NCLEX: Specialized Care

Specialized Care: Paralysis

Focus topic: Specialized Care

Residents might be unable to move a body part, which is called paralysis. Paralysis is classified according to how much of the body is affected. For example, paraplegia affects the lower half of the body; quadriplegia involves both arms and legs; hemiplegia means that half of the body, either the right or the left side, is paralyzed. A stroke or other neurological disease results in decreased blood flow and oxygen to the brain cells, causing them to die, which leads to paralysis. Signs and symptoms of a stroke depend on the location of the brain injury and the amount of the damage. A stroke on one side of the brain affects the opposite side of the body. Effects of a stroke include aphasia (being unable to speak), a partial paralysis or weakness of the face (causing drooping of the mouth, eyelid, and so on), or complete paralysis of the arm or leg on the affected side (leaving the arm or leg limp, or flaccid). An injury to the spinal cord can cause paralysis of the body below the injury site, leading to quadriplegia. Paralysis in any part of the body can pose problems with mobility and ADLs. Special care is required to keep the affected muscles and tendons functioning as much as possible. Mobility-impaired residents run the risk of contractures, or a shortening of the muscles due to lack of exercise or movement, pressure ulcers, and other hazards of immobility; respiratory difficulties, especially pneumonia; and muscle spasms, incontinence (bowel and bladder), and swallowing difficulties (dysphagia). Provide special care to protect affected residents with an injury causing paralysis from further complications, and maintain or restore normal functioning including the following:

  • Follow each resident’s care plan to help residents regain independence.
  • Maintain a calm, reassuring environment.
  • Arrange ADLs to promote rest and sleep.
  • Encourage independence and self-care to promote autonomy.
  • Show patience and empathy.
  • Use touch to help orient the resident and show genuine care and concern.

EXAM ALERT

Focus topic: Specialized Care

Feed the resident on the unaffected side of the mouth.

  • Allow the resident with dysphagia plenty of time to chew and swallow.
  • Be sure that the dysphagic resident swallows food each time it is offered and before continuing with the feeding.
  • Use thickener with fluids as ordered when feeding the dysphagic resident.

EXAM ALERT

Focus topic: Specialized Care

Keep the dysphagic resident upright for at least 30 minutes after feeding.

  • Perform passive range of motion to all affected extremities.
  • Assist the resident in bowel and bladder retraining.
  • Dress and undress the resident’s affected side first.

EXAM ALERT

Focus topic: Specialized Care

If assisting the stroke patient with hemiplegia to walk with a cane, use the cane on the affected side. When transferring the paraplegic from bed to wheel chair, lock the wheels on the bed as well as the wheel chair. Keep the bed of the paralyzed resident in its lowest position with wheels locked.

  • Report any change in the resident’s condition.
  • In all situations requiring your assistance to move a resident, use proper body mechanics: Keep the spine straight, bend your knees, lift with your legs (not your back), and seek assistance as necessary to protect you and the resident.

Specialized Care: Digestive and Elimination Problems

Focus topic: Specialized Care

Diseases or conditions involving the digestive and urinary system can cause malnutrition (inadequate intake and use of foods), elimination difficulties, and complications due to infections, cancer, or organ failure.

Infections

Focus topic: Specialized Care

Severe infections of the digestive organs include gall bladder disease (cholecystitis), pancreatitis (inflammation or infection of the pancreas), and hepatitis (liver infection) or nephritis, (kidney disease). Common symptoms include severe pain, nausea, vomiting, fever, diarrhea or constipation, dysuria or a yellowish color to the skin (jaundice), and life-threatening chemical imbalances. Residents recovering from infections might be kept NPO, meaning they can have no foods or fluids by mouth. The resident will receive fluids, nutrients, antibiotics, and other medications through an IV (within the vein), or intravenous access device. IV therapy provides direct access to the bloodstream through an IV catheter and tubing attached to a sterile bag of fluids; the solution is connected to a pump that controls the amount of fluid delivered. A sterile dressing covers the IV catheter insertion site and must be maintained according to facility procedure. The tasks of starting, adjusting, and discontinuing IV therapy are reserved for the licensed nurse. You can support the resident receiving IV therapy by being careful to not pull on the IV catheter, kink the IV tubing, or interrupt the IV flow.

