NCMB312 Medical Surgical Nursing Week 7-11 PDF

NCMB312: MEDICAL SURGICAL NURSING WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES PROFESSOR: DR. POTENCIANA A. MAROMA | OLFU VAL COLLEGE OF NURSING 3 RD YEAR 1ST SEMESTER | A.Y. 2024 – 2025 | TRANSCRIBER: RIZALYN RANGEL DIAVARRO OUTLINE I. Fluids a) Fluid Volume...

NCMB312: MEDICAL SURGICAL NURSING WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES PROFESSOR: DR. POTENCIANA A. MAROMA | OLFU VAL COLLEGE OF NURSING 3 RD YEAR 1ST SEMESTER | A.Y. 2024 – 2025 | TRANSCRIBER: RIZALYN RANGEL DIAVARRO OUTLINE I. Fluids a) Fluid Volume b) Fluid I ntake c) Sources of Body Fluids d) Fluid Output e) Functions of Body Fluids f) Composition of Body Fluids g) Translocation h) Tonicity of Body Fluids II. Fluid and Electrolyte Regulation a) Osmoreceptors b) Renin-Angiotensin-Aldosterone System (RAAS) c) Natriuretic Peptides d) Gastro-intestinal Regulation e) Osmosis f) Filtration g) Diffusion h) Activ e transport III. Electrolytes a) Sources of Electrolytes b) Dynamics of Electrolyte Balance i. Sodium (135-145 mEq/L) ii. Potassium (3.5-5.0 mEq/L) iii. Calcium (9.0-10.5 mg/dL) iv. Phosphorus (3.0-4.5 mg/dL v. Magnesium (1.3-2.1 mg/dL) vi. Chloride (98-106 mEq/L) IV. Fluid Imbalances a) Hypov olemia b) Hyperv olemia FLUID VOLUME c) Third spacing AGE & SEX FLUIDS  I nfants hav e higher proportion of body w ater than adults  50 – 60% of body w eight is w ater  I nfants hav e higher fluid turn-over due  Location: to immature kidney and rapid RR o Within the cells = I NTRAcellular fluids (40%) o Outside the cells = EXTRAcellular fluids (20%)  I nterstitial Fluid (15%)  I ntravascular Fluid (5%)  Transcellular Fluid – CSF, Pleural, Peritoneal, Synov ial Fluids  Water content of the body decreases w ith age RIZALYN RANGEL DIAVARRO 1|N C M B31 2 WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES – FLUID VOLUME IMBALANCES Whole blood – 500 mL Patients w ith Chronic Renal Failure – Packed RBCs 1 unit of packed RBCs is about 150 mL GENDER & BODY SIZE  Lean body has higher w ater content  Women hav e higher body fat but lesser w ater content  Tall and thin hav e more w ater  Short and fat hav e less w ater FLUID INTAKE FLUID OUTPUT  Av erage oral fluid intake in a healthy  Av erage fluid loss amounts to 2,500 adult: 2,500 mL/day (1,500 – 3,000 mL/day counterbalancing the input to mL/day) maintain equilibrium DAILY FLUID INTAKE ROUTES Standard Formula (Kayser Jones et al., 1999;  Urination (1,500 mL/day: 30 – 50 mL/hr : Mentes, 2000) 0.5 – 1 mL/kg/hr) 100 mL/kg for the 1st 10 kg of w t, plus (10 x  Bow el elimination (200 mL) 100 = 1,000)  Perspiration & breathing o Sensible loss 50 mL/kg for the next 10 kg of w t, plus (10 x o I nsensible loss = 50 = 500) unnoticeable/unmeasurable 15 mL/kg per remaining kg of w t SOURCES OF BODY FLUIDS  Liquids  Food  Other sources: IVF, TPN, Blood Products FUNCTIONS OF BODY FLUIDS  Transporter of nutrients, etc…  Medium or milieu for metabolic processes RIZALYN RANGEL DIAVARRO 2|N C MB312 WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES – FLUID VOLUME IMBALANCES  Body temperature regulation  Body fluids are ISOTONIC comparable  Lubricant of musculoskeletal joints w ith 0.9% NaCl  I nsulator and shock absorber  HYPERTONIC fluids hav e a higher or greater concentration of solutes COMPOSITION OF BODY FLUIDS (usually sodium) compared w ith  Composed of solute, solvents, plasma; ex. is 3% NaCl electrolytes, proteins, etc…  HYPOTONIC fluids hav e a lesser or lower  Plasma and interstitial fluids contain solute concentration than plasma; ex. essentially the same electrolytes and is 0.45%, 0.33% NaCl soln solutes, but plasma has a higher protein  The normal tonicity or osmolarity of content body fluids is 275-300 mOsm/L  The major ICF é are K+, PO-4 & Mg++  The major ECF é are Na+. HCO -3 & CI– TRANSLOCATION  Movement back and forth of fluid and exchange of chemicals from one location to another  A continuous process in and among all areas w here w ater is located CHEMICALS INVOLVED Electrolytes – substances that w hen dissolved in fluid carry an electrical charge Acids – substances that release H+ into fluid Bases – substances that bind w ith H+ FLUID AND ELECTROLYTE REGULATION  Under normal conditions, the following mechanisms regulates normal fluid v olume and electrolyte concentrations o Osmoreceptors o RAAS o ANP  Primarily, fluid v olume is regulated by intake (thirst) and output (urine). How? OSMORECEPTORS OSMORECEPTORS The delicate balance of fluid, electrolytes,  Specialized neurons in the acids, and bases is ensured by an: hypothalamus  Highly sensitiv e to serum osmolality  Adequate intake of w ater and nutrients o I ncreased osmolality –  Physiologic mechanisms that regulate osmoreceptors stimulates fluid v olume hypothalamus to synthesize ADH  Chemical processes that buffer the o Decreased osmolality – ADH is blood to keep its pH nearly neutral inhibited TONICITY OF BODY FLUIDS  Triggers thirst promoting increased fluid intake  Refers to the concentration of particles in a solution OSMOLARITY - no. of solutes per L of solvent OSMOLALITY - no. of solutes per kg of solvent RIZALYN RANGEL DIAVARRO 3|N C MB312 WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES – FLUID VOLUME IMBALANCES o Thirsty w hen ECF v olume NATRIURETIC PEPTIDES decreases by approx. 