chap 33 musculoskeletal
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Chapter 33Care of Patients with Musculoskeletal and Connective Tissue Disorders Theory Objectives State the factors to be assessed for the patient who has a connective tissue injury. Compare the assessment findings of a connective tissue injury with those of a fracture. State the care that is needed for the patient who has an external fixator in place. Identify the “do’s and don’ts” of cast care. Discuss the potential complications related to fractures. Identify the special problems of patients with arthritis and specific nursing interventions that can be helpful. Compare the preoperative and postoperative care of a patient with a total knee replacement with that of a patient with a total hip replacement.Explain the process by which osteoporosis occurs, ways to slow the process, and how the disorder is treated. Describe the care of the patient with a metastatic bone tumor. Identify important postoperative observations and nursing interventions in the care of the patient who has undergone an amputation.Clinical Practice ObjectivesTeach the patient going home with a cast about proper care of the cast and extremity. Provide pin care for a patient with external fixation. Observe a physical therapist who is teaching quadriceps exercise and then assist the patient to practice. Apply a sequential compression device for a patient as ordered.
Sprain
A sprain is a partial or complete tearing of the ligaments that hold various bones together to form a joint
A sprain occurs when a joint may be forced, during trauma, past its normal range of motion, or there may be twisting
The ankle, knee, and wrist are most commonly sprained
Signs and Symptoms
Grade I (mild): Tenderness at site; minimal swelling and loss of function; no abnormal motion
Grade II (moderate): More severe pain, especially with weight-bearing; swelling and bleeding into joint; some loss of function
Grade III (severe, complete tearing of fibers): Pain may be less severe, but swelling, loss of function, and bleeding into joint are more marked
Diagnosis
Physical examination
X-ray to rule out a fracture or other pathology
Treatment and Management
RICE
Rest
Ice after injury and for 24-72 hours
Compression—snug elastic bandage, careful to not to cut off circulation
Elevation
Grade II or III
Rest the joint
Crutches for lower extremity sprain
NSAIDs around the clock for first couple of days
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Strain
Signs, symptoms, and diagnosis
History of overexertion
Soft tissue swelling
Pain
Bleeding if muscle is torn
Etiology and Pathophysiology
A strain is a pulling or tearing of a muscle, a tendon, or both
A strain occurs by trauma, overuse, or overextension of a joint
The most common muscle strain occurs in the back muscles (back problems are discussed in Chapter 23, because they often have a neurologic
component)
Muscle strains do occur in other skeletal muscles—the most common sites are the hamstrings, quadriceps, and calf muscles
Complementary and Alternative Therapies
Soothing sore muscles
Arnica purchased and applied topically as an essential oil is supposed to soothe sore, tired muscles after a long day’s work
Valerian or kava brewed as a tea is also said to relax muscles
Honey or apple juice will make the teas more palatable
Treatment and Nursing Management
Ice and compression should be immediately applied and the part should be rested
The patient is taught to use ice for 20 minutes out of the hour only
When compression is used, the distal parts of the extremity must be checked for sensation and adequate circulation
Heat can be applied after 48 hours
Anti-inflammatory medications are used for discomfort and, when spasm is present, a muscle relaxant may be prescribed
Time is the greatest healer
The patient is cautioned against reinjury and is taught proper ways to lift and move
Surgical repair may be necessary
Dislocation and Subluxation
Etiology and pathophysiology
Signs and symptoms
History of outside force
Severe pain aggravated by movement
Muscle spasm
Abnormal joint appearance
X-ray
Treatment
Reduction of displacement under anesthesia
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Nursing management
Rest
Pain control
Heat or cold applications
Bursitis
Etiology and pathophysiology
Injury or overuse
Signs, symptoms, and diagnosis
Mild to moderate aching pain
Swelling
History of injury
Physical examination
Treatment
Rest, ice, and massage
Anti-inflammatory agents
Compression wrap
Bursa cortisone injection
Nursing management
Assess pain and perfusion
Assist with mobilization
Activity limitations
Other Connective Tissue Disorders
Rotator cuff tear
Anterior cruciate ligament injury
Meniscal injury
Achilles tendon rupture
Bunion (hallux valgus)
Carpal Tunnel Syndrome
Etiology and pathophysiology
Compression of the median nerve
Signs and symptoms
Pain
Numbness
Tingling of the hand, particularly at night
Repetitive movements of hands and wrists
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Diagnosis
Physical examination
Compression test
Electromyography
Treatment
Rest and splinting
Changing the angle of the wrist during repetitive movements
Steroid injections
Surgery
Nursing management
Fractures
Etiology and pathophysiology
Definition
Trauma
Osteoporosis and metabolic problems
Mechanism of injury
Signs and symptoms
Minimal to severe pain depending on the type of fracture, the bone(s) involved, and the amount of displacement
Swelling and/or bleeding
Tenderness, deformity of the bone, ecchymoses, crepitation with any movement, and loss of function
Fractures (cont.)