CAUTION:

Do not place the solution below the IV site.

Change the resident’s gown or clothing carefully to maintain the IV connection. Report any signs of infection, swelling at the IV site, or activation of IV pump alarms to the nurse immediately.

Cancers in the Digestive and Urinary Tract

Focus topic: Specialized Care

Cancerous growths, or tumors, can interfere with normal food intake, nutrient use, and elimination of digestive wastes, putting pressure on or within the digestive organs that interferes with normal digestion and circulation. As cancer cells grow, they rob normal cells of nutrients and interfere with normal cell activity. Cancer cells can travel through the body from an original invasion site to a distant organ (metastasis), resulting in further damage and, eventually, death. Common sites for metastasis are the brain, bone, and liver.

Residents recovering from surgery to remove a cancerous tumor in the GI tract, bladder, or kidney who cannot swallow or take foods or fluids by mouth (PO) might require tube feedings or total parenteral nutrition (TPN). A small tube inserted into the stomach through the nose (nasogastric tube or feeding tube) provides short-term nutrition during the healing process. If needed for an extended period, a gastrostomy tube (G tube) is inserted directly into the stomach through a stoma (a surgical opening in the abdomen). A pump attached to the feeding tube delivers the prescribed amount of food and fluid over time. For safety considerations, an alarm will sound to signal a pump problem. Residents receiving their total diet through a feeding tube are often NPO, or can have no food of fluids by mouth. Be careful to observe this order. It is also important to protect the skin and mucous membranes around the nose or the stoma because they can become irritated. Provide oral care at least every two hours or more, raise the head of the bed at least 35 degrees, and keep the call light in easy reach. Remember to keep the skin around the G tube clean and report any sign of skin breakdown or abdominal discomfort.

Residents recovering from surgery to remove cancer from the bladder, small intestine, or colon (large intestine that holds solid wastes) might also have a temporary or permanent ostomy, or surgical diversion to aid in elimination. Diversion means that, in the case of bladder cancer, an artificial appliance is attached to a stoma in the abdomen to provide an alternative path to expel urine. If a portion of the large intestine is removed, an appliance is attached to an abdominal stoma to collect feces/stool (colostomy). The resident will need ostomy care training and emotional support to adjust to dramatic changes in urine and bowel elimination that affect body image, especially if the ostomy is permanent.

Chronic Diseases

Focus topic: Specialized Care

Chronic liver disease such as cirrhosis (scarring of the liver) causes a buildup of toxic wastes in the body due to failure of the liver to handle the chemicals released by metabolism. The liver might eventually fail, which causes lethal consequences in other body systems, including hemorrhage from ruptured veins in the esophagus. Treatment for digestive disorders might include dietary restrictions, medications, chemotherapy, or surgery.

Chronic kidney disease, often linked to type I diabetes, affects all body systems and can result in kidney failure. The resident with kidney failure is at increased risk of life-threatening complications such as congestive heart failure and severe generalized infection, because the kidneys are not able to filter toxins from the body or control fluid and electrolyte absorption. Specialized care of residents with chronic diseases or those recovering from surgery includes.

  • Observing, recording, and reporting vital signs, and pain tolerance
  • Observing, recording, and reporting any changes in the surgical site
  • Strictly adhering to the diet order, including fluid restrictions
  • Keeping feeding tubes free of kinks
  • Prompt reporting of vomiting, diarrhea, constipation, or skin color changes
  • Observing, recording, and reporting of emesis (vomit) or abnormal stools or urine, especially color, consistency, or odor
  • Using standard precautions when handling bodily fluids
  • Prompt emptying and care of stoma appliances
  • Observing, recording, and reporting I & O
  • Observing and reporting any behavior changes

CAUTION:

Provide careful skin care, especially around stomas.

  • Providing frequent oral care
  • Providing comfort measures to help relieve pain and promote rest (position changes, diversion activities, quiet environment, and so on)
  • Removing noxious odors
  • Providing emotional support

Diabetes

Focus topic: Specialized Care

Diabetes mellitus, a disease of the endocrine system, is listed separately because it affects metabolism, impacts every system of the body, and is becoming an epidemic among Americans. Diabetes mellitus is a disease of the pancreas in which the body cannot use carbohydrates (sugars and starches) efficiently. The pancreas cannot produce enough insulin or does not use insulin properly to change carbohydrates to energy. When this occurs, the body burns fats for energy instead, leading to a dangerous imbalance in ketones, the product of fat breakdown.