700 mL  Ov erstretching (atrial & v entricular walls (2% of body w eight)  ANP & BNP are released)  Also sensitiv e to changes in BV & BP  ANP & BNP inhibit the release of RENIN through the info relayed by ALDOSTERONE and ADH = ↓ Blood baroreceptors (stretch)  A decrease in BV by 10% volume o “POTENT diuretic”  Systolic BP falls below 90 mmHg  RA is underfilled o “Na-wasting” o (-) thirst  ADH release, ADH is suppressed w hen BV, BP increases and RA is ov erfilled GASTRO-INTESTINAL REGULATION  The GI T digests food and absorbs w ater  Passive & active transport of é H2O & solutions, maintain the fluid balance in the body. most absorptive cells RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM (RAAS) area of final absorption prod. by kidney of water Fluids and electrolytes mov e among cells, prod. by liver compartments, tissue spaces, and plasma by the processes of:  Osmosis  Filtration  Diffusion and  Activ e transport Pt w/ kidney failure: RIZALYN RANGEL DIAVARRO - DIURETIC: to promote urine output 4|N C MB312 - ACE inhibitors: to prevent conversion of angiotensin I to II  WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES – FLUID VOLUME IMBALANCES OSMOSIS  Movement of water/liquid/solvent across a semipermeable membrane from a lesser concentration to a higher concentration  Osmotic pressure – the pow er of a solution to draw w ater toward an area of greater concentration  Colloidal osmotic pressure – the osmotic pull exerted by plasma proteins (e.g., albumin, globulin, fibrinogen) synthesized by liver *HYDROSTATIC PRESSURE - pressure of blood against BV walls *ONCOTIC PRESSURE - pulling water into capillaries from intestitial space - proteins that pull H20 from IS to balance the water in BV Did you know? 180 L of fluid from the blood is filtered by the kidney each day. DIFFUSION  Movement of particles, solutes, molecules from an area of higher concentration to an area of a lower concentration through a FILTRATION semipermeable membrane  Movement of both solute and solvent FACTORS AFFECTING RATE OF DIFFUSION across a semipermeable membrane a. Size of the molecules larger size moves from an area of higher pressure to lower slow er than smaller size pressure  Hydrostatic pressure – the pressure b. Concentration of solution – w ide difference exerted by the fluids w ithin the closed in conc. Has a faster rate of diffusion system; pushes w ater c. Temperature – ↑ in T˚ = ↑ rate of diffusion  I f HP > OP = Filtration RIZALYN RANGEL DIAVARRO 5|N C MB312 WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES – FLUID VOLUME IMBALANCES FACILITATED DIFFUSION SOURCES OF ELECTROLYTES  Require assistance from a carrier  Food intake/ingested fluids molecule to pass through a  Medications semipermeable membrane  I VF, TPN solutions  E.g., insulin-glucose DYNAMICS OF ELECTROLYTE BALANCE  Distribution o Na, Ca, Cl concentration are higher in ECF o K, Mg, PO4 concentration are higher in I CF  Excretion o Urine, feces, surgical w ound drainage, pathological conditions ACTIVE TRANSPORT  Regulation o Kidneys, GI T, hormones  Movement of solute from lower (aldosterone, ANF, PTH, concentration to higher concentration calcitonin) using energy (ATP)  E.g., Na-K pump ELECTROLYTES “Ions”  Substances present in I CF & ECF that carry electrical charge Sodium o Cations  NA+ , 135-145 mEq/L (mmol/L) o Anions  Major cation in ECF, major contribution of plasma osmolality  ECF Na+ lev el determines w hether w ater is retained, excreted or translocated  Regulation by kidney (aldosterone, ADH, NP) o ↑ serum Na = (-) aldosterone, (+) ADH & NP o ↓ serum Na = (+) aldosterone, (-) ADH & NP  Functions o Skeletal/heart muscle contraction, nerv e impulse transmission o Normal ECF osmolality o Normal ECF v olume RIZALYN RANGEL DIAVARRO 6|N C MB312 WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES – FLUID VOLUME IMBALANCES Potassium  Functions o B-complex v itamins, ATP,  ECF: 3.5-5.0 mEq/L or mmol/L assisting in cell div ision,  I CF: 140 cooperating in CHO, CHON &  Major I CF cation FAT metabolism, acid-base  Functions buffering, calcium homeostasis; o Regulates CHON synthesis, balanced & reciprocal glucose use & storage, relationship w / Ca++ maintains action potentials in  Regulated by PTH: ↑ PTH = ↓ P, ↓ PTH = ↑ excitable membranes P  Any change in blood K+ seriously affects physiologic activities (a Magnesium (Mg++) decrease of 1 meq/L = 25% difference  1.3-2.1 mg/dL (0.65-1.05 mmol/L) in total ECF K+ concentration)  60% stored in bones & cartilages; much Avocado – 1 medium is 1097 mg more is stored in I CF (heart, liver, Banana – 1 medium is 451 mg skeletal muscles) Therefore, avocado is the best source of  Functions potassium. o ICF – skeletal muscle contractions, CHO metabolism, Calcium++ ATP formation, Vit B-complex activ ation, DNA synthesis, CHON  9-10.5 mg/dL (2.25-2.75 mmol/L) synthesis  2 forms: bound & unbound (ionized) o ECF – regulates blood o Bound – attached to CHON coagulation & skeletal muscle (albumin) contractility o Ionized – “free” calcium; active  Regulated by the kidney & GI T (exact form; ECF mechanism are not know n)  Functions o Bone strength & density, Spinach – best source of magnesium activ ation of enzymes or reactions, skeletal/cardiac Chloride (CL-) muscle contraction, nerve  98-106 mEq/L (mmol/L) impulse transmission, blood  Major ECF anion; w ork w / Na+ to clotting maintain ECF osmotic pressure  Regulated by: Vitamin D. PTH,  I mportant in the formation of HCL in the thyrocalcitonin stomach  Participates in chloride shift (exchange betw een CI- & HCO3-) FLUID IMBALANCES  Hypov olemia  Hyperv olemia  Third spacing HYPOVOLEMIA (FLUID VOLUME DEFICIT)  Hypov olemia = Low volume of ECF  Dehydration = ↓ body fluid v olume in both ECF & I CF  Too little fluid in the v ascular space Phosphorus (P) (arteries, v eins)  3-4.5 mg/dL (0.97-1.45 mmol/L  BI G time deficit = SHOCK  Major anion I CF (80% is in bones) RIZALYN RANGEL DIAVARRO 7|N C MB312 WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES – FLUID VOLUME IMBALANCES  Occurs w hen loss of ECF v olume  Ev entually it depletes I CF w hich can exceeds the intake of fluid affect cellular functions = change in  Different from dehydration mentation o FVD (hypov olemia) should not be  Loss of body fluids + ↓ fluid intake confused w ith DEHYDRATION,  Abnormal fluid losses w hich refers to loss of water alone, o Vomiting w ith increased serum sodium o Diarrhea lev els. o GI suctioning o FVD may occur alone or in o Sw eating combination w ith other o Nausea imbalances. o Lack of access to fluids  ECF loss is greater than the fluid intake o Third – space fluid shifts o I t occurs w hen w ater and  edema electrolytes are lost in the same  ascites proportion as they exist in normal o Diabetes insipidus body fluids, so that the ratio of  decreased ability to serum electrolytes to w ater concentrate urine remains the same.  interferes w ith w ater reabsorption ETIOLOGY o Adrenal insufficiency  I nadequate fluid intake  impaired production of  Hemorrhage aldosterone  Prolonged v omiting and diarrhea o Osmotic diuresis  Wound loss (burn injury)  increase in urine output  Profuse urination or perspiration o Hemorrhage  Translocation of fluids (abdominal o Coma cav ity) o Low fluid v olume  Addisons Disease o Urination o Reabsorption o ECF loss ASSESSMENT AND DIAGNOSTIC FINDINGS  Thirst = one of the earliest symptoms  Weight loss ≥ 2lb/24 hr  ↓ BP, ↑ T°, rapid & w eak thready pulse, rapid & shallow respiration, scant & dark yellow urine, dry & small v olume stool, w arm & flushed dry skin, poor skin turgor “tents”, sunken eyes, clear lungs, effortless breathing, w eakness, flat jugular v eins, reduced cognition, sleepy PATHOPHYSIOLOGY  ↑ HR to maintain adequate CO  BP falls w ith postural changes, or it may become sev erely lowered when blood is rapidly lost  Hemoconcentration occurs = ↑ potential for blood clots, urinary stones (compromises kidney's function to excrete nitrogen wastes) RIZALYN RANGEL DIAVARRO 8|N C MB312 WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES – FLUID VOLUME IMBALANCES o nurse prov ides if the patient is unable to carry out self-care activ ities  I ncontinence o w ear diapers o urinal o pace fluid intake  Remind to drink adequate fluids MEDICAL MANAGEMENT Fluid deficit is restored by: CLINICAL S/SX  Treating its etiology Contributing Factors  I ncreasing the v olume of oral intake  Vomiting, diarrhea, fev er, fistulas,  Administering I VF replacement sw eating, burns, blood loss, GI  Controlling fluid losses suctioning, 3rd – space fluid shifts, Correction of Fluid Loss anorexia, nausea, inability to gain  oral route access to fluid, diabetes insipidus,  I V route uncontrolled diabetes  isotonic electrolyte solutions Signs and Symptoms o lactated Ringer’s  acute w eight loss o 0.9% NaCl  ↓ skin turgor o 0.45% NaCl  oliguria  hypotonic  concentrated urine Strict Monitoring  capillary filling time prolonged  I&O  ↓ CVP  w eight  ↓ BP  v ital signs  flattened neck v eins  CVP  dizziness  LOC  w eakness  breath sounds  thirst and confusion  skin color  ↑ pulse  treatment is based on the sev erity of  muscle cramps fluid loss  sunken eyes  nausea Renal Function  ↑ temperature  determine the cause of depressed  cool, clammy, pale skin renal function  Hgb and Hct  prerenal azotemia  serum osmolality  acute tubular necrosis  urine osmolality  fluid challenge test  specific gravity o v ital signs  urine Na o breath sounds  BUN and Creatinine o sensorium o CVP GERONTOLOGIC CONSIDERATIONS o UO  I & O from all sources o 100 to 200 mL of normal saline  Daily w eight solution ov er 15 minutes  SE of medications o prov ide fluids rapidly enough to  Documentation and prompt reporting attain adequate tissue perfusion  Skin turgor o ↑ UO, ↑ BP, ↑ CVP  Functional assessment RIZALYN RANGEL DIAVARRO 9|N C MB312 WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES – FLUID VOLUME IMBALANCES Shock o longitudinal furrows  25% intrav ascular v olume loss or rapid  Dry mouth fluid v olume loss  Urine Specific Gravity o > 1.020 NURSING MANAGEMENT  healthy renal  Gathers assessment data conservation of fluid  Plans measures to restore fluid balance  Mental Function  Ev aluates the outcomes of o ↓ cerebral perfusion interv entions  mild anxiety  Prov ide health teaching  confusion and agitation  comatose  Hemodynamic o acute cardiopulmonary decompensation  Prev enting Hypovolemia o identify patients at risk and take measures to minimize fluid losses  Correcting Hypovolemia o oral fluids  oral rehydration solutions o antiemetics o Parenteral  I sotonic o Enteral HEALTH TEACHING  I ntake and Output  Respond to THI RST because it is an early  q8 or q1 indication of reduced fluid v olume  May impact the mortality of patients  Consume at least 8-10 (8 ounce)  Expect a concentrated urine glasses of fluid each day, and more  Daily body w eight during hot, humid w eather o 0.5 kg w eight loss is  Drink w ater as an inexpensive means to approximately 500 ml fluid loss meet fluid requirements  Closely monitored  Av oid bev erages w ith alcohol & o tachycardia caffeine o sev ere hypotension  I nclude a moderate amount of table o tachypnea salt or foods containing sodium each o ↓ peripheral pulses day o ↓ temperature  Rise slow ly from a sitting or lying position o ↓ CVP to av oid dizziness and potential injury  Skin and tongue turgor o pinch skin HYPERVOLEMIA (OVERHYDRATION) o dependent on interstitial fluid  High v olume of w ater in the IV v olume compartment o skin flattens more slow ly  Too much fluid in the v ascular space o remain elev ated for many (arteries, v eins) seconds  Fluid Volume Excess (FVE) o ov er the sternum o isotonic expansion of the ECF o inner aspects of the thighs o ↑ in total body w ater o forehead o tongue turgor is not affected by ETIOLOGY age  Excessive oral intake, rapid I V infusion o smaller tongue  Heart failure RIZALYN RANGEL DIAVARRO 10 | N C M B 3 1 2 WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES – FLUID VOLUME IMBALANCES  Kidney disease o consumption of excessive  