age (final care study)

8/8/2019 AGE (Final Care Study)

1/25

LICEODECAGAYANUNIVERSITYR.N.P. Blvd., Carmen, Cagayan de Oro City

C O L L E G E O F N U R S I N G

A Case StudyPFC Omel Penar

With

Acute Gastroenteritis

Submitted to:

LTC. Domingo, RN

Clinical Instructor

As Partial Requirement for NCM501202

Submitted by:

Ramyr R. Ociones

March 21, 2008

1


2/25

I. Introduction

a. Overview of the Case

b. Objective of the Study

c. Scope and Limitation of the Study

II. Health History

a. Profile of Patient

b. History of Illnesses

c. Chief Complain

III. Developmental Data

IV. Medical Management

a. Medical Orders and Rationale

b. Drug Study

V. Pathophysiology with Anatomy & Physiology

VI. Nursing Assessment (System Review & Nursing. Assessment II)

VII. Nursing Management

a. Ideal Nursing Management (NCP)

b. Actual Nursing Management (SOAPIE)

VIII. Health teachings

IX. Prognosis

X. Evaluation

XI. References

2


3/25

INTRODUCTION

Overview of the Case

Acute Gastroenteritis is an infection of the bowel (intestines) that causes

diarrhea and sometimes vomiting. Diarrhea and vomiting can cause the loss of

important fluids and minerals the body needs (dehydration).

Acute Gastroenteritis is more common in the winter and early spring. Most

gastroenteritis is caused by a virus or one of several kinds of bacteria that get

into the intestinal tract (bowels). Bacteria or viruses get to the intestinal tract by

putting dirty hands, toys or other objects near or into the mouth. The most

common symptoms are diarrhea (frequent loose, watery stools) lasting 2-3 days

but usually not more than a week, nausea and vomiting lasting 1-2 days,

abdominal/stomach pain and possibly, fever.

b. Objective of the Study

The objective of this study is to find a case relating to our concept fluid

and electrolyte balance. Rule-out LBM and vomiting and later on diagnosed as

positive for acute gastroenteritis was the condition of my patient PFC Omel

Penar. As a nursing student, I have to do interventions for my patient and to

provide care which is relevant to her condition. Considering that my patient

needs systematic care to restore her fluids and electrolyte that is lost from her

condition. And one goal is that to provide a good patient outcome and prevent

conflicts to restore my patients normal state.

In the case of my patient who is suffering from acute gastroenteritis (AGE)

the etiology is to determine, it is most often results from any non-inflammatory or

inflammatory infection of the colon or either in the upper part of the small bowel.

3


4/25

It can range from mild dysfunction to severe complication, and the most common

is dehydration due to diarrheal reaction of the body.

As an NCM501202 students, this care study helps us not just to pass this

said requirement but also to evaluate our efficacy upon rendering our services in

the optimum capacity or the ability to care to a patient suffering this kind of

illness. These studies also provide information on actual handling, caring and an

overview of the patients nutritional status and dietary management with acute

gastroenteritis.

c. Scope and Limitation of the Study

Our concept is about Fluid and Electrolyte Balance. At Camp Evangelista

Station Hospital, Cagayan de Oro City, I have to find a case which is relevant to

the concept. At the Military Ward where I am assigned, there are cases of acute

gastroenteritis and one of them is my patient PFC Omel Penar. For two days,

from January 30-31, 2008, my duty time is limited from 7-3pm. On the first day I

have assessed my patient and up to the last day of confinement of my patient

and did some interventions like maintaining hydration of the patient and ways toreturn her normal bowel functioning. Questions were being answered by the

patient. The actual nursing interventions were all carried out with the supervision

of a clinical instructor and limited to those which were permitted or allowed by

agency protocol. This study was completed altogether by both research using

different references and actual hands-on exposure and interaction with the

patient.

4


5/25

HEALTH HISTORY

a. Profile of Patient

Patients Name: PFC Omel Penar

Birth Date:

Birthplace:

Age:

Sex: Male

Height:

Weight:Status: Single

Religion: Roman Catholic

Nationality: Filipino

Address:

Allergy: None

Date of Admission:

Time of Admission:

Chief Complaints: LBM and Vomiting

Admitting Diagnosis: Acute Gastroenteritis

Vital Signs:

Temperature:

Pulse Rate:

Respiratory Rate:

BP:

5


6/25

b. History of Illnesses

My patient was PFC Omel Penar, he was admitted last August 3,

2007 and his condition started a day prior to admission, patient had 6

episodes of LBM associated with nausea & vomiting, abdominal pain

with no medications taken.

c. Chief Complaints

A case of my patient, PFC Omel Penar, was due to LBM and vomiting.