Diagnosis
Physical examination
X-ray
Types of Fractures
Complete ________________________________________________________________________________________________________________
Incomplete_______________________________________________________________________________________________________________
Comminuted _____________________________________________________________________________________________________________
Closed (simple) ___________________________________________________________________________________________________________
Open (compound) _________________________________________________________________________________________________________
Greenstick _______________________________________________________________________________________________________________
Elder Care Points The elderly are more at risk for fractures because of decreased reaction time, failing vision, lessened agility, alterations in balance, and decreased muscle tone
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Proton pump inhibitors (PPIs) increase the risk for fracture of the hip, wrist, and spine
In epidemiologic studies, the risk was highest for people over age 50, who had used PPIs for more than a year
Treatment of Fracture
Emergency care
Prevent shock and hemorrhage
“Splint as it lies”
Tetanus immunization
Prophylactic antibiotics
Primary aim of treatment
Establish union between broken ends to restore bone continuity
Five Stages of Bone Healing and Repair
1. Blood oozes from the torn blood vessels in the area of the fracture; the blood clots and begins to form a hematoma between the two
broken ends of bone (1 to 3 days)
Five Stages of Bone Healing and Repair (cont.)
2. Other tissue cells enter the clot, and granulation tissue is formed. This tissue is interlaced with capillaries, and it gradually becomes firm
and forms a bridge between the two ends of broken bone (3 days to 2 weeks)
Five Stages of Bone Healing and Repair (cont.)
3. Young bone cells enter the area and form a tissue called “callus.” At this stage, the ends of the broken bone are beginning to “knit”
together (2 to 6 weeks)
Five Stages of Bone Healing and Repair (cont.)
4. The immature bone cells are gradually replaced by mature bone cells (ossification), and the tissue takes on the characteristics of typical
bone structure (3 weeks to 6 months)
Five Stages of Bone Healing and Repair (cont.)
5. Bone is resorbed and deposited, depending on the lines of stress. The medullary canal is reconstructed during consolidation and
remodeling (6 weeks to 1 year)
Reduction of Fractures
Closed reduction
Open reduction
Stabilization
Internal fixation
External fixation
Casts, splints, and braces
Traction
Internal Fixation
Pins, nails, or metal plates
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Open reduction and internal fixation
Prosthesis and autotransfusion
IV antibiotics and risk for infection
Nursing care
Maintain good alignment of the affected leg
Prevent complications of immobility
Control pain
Examples of Internal Fixation
External Fixation
Indications
Massive open fractures with extensive soft-tissue damage
Infected fractures that do not heal properly
Multiple trauma such as burns, chest injury, or head injury
Nursing Management
Pin site care and premedicate for pain
Showering
Physical therapy and ADLs
Casts and Fractures
Materials including plaster and synthetic casts
Long-leg and short-leg casts, slings, and spicas
Synthetic Limb Cast
Braces and Splints
Fracture boot, hinged brace, and slab
Patient teaching
Explain the procedure—feel warmth as cast sets and dries
Never put a fresh cast on plastic
Never cover a fresh plaster cast with a blanket
Walking Boot
Skeletal Traction
Pins, wires, or tongs directly through the bone at a point distal to the fracture so that the force of pull from the weights is exerted directly on the
bone
Skeletal traction uses 10 or more pounds of weight and the body acts as the countertraction
Skin Traction
Bandage (moleskin or foam traction boot) is applied to the limb below the site of fracture and then pull is exerted on the limb
No more than 7 to 10 lb of weight are used
Continuous or intermittent
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Common Types of Traction
Points of Care for the Patient in Traction
Traction devices must be assessed to see that they are in correct position and that the weights are hanging free
The patient’s body position should be assessed for proper alignment
Complications of Fractures
The sooner a fracture is fixed, the less likely the chance for complications.
Healing can be impeded by improper alignment and inadequate immobilization
Continued twisting, shearing, and abnormal stresses prohibit a strong, bony union.