Excessive salt intake amounts of salts  Adrenal gland dysfunction – o excessive administration of administration of corticosteroids sodium – containing fluids (prednisolone) ASSESSMENT FINDINGS  ESRD Clinical S/Sx  Contributing Factors o Kidney injury o Heart failure o Liv er cirrhosis o Ov erzealous administration of Na containing fluids o Fluid shifts (treatment of burns) o Prolonged corticosteroid therapy o Sev ere stress o Hyperaldosteronism Signs & Symptoms  Early signs: w eight gain, elev ated BP, increased breathing effort  Dependent edema (feet, ankles, sacrum, buttocks) PATHOPHYSIOLOGY  Rings, shoes & stockings leav e marks in the skin  Circulatory ov erload; compromises  Prominent jugular v ein w hen sitting cardiopulmonary function  The heart compensates: ↑ BP, ↑ force of  Moist breath sounds (fluid congestion in the lungs) contraction  Pitting edema dev elops (if there is 3L excess in I V v olume)  Vital Signs o ↓ function of the homeostatic  Tachycardia mechanisms responsible for regulating  bounding pulse fluid balance  ↑ BP o heart failure  ↑ CVP o renal failure  Respiration system o cirrhosis of the liv er o tachypnea o ↓ function of the homeostatic o shortness of breath mechanisms responsible for regulating o crackles fluid balance o cough RIZALYN RANGEL DIAVARRO 11 | N C M B 3 1 2 WEEK 7: CONCEPT OF FLUIDS AND ELECTROLYTES – FLUID VOLUME IMBALANCES o orthopnea o Loop diuretics  GI system  block Na reabsorption in o acute w eight gain the ascending limb of the o ascites Loop of Henle  Other s/sx  sev ere hypervolemia o peripheral edema  furosemide (Lasix) o distended jugular v eins o K, Mg, Ca, NaHCO3 o ↑ UO o Hypokalemia o Hyperkalemia DIAGNOSTIC FINDINGS  potassium – sparing  Hemodilution (↓ blood cell count, ↓ diuretics hematocrit)  spironolactone  Low Urine SG o Hyponatremia  CVP (>10 cm H₂O) (2kgs reduces within 24 the hours of chance life) of being infected and becomin g a carrier of hepatitis B. Prevents liver cirrhosis and liver cancer. (DTwP– 6 weeks 3 4 It is a HIB– weeks/ protecti HepB) & 1month on other (6,10,14 against DTaP ) Diphtheri combinat a, Yellow – range of recommended age ions Pertussis, Green – catch up immunization Tetanus, Hepatitis *Primary doses are given at least 4 weeks apart RIZALYN RANGEL DIAVARRO 11 | N C M B 3 1 2 WEEK 10: COMMUNICABLE DISEASE NURSING AND IMMUNIZATION /Pentaval B, and Measles- 12 2 4 weeks Protectio ent Haemop Mumps- months /1mont n vaccine hilus Rubella h against Influenza (MMR) measles, Type B Vaccine mumps, IPV/OPV 6 weeks 3 4 Protectio – MCV2 and weeks/ n rubella 1month against virus. (6,10,14 polio ) diseases. VACCINE Minim # of Minimu Reason PCV 6 weeks 3 4 Protectio um Doses m weeks/ n Age interval 1month against at first betwee (6,10,14 pneumo dose n doses ) nia Varicella 12 2 3 Protectio Vaccine mont months n VACCINE Minimu # of Minimu Reason hs (for against m Age Dos m childre chicken at first es interval n 13yo pox. dose betwee & n doses above Rotavirus 6 weeks 2 4 week s Protect – 4wks.) vaccine /1mont against Hepatitis 12 2 6 Protectio h diarrhea A mont months n (2nd caused Vaccine hs against dose is by (HAV) Hepatitis not severe A virus. later forms of Human 9 9-14 >6mont Prevent than rotavirus Papillom years y/o = hs most 32wks.) disease. a virus old 2 >0, 2, & genital Influenza 6 2 4 weeks Protectio (HPV) 15 & 6month warts Vaccine months /1mont n Vaccine abov s and h against e=3 most flu cases of viruses. cervical Measles 9 1 --- Prevents cancer. Vaccine months death, Meningo 9 2 >8 Protectio - MCV1 (but malnutrit coccal mont weeks n may be ion, and conjugat hs - >boost against given protecti ed baby er @ meningo as early on from vaccine 11-12 16yo coccemi as 6 measles. y/o - a. months adole of age scent in cases of FULLY IMMUNIZED CHILD – when a child outbre aks as receives 1 dose of BCG, 3 doses of OPV, 3 declare doses of DPT, 3 doses of HBV, and 1 dose of d by Measles before reaching 1 year old. public health authorit TETANUS TOXOID IMMUNIZATION SCHEDULE ies) FOR WOMEN Japanes 9 2 12-24 Protectio VACCINE Minimum Percent Duration e months (18y months n age or Protected of Encephal o& against interval Protection itis Vac. abo Japanes for the (JE) ve - e mother 1 Enceph dos alitis TT1 As early as --- --- e) virus. possible RIZALYN RANGEL DIAVARRO 12 | N C M B 3 1 2 WEEK 10: COMMUNICABLE DISEASE NURSING AND IMMUNIZATION during portion of pregnancy thigh TT2 At least 4 80% Infant will /Vastus weeks later be lateralis protected OPV 2-3 drops PO Mouth by IPV 0.5 ml IM Outer neonatal portion of tetanus. thigh /Vastus 3 years lateralis protection PCV 0.5 ml IM Upper TT3 At least 6 95% Infant will outer months be portion of later protected thigh by /Vastus neonatal lateralis tetanus. Rotavirus V. 1 ml PO Mouth Influenza V. 0.25ml - 6 IM / SC Deltoid Years to 35 mos. region of protection arm TT4 At least 1 99% Infant will 0.5ml - year later be 36mos to protected 18yo by MCV1-MV 0.5 ml SC Outer neonatal aspect of tetanus. the upper 10 years arm protection JEV 0.5 ml SC Upper TT5 At least 1 99% All infants arm year later born to MCV2-MMR 0.5 ml SC Outer that aspect of mother the will be upper protected arm Varicella V. 0.5 ml SC Outer Lifetime aspect of protection the for the upper mother arm HAV C- 0.5ml IM Deltoid ADMINISTRATION OF VACCINES A- 1ml region of arm VACCINES DOSE ROUTE SITE HPV 0.5 ml IM Deltoid BCG 0.05 ml - ID Right region of 12 Deltoid arm months Region of old/school arm THE EPI VACCINES AND ITS CHARACTERISTICS entrants HBV 0.5 ml IM Upper Type of Storage Hours of 19 & outer Vaccine Temp. Life after above - portion of opening 1ml thigh Most OPV -15 to -25 C 8 hours /Vastus Sensitive to Measles (At the lateralis Heat (Freeze freezer) Pentavalent 0.5 ml IM Upper dried) outer RIZALYN RANGEL DIAVARRO 13 | N C M B 3 1 2 