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NURSING PROCESS-DIAGNOSING PREPARED AND PRESENTED BY MRS.S.ANUCHITHRA RADHAKRISHNAN, VICE PRINCIPAL CUM HOD OBG NURSING, P.D.BHARATESH COLLEGE OF NURSING, HALAGA, BELGAUM.
INTRODUCTION Diagnosing is the 2nd phase of nursing process Nurse uses critical thinking skills to interpret assessment data Pivotal step of Nursing process To diagnose in nursing means to analyze assessment information and derive meaning from the analysis. All the activities preceding this phase are directed toward formulating nursing diagnosis contd…
INTRODUCTION The use of the nursing process and nursing diagnoses is rapidly becoming an integral part of an effective system of nursing practice. Identification & Development of Nursing Diagnosis began in year 1973 It is derived from actual or potential problems. Derived from physiological, social, cultural, developmental and spiritual dimensions of client. contd…
INTRODUCTION Focus : Helping client to achieve a maximal level of wellness and highest level of independence. Medical diagnosis deals with disease or medical condition or pathology (treating or curing) Nursing deals with human response to bio-psycho-social stressors and/or health problems that a nurse is licensed and competent to treat. contd…
INTRODUCTION NANDA – North American Nursing Diagnosis Association To promote a taxonomy of nursing diagnostic terminology Taxonomy is the classification system Currently NANDA approved 206 Nursing Diagnosis labels In 2000 Taxonomy I is revised & now referred to as Taxonomy II contd…
206 nursing diagnoses that are grouped (classified) within 13 domains (categories) of nursing practice. They are1. Health Promotion;2. Nutrition;3. Elimination and Exchange;4. Activity/Rest;
5. Perception/Cognition;6. Self-Perception;7. Role Relationships;8. Sexuality;9. Coping/Stress Tolerance;10. Life Principles;11. Safety/Protection;12. Comfort;13.Growth/Development.
DEFINITIONA nursing diagnosis is a statement of the high risk or actual problems in the client’s health status the nurse is licensed competent to treat Note: It is not medical diagnosis Data Analysis + Problem Identification = Formulation Of Nursing Diagnosis
DEFINITION “It is a clinical judgment about individual, family or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurses are accountable”.
THE GENERAL USE/PURPOSE OF NURSING DIAGNOSES1. Gives Nurses a Common Language2. Promotes Identification of Appropriate Goals3. Provides Acuity Information4. Can Create a Standard for Nursing Practice5. Provides a Quality Improvement Base
THE SPECIFIC USE/PURPOSE OF NURSING DIAGNOSESa. For client: 1. Individualization of care 2. Appropriate selection of interventions 3. Establishment of goalb. For Nursing: 1. Facilitates communication, documentation 2. Continuity of care among health care providers
IV).CHARACTERISTICS OF NURSING DIAGNOSIS1. It states a clear and concise health problem2. It is derived from existing evidences about the client3. It is potentially amenable to nursing therapy4. It is the basis for planning and carrying out nursing care
V).TYPES OF NURSING DIAGNOSIS1. Actual Nursing Diagnosis2. Risk Nursing Diagnosis3. Health-Promotion Nursing Diagnosis4. Possible Nursing Diagnosis5. Syndrome Diagnosis
1. ACTUAL NURSING DIAGNOSIS Actual Nursing Diagnosis is a client problem that is present at the time of Nursing Assessment It is based on the presence of associated signs & symptoms Firm diagnosis supported by nurses findings (validated)
DEFINITION OF ACTUAL NURSING DIAGNOSIS “A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community”.
EXAMPLES OF ACTUAL NURSING DIAGNOSIS Ineffective breathing pattern related to bacterial / viral inflammatory Process. Ineffective breathing pattern related to Tracheo-bronchial obstruction Anxiety related to changes in the environment and routines, threat to socio economic status. Anxiety related to change in health status and situational crisis. Body image disturbance related to temporary presence of a visible drain/ tube.
2.RISK NURSING DIAGNOSIS It is a clinical judgment that a problem doesn’t exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. Describes human responses to health conditions / life processes that may develop in a vulnerable individual / family / community.
2.RISK NURSING DIAGNOSIS It is supported by risk factors that contribute to increased vulnerability. Eg. A client with Diabetes Mellitus or a compromised immune system is at high risk than others. Therefore the nurse would appropriately use the label risk for infection to describe the client’s health status.