The exact cause of diabetes is unknown but several factors such as age, obesity, and family history can contribute to developing diabetes. Residents with type 1 diabetes must take insulin to live; those with type 2 diabetes can control their disease with diet and medication. Both types of diabetes require a careful diet that contains the right amount of proteins, fats, and carbohydrates to maintain adequate nutrition and systems functioning. Signs and symptoms of diabetes include excessive thirst, excessive hunger, excessive urination (polyuria), weight loss, night sweats, and irritability.

Despite treatment, diabetes can cause blindness, cardiovascular disease, kidney failure, leg ulcers, and nerve damage. Poor circulation due to diabetes can lead to amputation of the leg. Death can result from a diabetic coma, caused by extreme blood sugar (glucose) levels such as hyperglycemia (abnormally high amounts of glucose in the blood) or by dangerously low blood sugar, called hypoglycemia.

Specialized Care

Strict adherence to the diabetic diet is essential to meet caloric needs and control blood glucose levels.

NOTE:

Snacks are part of the diet because they are important to maintain a steady supply of glucose to prevent hypoglycemia.

Diabetic residents might have trouble following a restricted diet, eating foods not prescribed, or overeating. Family members or others might supply snacks or forbidden foods, making compliance a challenge for the nursing staff. You must praise and support the efforts of the diabetic resident as well as educating and supporting family members to follow the care plan to promote health and prevent complications. Careful monitoring of food consumption is important to keep the resident safe. Tell the nurse if the resident does not finish the food served during a meal or refuses snacks.

Special care of the diabetic resident includes

  • Inspecting the resident’s skin daily, paying attention to the feet for decreased sensation or pain (indicates nerve damage), redness, or a skin break (sign of tissue damage due to poor circulation)
  • Keeping the skin and feet clean, dry, and moist; do not apply moisturizing lotion between the toes

EXAM ALERT

Focus topic: Specialized Care

Follow facility policies regarding nail trim for diabetic residents. If allowed, carefully trim toenails to avoid accidental cuts; never remove corns or calluses.

  • Avoiding pressure on the feet or toes by tight shoes, socks, or bed linens
  • Serving meals and snacks on time
  • Encouraging the resident to follow the care plan
  • Observing and reporting any changes in condition immediately
  • Protecting the resident from thermal injury due to extreme water temperature (diabetic clients often have reduced sensation to temperature caused by nerve damage in the extremities, known as diabetic neuropathy)
  • Including the resident in all aspects of care to promote independence, self-esteem, and compliance with the care plan
  • If allowed by state law for your level of practice, monitoring blood sugars as ordered; promptly reporting excessively high or low blood sugar levels to the nurse
  • Assisting the resident to manage stressful situations because increased stress causes a rise in blood sugar levels

Specialized Care: HIV (Human Immunodeficiency Virus) and AIDS (Acquired Immunodeficiency Syndrome)

Focus topic: Specialized Care

Residents with HIV have been attacked by a virus, which robs them of the ability to fight infections. This viral invasion makes them targets for serious illnesses or cancer. Once infected, the HIV is always present. HIV can be transmitted by infected persons who share IV drug needles or have sexual contact. Although transmission of the virus is not spread by casual contact (for example, touching, caressing, sneezing or coughing, and so on), caregivers need to use standard precautions to protect themselves when handling the blood or body fluids of the HIV-infected resident, most particularly, to avoid a needle stick or sharps injury. Residents with HIV might develop AIDS, a progressive weakening in the HIV resident, which can occur many years after contracting the virus.

AIDS exposes the resident to opportunistic diseases, illnesses that take advantage of the resident’s weakened immune system. Although there is no cure for HIV/AIDS, residents receive treatment to combat infections, relieve respiratory distress, weakness, and fatigue, decrease pain and discomfort, and promote nutrition. Although medications and treatments are prolonging the life of AIDS residents, the drugs given to treat AIDS have serious side effects such as nausea, vomiting, and diarrhea.

