Respiratory N172- Monitor/Manage/Teach
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These chemoreceptors are found in the medulla and respond to changes in hydrogen ion concentration.
These chemoreceptors are found in the carotid and aortic bodies and respond to decreases in:
and increases in PaCO2
What do Central chemoreceptors stimulate?
Increase in respiratory rate
What do Peripheral chemoreceptors stimulate?
the respiratory center
What does a PFT do?
it identifies if a person has an obstructive or restrictive defect with their lungs
What does an increase in airway resistance indicate?
- Obstructive defect
- COPD-hypersecretions, mucous
What does a limitation in chest expansion indicate?
- Restrictive Defect
- Asthma-narrowing of airway
What do you tell a patient about prior to a PFT?
Don't smoke 6-8 hrs before, and don't use your inhaler 4-6 hours before
What PFT tells the amount of air that can ben quickly and forcefully exhaled after maximum inspiration?
- Forced vital capacity
What PFT tells the amount of air exhaled in the first second of Forced Vital Capacity?
- Forced Expiratory volume in first second of expiration
What does the result of the FEV1 test tell you?
it grades the severity of a persons airway obstruction
What PFT will you use to differentiate a Obstructive from Restrictive defect?
What PFT will you perform when you want to monitor a persons bronchoconstriction with asthma?
- Peak Expiratory Flow Rate
Maximum airflow rate during forced expiration
When performing a PA for respiratory what do you inspect?
- Respiratory rate, rhythm, quality, IE Ratio
- Skin color
- Shape of chest
Where do you start auscultation of the lungs?
What if they tire easily?
Start at the apex....side to side and moving down.
Start at bases....or divide it up and have breaks in between
What changes does COPD cause in a persons thoracic cavity?
Barrel chest from an in crease AP diameter related to chronic air trapping
Ratio for normal inspiration : Expiration
1 : 3
Inspiration : Expiration ratios for a person with:
Asthma....1:3 or 1:4....prolonged expiration
COPD.....1 : 5
Describe the normal sound heard over the lungs during percussion
Describe the sound heard over hyper-inflated lungs when performing percussion, like when a person has COPD and acute asthma when
Hyperresonance.....Loud, low pitched
Describe the sound heard over a gas filled stomach or intestine or pneumothorax when doing percussion
Describe the noise you will hear when doing percussion over lungs with pneumonia
3 Normal types/places of breath sounds and their ratios
- Bronchovesicular 1:1
- Bronchial 2:3
- Vesicular 3:1
Where do you hear Vesicular breath sounds and describe them.
Heard over most lung fields...they are soft, low pitched and rustling sound
Where do you hear Bronchovesicular breath sounds and describe them.
Heard over the main bronchi...and they are loud and high pitched. Sound like air blowing through a hollow pipe.
Where do you hear Bronchial breath sounds and describe them.
Over the trachea....and they are loud and high pitched. Sound like air blowing through a pipe.
What do you use "Egophony" to diagnose?
How do you do it?
- Pneumonia and Pleural Effusion
- While listening over the thorax, have the patient repeat the letter "e". If it is heard as an "a", then they are positive for one of the above.
What does "Whispered Pectoriloquy" diagnose and how do you do it?
- Lung consolidation....Cancer (solid) and Pneumonia (fluid)
- Have the patient whisper "1,2,3"...if it is heard through the stethoscope clearly/distinctly....then they have one of the two.
Describe fine crackles...and what it means.
High pitched sound heard before the end of inspiration (collapsed alveoli snap open).
- Early Pulmonary Edema
- Early CHF
(Roll finger in hair by ears)
Describe Coarse Crackles...and what does it mean.
Series of long-duration, discontinuous low pitched sounds caused by air passing thru occluded mucous.
- Severe Congestion
- Heart Failure
- Pulmonary Edema
Describe Rhonchi...and what does it mean.
Continuous rumbling, snoring or rattling from obstruction of large airways with secretions. Most prominent during expiration.
- Cystic Fibrosis
Describe wheezes and what does it mean.
High pitched squeak....first evident on expiration, but then evident on inspiration as obstruction increases. Possibly audible without stethoscope.
- Asthma (Bronchospasm)
- Airway Obstruction
Describe Stridor and what does it mean.
Continuous musical sound as a result of a partial obstruction of the larynx or trachea.