Fractures and Infection
Open comminuted fractures and surgery
Antibiotics
Inadequate calcium and phosphorus, vitamin deficiency, and atherosclerosis
Temperature, white blood cells, and wound appearance (redness, swelling, heat, and purulent drainage)
Osteomyelitis
Osteomyelitis is a bacterial infection of the bone
Staphylococcus aureus
Sudden onset with severe pain and marked tenderness at the site, high fever with chills, swelling of adjacent soft parts, headache, and malaise
Diagnosis
The earlier osteomyelitis is diagnosed and treated, the better the prognosis
History of injury to the part, open fracture, boils, furuncles, or other infections
Sedimentation rate and WBC count
X-rays
Biopsy, in which the bone sample exhibits signs of necrosis
Treatment
Antibiotics are prescribed for 4 to 6 weeks, and the abscess is incised and drained
Dead bone and debris are débrided from the site
The affected limb is immobilized for complete rest
Sometimes amputation is the only cure
Nonunion of Fractures
Electrical bone growth–stimulating device
Surgery and bone grafting
Fat Embolism
Signs and symptoms
Change in mental status
Respiratory distress, tachypnea, crackles and wheezes
Rapid pulse, fever, and petechiae (a measles-like rash over the chest, neck, upper arms, or abdomen)
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Nursing Management
Stay with the patient
High Fowler’s position
Use a non-rebreather mask
Establish a peripheral IV
Summon the physician immediately
Anticipate hydration with IV fluids and correction of acidosis
Intubation and mechanical ventilation
Venous Thrombosis
The veins of the pelvis and lower extremities are very vulnerable to thrombus formation after fracture, especially hip fracture
Immobility, traction, and casts may contribute to venous stasis
Compression stockings, sequential compression devices, range-of-motion (ROM) exercises on the unaffected lower extremities are used to help
prevent the problem
Compartment Syndrome
External or internal pressure that restricts circulation in one or more muscle compartments of the extremities
Severe, unrelenting pain unrelieved by narcotics
Assess for 6 “Ps”: pain, pallor, paresthesia, pulselessness, paralysis, and poikilothermia (cold to the touch)
Treatment and Nursing Management
Recognition and immediate notification of the physician can prevent permanent loss of function
If a cast is in place, the cast can be bivalved (split through all layers of the material)
Dressings will be cut or replaced
Surgical fasciotomy (linear incisions in the fascia down the extremity) may be necessary to relieve the pressure on the nerves and blood vessels if
other measures do not relieve the problem
Elevation is the key to preventing compartment syndrome; toes and fingers should be higher than the trunk
Fascial Compartments of the Calf
Nursing Management of Fractures
Assessment (data collection)
Initial assessment (pretreatment)
Mechanism of injury
Physical assessment
Special consideration of open fractures
Daily assessment (posttreatment)
Physical assessment of neurovascular status
Thorough assessment of a patient in a cast
Nutrition for immobile musculoskeletal patients
Nursing Management of Fractures (cont.)
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Cast care—fiberglass and polyester cotton knit casts and plaster casts
Comfort measures
Positioning and repositioning
Itching and skin care
Nursing Management of Fractures (cont.)
Evaluation
Pain should be under control
Progress toward independent ADLs
No problems with immobility (skin breakdown, constipation, atelectasis, or DVT)
No complications (infection, compartment syndrome)
If the goals are not being met, the plan should be revised
Inflammatory Disorders of the Musculoskeletal System
Lyme disease
Osteoarthritis
Rheumatoid arthritis
Gout
Osteoporosis
Paget’s disease
Bone tumors
Lyme Disease
Cause
Spirochete, Borrelia burgdorferi
Signs and symptoms
Flu-like symptoms
Bull’s-eye rash
Pain and stiffness in joints and muscles
Carditis
Meningitis, peripheral neuritis, or facial paralysis
Fatigue, cognition problems, and arthralgia
Treatment
Osteoarthritis
Etiology and pathophysiology
A noninflammatory degenerative joint disease that can affect any weight-bearing joint
Risk factors: Heredity, aging, female gender, obesity, previous joint injury, and recreational/occupational usage
Healthy People 2020 Goals Related to Arthritis
Reducing the mean level of joint pain, activity limitations, care limitations, effect on employment and the proportion of those who find it
very difficult to perform specific joint-related activities
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Increasing health care provider counseling for weight and physical activity; the proportion of those seeing a health care provider for joint
symptoms and effective evidence-based arthritis education as an integral part of managing the condition
Osteoarthritis
Signs, symptoms, and diagnosis
Asymmetrical
Typically affects only one or two joints
Chief symptoms
Aching pain with joint movement and stiffness and limitation of mobility
Joints may be deformed and nodules may be present
Treatment of Osteoarthritis
Pain management—including salicylates, acetaminophen, or NSAIDs
Strengthening and aerobic exercise
Weight reduction if the patient is overweight
Maintenance of joint function
Complementary and alternative therapies
Nursing Management of Osteoarthritis
Balance exercise and rest
Moist heat application
Encourage to maintain weight within normal limits
Imagery, relaxation, and diversion
Quadriceps strengthening exercises may relieve pain and disability of the knee
Rheumatoid Arthritis
Etiology and pathophysiology
Rheumatoid factor and small joints
Remissions and exacerbations
Pannus, ankylosis, and damage/atrophy of muscles
Subcutaneous nodules in the pleura, heart valves, or eyes
Rheumatoid Arthritis (cont.)