The ravaging effects of drug treatment can discourage residents; they need emotional support to help them comply with the medical care plan. Counseling services can help these residents deal with the lack of information about the disease, accept the realities of AIDS, and restore hope. Listening to the resident and being empathetic, caring, and nonjudgmental are essential approaches you must take when caring for these residents. Support of family members, friends, or support groups can also help improve the quality of life for the AIDS resident.

Specialized Care: Psychological Problems

Focus topic: Specialized Care

Psychological problems, meaning those conditions affecting thought, mood, and behavior, can be as threatening to the health and well-being of residents as physical illnesses. This section reviews those conditions placing the resident at highest risk for psychological distress and, sometimes, physical danger.

Specialized Care: Confusion

Focus topic: Specialized Care

Residents might become confused for physical or psychological reasons. Any disease or condition that causes hypoxia can lead to confusion. Drug interactions and side effects, hearing difficulty, and reasoning problems might also contribute to confusion. Other causes can include stress and grief, changing routines or living arrangements, hospitalization, and language or cultural factors. Confused residents often tell the same story repeatedly; they live in the past because it is a more familiar time for them and continually repeat the same task such as buttoning their clothes and pacing. They might become frightened and resist care and involvement in activities.

Confused residents might become suspicious of facility staff, accusing them of stealing from them or trying to hurt them or to keep them from leaving the facility. Residents might also experience Sundowner’s Syndrome, which means increased confusion or disorientation in the afternoon or evening hours. Confused residents who are ambulatory might wander from the facility and injure themselves or become lost. If confined to the bed or wheel chair, they might try to get up and risk falling or injuring themselves.

It is important to remind the confused resident of who they are, where they are, and the current date and time. This is part of reality orientation. Keeping calendars, clocks, and bulletin boards current can support reality for the resident. Sharing current events with the resident can also help. Being acutely aware of environmental hazards that might harm the confused resident and taking every precaution to protect the resident is a priority.

Specialized Care: Aggressive Residents

Focus topic: Specialized Care

Confused residents who become defensive, aggressive, or combative need your calm demeanor and understanding so that you can find out what is causing the resident’s behavior. Do not argue with the resident or return his or her aggression. To diffuse the aggressive behavior, leave the situation if you can and return later. Sit down or, if you must stand, turn your body slightly away from the resident with your arms at your side and your hands open; maintain eye contact with the resident. This open stance also enables you to quickly move out of reach of the resident. Keep your voice calm, supportive, and nonthreatening. Using clear, simple language, attempt to “talk them down.” Listen carefully to the resident, letting them know that you are paying attention to what they are telling you and acknowledge their feelings.

Allow the resident to make as many choices as possible to resolve issues, to “save face” and provide them with an opportunity to regain self-control. Watch for signs of increased aggression such as jaw or fist clenching, pacing, crying, or yelling. If the resident becomes violent toward you or others, protect them as well as yourself from harm. Special training is often needed to safely restrain the combative resident. Never hit, push, pull, or otherwise retaliate against a resident, despite the provocation; this is considered assault.

Specialized Care: Dementias

Focus topic: Specialized Care

Dementia is an irreversible, progressive loss of mental function as evidenced by the loss of memory, ability to make judgments, ability to comprehend/understand and learn, ability to carry out tasks or to use language. Residents with dementia lose their ability to socialize, maintain an occupation, or think abstractly or rationally. They become disoriented, meaning they are confused as to who they are, or cannot recall the current date or time. In later stages of the disorder, residents with dementia become agitated, depressed, and suspicious of others (paranoid). They are frightened and frustrated because they try to adjust to their changing world. Dementia is not a part of aging but, when it occurs, it can be devastating to the resident and family, especially when the resident appears healthy but cannot function normally. In the advanced stage, residents become totally incapacitated and can die from complications of immobility.

Dementia can take many forms but the most common is that associated with Alzheimer’s disease, an increasing population within the long-term care setting. Alzheimer’s disease is the most common type of irreversible dementia in persons over age 65, affecting men and women alike. Alzheimer’s disease progresses in stages eventually destroying all mental and physical abilities. In the Alzheimer’s resident, confusion results from the resident’s decreased cognitive ability, contributing to a lowered ability to manage stress; the resident becomes easily agitated or frustrated and might experience depression when the resident realizes his or her condition is getting worse.