- Vocal Cord edema after extubation
- Foreign body
What do absent breath sounds mean?
- Pleural Effusion
- Large atelectasis
Describe Pleural Friction Rib...and what does it mean.
Creaking or grating sound
- Pulmonary Infarct
Normal Lab Values for ABG's
- pH 7.35-7.45
- PaO2 80-100 mmHg
- SaO2 >95%
- PaCO2 48-32 mmHg
- HCO3 22-26
Acid vs. Base
Acid-low pH but high CO2 (hydrogen ions) (acidosis)
Base-high pH low CO2 (hydrogen ions) (alkalosis)
(hydrogen = acid)
When we are in compensation for Respiratory Acidosis, what's the faulty system and what compensates? Respiratory Alkalosis?
- Metabolic Alkalosis
- Metabolic Acidosis
Describe compensation by Metabolic Alkalosis and Metabolic Acidosis.
Describe compensation by Respiratory Acidosis and Respiratory Alkalosis.
When we are in compensation for Metabolic Acidosis, what's the faulty system and what compensates?
- Respiratory Alkalosis
- Respiratory Acidosis
How do I treat a person who is in Respiratory Acidosis? Respiratory Alkalosis?
Increase their ventilation
Decrease their ventilation
How do I treat a person in Metabolic Acidosis? Metabolic Alkalosis?
Treat the problem and/or administer Sodium Bicarbonate (NaHCO3)
Treat the problem, administer acid and/or dialysis
Etiology of Respiratory Acidosis
- Pulmonary Edema
- Overdose (respiratory ctr depression)
Symptoms of Respiratory Acidosis
- Decreased mental status
- Headache, weak, tremors
Treatment for Respiratory Acidosis
- Aerosol Therapy/Suctioning
- Pain Meds
Artificial Airways/Mechanical Ventilation
Etiology for Respiratory Alkalosis
Hyperventilation due to anxiety, pain, fever or Pulmonary Embolism
- Mechanical Hyperventilation
Treatment for Respiratory Alkalosis
- Sedation/Pain Meds
- Rebreathe CO2 (paper bag)
- Reduce ventilator settings to decrease RR
Etiology of Metabolic Acidosis
- Low Base
- Diarrhea, Renal Failure, Fistula, Pancreatic Drainage
- Increased Acid
- Alicylate OD
Treatment for Metabolic Acidosis
- TREAT THE UNDERLYING CAUSE!!!
- Monitor I&O and electrolytes
- Correlate I&O with weight, VS, skin color, turgor and temp
- Prevent Infection
- Monitor arrhythmias
- Protect from injury (seizures)
- Monitor ABG's
- In sever cases NaHCO3 may be ordered
Etiology of Metabolic Alkalosis
- Increased Base
- NaHCO3 administration
- Ingestion of Antacids (alkaloids)
- Decreased Acids
- N/G tube suctioning
- Electrolyte Imbalance
Symptoms of Respiratory Alkalosis
- Increased Respiratory Rate
- Paresthesias (tingly)
Symptoms of Metabolic Acidosis
- Decreased Mental Status
Symptoms of Metabolic Alkalosis
- Hand Tremor
- Light headedness
- muscle twitch
Treatment for Metabolic Alkalosis
- TREAT THE UNDERLYING CAUSE
- Monitor VS and electrolytes
- Monitor I&O
- Protect pt from injury
- Admin Acid (Ammonium chloride)
- Increase HCO3 excretion with Diamox
- In sever cases dialysis may be ordered
What drug will increase the excretion of HCO3 when a person is in Metabolic Alkalosis?
When a person has COPD what will their ABG's looks like, how will the body compensate (2 ways)
- Low pH <7.35
- High PaCO2 > 48
- High HCO3 >26
- Compensated Respiratory Acidosis
- Kidneys have kicked in to hold in or conserve HCO3 to help increase the pH back to a normal range
What does a V/Q scan look for?
Assesses perfusion of the lung...or lack there of when a person has a pulmonary embolism
minimal nursing intervention cuz it's like an x-ray
What does a Bronchoscopy do?
It is used for diagnosis or treatment by a lighted scope being passed in to the bronchial tree.