6


7/25

DEVELOPMENTAL TASK

Eriksons Psychosocial Development:

My patient is under middle adulthood stage according to Erik Eriksons

Psychosocial Development theory. According to his theory, Generativity is the

concern of establishing and guiding the next generation. Simply having or

wanting children doesn't achieve generativity.

My patient is experiencing psychosocial crisis between Generativity vs.Stagnation, but because of evidently that he dont have his own family and work

as a military to supply his financial needs, he was able to overcome this stage.

Nurturing significance other or nurture close relationships; Management of career

and own household; the patient does not meet the satisfaction within himself; he

was trying to look for partners in life.

Jean Piagets cognitive Development:

According to this theory my patient is under the Formal Operational

Stage (Adolescence and adulthood). In this stage, my patients intelligence is

demonstrated through the logical use of symbols related to abstract concepts.

Freud Psychosexual Development:

In the genital stage, the clients energy once again focuses on his genitals,

interest turns to heterosexual relationships. According to this theory our patient

was not able to overcome this stage because he doesnt have a wife he was not

fully complete the criterion in actualization of his needs. As he grows into a more

7


8/25

mature individual new crisis he will be experiencing but the past stages of

development he was able to overcome them all and was not stagnated or fixated.

MEDICAL MANAGEMENT

8


9/25

DOCTORS ORDER RATIONALEAugust 6, 2007

> Vital signs every 2 hours

> NPO

> Meds:

Paracetamol 80mg IVTT every6 hours PRN

Ranitidine Hydrochloride 8g

IVTT every 8 hours

Cefuroxime 50mg IVTT every 8

hours

Buscopan 6mcg IVTT PRN

> Intake and Output every shift

> IVF follow up D5 IM B 500 cc

@ 30 gtts/min and D5LR /

PNSS 1L @ 40 gtts/min

Au ust 7 2007

> To monitor patients condition if there is an

improvement or if there is a change to prevent

further complications.

> Still for urinalysis and fecalysis exam.

> Paracetamol is for fever reduction.

> Relieves GI discomfort.

> Hinders or kills susceptible bacteria.

> To prevent nausea and vomiting for motion

sickness.

> To know if the patient has a normal fluid

intake and output. To know for normal kidney

functioning and for laboratory purposes.

> Fluids are required to replace losses, to

prevent patient dehydration. It aids also for

mobilization of secretion.

Name of

drug

Date

Ordered

Classificatio

n

Dosage/

Frequency

Route

Mechanism of

Action

Specific

Indication

Contraindications

Side EffectsNursing

Implicatio

Paracetamol

(Biogesec)

August

6, 2007

Antipyretic,

analgesic

80mg

IVTT

every 6

hours

PRN

Chemical

Effect: May

produce

analgesic

effect by

blocking pain

impulses, by

inhibiting

prostaglandin.

Therapeutic

Effect:

Relieves painand reduces

fever.

Relieves

pain and

reduces

fever.

- Contraindicated

in patients

hypersensitive to

drug.

- Use cautiously

in patients with

long term alcohol

use because

therapeutic

doses cause

hepatotoxicity in

these patients.

Hematologic:

hemolytic

anemia,

neutropenia,

leucopenia,

pancytopenia;

Hepatic: liver

damage,

jaundice;

Metabolic:

hypoglycemia;

Skin: rash,

urticaria.

- Assess

patients

pain or

temperatu

before and

during

therapy.

- Assess

patients

drug histor

- Be alert f

adverse

reactions

and drug

interaction

Name of

drug

Date

Ordered

Classificatio

n

Dosage/

Frequency

Route

Mechanism

of Action

Specific

Indication

Contraindications Side Effects Nursing

Implication

Cefuroxime

(Zinacef)

August

6, 2007

Antibiotic 50mg

IVTT

every 8

hours

Chemical

effect: Inhibits

cell-wall

synthesis,

promoting

osmotic

instability.