They experience learning difficulties, cannot complete complex tasks, and have trouble concentrating. They get very upset, cry, or become combative with any change in their normal routine or overstimulating events. As the disease progresses, symptoms worsen and losses become more severe, making ADLs, speaking, and activity more difficult. Residents might see or hear things that are not present (hallucinations), think irrationally (delusions), or become suspicious (paranoid). They might wander and lose interest in eating. Anorexia, or loss of appetite, can lead to nutritional deficiencies. Wandering and getting lost can put them in grave physical danger because they are not afraid of road traffic or other environmental hazards. During the late stages of the disease, Alzheimer’s residents no longer recognize others and cannot communicate.

NOTE:

Family members need support to deal with this loss of recognition by their loved one, which causes them severe psychological pain, sometimes referred to as “the long goodbye.”

Eventually, Alzheimer’s residents lose their swallowing reflex, become incontinent, lapse into a coma, and die.

Special care of residents with dementia includes

  • Protecting the resident from accidents and injuries
  • Providing a reassuring environment (controlling noise, loud television, radios, and conversation)
  • Keeping the environment clean and uncluttered
  • Using siderails and other assistive devices per facility protocol to protect resident from wandering
  • Maintaining routines to avoid confusion and over stimulation
  • Allowing the resident time to complete tasks and make simple decisions
  • Avoiding disagreements with the resident
  • Gently touching and reassuring the resident who is suspicious; offering simple explanations
  • Reorienting and using distraction for agitated or wandering residents
  • Arranging evening activities to prevent Sundowner’s Syndrome
  • Providing emotional support to family and friends
  • Referring family and friends to the nurse for more information on the resident’s progress

Recent advances in pharmaceutical research have made medical treatment of Alzheimer’s disease more promising.

Specialized Care: The Depressed Resident

Focus topic: Specialized Care

Depression is listed here as a mood disorder that interferes with normal activity of the resident and is either short-term or chronic in nature. Symptoms of depression include insomnia or excessive sleeping, extreme sadness, crying, fatigue, poor hygiene and grooming, changes in appetite and weight, withdrawing from social activities, and feelings of worthlessness and hopelessness. Losing loved ones, a spouse, friends, and pets and dealing with chronic or terminal illness can be very stressful for residents, leaving them to mourn, or grieve for the loss of loved ones, declining health, or a past lifestyle. These feelings and reactions are part of the grief process, which occurs in stages necessary for adjusting to a loss. They might enter a stage of denial, and then become angry and depressed. They experience other grief stages that include a physical bargaining stage, in which a resident might make a promise to self or to God that, if the situation could change, they would do or feel something different to change their life. In the acceptance stage, the grieving resident finds peace in accepting the loss and can move on. Not all residents resolve their grief and might go back and forth between the five grief stages. Those who can find acceptance can regain hope and find joy in their lives.

Residents might also regret their loss of independence, their reliance on others, and changes in their primary role as spouse, homemaker, or wage earner. Their new role of widow or widower might be very difficult to assume as well. Chronic health problems and infirmity can further increase their loss of self-esteem as well as worries about their declining health and the prospect of dying. Further, residents might resent being placed in a long-term care facility, acting out their frustration on others, especially family members responsible for the placement decision. Severe depression can lead to serious illness, disability, and suicide. Watch for statements such as “I might as well be dead,” “I’m not good for anything,” or “Everybody would be better off without me.”

CAUTION:

Although you must keep confidential what the depressed resident shares, report immediately any statement that might signal suicidal ideation, or thoughts of committing suicide. Likewise, you cannot promise the resident that you will not tell others because doing so would put the resident at risk for harm.

Special care of the depressed resident includes

  • Encouraging the resident to express feelings
  • Being empathetic
  • Encouraging self-care, decision making, and independence
  • Assisting the resident to meet personal care needs (including grooming, eating, and toileting)
  • Encouraging activity to help improve mood
  • Observing warning signs of potential suicide (talking about killing self, describing method and timeline, and giving away belongings)
  • Observing and removing potential hazards in the environment to protect the resident from harming self (including razors, other sharps, cords, and so on)
  • Being realistic with reassurances; avoiding making statements like “Everything’s going to be alright”
  • Avoiding judgmental statements like, “You shouldn’t be depressed”
  • Encouraging physical activity and socialization to help improve mood
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Specialized Care: The Terminally Ill Resident