- NPO 6-12 hrs prior to test, and swallow eval done after test prior to food/fluids
- HOB 30 degrees
- Teach pt. may have a little blood, and a scratchy throat after
Isotonic Solutions do what?
Increases plasma volume.
Since this solution doesn't cause a fluid shift in to other compartments, watch for HEMODILUTION (decrease in Hgb, Hct and Electrolytes)
Hypotonic Solutions do what?
They hydrate cells interstitial compartment...CELLS SWELL AND VESSELS Shrink
It pulls fluid from the intravascular space to intracellular space. Watch for HYPOTENSION, CEll and BRAIN EDEMA and DEATH
Hypertonic Solutions do what?
They hydrate and replace electrolytes. Pulls ECF from interstitial space to intravascular space
CELLS SHRINK and VESSELS SWELL. Watch for Circulatory overload, irritation of vein walls and CELL DEHYDRATION
What is a Thoracentesis used to do?
What are my nursing interventions?
Removal of specimen for diagnosis, removal of pleural fluid or to instill medication
Monitor pulse, color O2 saturation during procedure
Apply dressing over the puncture site and position pt on unaffected side for 1 hr after.
Recheck vital signs regularly after.
What sort of respiratory condition will a person be in when they are experiencing an asthma attack?
Respiratory Alkalosis initially....then Respiratory Acidosis.
What is an asthma attack?
Inflammation of the bronchials resulting in airflow obstruction caused by the inflammatory cascade.
What's important to know about a person who has had an acute asthma attack?
They are susceptible to another one for the next 4-10 hours that can be more severe and last longer
Signs and Symptoms of an asthma attack
- Wheezing and Coughing...but not a good predictor of severity of their attack
- Tight Chest
- Prolonged Expiration
- Use of Accessory Muscles
- Increased RR
- Severe Anxiety
- Silent chest
Signs of Hypoxemia
- Inappropriate Behavior
- Increased pulse and BP
When percussing a person during an asthma attack what will I hear?
A person with Emphysema will be in Respiratory_____________ . Compensated with ________________.
What is Chronic Bronchitis?
When a person has a chronic productive cough for 3 months in each of 2 consecutive hears.
It is an inflammation of the Bronchi and Bronchioles due to chronic exposure to irritants
2 Types of COPD
Chronic Bronchitis and Emphysema
What is Emphysema?
When a person has a loss of lung elasticity and hyperinflation of lung tissue. It causes destruction of the alveoli leading to decreased surface are for gas exchange, carbon dioxide retention.
How do you get COPD?
Continued exposure to noxious particles causing an inflammation of the airways, hyperplasia of cells and increased production of mucous.
What does hyperplasia of cells cause in a person with COPD?
It reduces the diameter of their airway and increases the difficulty in clearing secretions.
Signs and symptoms of COPD
- Dyspnea upon exertion
- Productive cough....mostly in the AM
- Rapid/Shallow Respirations
- Barrel Chest
- Thing Extremities
- Pallor and Cyanosis
- Decreased O2 Saturations
When percussing a person with COPD what will I hear?
Hyper-Resonance due to trapped air
People with COPD get this....right sided heart failure
When a person is in the late stages of COPD they will look like this....
Super thin with enlarged neck muscles
Nursing Interventions for a person with COPD
- QUIT SMOKING!!!
- Drug Therapy
- O2 Therapy
- Airway Clearance Techniques
- Breathing Retraining
- Weight Management
- Good Fluid Intake
What are Airway Clearance Techniques?
- Teach Huff Coughing (Forced Expiratory Cough)
- Chest Physiotherapy
Examples of Breathing Retraining
- Pursed Lip Breathing...prolongs exhalation and slows RR
- Diaphragmatic Breathing....use of diaphragm and not accessory muscles
What's the problem with weight and the person with COPD?
They are underweight and this correlates to a poor prognosis. Teach how to make eating less exhausting.
Why increase fluids on a person with COPD?
Cuz of the mucous accumulation...but not good if they have CHF or Renal failure too!!
When you inspect a person with COPD what are you looking at?
- Respiratory Rate, rhythm, quality and IE Ratio
- Skin Color
- Shape of Chest
- Use of Accessory Muscles?
What is the minimum O2 saturation level for a person with COPD?
When Auscultating a persons lungs with COPD what strategies do I use?
If the patient tires easily start at the bases...or separate your listening with breaks in between
What is postural drainage?
