on a farm alone, 5 miles from the closest city. He has diabetes & arthritis. He needs assistance with his meds, meals, & bathing. He can nolonger safely drive a car. He can’t keep up with the house work. -What are the gains of moving into the nsg.home? -What are the losses? Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 51
    52. 52.  Watch video – the Aging Process Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 52
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