NURBN2000 Health Assessment And Nursing Care
Question:
2.Identify 4 major issues for Kevin Jones, his social history and provide a summary of your overall assessment of him. Ensure that you use ‘objective’ language. This would be similar to what you would write in nursing notes as an admission history.
3.Using the Nursing diagnosis section, select the three (3) health nursing diagnosis that you think are a priority for Kevin and include the evidence from your assessment that supports this.
4.Now prioritise these 3 important nursing problems to formulate a nursing care plan for Kevin
5.Develop a nursing care plan with rationale (referenced) and related interventions that could be implemented for Kevin.
Complete the evaluation sections of the care plan – identify ways that you could measure success in relation to each of these interventions
Discussing the physical and mental health components for Kevin. This will need to be written according to academic writing & referencing standards.
Answer:
Introduction
In Assessment Task 2 –Part B you are required to complete a comprehensive health assessment and nursing care plan on information given to you in the case study- Mr. Kevin Jones. The case study information is located in the Book – Case Study Guidelines for Assessment Task 2 (B).
Using the information gathered from the case study of Mr. Kevin Jones, you are expected to document the assessment you have undertaken. You are also asked to identify four (4) priority issues, develop, implement and evaluate your nursing care plan for Mr. Kevin Jones. All information is to be recorded in this Health Assessment & Nursing Care Plan Workbook. Your completed Health Assessment & Nursing Care Plan Workbook will be assessed using the marking guide in the NURBN2000 Moodle shell. Print a copy of the marking guide and keep it with you while writing your Care Plan to ensure you answer the questions correctly.
Guidelines for Health Assessment and Nursing Care plan (Total: 2000 words)
- This assessment relies on students being familiar with the nursing process as you will be required to follow the steps outlined in this process. If you are not familiar with this, review in any recommended nursing textbook – however, this has been covered in your prior EN training.
- Complete the workbook, ensuring you have answered all the questions
- Students will demonstrate clinical decision making skills in
- The Nursing Process.
- Identification/ assessmentof nursing problems (nursing diagnosis)
- Planning andImplementation of nursing care
- Documentationof nursing data.
- Evaluationof nursing care
Read this plan for the assessment task:
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Activity-Assessment Task 2: Total 2000 words |
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Nursing Care Plan 3 Diagnosis/Problems Expected outcomes Interventions Rationale Evaluation
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Referenced 600 word assessment identifying physical & mental health components e.g. dehydration may result in anxiety & confusion (Gulanick & Myers, 2012) Remaining word count utilised in the rest of document (1400 words) Your care planning will be based on your assessment data Develop a Care Plan based on data gathered in your assessment (a,b,c). Then, identify three (3) main nursing problems and provide goals, interventions, rationale and implementation of that care. |
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Evaluate (how successful was the care for each of the 3 problems identified) |
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Submit Workbook |
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Adult Health Assessment
Outline:
- Students are required to discuss the physical and mental health components for the assessment(600 words). This will need to be written & referenced according to academic writing & referencing standards.
- Identify 4 majorissues for Kevin Jones, his social history and provide a summary of your overall assessment of him. Ensure that you use ‘objective’ language. This would be similar to what you would write in nursing notes as an admission history.
- Using the Nursing diagnosis section, select the three (3) health nursing diagnosisthat you think are a priority for Kevin and include the evidence from your assessment that supports this.
- Now prioritise these 3 important nursing problemsto formulate a nursing care plan for Kevin
- Develop a nursing care plan with rationale (referenced) and related interventionsthat could be implemented for Kevin.
- Complete the evaluation sectionsof the care plan – identify ways that you could measure success in relation to each of these interventions.
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Discussing the physical and mental health components for Kevin. This will need to be written according to academic writing & referencing standards.(NB: your assessment will roll on the next page).
Mr Kevin Jones is a 75-year-old gentleman, admitted under my care with the history of hypertension, and alcoholism. He had stroke and paralysis. Assessment is necessary to identify the risk factors and appropriate intervention for improving the physical and mental health outcomes (Berman et al., 2014).
Stroke in the patients may have caused Paralysis. It is the common disability. Stroke and paralysis may cause impaired voluntary movement of muscles. It is due to brain damage due to the permanent block of blood supply. Kevin leans on one side. He has slurred speech as per assessment. He forgets where his right hand may be. Slurred speech after a stroke may occur due to the damage to left hemisphere of the brain called hemiplegic. Hemiplegia may have caused vision problems and his swallowing and walking difficulties. It may become even severe if neglected and walking difficulty increases the risk of fall (Ben Natan et al., 2016).