A positioning technique that drains secretions from specific segments of the lung and bronchi into the trachea.
- Put in different positions for 5 min each.
- Do 1 hr before meals or 3 hours after
- Side lying position if pt cant tolerate a head down position
- Use aerosolized bronchidilators and hydration therapy prior to procedure
- Do 2-4 times a day
- Loss of weight
- Muscle Atrophy
- Loss of appetite
When should a person drink if they have COPD?
How do you evaluate a person with asthma?
- Is the client able to.....
- maintain adequate gas exchange
- prevent acute attacks
- have relief of symptoms
- adhere to the medication regime
How do you evaluate a person with COPD?
- Is the client able to.....
- maintain adequate gas exchange
- be able to keep a patent airway
- remain free from infection
- maintain a healthy weight
What's the Gold standard for care of a patient with COPD?
- Prevention of disease progression
- Relieve symptoms and improve exercise tolerance
- Prevent and treat complications
- Promote patient participation in care
- Prevent and treat exacerbations
- Improve quality of life and reduce mortality risk
Why are the lungs a common site for both primary and secondary lung cancer?
Venous return and lympathics bring tumor cells from distant sites in the body to the heart and pulmonary circulation which provides a hospitable environment for the tumor cell
Assess for the risk of lung cancer is divided in to 3 categories
- Non smokers, but former smokers
- True non smokers
10 years following cessation of smoking, lung cancer mortality is reduced...
How do cigarettes cause cancer?
The carcinogens inhaled are a lower airway irritant that changes bronchial epithelium
Gender differences of lung cancer....
- Higher incidence in men
- More men die
BUT....women smokers have a higher risk of developing LC than male smokers
What lobes of the lungs does the cancer prefer?
What is detected before the actual cancer in the lung?
SCLC occurs in people who....
are smokers or have been exposed to environmental carcinogens.
First sign of SCLC? Prognosis
Less than 2 years to live. Metastasizes early and grows FAST
Staging of SCLC
Limited...tumor is confined to the chest and regional lymph nodes
Extensive....cancer has extended to the chest wall or to other parts of the body.
If you have Extensive SCLC what is your estimated life span?
Whats the cancer most common in people who haven't smoked?
NSCLC....most common in women
How does somebody know that they have NSCLC?
something else starts to bother them....cuz there are no clinical manifestations till it is widespread/metastasized
Get a chest x ray for something else and see masses
Once the lung cancer has spread....what will a person see that may alert them to something is wrong?
- Persistent cough with sputum
- Blood tinged Sputum
- Chest pain
Late manifestations of lung cancer....
- anorexia/weight loss
- SVC Syndrome
- Palpable Lymph nodes in the neck
Heart conditions from late manifestations of lung cancer...
- Cardiac Tamponade
Where does lung cancer usually metastasize to?
- long bones
Collaborative management of a lung cancer patient?
- ID risk factors and appropriate referrals for screening
- Promote smoking cessation and healthy living
- Nursing care related to chemo, targeted therapy, radiation and surgery
General nursing care for patient with lung cancer
- Provide support and reassurance
- Care of the patient
- Management of disease symptoms and side effects of treatments
- Assess smoking cessation readiness
- Patient teaching on pain management
- Coping strategies
What is the treatment of choice for people with Stage I and II NSCLC?
What are factors that effect survival for cancer?
the size of the primary tumor and co morbidities
removal of entire lung
removal of one or more lobes of the lung
Removal of large portion of a lobe
removal of a small portion of a lobe
removal of entire lobe and part of the bronchus
Surgery is very rare for the patient with SCLC...in what case would you do surgery?
when a patient has a solitary pulmonary nodule without metastases or regional lymph node involvement
Preoperative care for lung cancer
- What to expect post op ....
- Pain meds
How do you stage NSCLC?
TNM staging system
- T=tumor size, location and degree of invasion
- N=regional lymph NODE involvement
- M=presence or absence of distant metastases
TNM for NSCLC assists with designation of....
estimating disease progression and appropriate treatment
When a person has a chest tube put in after surgery what is important?
- XRAY to confirm placement
- Note drainage
- Palpate for Crepitus
- Pain Management
What are the potentials for complications after lung surgery?