Therapeutic

effect: Kills

susceptible

bacteria

Hinders

or kills

susceptible

bacteria.

- Contraindicated

in patients

hypersensitive to

drug or other

cephalosporins.

- Use cautiously

in patients with

history of

sensitivity to

penicillin

because of

possibility ofcross-sensitivity

with other beta-

lactam

antibiotics.

CNS:

headache,

malaise,

dizziness.

GI: nausea,

anorexia,

vomiting,

diarrhea,

glossitis,

abdominal

cramps.

Respiratory:

dyspnea

Skin: rashes,

urticaria.

- Assess

patients

infection

before

therapy.

- Ask patien

about

previous

reactions to

cephalospor

- Be alert for

adverse

reactions an

drug

interactions.

Name of drug DateOrdered

Classification

Dosage/Frequency

Route

Mechanism ofAction

SpecificIndication

Contraindications Side Effects NursingImplicatio

Ranitidine

Hydrochlorid

e

(Zantac)

August

6, 2007

Histamine H2

receptor

blocking

drug

8g IVTT

every 8

hours

Chemical

Effect: Inhibits

action of

histamine on

the H2 at

receptor sites

of parietalcells,

decreasing

gastric acid

secretion.

Therapeutic

Effect:

Relieves GI

discomfort.

Relieves

GI

discomfort

- Contraindicated

in patients

hypersensitive to

drug and those

with acute

porphyria.

- Use cautiously

in patients with

hepatic

dysfunction.

Adjust dosage in

patients with

impaired renal

function.

CNS: vertigo,

malaise,

headache;

EENT: blurred

vision;

Hepatic:

jaundice;

Other: burning

and itching at

injection site.

- Assess

patient for

abdomina

pain. Note

presence o

blood in

emesis,stool, or

gastric

aspirate.

9


10/25

Laboratory Results

Hematology

Complete Blood Count

August 3, 2007

Result Expected Values

ame of

drug

Date

Ordere

d

Classificatio

n

Dosage/

Frequen

cy

Route

Mechanism

of Action

Specific

Indicatio

n

Contraindicati

onsSide Effects

Nu

Imp

opolami

ne

tylbromi

de

scopan

)

August

6,

2007

Anticholiner

gics

6mcg

IVTT

PRN

Chemical

Effect:

Inhibits

muscarinic

actions of

acetylcholin

e onautonomic

effectors

innervated

by

postganglio

nic

cholinergic

neurons.

Therapeuti

c Effect:

Prevent

nausea and

vomiting

To

prevent

nausea

and

vomiting

for

motionsicknes

s.

-

Contraindicat

ed in patients

with

angleclosure

glaucoma,

obstructiveuropathy,

obstructive

disease of the

GI tract,

asthma,

chronic

pulmonary

disease.

- Use

cautiously in

children

younger than

age 6.

CNS:

disorientatio

n,

restlessnes

s, irritability,

dizziness,

drowsiness,headache;

GI:

constipation

, dry mouth,

nausea,

vomiting,

epigastricdistress;

Skin: rash

and

dryness.

- As

patie

drug

histo

- Be

for

adve

reac

and

inte

ns.

10


11/25

White Cell Count - 7,300 5,000 10,000

Red Cell Count - 4.20 5.40 million

Hemoglobin - 12.0 12.0 16.0 gm/dl

Hematocrit - 36.2 37.0 47.0 vol. %

Platelet Count - 236,000 150,000 400,000 mm

Differential Count

Granulocyte - 58 43.4 76.2 %

Lymphocytes - 37 17.4 48.2 %

Monocytes - 4 4.5 10.5 %

Eosonophil - 1 0 7.0 %

Blood Electrolytes

Na+ - 133.2 135.0 148.0 mmol/L

K+ - 4.10 3.5 5.3 mmol/L

PATHOPHYSIOLOGY WITH ANATOMY& PHYSIOLOGY

Anatomy & Physiology

11


12/25

The human digestive system consists of a series of organs and structures that

help break down food and absorb nutrients for use throughout the body. Food

enters the digestive system through the mouth and passes through the

esophagus, stomach, small intestine, large intestine, and rectum. Other organs,

such as the liver, further aid in the breakdown of food, absorption of nutrients,

and elimination of indigestible materials from the body.