The patient seems to have impediments to mobility as a result of paralysis risk assessment. Currently, the patient is using three-pronged stick, and he is anxious about the balance. There may be a need to further assess the strength to perform ROM. It will help determine if the patent can participate in the rehabilitative activities and exercises. Further, assessment showed affect of paralysis on mental health components. Lack of family members support may have caused anxiety and can be due to independent nature of Kevin. He may not be able to perform his activities of daily living. Fear of fall and injury in this situation can be due to anxiety. and is mainly autonomic response (Berman et al., 2014). Kevin’s agitated and irritated behaviour with nurses and physiotherapist relates to severe anxiety. In this level of anxiety, people are overwhelmed and report overloaded with stimuli. It needs immediate treatment as Kevin has history of Depression and Anxiety (Kang et al., 2017).
The chest x-ray of Kevin revealed lower lobe pneumonia. It is the lower respiratory tract infection (bacterial or viral). It is characterised by patchy consolidation in the lower lobe. Fever, infection, or dehydration may have caused disorientation in patient as per assessment. Dehydration and anxiety may have led the patient to convey his needs poorly (Cacciatore et al., 2017). His case details inform about fever, loss of appetite, taking fewer fluids, malaise and body ache over the past few days. It may be the cause of loss of weight and dehydration. He is complaining chronic cough with sputum. His vital signs are recorded as BP – 90/60, Temp 38.3 (mild fever), O2 sats – 93%, Resp rate – 24/ min (indicating critical illness and shortness of breath) (Berman et al., 2014). There are Crackles & wheezes on auscultation, diminished breath sounds. Patient has low blood pressure that may have increased the risk of another stroke. His auscultation reports indicate the probability of pleural effusion. Thickening of the reactive airway wall and decreased airway lumen may have caused Wheezes. Without treatment, it may lead to heart failure (Manabe et al., 2015).
The loss of appetite and less fluid intake may have decreased urinary output. Dehydration in Kevin has caused skin turgor dry, and mucous membranes dry. Dehydration may have caused anxiety and confusion (Berman et al., 2014). The excess protein intake by Kevin may have caused increased urine concentration. The condition indicates excessive protein breakdown. Increased blood urea nitrogen is also the risk factor for heart failure and kidney damage (Shimizu et al., 2015). Kevin has bowel dysfunction as bowels are a little erratic and his stool has been hard and dry lately. Improper diet may have caused this condition. Urinary incontinence may have caused the patient’s distress. His condition of dribbling after passing urine may be due to incomplete bladder empty and weak balder muscles. It may increase both physical and emotional distress. Kevin had the history of Prostate Enlargement. There may be a risk of symptom of the urethral diverticulum, prostatitis and other medical problems (Gibson & Wagg, 2014).
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(a) Identify 4 Key Health Issues/ problems for nursing care
- — Impaired physical mobility
- — Anxiety due to physical distress and emotional outburst
- — Ineffective breathing pattern
- — Deficit fluid volume
(b) Document Kevin’s social history
According to Shier et al. (2013), social factor influence the healthcare delivery. As per Kelvin’s case history, he has an unsatisfactory family life. He is widowed for 13 years. He has three grown-up children and, two of them live outside of Victoria and his middle son lives nearby but leads a busy working and family life. Therefore, Kevin is isolated from emotional support of loved ones. He does not get well with his daughter in law. He lives in a rural location and is therefore socially isolated. Therefore, the personal life is of clinical significance. There is no one to take care if Kevin experiences fall due to mobility impairment. There is a high risk of anxiety and depression due to current illness and past life. He has good occupational life as a farmer and is fiercely independent in his activities. His financial condition is also not strong and may affect treatment. He is not physically and mentally strong enough to undertake farming activities. His living conditions are of clinical significance as he lives in an old farmhouse that needs renovation. He has no shower and has a wood fire and stove. Living conditions may have contributed to lower lobe pneumonia. Owing to current illness living independently would increase the risk of illness and infection for Kevin.