- VTE (Venous Thrombeo Embolism)
- Pulmonary Edema
- Cardiac Dysrhythmias
- Hypovolemic shock
What's a Hemothorax?
Accumulation of blood in the pleural space
Blood tinged sputum
How do you manage pain for a person after surgery?
If they have a PCA you can look at how many times they push the button in an hour, if it is excessive ask them how this approach is working. May need to change it.
If you see drainage around a chest tube or incision site....what do you note?
Color and circle around the drainage stain so you can tell if it is getting larger
Why will a person with a chest tube have MULTIPLE CHEST X RAYS?
to check for placement....and to make sure they are progressing
Primary treatment for SCLC
When do you use chemo with NSCLC?
as adjuvant therapy when a person has a non resectable tumor
What does targeted therapy do for cancer?
blocks the growth of molecules involved in tumor growth
When is Radiation therapy used for lung cancer?
- Treats both NSCLC and SCLC
- Curative, palliative and adjuvant therapy
- Used in combo with chemo
- Used for patients that cant tolerate surgery
- Pre-op to reduce the size of the tumor before surgery
Name some complications of radiation therapy for lung cancer
- skin irritation
- radiation pneumonitis
Palliation for lung cancer
- treatment of dyspnea and pain
- radiation therapy
- laser therapy
Where do laryngeal cancers usually metastasize to?
- METS to lung and liver
Risk factors for Head and Neck cancer
- Poor diet in fruits and vegetables
- Tobacco and alcohol
Who usually identifies head and neck cancers?
- They should assess area under the tongue using a flashlight to visualize the area. Also palpate for lumps
What are the white and red patches called found in the mouth that are a sign of cancer?
- Leukoplakia (white)
- Erythroplakia (red)
Clinical manifestations of cancer of the oral cavity
- painless growth in the mouth
- ulcer that doesn't heal
- change in the fit of dentures
- pain in the late stages cuz aggrevated by acidic foods
Manifestations of cancers of oropharynx, hypopharynx and supraglottic larynx
- C/o persistent unilateral sore throat
- otalgia (ear pain)
- hoarseness....that lasts longer than 2 weeks
- lump in throat
Late stages of head and neck cancers
- decreased motility of the tongue
- airway obstruction
- cranial nerve neuropathies
placement of a radioactive source into or near the tumor. The goal is to deliver high doses of radiation to the target area while limiting exposure of surrounding tissues
Nursing Care for a patient who has had radiation treatment for head and neck cancer
- Assess skin, mouth; area being radiated.
- Check patients ability to swallow and communicate
- Is there redness, skin irritation, swelling, dry mouth??
- Bone pain?
After radiation treatment for Head and neck cancer when should you notify a doctor immediately?
if you have a moist skin reaction
After radiation what's the deal with the sun?
No sun exposure for 1 YEAR after treatment is done!!!
Fatigue is a common side effect of radiation...what should you teach the patient to do to manage this?
- Frequent rest periods during the day
- light exercise
How do you treat Xerostomia?
- increase fluid intake
- chew sugarless gum and candy
- use nonalcoholic mouth rinses (baking soda too)
- Brush teeth with soft tooth brush
- Mouth rinses with 1/2 water and 1/2 NS
What medication can increase saliva production?
Inflammation of the mucous membrane in the mouth
partial removal of one vocal cord when there is a superficial tumor
removal of one vocal cord or part of a cord...requires a TEMPORARY Trach
removing structures above the true cords, the false vocal cords and epiglottis...requires a temporary tracheostomy
What 2 surgeries will the patient receive a temporary Trach?
Hemilaryngectomy and Supraglottic Laryngectomy
What is the patient at high risk for with the supraglottic laryngectomy?
high risk for aspiration cuz it removes the epiglottis
Which 2 surgeries allow the voice to be preserved, but the quality of the voice is breathy and hoarse?
hemilaryngectomy and Supraglottic Laryngectomy
used for treatment of advanced lesions...removal of the entire larynx and pre-epiglottic region
Which surgery requires a permanent tracheotomy?
When is a Radical Neck dissection performed?
and what does it do?
With a total laryngectomy
Decreases the risk of lymphatic spread
Other structures may be removed as well....thyroid, IJV, mandible....
What's a modified neck dissection?