EXAMPLES OF RISK NURSING DIAGNOSIS Eg. Admission in hospital prone for acquiring infection- compromised immune system1. Risk for infection related to compromised immune system.2. Risk for injury related to altered mobility and disorientation.3. Risk for aspiration related to decreased cough and gag reflex
EXAMPLES OF RISK NURSING DIAGNOSIS1. Risk for impaired skin integrity related to immobility.2. Risk for impaired skin integrity related to edema and neuropathy3. Risk for injury related to generalized weakness4. Risk for Impaired skin integrity (left ankle) related to decrease peripheral circulation in diabetes.5. Risk for Impaired skin integrity related to loss of pain perception
3. HEALTH-PROMOTION NURSING DIAGNOSISA clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state.
3. HEALTH-PROMOTION NURSING DIAGNOSIS Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement. Health-promotion nursing diagnosis are one part statement includes diagnostic label.
EXAMPLES OF HEALTH-PROMOTION NURSING DIAGNOSIS- Readiness for Enhanced Self-Esteem.- Readiness for enhanced spiritual well being- Readiness for enhanced family coping.
4. POSSIBLE NURSING DIAGNOSISA possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear. A possible diagnosis requires more data either to support or to refuse it. Possible nursing diagnosis are suspected because of the prescence of certain factors. Tentative-additional data needed to confirm or rule out problem.
EXAMPLES SITUATION FOR FORMULATING POSSIBLE NURSING DIAGNOSIS Eg. Elderly widow who lives alone admitted in hospital no visitors and she is pleased with attention and conversation from the nursing staff. Until more data are collected, the nurse may write a nursing diagnosis of Possible social isolation R/T unknown etiology
EXAMPLES OF POSSIBLE NURSING DIAGNOSIS- Potential risk of constipation as a result of enforced bed rest.-Potential risk of pressure sore development from enforced bed rest.
5. A SYNDROME DIAGNOSISA clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.
5. A SYNDROME DIAGNOSIS Rape-trauma syndrome related to anxiety about potential health problems and as manifested by anger, genitourinary discomfort, and sleep pattern disturbance.
Impaired physical mobility Impaired gas exchange and Risk for tissue Impaired integrity Eg. Disuse syndrome Risk for activity intolerance Includes Risk for constipation Risk for infection Risk for injury Risk for powerlessness
COMPONENTS OF NANDA NURSING DIAGNOSIS A Nursing Diagnosis has 5 componentsA. LabelB. DefinitionC. EtiologyD. The defining characteristicsE. Risk factors and Related factorsEach component serves a specific purpose
A. LABEL Provides a name for a diagnosis. It is a concise term or phrase that represents a pattern of related clues. It may include modifiers. Describes the client’s health problem or response for which nursing therapy is given
A. LABEL It describes the client’s health status clearly and concisely in few wordsPurpose: Is to direct the formation of client goals and desired outcomes. It may also suggest some Nursing interventions
To be clinically useful, Diagnostic labels need to be specific; when the word specify follows a NANDA label, the nurse states the area in which the problem occurs, For eg, Deficient knowledge (medication) or Deficient knowledge (dietary adjustments) Each diagnostic label approved by NANDA carries a definition that clarifies its meaning contd…
Qualifiers are words that have been added to some NANDAlabels to give additional meaning to the diagnostic statement ;for eg. 1. Deficient (inadequate in amt, quality, or degree, not sufficient, Incomplete) 2. Impaired (made worse, weakened, damaged, reduced, Deteriorated, Absent , lessened, either temporarily or permanently ) 3. Altered (distorted, changed)
1. Risk for (chance of something going wrong, hazard, damage, something likely to cause injury, something to harm, danger, or loss)2. Decreased (reduce, lessen, decline, diminution lesser in size, amount or degree)3. Ineffective (not producing the desired coping, unproductive, unsuccessful, useless)4. Compromised (to make vulnerable to threat)
NANDA MODIFIERS1. Acute (sever, serious, intense, critical)2. Chronic (constant, persisting, ever present)3. Depleted (exhausted, tired, useless)4. Disturbed ( troubled, uneasy, unbalanced, bothered)5. Dysfunctional ( inability to function, organ or part of body unable to function)
NANDA MODIFIERS1. Enhanced (improved, better)2. Excessive (extreme, too much, unnecessary, disproportionate)3. Increased (greater than before, improved)4. Intermittent (irregular, alternating, discontinuous)5. Potential for (likely to occur, may or might)
B. DEFINITION Provides a clear, precise description; delineates its meaning and helps differentiate it from similar diagnoses. Based on data collected Must be approved NANDA format begin with modifiers contd..