Anatomy of the Stomach

12


13/25

Located on the left side of the body, under the diaphragm, the stomach is a

muscular, saclike organ that connects the esophagus and small intestine. Its

main function is to break down food. Cells in the stomach lining secrete

enzymes, hydrochloric acid, and other chemicals to continue the digestive

process begun in the mouth and produce mucus to keep these substances from

digesting the lining itself.

Pathophysiology of the Gastroenteritis

13


14/25

Definition: Gastroenteritis is the irritation and inflammation of the digestive tract.

This condition may cause abdominal pain, vomiting and diarrhea. Severe cases

of gastroenteritis can result in dehydration. In such cases, fluid replacement is

the primary factor in treatment. All ages and both sexes may be affected yet the

most severe symptoms are experienced by infants and those individuals over

sixty years old. The use of certain drugs such as aspirin, antibiotics or cortisone

drugs may increase risk for this condition.

Food poisoning, stress, excessive alcohol or tobacco use, viral infections, food

allergies, improper diet, certain drugs, food consumed in foreign countries and

intestinal parasites are all possible causes for this condition

Gastroenteritis caused by viral infection or bacteria is easily passed from one

person to another. Care should always be taken to wash the hands often,

especially when preparing food and after bowel movements. Hand washing after

bowel movements is important since the organism that causes this condition lives

in the digestive tract.

Predisposing factor:

Stress

Gastritis

Cigarettes smoking

Alcohol

Drugs

14


15/25

Hydrochloride+

Pepsin

EmptyStomach

Increased secretion [gatric andmucus]

HyperacidityInflammation Loss

BowelMovement

Dehydration

Damage of themucousmembrane

decreasehematocrit count

GASTROENTERITIES

Collaborative Management

Medical Management:Antacids,hystamin blockersFluid electrolyte replacementBland or liquid diet

Nursing InterventionsHealth Teachings:Avoid alcoholAvoid smokingAvoid pass meal or overeating

Signs and Symptoms:AnorexiaNausea & vomitingAbdominal paincrampingDiarrheaGastric painFever

15


16/25

NURSING SYSTEMS REVIEW CHART

Name: Edwin Quilab Fabro Sr. Date: 01-09-08

Vital Signs:

Pulse: 80 bpm Bp: 150/100 mmHg RR: 20 cpm Temp: 36.5 CHeight: 57 Weight: 150 lbs.

EENT[ ] impaired vision [ ] blind[ ] pain redden [x] drainage[ ] gums [ ] hard of hearing [ ] deaf NGT inserted[ ] burning [ ] edema [ ] lesion [ ] teeth[ ] assess eyes ears nose productive cough[ ] throat for abnormality [ ] no problem

RESP: rashes[ ] asymmetric [x] tachypnea [ ] barrel chest[ ] apnea [ ] rales [x] cough abdominal distention[ ] bradypnea [ ] shallow [ ] rhonchi[x] sputum [ ] diminished [ ] dyspnea[ ] orthopnea [ ] labored [ ] wheezing[ ] pain [ ] cyanotic[ ] assess resp. rate, rhythm, pulse blood[ ] breath sounds, comfort [ ] no problemCARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [ ] edema [ ] fatigue[ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] painAssess heart sounds, rate rhythm, pulse, blood

Pressure, circ., fluid retention, comfort[x] No problemGASTROINTESTINAL TRACT:[ ] obese [x] distention [ ] mass[ ] dysphagia [ ] rigidity [ ] pain[ ] assess abdomen, bowel habits, swallowing[ ] bowel sounds, comfort [x] no problemGENITO URINARY AND GYNE[ ] pain [ ] urine [ ] color [ ] vaginal bleeding[ ] hematuria [x] discharge [ ] nucturia[ ] assess urine frequency, control, color, odor,[ ] gyne bleeding [ ] discharge [x] no problemNEURO: hard to discharge[ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] grip[ ] assess motor, function, sensation, LOC,[ ] grip, gait, coordination, speech [x] no problemMUSCULOSKELETAL and SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechie[x] rashes [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [ ] cool [ ] flushed[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoreticAssess mobility, motion gait, alignment, skin color,texture, turgor, integrity [ ] no problem

16


17/25

NURSING MANAGEMENT

Ideal Nursing Management (NCP)

ACTIONS/INTERVENTIONS

Sleep Enhancement (NIC)

Independent

Provide comfortable bedding and

some of own possessions; e.g., pillow,

afghan.