WEEK 10: COMMUNICABLE DISEASE NURSING AND IMMUNIZATION Most Hepa B +2 to +8 C 8 hours ✓ Giving doses of a vaccine at less than Sensitive to DPT (Body of the recommended 4 weeks interval Cold Tt Refrigerator) may lessen the antibody response. Sensitive to BCG +2 to +8 C 4 hours Sunlight (Body of Lengthening the interval between and refrigerator) doses of vaccines leads to higher Fluorescent antibody levels. light ✓ No extra doses must be given to children who missed a dose of EPI COLD CHAIN and LOGISTICS DPT/HB/OPV. The vaccination must be Cold Chain Manager = Public Health continued as if no time had elapsed between doses. Nurse ✓ Do not give more than one dose of the Temperature monitoring of vaccines is done in all levels of health facilities to same vaccine to a child in one session. Give doses of the same vaccine at the monitor vaccine temperature. Temperature checking is done twice a correct intervals. ✓ Strictly follow the principle of never, day early in the morning and in the ever reconstituting the freeze-dried afternoon before going home. vaccine in anything other than the Temperature is plotted every day in diluent supplied with them. monitoring chart to monitor break in cold chain. ✓ If you are giving more than one vaccine, do not use the same Vaccine can be stored in Refrigerator: syringe/needle and do not use the same arm or leg for more than one Regional – 6 months injection. Municipal / City – 3 months ✓ Repeat BCG vaccination if the child Main Health Center – 1 month does not develop a scar after the first injection. Transport Box: 5 days ✓ It is safe and effective with mild side FEFO (first expiry and first out) vaccine is effects after vaccination. Local practiced to ensure that all vaccines are reaction, fever, and systematic utilized before its expiry date. symptoms can result as part of the normal immune response. Proper arrangement of vaccines and labelling of vaccines expiry date are CONTRAINDICATION TO IMMUNIZATION done to identify those near to expire ✓ Anaphylaxis or severe hypersensitivity vaccines reaction to a previous dose of vaccine is an absolute contraindication to Vaccine Wastage subsequent doses of vaccine Wastage is defined as loss by use, ✓ Person with a known allergy to a decay, erosion or leakage or through vaccine component should not be wastefulness vaccinated. ✓ DPT2 or DPT3 is not given to a child who GENERAL PRINCIPLES IN VACCINATION has convulsions or shock within 3 days ✓ It is safe and immunologically effective after DPT1. Vaccines containing the to administer all EPI vaccines on the whole cell pertussis component should same day at different sites of the body. not be given to children with an ✓ The vaccination schedule should not evolving neurological disease be restarted from the beginning even if (uncontrolled epilepsy or progressive the interval between doses exceeded encephalopathy). the recommended interval by months ✓ Do not give live vaccines like BCG to a or year. individual who are immunosuppressed due to malignant disease (child with RIZALYN RANGEL DIAVARRO 14 | N C M B 3 1 2 WEEK 10: COMMUNICABLE DISEASE NURSING AND IMMUNIZATION AIDS), going therapy with immunosuppressive agents or radiation. ✓ A child with a sign and symptoms of severe dehydration ✓ Fever of 38.5 C and above The following are NOT contraindication. Infants with these conditions SHOULD be immunized: ✓ Allergy or asthma (except if there is a known allergy to a specific component of vaccine mentioned above) ✓ Minor respiratory tract infection ✓ Diarrhea / vomiting ✓ Temp. below 38.5 C / low grade fever ✓ Family history of adverse reaction following immunization ✓ Family history of convulsions/seizures ✓ Known or suspected HIV infection with no signs and symptoms of AIDS ✓ Child being breastfed ✓ Chronic illness such as diseases of heart, lung, kidney or liver ✓ Stable neurological condition such as cerebral palsy or Down’s Syndrome ✓ Premature or low birthweight (vaccination should not be postponed) ✓ Recent or imminent surgery ✓ Malnutrition ✓ History of jaundice at birth Generally, one should be immunized unless the child is so sick that he needs to be hospitalized. Note: If parent strongly objects to an immunization for a sick infant, do not give it. Ask the mother to comeback when child is well. RIZALYN RANGEL DIAVARRO 15 | N C M B 3 1 2 NCMB312: MEDICAL SURGICAL NURSING WEEK 11: MEASLES, GERMAN MEASLES ETC. / PTB, MUMPS ETC. PROFESSOR: SIR GERARDO A. NICOLAS | OLFU VAL COLLEGE OF NURSING 3RD YEAR 1ST SEMESTER | A.Y. 2024 – 2025 | TRANSCRIBER: RIZALYN RANGEL DIAVARRO OUTLINE CLINICAL MANIFESTATIONS I. Measles II. German Measles Pre-Eruptive → Eruptive/ Stage of Skin Rashes III. Chicken pox → Convalescent Stage IV. Influenza Pre-Eruptive Stage - Highly Contagious Stage V. COVID 19 VI. Pulmonary Tuberculosis High-grade fever VII. Pneumonia 3 C’s and 1 P VIII. Diphtheria o Coryza IX. Pertussis X. Mumps o Cough o Conjunctivitis MEASLES o Photophobia Enanthema Francis Home (1757) – a Scottish physician, first o Koplik’s spot – Pathognomonic discovered measles sign; a bluish-whitish spot with a red halo margin usually located Maurice Hilleman – first discovered measles vaccine – 1963 first available 1968 improved in the inner cheek opposite the second molar vaccine o Stimson’s line – line of Other Names inflammation along the margin of lower eyelid Rubeola Sore throat 7-day Measles Morbilli Disease Hard Measles Little Red Disease Etiologic Agent Morbilli Virus (paramyxovirus) Sensitive to heat, light, and extreme acidity and alkalinity Mode of Transmission Direct contact with respiratory Eruptive Stage / Stage of Skin Rashes secretions coming from infected patients Exanthema Indirect contact with objects o Maculopapular Rash contaminated with secretions ▪ Reddish in color; warm to