(c) Summary of overall assessment for Kevin
In case of Kevin paralysis and pneumonia has been a major health issue. Based on an overall assessment of Kevin it can be concluded that he is at high risk of fall due to mobility impairment. His physical distress, respiratory infection and fluid volume deficit have increased anxiety and emotional distress. Treating respiratory infection is necessary to cure his ineffective breathing pattern. These are areas of clinical significance. Dehydration and bowel elimination problem is an area of priority care. Kevin needs a proper diet to decrease the high blood urea nitrogen as it also includes the risk of heart and kidney failure.
A nursing diagnosis is a statement that describes the PERSON’S actual or potential response to a health problem that requires nursing care. It is a three-part statement with diagnosis, cause and evidence.
Ref: Berman, A., Snyder, S., J., Levett-Jones, T., Dwyer, T., Hales, M., Harvey, N. Luxford, Y., Moxham, L., Park, T., Parker, B., Reid-Searl, K., Stanley, D. (2014). Kozier & Erb’s Fundamentals of Nursing (3r Australian Ed.). Pearson: NSW, Australia. 2012, Ch. 13 Page 233 -249
Based on Assessment data you have gathered, select the three (3) priority diagnoses that you feel are the most appropriate for Kevin.
Ensure you include what evidence you have to support this.
(1) Impaired mobility due to paralysis
Evidenced by: Kevin’s anxiety related to balance, mobilising with three-pronged stick, patient unable to sense his right hand and evident from the patient leaning one side
(2) Ineffective airway breathing due to lower lobe pneumonia
Evidenced by: cough with sputum production, crackles and wheezes, diminished breath sound in the auscultation report, changes in the respiratory and pulse rate
(3 Deficit fluid volume due to dehydration
Evidenced by: dry skin turgor, bowel elimination problem, dry mucus’s membrane, high blood urea nitrogen, concentrated urine
Nursing Care Plan (Berman et al., 2012, Ch. 13 Page 233 -273)
To develop the Nursing Care Plan:
- Critically analyse, cluster and validate your assessment data for Kevin into the following format:-
- Include three(3) nursing problems diagnosis with Goals (outcomes), Nursing Interventions, Rationales (reasons)
- Write clear statements that reflect the problem. You may use your wording.
- You may use the health patterns cluster statements below to assist you to identify a nursing diagnosis, or you may use ones that reflect the individual client.
Goals or expected outcomes
Have a time frame and are realistic outcomes related to the nursing diagnosis.
Interventions
Are the nursing actions needed to achieve the goal?
Rationale (must be referenced)
The reasons for nursing interventions are recorded in detail.
Evaluation
Determines if nursing interventions are effective and goals have been achieved.
The evaluation consists of:
- Collection of data related to outcomes
- Comparison of this data with predicted outcomes
- Revision of nursing actions to goals and or outcomes
- Drawing conclusions about problem status and then modifying or terminating the care plan
- Documenting changes in nursing interventions and outcomes
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Nursing diagnosis: 1 (Nursing Problem)
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Impaired mobility
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Evidenced by
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Patient Leaning One Side, Mobilising With the three-pronged stick, and anxiety about balance
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Goal & time frame
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The goal of the intervention is to avoid risks associated with poor mobility such as fall and injury and, Assist the patient to restore and preserve as much as mobility possible. The goal may be achieved within time frame of 1 month.
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Nursing Interventions. (actions to address the problem) |
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Write nursing interventions here 1. Ensure safe environment for the patient such as use of bed rails, maintaining lower level of bed and keeping things close to him 2. Encourage the patient for independent activity and positively reinforce Kevin 3. Execute the ROM exercises to all extremities 4. Allow patient to talk about anxiety and other feelings of discomfort and refer to psychiatrist (Moreira et al., 2013, Berman et al., 2014) |
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Rationale: (reasons) – References needed to validate nursing interventions The rationale for above symptoms are 1. The measures would protect the patient from falls and promote secure environment 2. It will help boost the patient as he is anxious about balance and fiercely independent (Berman et al., 2014) 3. Exercise helps prevent contracture deformation and maintain the muscle strength. It will help patient gain enhance sense of balance 4. The patient can recognise the factors causing anxiety. Counselling may help as the patient has a risk of depression (Murray et al., 2016, Berman et al., 2014).