Surgery that spares as many structures as possible
Prior to having surgery on the head and neck make sure the patient visits....
a dentist specializing in oncology
Prior to surgery....who should the patient meet with besides the surgeon?
Medical Oncologist Consultant
What plans should be in place prior to head and neck surgery?
- plan to prevent airway obstruction
- wound problems
Prior to head and neck surgery it is the physicians responsibility to discuss
- Risks of surgery
- If trach is needed and for how long
- Wound Problems
Prior to radiation/surgery the patient should have a speech eval....why?
- plan for voice restoration
- swallow exercises
- prevention of long problems with eating
Head and Neck surgery Pre Op teaching....
- deep breathing
- pain management
- special breathing with Trach
Priorities or nursing care for a patient after head and neck surgery.....
- Airway maintenance
- Gas Exchange
- Reconstructive tissue care
- pain control
- Psych adjustment
How may a person eat after head and neck surgery?
After head and neck surgery what do I check every 4 hours?
Incision sites, dressings.....
Color, amount, and drainage
How is O2 delivered to a person with a trach?
with a humidifier to prevent drying of secretions
Things to assess after head and neck surgery...
- auscultation of breath sounds
What is the PT's main concern after head and neck surgery?
providing patient with exercises to maintain strength and movement in the affected should and neck....to prevent development of frozen shoulder
Should a person use the valsalva maneuver after head and neck surgery?
NOT if they have a hole in their throat
When a person has reconstruction after head and neck surgery what am I concerned with?
Rejection of new tissues...any flaps/grafts
Details of trach/stoma care.....
- Patient/Family Education on care
- Body image/emotional support
- Trach Care
- Caution when showering, shaving, applying makeup (Shield opening)
- Bedside humidifier
- Medic Alert Bracelet
How do you shield a trach stoma for a shower?
- manufacturers cover
- dry cloth
- childs bib with the plastic faced outward
it is a soft plastic device inserted in to the fistula made btwn the esophagus and trachea
Allows for air from the lungs to enter the esophagus by way of the stoma
Speak manually by blocking stoma....words are formed by moving tongue and lips
it is a hand held batter powered device that speech is made by sound waves
Cooper Rand device
Special plastic tube placed in the corner of the mouth to create vibrations
placed against the neck rather than in the mouth
method of swallowing, trap the air in the esophagus and release air to creat sound
African Americans and respiratory disease process
- highest mortality rates
- highest incidence of lung cancer
- most likely to die from lung cancer
What is the prediction when you are diagnosed with asthma at an older age?
you will have more complications due to your older immune system and comorbidities
Why do people get chest tubes?
- Pneumothorax (collapsed lung)
- Hemothorax (blood in lungs)
- Post op drainage
- lung abscess
- Pleural Effusion (fluid in lungs)
What do you assess on a patient with a chest tube?
- Any signs of resp. distress? (deviated trach?)
- Is the dressing in tact? Crepitus?
- Are there any kinks in the tubing?
- Clots in tubing?
- Is there the expected amount of drainage in the collection chamber? type/color?
- Does the water seal chamber have the correct water level? Bubbling
- Is the suction chamber suctioning at the prescribed amount?
What does it mean when there are bubbles in the water seal chamber?
there is an air leak somewhere....
You will see bubbles flowing from right to left in the chamber
Rated by 0-5 (low to high)
leakage of air in to the subcutaneous tissues
*monitor for discomfort and respiratory distress
If a chest tube was just placed and a patient had a large pneumothorax....expect to see what in the chamber?
air leak.....cuz air is being removed from the chest
Patient teaching for a chest tube
- IS q1-2
- Report pain and PQRST
- *Report sudden pain or SOB
- *report tube disconnection or dislodgement
- * Report change in color of the drainage
What do you do if a chest tube disconnects?
- Get help from coworkers...bring supplies to you
- Put patient in comfy position
- Place end of tubing in to sterile water
- Notify MD
- Use standard precautions for body fluids
What do you do if the chest tube gets dislodged?
- Get help from co workers....bring supplies to you
- Put patient in comfy position
- Call MD
- If necessary call Rapid Response
- Assess exit site for drainage pain and bleeding
- Lungs sounds
Give MD SBAR when he calls you back. May need to put a sterile dressing over exit site
Nursing care for a patient with a Trach
- Emotional support about body image
What would you like to do?
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