Airborne transmission touch ▪ Cephalocaudal in Incubation Period distribution Pruritus 10-12 days (8-20 days) Irritability Period of Communicability Lethargy Anorexia 4 days before and 5 days after the appearance of rashes RIZALYN RANGEL DIAVARRO 1|NCMB312 WEEK 11: MEASLES, GERMAN MEASLES ETC. / PTB, MUMPS ETC. Convalescent Stage DIAGNOSTIC TEST Nose and Throat Swab Rashes disappear in the same manner Urinalysis as they appear in the body Blood exam LEAVES A BRANNY DESQUAMATION Viral serology o Complement Fixation o Hemagglutinin Inhibition Test o Neutralization Test COMPLICATIONS Bronchopneumonia – most common and dreaded complication Otitis media Nephritis Encephalitis Maculopapular Reddish and warm to touch Blindness MEDICAL TREATMENT Pen G – to prevent secondary bacterial complication Antiviral: ISOPRENOSINE Vitamin A o 6-12 months: 100,000 IU o >12mos-5 years: 200,00 IU NURSING INTERVENTIONS Isolation Antipyretic and TSB CEPHALOCAUDAL distribution Increase oral fluid intake Bed rest Nasal and Oral Care Eye Care Skin Care Negative pressure generally refers a place where pressure is smaller in one place relative to another place. Negative pressure occurs when there is less air in your home than outside. PREVENTIVE MEASURES Vaccine Live Attenuated Measles Vaccine: 9 months MMR o 1st dose: 12-15 months o Booster dose: 11-12 years Exposed: Measles Immune Serum Globulin with 1 week after exposure RIZALYN RANGEL DIAVARRO 2|NCMB312 WEEK 11: MEASLES, GERMAN MEASLES ETC. / PTB, MUMPS ETC. Eruptive Convalescent Pre-Eruptive Stage Low grade fever Headache Malaise Anorexia Sore throat Community Setting Coryza Barangay with Population: 2,000 Conjunctivitis Target Infants for Measles Vaccination: 60 Lympadenopathy Formula: 2000 X 3% = 60 o Postcervical GERMAN MEASLES o Postauricular o Suboccipital George de Maton (1814) – first discovered German measles; first suggested that the Eruptive Stage disease is different from both measles and scarlet fever in 1814 Exanthema o Maculopapular rash Friedrich Hoffmann – made the first clinical ▪ Reddish in color; warm to description of rubella in 1740. touch Norman Gregg – documented the ▪ Cephalocaudal in teratogenic property of the infection in 1941. distribution Other Names Rubella 3 Day Measles Etiologic Agent Rubivirus (Rubella Virus) Togavirus – with an envelope Mode of Transmission Direct contact with respiratory Forscheimer Spot secretions coming from infected o A red, petecchial macule on the patients surface of the soft palate Indirect contact with objects Testicular pain especially in younger contaminated with secretions adults Transplacental Transmission Polyarthralgia and Polyarthritis Incubation Period 2 – 3 weeks Period of Communicability 7 days before and 5 days after the appearance of rashes CLINICAL MANIFESTATIONS Pre-Eruptive RIZALYN RANGEL DIAVARRO 3|NCMB312 WEEK 11: MEASLES, GERMAN MEASLES ETC. / PTB, MUMPS ETC. Convalescent Stage NURSING INTERVENTIONS Rashes disappear in the same manner Same with MEASLES as they appear on the body o Isolation DOES NOT LEAVE A BRANNY o Antipyretic and TSB DESQUAMATION o Increase oral fluid intake o Bed rest o Nasal and Oral Care o Eye Care o Skin Care PREVENTIVE MEASURES Live Attenuated Rubella Vaccine MMR Exposed: Immune Serum Globulin, IM within 1 week after exposure (especially for pregnant women) CHICKEN POX DIAGNOSTIC TEST Other Name Viral Isolation from Nasopharyngeal Varicella secretions Viral Serology Etiologic Agent o Complement Fixation o Hemagglutinin Inhibition Test Varicella-Zoster virus o Neutralization Test Herpesvirus varicellae o Only pathogenic to humans COMPLICATIONS Mode Of Transmission Encephalitis – most common Otitis media Direct contact with respiratory Rubella Syndrome secretions coming from infected o IUGR patients o Mental retardation Indirect Contact with objects o Cardiac defects contaminated with secretions o Eye defects: glaucoma and Airborne transmission cataract Transplacental transmission o Ear defects: hearing loss Incubation Period 10 – 21 days Period of Communicability 2 days before the rashes appear until all vesicles have encrusted CLINICAL MANIFESTATIONS Pre-Eruptive MEDICAL TREATMENT Eruptive Convalescent Symptomatic and Supportive Antipyretic Pre-Eruptive Analgesic Fever RIZALYN RANGEL DIAVARRO 4|NCMB312 WEEK 11: MEASLES, GERMAN MEASLES ETC. / PTB, MUMPS ETC. Headache Sore throat Malaise Eruptive Exanthema o Vesiculopapular Rashes ▪ Centrifugal in distribution – away from the center, lesions on the face and extremities ▪ Extremely pruritic o 5 Stages of Rashes a) Macule- “flat” b) Papule- “elevated” c) Vesicle- “fluid-filled” d) Pustule- “pus-filled” e) Crust/Scab- dry Centrifugal versus Centripetal 1) Towards to the center 2) Outer to inner 3) Inner to Outer 4) Covered to Uncovered DIAGNOSTIC TESTS 5) Uncovered to Covered Determination of V-Z virus through: 6) Away from the center o Viral Isolation Celestial Map o Microscopic Examination of A condition wherein all the stages of Vesicular Fluid chicken pox rash are simultaneously o Viral Serology present COMPLICATIONS Convalescent Skin Infections o Erysipelas Rashes disappear o Cellulitis o Impetigo MEDICAL TREATMENT Antivirals: to slow down vesicle formation and speed up skin healing o ACYCLOVIR o ZOVERAX Antipyretic: No NSAID- strong link with Reye’s Syndrome For pruritus o Antihistamine o Calamine lotion o Soda bath NURSING INTERVENTIONS Symptomatic and Supportive RIZALYN RANGEL DIAVARRO 5|NCMB312 WEEK 11: MEASLES, GERMAN MEASLES ETC. / PTB, MUMPS ETC. PREVENTIVE MEASURES Sore throat GI manifestations: Nausea and Vaccine vomiting o Live Attenuated Varicella Vaccine DIAGNOSTIC TEST ▪ 2 doses at 1 month apart Nose and Throat Swab to be immune Viral Culture o MMRV Viral Serology INFLUENZA RTPCR (Real Time Polymerase Chain