Establish new sleep routine

incorporating old pattern and new

environment. Match with roommate

who has similar sleep patterns and

RATIONALE

Increases comfort for sleep and

physiologic/psychologic support.

When new routine contains as

many aspects of old habits as

possible, stress and related anxiety

may be reduced, enhancing sleep.

NURSING DIAGNOSIS: Sleep Pattern Disturbances

Risk factors may include

Internal factors: illness, psychologic stress, inactivity

External factors: environmental changes, facility routines

Changes in activity pattern

Possibly evidenced by

Reports of difficulty in falling asleep/not feeling well-rested

Interrupted sleep, awakening earlier than desired

Change in behavior/performance, increasing irritability

DESIRED OUTCOMES/EVALUATION CRITERIA CLIENT WILL:

Sleep (NOC)

Report improvement in sleep/rest pattern.

Verbalize increased sense of well-being and feeling rested.

17


18/25

nocturnal needs.

Encourage some light physical

activity during the day. Make

sure client stops activity several

hours before bedtime as

individually appropriate.

Promote bedtime comfort regimens;

e.g., warm bath and massage, a glass

of warm milk, wine/brandy at bedtime.

Instruct in relaxation measures.

Reduce noise and light.

Encourage position of comfort, assist

in turning.

Lower bed and position one side

against wall when possible.

Collaborative

Administer sedatives, hypnotics

with caution as indicated.

Decreases likelihood that night owl

roommate may delay clients falling

asleep or create interruptions that

cause awakening.

Daytime activity can help client

expend energy and be ready for

nighttime sleep; however,

continuation of activity close to

bedtime may act as stimulant,

delaying sleep.

Promotes a relaxing, soothing

effect.

Helps induce sleep.

Provides atmosphere conductive tosleep.

Repositioning alters areas of

pressure and promotes rest.

May heave fear of falling because of

change in size and height of bed.

May be given to help client

sleep/rest during transition period

from home to new sitting.

18


19/25

Actual Nursing Management (SOAPIE)

19


20/25

S Kalit lang nigamay iyang timbang as verbalized by the patients mother.

O

frequent touching of the abdomen

rashes noted on his arm

abdominal distention noted

ARisk for fluid volume deficient as evidenced by sudden losses of weight and

loose bowel movement.

PLong term: At the end of an hour, the patient will be able to demonstrate

maintenance of weight.

Short term: At the end of 45 minutes, the patient will be able to verbalize a

normal pattern of bowel functioning.

I

Monitor bowel sounds.

Promot pleasant, relaxing environment.

Check stools.

Consult dietitian.

Monitor laboratory studies.

E After giving an intervention the patient verbalized a normal pattern of bowel

functioning and regains his weight.

S Unsahay ra jud nako cya gapa totoyon as verbalized by the patients

mother.

O

frequent touching of the abdomen

loose of bowel movement


A Interrupted Breastfeeding related to physiologic response of the stomach due

to over stimulation of the gastric acid as evidence by infant illness.

PLong term: At the end of an hour, the patient will be able to promote

breastfeeding to his mother.

Short term: At the end of 30 minutes, the mother of the patient will be able to

verbalize that the interventions are effective and to know how important

breastfeeding to her child is.

I

Check nutritional status of the mother.

Provide breast pump to the mother.

Promote breastfeeding technique to the mother.

Consult health care provider.

Monitor fluid intake of the mother.

E After giving an intervention the patient verbalized a response to feeding and

method.

20


21/25

HEALTH TEACHINGS

SNag kalibanga man gud cya mao na gipa admit na dayon nako sa hospital

as verbalized by the patients mother.

O

vomiting

loose of bowel movement


NGT inserted

A Diarrhea related to hyperactive bowel movement.

P

Long term: At the end of the shift, the patient will be able to promote return to

normal bowel movement.

Short term: At the end of 1 hour, the patient will be able to reestablish and

maintain normal pattern of bowel functioning.

I

Monitor intake and output.

Assess for fecal impaction.

Check stools.

Monitor bowel sounds.

Monitor laboratory studies.

EAfter giving an intervention the patient would be able to reestablished and

maintained normal pattern of bowel functioning.

21


22/25

MEDICATIONS > Advised and encouraged patient or family

to give the patient paracetamol when she

has fever.