Focus topic: Specialized Care

Coming to grips with one’s own mortality is a term describing the need to realize that everyone’s life is finite, or has a timeline. A normal developmental task of elders is to leave a legacy they can be proud of and to be prepared to face death with as much dignity as possible. For that purpose, the resident might have an advance directive such as a living will, power of attorney for health care, or a health-care surrogate, which act as legally binding documents outlining allowances and restrictions for treatment and care should they become terminally ill (near death) and unable to make decisions for their own care. In such cases, the resident authorizes another person to carry out his or her expressed wishes. The resident’s right to make end-of-life decisions is protected by law in the Patient Self-Determination Act, which gives patients the right to refuse medical or surgical treatment and the right to prepare legally binding advance directives for such purpose.

End-of-life issues can become controversial, especially if family members or loved ones disagree with the resident’s wishes. If the resident does not want to be resuscitated in case of respiratory or cardiac arrest, the doctor will write an order for do not resuscitate, or DNR. It is important to carry out the order. Current research and development to prolong life are legal/ethical issues debated in the legislature as well as the court system. A controversial practice, euthanasia (mercy killing) is legal in Oregon as a means to end suffering and promote dignity of terminally ill persons.

Terminally ill residents might receive hospice care, specialized treatment by a team of doctors, nurses, therapists, chaplains, and volunteers who provide pain relief, comfort measures (also called palliative care), emotional and psychological support, and grief counseling for families as well as respite (relief) care for caregivers. Terminally ill residents have a right to the same level of care and comfort as other residents. They deserve to be informed of their condition and to be included in all aspects of their care as much as possible. Often, nursing staff and family ignore the dying resident, “talking over him or her” as though the resident were not present or excluding him or her from conversation. Terminally ill residents must be treated holistically (as a completely human being), meaning they deserve to receive optimal physical, psychological, and spiritual support. Physical needs include personal care, comfort measures, pain relief, food, fluids, and ADLs as tolerated. Keeping the resident comfortable is of utmost importance. Many residents might appear depressed and consider suicide when, in fact, they are experiencing intense pain. Do not ignore their reports of pain and observe closely for other signs of discomfort,especially for residents whose culture does not allow them to complain.

Providing comfort measures, listening to the dying resident, and spending time with him or her are essential in helping to allay fears, which arise more often from not being able to manage pain rather than fear of dying. Perform personal care to promote rest and prevent discomfort or fatigue. Tailor your care to the needs of the dying resident, offering food or fluids, skin and oral care, and assisting with toileting as much as his or her condition will permit. The dying resident receiving strong pain killers (analgesics), especially narcotics, might experience constipation; report bowel changes or abdominal discomfort immediately to prevent further complications. Analgesics can also cause confusion, putting the resident at risk for falls. Monitor the resident carefully for any change in alertness that might indicate confusion.

Because talking about death is uncomfortable, caregivers or family members and friends might avoid talking about it and, due to their own fears, might avoid spending time with the dying resident. It is equally important for you to confront your own thoughts and attitudes about dying in order to be effective when caring for the terminally ill resident. If the resident wants to talk about death, listen carefully and respond openly, honestly, and with compassion.

NOTE:

Remember that there are no correct answers to many questions about dying; admitting that you do not have an answer to a question is reassuring in its honesty.

Often, the resident is not looking for answers but needs someone to listen. Along with fear of pain is the resident’s common fear of dying alone. Although it might be easier to avoid the resident, staying with him or her to provide emotional support is a form of “being in the moment” and “giving of yourself,” the most meaningful care you can provide.

Signs of impending death for terminally ill residents include rapid, irregular and shallow respirations, followed by decreased respirations and periods of apnea (Cheyne-Stokes respirations). Other signs of impending death include decreased blood pressure; increased, weak pulse; cyanotic lips, nail beds, hands, and feet; ashen, cold skin; loss of gag reflex; and decreased body functions and awareness, which progresses to unconsciousness or coma. Death occurs when the vital signs are absent. You must report these changes immediately to the nurse, staying with the deceased resident until the nurse arrives. When family members or friends visit the resident, respect their need for privacy but offer your condolences and assistance. Other residents might need support to adjust to the loss. Roommates are especially affected. Be honest and open with them but be careful to maintain confidentiality regarding details of the resident’s death.

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