Reaction) – Confirmatory Test Other Names COMPLICATION “La Grippe” Flu Atypical Pneumonia EO 280 (Bird flu) o An infection affecting the lower respiratory tract. The types of Etiologic Agent bacteria that cause it tend to create less severe symptoms Influenza Virus than those in typical o A: epidemic and pandemic pneumonia. If the atypical cases pneumonia is caused by the ▪ H (Hemagglutinin) – 16 bacteria Mycoplasma, then it is ▪ N (Neuraminidase) – 9 common to have ear and sinus o B: epidemic cases infections. o C: sporadic cases – H-18; N-11 CDC 2018 MEDICAL TREATMENT Influenza A: Amantadine HCl Mode of Transmission (Symmetrel)- prevention and treatment Direct Contact with nasopharyngeal of RTI caused by the virus secretions Antibiotics: secondary infection Indirect Contact with objects AH1N1 contaminated with secretions o Oseltamivir (Tamiflu) Droplet o Zanamivir (Relenza) Vaporizer – reduce irritation to Incubation Period respiratory mucosa 1-4 days average of 2 days Reye’s (Reye) syndrome is a rare but serious 24-48 hours condition that causes swelling in the liver and brain. Reye's syndrome most often affects Period of Communicability children and teenagers ages 16 years old and below recovering from a viral infection, most Adult commonly the flu or chickenpox. o Until the 5th day of illness up to 7 days Symptoms of Reye's syndrome increase if Children aspirin enters their body, which worsens o Up to 10 days damage to mitochondria. Damaged mitochondria cause levels of ammonia to CLINICAL MANIFESTATIONS increase in their blood, followed by swelling of Chills their brain (cerebral edema and intracranial Hyperpyrexia pressure). Malaise NURSING MANAGEMENT Coryza Headache Symptomatic and Supportive Myalgia Respiratory Isolations RIZALYN RANGEL DIAVARRO 6|NCMB312 WEEK 11: MEASLES, GERMAN MEASLES ETC. / PTB, MUMPS ETC. Bed Rest: Limit strenuous activity The incubation period for COVID-19 is 4 Watch out for complications – 14 days from exposure to symptoms Instruct patient to avoid crowded onset. (CDC, June 2020) areas and close contact with infected Older people, and those with underlying persons medical problems like cardiovascular disease, PREVENTIVE MEASURES diabetes, chronic respiratory disease, and cancer are more likely to develop serious Live Attenuated Influenza Vaccine illness. o Single dose o Annual vaccination to people Mode of Transmission at risk like elderly and immunocompromised persons The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when an infected person coughs or sneezes, so it’s important that you also practice respiratory etiquette (for example, by coughing into a flexed elbow). Do not touch your mouth, eyes and nose. CLINICAL MANIFESTATIONS Most common signs/symptoms: fever, dry cough, and tiredness. Less common symptoms: aches and pains, sore throat, diarrhea, conjunctivitis, headache, loss of taste or smell, rash on skin, or discoloration of fingers or toes. Serious symptoms: difficulty breathing or COVID 19 shortness of breath, chest pain, and loss of speech or movement. The coronavirus disease (COVID-19) is an infectious disease caused by a newly DIAGNOSTIC TEST discovered and a new strain of coronavirus. This new virus and disease were unknown COVID-19 (Coronavirus) Molecular (Swab) before the outbreak began in Wuhan, China, Test (PCR) Polymerase Chain Reaction Test - in December 2019. On 30 January 2020, the this test uses a long swab to collect material, Philippine Department of Health reported the including physical pieces of coronavirus, from first case of COVID-19 in the country with a 38- the back of the nose where it meets the year-old female Chinese national. On 7 throat; considered as confirmatory test. March, the first local transmission of COVID-19 (+) – viral genetic material is present was confirmed. (-) – viral genetic material is present COVID-19 (Coronavirus) Antibody (Serology) Etiologic Agent Test (RDT) Rapid Diagnostic Test – this is a blood COVID-19 is caused by the SARS-CoV- test. It is designed to detect antibodies 2 virus. (immunoglobulins, IgG and IgM) against the coronavirus. Incubation Period (1) Health care provider believes that the patient may have been exposed to Incubation period is the period the coronavirus which causes between exposure to an infection and COVID19 based on the current or the appearance of the first symptoms. previous signs and symptoms (e.g., fever, cough, difficulty breathing); RIZALYN RANGEL DIAVARRO 7|NCMB312 WEEK 11: MEASLES, GERMAN MEASLES ETC. / PTB, MUMPS ETC. (2) Live in or have recently traveled to a The difference between RDT and PCR, RDT just place where transmission of COVID-19 detects the antibodies while PCR detects for is known to occur; the virus itself that is why PCR is the (3) Have been in close contact with an confirmatory test. individual suspected of or confirmed NURSING ASSESSMENT to have COVID-19; and (4) Have recovered from COVID-19 Assessment of a patient suspected of COVID- 19 should include: The Antibody Test for IgG – this test detects IgG Travel history. Health care providers antibodies that develop in most patients should obtain a detailed travel history within seven to 10 days after symptoms of for patients being evaluated with fever COVID-19 begin. and acute respiratory illness. IgG antibodies remain in the blood after an Physical examination. Patients who infection has passed. These antibodies have fever, cough, and shortness of indicate that the patient may have had breath and who has traveled to COVID-19 in the recent past and have Wuhan, China recently must be placed developed antibodies that may protect him under isolation immediately. from future infection. NURSING DIAGNOSIS The Antibody Test for IgM – this test detects IgM Based on the assessment data, the antibodies. major nursing diagnosis