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Evaluation of Care (how successful were the interventions) The success of the goal would be evidenced by patient performing the daily activities within the limits of disease. It will be evaluated using a five-point Likert scale. The patient may show interest in increasing mobility with reduced anxiety. The patent may be well capable of using the adaptive device and takes an interest in safety measures to prevent injury. If the expected outcomes are not achieved, then the patient would be kept under care for two more weeks. The barriers to mobility would be identified and addressed. The patent will be helped to accept the limitations and continue with the interventions with positive reinforcement (Sorond et al., 2015; Berman et al., 2014). |
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Nursing diagnosis: 2 (Nursing Problem)
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Ineffective airway breathing
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Evidenced by
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Changes in the respiratory rate, and pulse rate, crackles and wheezes, Diminished breath sounds in the auscultation report, and it is also evidenced by a cough with sputum production. |
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Goal & time frame
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The goal of the intervention is to maintain adequate ventilation and Restore the normal pattern. The time frame for the outcome to be achieved in two days. |
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Nursing Interventions (actions to address the problem) |
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Write nursing interventions here 1. Collaboration of oxygen as indicated 2. Regular monitoring of the vital signs 3. Regular assessment of the frequency and depth of breathing 4. Change patient to upright positions frequently and give good lung disposal 5. Assist patient with deep breathing exercises, and encourage effective coughing, and proper splinting of chest ( Berman et al., 2014, Pp. 233 -273) 6. Force warm fluid as per heart condition 7. Provide respiratory medication as per physician’s order 8. Stay with patient during respiratory distress and anxiety (Simonetti et al., 2014) |
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Rationale: (reasons) – References needed to validate nursing interventions The rationale for above symptoms are- 1. To maintain the oxygen saturation of 99% 2. The patient has vital sign abnormalities and require further evaluation 3. The inconvenience, fluid in lungs, movement of the chest wall may result in tachypnoea and slow breathing (Berman et al., 2014) 4. It will help in faster cleaning of infection and upright position help favours deeper cough effort 5. Maximum lung expansion can be achieved by deep breathing exercises. Chest discomfort can be prevented by splinting (Berman et al., 2014, pp.273) 6. Warm fluid helps in expectoration of secretion and mobilisation 7. Air passage can be opened, Beta-adrenergic agonist 8. To reduce patient oxygen demand and anxiety (Hill et al., 2018, Berman et al., 2014)
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Evaluation of Care (how successful were the interventions) The patient is expected to demonstrate the behaviour to achieve airway clearance and show clear breath sound on auscultation. The vital signs may be normal with reduced cough and sputum indicating airway clearance. Auscultation reports may show clear breathing sound. A relaxed breathing is expected at the normal rate. The patient is expected to breathe normally when carrying out the activities of daily living. If the normal breathing pattern is not restored, then the GP would be consulted again to revise the dosage of the medications (Quinn et al., 2014; Berman et al., 2014). |
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Nursing diagnosis: 3 (Nursing Problem)
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Deficit fluid volume
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Evidenced by
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Bowel elimination problem, Concentrated urine, Dry mucous membrane and Dry Skin Turgor |
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Goal & time frame
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The goal is to help the patient in restoring adequate fluid volume, prevent fluid volume loss, and dehydration. It may be achieved within time frame of 2 weeks. |
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Nursing Interventions (actions to address the problem) |
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Write nursing interventions here. 1. Monitor and care to restore the normal vital signs such as temperature and blood pressure 2. Urge the patient to drink amount of fluid prescribed (Berman et al., 2014) 3. Maintain IV flow rate 4. Encourage fluid rich food and consult dietician 5. Education on nutrition and hydration, Educate the patient about self-care and avoiding caffeine, alcohol and artificial sweeteners 6. Refer the patient to home care nurse and design emergency plan (Berman et al., 2014, pp. 1390-1394) |
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Rationale: (reasons) – References needed to validate nursing interventions The rationale for above symptoms are- 1. The patient is having mild fever and increase in temperature may elevate the metabolic rate and loss of thorough fluid evaporation 2. To prevent dehydration (Berman et al., 2014) 3. To prevent fluid overload (Doenges et al., 2014) 4. To increase interest in eating and maintain proper diet well balanced with carbohydrates, fats and proteins. Diet would be modified to reduce the protein breakdown 5. To prevent constipation and concentrated urine. It will ensure the continuity of care. Education will help in proper faecal elimination and urine elimination (Berman et al., 2014) 6. Home care will allow patient to be free of anxiety, and emergency plan will help in preventing adverse outcomes (Godfrey et al., 2012) |
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Evaluation of Care (how successful were the interventions) The outcomes may be successful if the patient explains the measures to be taken to prevent unnecessary fluid loss. The patient is expected to demonstrate the awareness of behaviour to maintain normal fluid volume in the body. Kevin may actively participate in lifestyle changes to avoid dehydration. A normovolemic condition of the patient may be evidenced by systolic BP 90 mm HG or above and heart rate 60 to 100 beats/min. The skin turgor may be normal. The urine output may be greater than 30 ml/hr (Berman et al., 2014). The patient may be referred again to the dietician if constipation persists for diet modification (Doenges et al., 2016; Berman et al., 2014). |
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References
Ben Natan, M., Heyman, N., & Ben Israel, J. (2016). Identifying risk factors for elder falls in geriatric rehabilitation in Israel. Rehabilitation nursing, 41(1), 54-59.