Signs and symptoms
Joint pain, warmth, edema, limitation of motion, and multiple joint stiffness
Symmetrical—affects joints of the hands, wrists, and feet
Limitations of ADLs
Comparison of Rheumatoid Arthritis and Osteoarthritis
Definition
Pathology
Etiology
Rheumatoid factors (autoantibodies)
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Age at onset
Weight
General state of health
Appearance of joints
Muscles
Other
Rheumatoid Arthritis
Diagnosis
History of morning stiffness that lasts more than one hour or arthritis pain in 3 or more joints that lasts more than 6 weeks
Blood tests for RF, C-reactive protein, and erythrocyte sedimentation rate
X-rays confirm the cartilage destruction and bone deformities
Treatment of Rheumatoid Arthritis
Relieve pain
Minimize joint destruction
Promote joint function
Preserve ability to perform self-care
Medications for Rheumatoid Arthritis
NSAIDs (i.e., ibuprofen) are the first-line agents used for arthritis pain
Other medications include salicylates, corticosteroids, antimalarial drugs, methotrexate, gold compounds, sulfasalazine, d-penicillamine, and
disease-modifying antirheumatic drugs (DMARDs)
Tumor necrosis factor drugs (TNF inhibitors)
Systemic corticosteroids
DMARDs
Medications for Rheumatoid Arthritis (cont.)
The injection of steroids directly into a joint (intra-articular administration) has been used successfully in treating painful flare-ups, shortening the
period of inflammation, and relieving pain and other symptoms
When intra-articular steroid therapy is used, it is recommended that not more than two or three doses be injected into any joint within 1 year’s
time
Clinical Cues
Monitor patients taking NSAIDs for GI intolerance
Assess liver, kidney, and central nervous system function frequently
Watch for signs of blood dyscrasias and check for tinnitus and hearing loss regularly
The side effects of NSAIDs can be serious and sometimes permanent
If early signs of toxicity appear, they should be reported promptly to the physician
Elder Care Points
Elderly arthritis patients must be taught to watch for side effects and promptly report to the physician or nurse
Dizziness, which predisposes to falls, can occur with analgesics for arthritis pain, particularly if the medication contains codeine
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Advise patients to arise slowly, hold on to furniture until steady, and to wait until dizziness passes before trying to walk
Assistive devices for ambulation can also prevent falls
Surgical Intervention and Orthopedic Devices
Casts/braces and splints
Surgery
Synovectomy
Osteotomy
Tendon reconstruction
Joint replacement
Total hip replacement including preoperative and postoperative care
Total knee replacement
Total Hip Replacement Discharge Teaching
It is OK to lay on operated side
For 3 months, you should not cross your legs
Put a pillow between legs when rolling over or lie on your side in bed
It is OK to bend your hip but not beyond a right (90-degree) angle (demonstrate)
Avoid sitting in low chairs
Continue daily exercise program at home
Nursing Management of Rheumatoid Arthritis
Expected outcomes
Patient’s pain will be controlled with medications, heat, and exercise within 2 weeks
Patient’s mobility will improve with the use of assistive devices and physical therapy within 3 weeks
Patient will demonstrate less disturbance of body image by partaking in more social activities within 1 month
Implementation and Evaluation of Rheumatoid Arthritis
Rest and exercise
Instructions for joint protection
Applications of heat and cold
Safety considerations
Patient teaching
Diet
Psychosocial care
Resources for patient and family education
Gout
Etiology and pathophysiology
Uric acid levels
Possible factors
Genetic increase in purine metabolism
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
High-purine diets
Big toe
Diuretic therapy and secondary gout
Gout (cont.)
Signs and symptoms
Tight reddened skin over an inflamed, edematous joint accompanied by elevated temperature and extreme pain in the joint
Elevated serum uric acid
Diagnosis
History and physical examination
Serum uric acid
Gout (cont.)