> Do not give patient more than 5 doses in

24 hours unless prescribed by physician.

EXERCISE > Patient was instructed to ambulate, do

ROM and deep breathing exercise and do

ADLs as tolerated by patient. Tolerable

exercises will promote blood circulation and,

sense of well being, and promote fast

healing. Relaxation exercise may do.

TREATMENT > Patient instructed to increased fluid intake.

This is to promote regain of electrolytes and

fluid balance. Treatment regimen such as

some diet restriction, exercise, compliance

on medication and to submit self 1 week

after being discharge from the hospital.

OUT-PATIENT

(Check-up)

> Advised the parents to visit the nearest

hospital for further check-up for their child.

DIET > Patient was instructed to avoid eating of

salty foods. Encourage to eat foods with

high protein content such as the egg whites,

and lean meats and also vegetable and

increased fluid intake.

PROGNOSIS

22


23/25

Patients with acute gastroenteritis usually progress especially when it is

not yet to its mere complication. The rate of progression depends on the

underlying diagnosis, on the successful implementation of secondary

preventative measures, and on the individual patient. If the patient is untreated

the prognosis becomes worst and poor.

In the case of my patient, as he undergone tough treatment at Camp

Evangelista Station Hospital, his prognosis is considered as good. As evidenced

by tolerating slowly the abdominal pain and maintaining bowel movement in the

whole duration of the treatment.

EVALUATION

23


24/25

At the end of my hospital duty, we as a student nurse were able to render

care to my patient to help him resolve his problem regarding health. Through

observing the patients status, we were able to identify some problems during our

assessment. Because of a couple of interventions or health teachings applied

and imparted to the patient, we were able to render his needs on his problem;

alleviated pains felt by the patient due to the effects of the eye surgery and even

have improved his sleeping/resting pattern.

Patient was willing to pursue his medical therapy just to promote health

and wellness for the betterment of his condition. During the treatment, the patient

was able to developed or enhanced health awareness on his disease and with

this knowledge instilled to his mind, he was then aware on how the disease was

occur and what are the proper ways or interventions done just to minimize or

prevent this disease from getting worst.

We have also made the patient realized the importance of completing the

course of therapy by taking the medicines prescribed or ordered to him by hisphysician. In addition, eating healthy or nutritious foods that were prescribed to

him by the health providers was further been explained to him especially the

benefits he will gain in eating these nutritious foods.

In general, the patient was very cooperative to what health measures

administered to him by the health providers.

Moreover, these several interventions given to the patient made his body

functions different than as before.

Reference

24


25/25

WEBSITE:

o

http://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edit

o http://www.patient.co.uk/showdoc/40000681

o http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_deve

lopment#Middle_Adulthood_.2835-60_Years.29

"http://en.wikipedia.org/wiki/Erikson

%27s_stages_of_psychosocial_development"

Category: Developmental psychology

BOOKS:

1. Erikson, Erik H. Childhood and Society. New York: Norton,

1950.

2. Erikson, Erik H. Identity and the Life Cycle. New York:

International Universities Press, 1959.

3. Medical Surgical Nursing by Smeltzer

4. Nursing Pocket Guide by Sheesy Gail
http://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edithttp://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edithttp://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edithttp://www.patient.co.uk/showdoc/40000681http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_development#Middle_Adulthood_.2835-60_Years.29http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_development#Middle_Adulthood_.2835-60_Years.29http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_developmenthttp://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_developmenthttp://en.wikipedia.org/w/index.php?title=Special:Categories&article=Erikson%27s_stages_of_psychosocial_developmenthttp://en.wikipedia.org/wiki/Category:Developmental_psychologyhttp://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edithttp://en.wikipedia.org/w/index.php?title=Piaget%27s_cognitive_development&action=edithttp://www.patient.co.uk/showdoc/40000681http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_development#Middle_Adulthood_.2835-60_Years.29http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_development#Middle_Adulthood_.2835-60_Years.29http://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_developmenthttp://en.wikipedia.org/wiki/Erikson's_stages_of_psychosocial_developmenthttp://en.wikipedia.org/w/index.php?title=Special:Categories&article=Erikson%27s_stages_of_psychosocial_developmenthttp://en.wikipedia.org/wiki/Category:Developmental_psychology

age (final care study)

Documents