Berman, A., Snyder, S. J., Kozier, B., Erb, G. L., Levett-Jones, T., Dwyer, T., … & Parker, B. (2014). Kozier & Erb’s Fundamentals of Nursing Australian Edition (Vol. 3). Pearson Higher Education AU.
Cacciatore, F., Gaudiosi, C., Mazzella, F., Scognamiglio, A., Mattucci, I., Carone, M., … & Abete, P. (2017). Pneumonia and hospitalizations in the elderly. Geriatric Care, 3(1).
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing care plans: guidelines for individualizing client care across the life span. FA Davis.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.
Gibson, W., & Wagg, A. (2014). New horizons: urinary incontinence in older people. Age and ageing, 43(2), 157-163.
Godfrey, H., Cloete, J., Dymond, E., & Long, A. (2012). An exploration of the hydration care of older people: a qualitative study. International Journal of Nursing Studies, 49(10), 1200-1211.
Hill, C. J., Lazzeri, M., & D’Abrosca, F. (2018). Breathing Exercises and Mucus Clearance Techniques in Pulmonary Rehabilitation. In Textbook of Pulmonary Rehabilitation (pp. 205-216). Springer, Cham.
Kang, H. J., Bae, K. Y., Kim, S. W., Shin, H. Y., Shin, I. S., Yoon, J. S., & Kim, J. M. (2017). Impact of Anxiety and Depression on Physical Health Condition and Disability in an Elderly Korean Population. Psychiatry investigation, 14(3), 240-248.
Manabe, T., Teramoto, S., Tamiya, N., Okochi, J., & Hizawa, N. (2015). Risk factors for aspiration pneumonia in older adults. PLoS One, 10(10), e0140060.
Moreira, R. P., Araujo, T. L. D., & Pagliuca, L. M. F. (2013). Physical mobility of stroke patients in the home: a proposed concept. Northeast Network Nursing Journal, 14(5).
Murray, M. J., DeBlock, H., Erstad, B., Gray, A., Jacobi, J., Jordan, C., … & Patterson, A. (2016). Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Critical care medicine, 44(11), 2079-2103.
Quinn, B., Baker, D. L., Cohen, S., Stewart, J. L., Lima, C. A., & Parise, C. (2014). Basic Nursing Care to Prevent Nonventilator Hospital?Acquired Pneumonia. Journal of Nursing Scholarship, 46(1), 11-19.
Shier, G., Ginsburg, M., Howell, J., Volland, P., & Golden, R. (2013). Strong social support services, such as transportation and help for caregivers, can lead to lower health care use and costs. Health Affairs, 32(3), 544-551.
Shimizu, K., Imamura, T., Noiri, E., Yahagi, N., Nangaku, M., & Kinugawa, K. (2015). Ratio of urine and blood urea nitrogen concentration predicts the response of tolvaptan in congestive heart failure. Nephrology, 20(6), 405-412.
Simonetti, A. F., Viasus, D., Garcia-Vidal, C., & Carratalà, J. (2014). Management of community-acquired pneumonia in older adults. Therapeutic advances in infectious disease, 2(1), 3-16.
Sorond, F. A., Cruz-Almeida, Y., Clark, D. J., Viswanathan, A., Scherzer, C. R., De Jager, P., … & Ferrucci, L. (2015). Aging, the central nervous system, and mobility in older adults: neural mechanisms of mobility impairment. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 70(12), 1526-1532.
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