Treatment
NSAIDs for 2-5 days
Colchicine, allopurinol, and probenecid (Benemid)
Febuxostat (Uloric)
Nursing management
Patient teaching and medications
Diet management—weight control and restriction of high-purine foods
Fluid intake
Audience Response Question 1
Dietary management of gout includes which measure(s)? (Select all that apply.)
1. Weight reduction
2. Salt restriction
3. High caloric intake
4. Avoiding foods high in purine
5. High-carbohydrate diet
Osteoporosis
Etiology and pathophysiology
Osteopenia
Risk factors: Age, chronic disease (i.e., liver, lung, kidney), medications (i.e., steroids, anticonvulsants, anticoagulants, proton pump inhibitors,
selective serotonin inhibitors), long-term calcium deficiency, vitamin D deficiency, smoking, excessive caffeine or alcohol intake, and sedentary
lifestyle
Osteoporosis (cont.)
Signs and symptoms
No early signs and symptoms
Height loss, kyphosis, and compression of the spine
Diagnosis
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Bone x-rays
Dual energy x-ray absorptiometry (DXA or DEXA); reported as a T score
Treatment
Goals
Stop bone density loss
Increase bone formation
Prevent fractures
Estrogen replacement therapy
Adequate dietary and supplemental calcium and vitamin D
Weight-bearing exercise
Bisphosphonates
Parathyroid hormones
Osteoporosis and Vertebral Fracture
Pain medication, activity limitation, physical therapy, and bracing
Vertebroplasty
Kyphoplasty
Nursing Management
Promote screening for osteoporosis
Teach the benefits of healthy lifestyle, need for calcium supplement, and weight-bearing exercise
Medications, cautions, and side effects
Upright position for 1 hour after taking bisphosphonate-type drugs to prevent esophageal irritation and erosion
Paget’s Disease
Etiology
Abnormal weak bones
Signs and symptoms
Pain
Diagnosis
X-ray
24-hour urine collection
Serum alkaline phosphatase
Paget’s Disease (cont.)
Nursing management
Firm mattress
Light brace or corset
Avoid lifting and twisting
Bone Tumors
Etiology and pathophysiology
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Benign and malignant tumors
Primary and secondary tumors
Osteosarcoma and Paget’s disease
Bone Tumors (cont.)
Signs and Symptoms
Pain, warmth, and swelling
Diagnosis
X-ray, bone scan, and biopsy
Treatment
Surgery, radiation, and chemotherapy
Amputation
Lower-limb amputations are related to peripheral vascular disease, diabetes mellitus and resultant gangrene, severe trauma, malignancy,
congenital defects, and military injuries from shrapnel and land mines
Upper-extremity amputations are brought on by crushing blows, thermal and electric burns, severe lacerations, vasospastic disease, malignancy,
and infection
Care After Accidental Amputation
Rinse the detached part only enough to remove visible debris
Wrap the part in a clean, damp cloth
Place the part in a sealed plastic bag or in a dry water-tight container
Immerse the bag or container in a mixture of water and ice (3 parts water to 1 part ice). Do not let the part get wet or freeze
Care After Accidental Amputation (cont.)
Alternatively, place the container in an insulated cooler filled with ice
If no ice is available, keep the part cool; do not expose it to heat
Tag the bag or container with the person’s name and the name of the body part and take it to the hospital with the person
Amputation:
Preoperative Care
Patient participation in decision-making
Stages of loss and grieving
Phantom sensations
Physical preparation
Muscle strengthening exercises
Amputation:
Postoperative Care
Hemorrhage and edema of residual limb
Elevation for 24 hours
Monitoring for excessive bleeding
Dressing care
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Ch. 33 Care of Pt’s w/Musculoskeletal & Connective Tissue Disorders
Phantom limb sensations
Miacalcin IV infusion
Transcutaneous electrical nerve stimulator
Stump stocking
Amputation:
Postoperative Care (cont.)
Alternative modes for managing stump after amputation
Soft dressing with delayed prosthetic fitting
Rigid plaster dressing and early prosthetic fitting
Rigid plaster dressing and immediate prosthetic fitting
Amputation:
Postoperative Care (cont.)
Adequate healing and weight-bearing
Below-the-knee amputation is better to begin walking and weight-bearing than above-the-knee amputation
Abduction contractures and proper positioning
Adjusting to the new center of gravity
Patient teaching: stump care, activity and weight-bearing, and exercise
Rehabilitation
Community care
C-Leg Prosthesis in Action
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