for a patient with IgM is usually the first antibody produced by COVID-19 are: the immune system when a virus attacks. A Infection related to failure to avoid positive IgM test indicates that you may have pathogen secondary to exposure to been infected and that the immune system COVID-19. has started responding to the virus. Deficient knowledge related to unfamiliarity with disease transmission IgM (+) and IgG (+) – the body is making a information. long-term antibodies but the virus still in the Hyperthermia related to increase in body and infected. Need hospitalization. metabolic rate. IgG (+) and IgM (-) – the body has antibodies Impaired breathing pattern related to against SARS COV 2, there is already immunity shortness of breath. and not any more infectious. No need a Anxiety related to unknown etiology of confirmatory test and no need for quarantine. the disease. IgM (+) and IgG (-) – if the patient is positive in NURSING CARE PLANNING AND GOALS IgM, the patient is infected and infectious, The following are the major nursing care carrier of SARS Cov 2 and need isolation for 2 planning goals for COVID-19: weeks because of the chance of transmitting Prevent the spread of infection. the virus. Learn more about the disease and its Confirmatory test is advised. Contact tracing management. for those people whom they meet along the Improve body temperature levels. way and be tested and informed the LGU for Restore breathing pattern back to the results. normal. Reduce anxiety. IgM (-) and IgG (-) – no virus in the body and it’s too early for the body to produce NURSING INTERVENTIONS antibodies that RDT detects. Still even if 1) Monitor the patient’s temperature; the negative result, practice hand washing, put infection usually begins with a high face mask, physical distancing and boost the temperature; monitor the respiratory immune system and repeat the RDT after 7-14 rate of the patient as shortness of days. breath is another common symptom. RIZALYN RANGEL DIAVARRO 8|NCMB312 WEEK 11: MEASLES, GERMAN MEASLES ETC. / PTB, MUMPS ETC. 2) Monitor the patient’s O2 saturation cough or sore throat, and either of the because respiratory compromise results following: in hypoxia. 1) a history of travel to or residence in an 3) Keep tissues at the patient’s bedside; area that reported local transmission of dispose secretions properly; instruct the COVID-19 during the 14 days prior to patient to cover mouth when coughing symptom onset, or or sneezing; use masks, and advise 2) with contact to a confirmed or those entering the room to wear masks probable case of COVID-19 during the as well; place respiratory stickers on 14 days prior to symptom onset. chart, linens, and so on. B. Individuals with sudden respiratory infection 4) Enforce strict hand hygiene. Teach the and severe symptoms such as shortness of patient and folks to wash hands after breath, difficulty of breathing or severe coughing to reduce or prevent the pneumonia with unknown cause, and requires transmission of the virus. hospitalization. 5) Manage hyperthermia. Use appropriate therapy for elevated C. Individuals with fever or cough or shortness temperature to maintain normothermia of breath or other respiratory signs or and reduce metabolic needs. symptoms and under any of the following 6) Educate the patient and folks. Provide conditions: information on disease transmission, 1) aged 60 years and above, diagnostic testing, disease process, 2) with a co-morbidity, complications, and protection from the 3) assessed as having high-risk virus. pregnancy, or 4) a health worker. EVALUATION Nursing goals are met as evidenced by: Probable Case Patient was able to prevent the spread Suspect case whom testing for COVID-19 is of infection. inconclusive. B. Suspect case who tested Patient was able to learn more about positive for COVID-19 but whose test was not the disease and its management. conducted in a national or sub-national Patient was able to improve body reference laboratory, or an officially temperature levels. accredited laboratory. Patient was able to restore breathing pattern back to normal. Confirmed Case Patient was able to reduce anxiety. Any individual who was laboratory-confirmed for COVID-19 through RTPCR in a national or sub-national reference laboratory, or a DOH certified laboratory testing facility. MEDICAL MANAGEMENT Suspect Case A. Individuals with influenza-like illness (ILI). Symptoms include fever of at least 38°C and RIZALYN RANGEL DIAVARRO 9|NCMB312 WEEK 11: MEASLES, GERMAN MEASLES ETC. / PTB, MUMPS ETC. Meds 1) Ceftriaxone 2q IV OD (Day 3) 2) Azithromycin 500 mg IV OD x 5 days (Day 3) 3) Multivitamins + Zinc tab OD 4) Ascorbic Acid tablet 1 tablet BID 5) Omeprazole 40 mg IV OD 6) NAC 600 mg/tab + ½ glass H₂O BID 7) Paracetamol 300 mg IV Q4 for temp > 37.8° Still for transfusion of 2u PRBC property typed & crossmatched VS Q4 I&O Q shift For Bahay Kalinga Referral Refer Accordingly PREVENTIVE MEASURES To prevent infection and to slow transmission of COVID-19, do the following: 1) Wash your hands regularly with soap and water, or clean them with alcohol- based hand rub. 2) Maintain at least 1 meter distance between any individual and people coughing or sneezing. 3) Avoid touching the face. 4) Cover the mouth and nose when coughing or sneezing. 5) Stay home if feel unwell. 6) Refrain from smoking and other activities that weaken the lungs. RIZALYN RANGEL DIAVARRO 10 | N C M B 3 1 2 WEEK 11: MEASLES, GERMAN MEASLES ETC. / PTB, MUMPS ETC. 7) Practice physical distancing by avoiding unnecessary travel and staying away from large groups of people. 8) Boost the immune system by taking Vitamin C, Vitamin D and Zinc and eat nutritious foods. Classification Class 0 – no exposure, no infection Class 1 – (+) exposure, (-) infection Class 2 – (