Use the exact NANDA wording to state the problem Examples 1.Poor sleep pattern / Sleep Pattern, disturbed 2.Poor circulation / Tissue perfusion, ineffective (cardiopulmonary)
C. ETIOLOGY The factors contributing to or causing the problem It can’t be a medical diagnosis Must be modifiable by nursing intervention Nurse must be able and license to do something about it. contd…
ETIOLOGY Will be one of five categories: Pathophysical, Environmental, Situational, Psychological, or Maturational The etiology component of a nursing diagnosis identifies one or more probable cause of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care. Contd…
PROBLEMS HAVING DIFFERENT ETIOLOGIES AND DIFFERENT INTERVENTIONS Problem Client Etiology Nursing Intervention A Long term Gradual withdraw of laxative laxatives use Teach components of high fiber diet. B Inactivity -exercise informationConstipation & about daily schedule insufficient - types of fluid he likes fluid - Plan to include sufficient intake amount of fluid in his diet.
PROBLEMS HAVING DIFFERENT ETIOLOGIES AND DIFFERENT INTERVENTIONSProblem Client Etiology Nursing InterventionIneffective A Breast 1. Massage of breast beforebreast engorge feedingfeeding ment 2. Use hot packs 3. Hot shower before nursing infant B Inexperie 1. Advice to feed infant on nce and demand lack of 2. Show her how infant is knowled sucking & swallowing ge 3. Demonstrate different holding positions for feedings.
D.DEFINING CHARACTERISTICS Defining Characteristics are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label For Actual Nursing Diagnosis- The Defining Characteristics are the client’s signs and symptoms For Risk Nursing Diagnosis- No subjective and objective signs are present Thus the factors that cause the client to be more than “Normally” vulnerable
E. RISK FACTORSEnvironmental factors and physiological, psychological, genetic or chemical elements that increase the vulnerability of an individual, family or community to an unhealthful event.
E. RELATED FACTORS Factors that appear to show some type of patterned relationship with the nursing diagnosis. Such factors may be described as antecedent to, associated with, related to, contributing to or abetting. Only actual nursing diagnoses have related factors.
DIFFERENCE BETWEEN MEDICAL & NURSING DIAGNOSESSl Nursing Diagnoses Medical DiagnosesNo 1 It is a statement of Medical Diagnoses is Nursing judgment made by physician2 Refers to a condition Refers to a condition that Nurses are licensed that only a physician to treat can treat.
DIFFERENCE BETWEEN MEDICAL & NURSING DIAGNOSESSl Nursing Diagnoses Medical DiagnosesNo. 3 Nursing Diagnoses Medical Diagnoses describe a client’s refers to disease physical, socio-cultural, processes psychologic, and spiritual responses to an illness or health problem.
DIFFERENCE BETWEEN MEDICAL & NURSING DIAGNOSESSl Nursing Diagnoses Medical DiagnosesNo. 4 It changes depend Fairly uniform from upon the response of one client to another the client to an illness & health problem. 5 Nursing Diagnoses Medical Diagnose change as the client remains same for as responses change. long as the disease process is present.
THE DIAGNOSTIC PROCESS The Diagnostic Process uses critical thinking skills of analysis and synthesis. Critical thinking is a cognitive process during which a person reviews data and considers explanations before forming an opinion. Analysis – is the separation into components that is breaking down of the whole into its parts. Synthesis – is the opposite that is the putting together of parts into the whole.
The diagnostic process is used continuously by most nurses. An experienced nurse may enter a client’s room and immediately observe significant data and draw conclusions about the client. As a result of attaining knowledge skill and expertise in the practice setting, the expert nurse may seem to perform these mental processes automatically. Novice nurses, however, need guidelines to understand and formulate nursing diagnoses.
THE DIAGNOSTIC PROCESSThe diagnostic process has 3 steps:-1] Analyzing data2]Identifying health problems, risks and strengths.3] Formulating Diagnostic statements.
Assessinga. Collect datab. Organize datac. Validate datad. Document data DIAGNOSING a.Analyze data b.Identify health problems, risks and strength, c.Formulating nursing diagnosis
1] ANALYZING DATA In analyzing data following steps are involved. A. Compare data against standards (identify significant cues) B. Cluster cues (generate tentative hypotheses) C. Identify gaps & inconsistencies. For experienced nurses, these activities occur continuously rather than sequentially.
A. COMPARING DATA AGAINST STANDARDSA Standard or Norm is generally accepted measure, model rule, or pattern. Eg. of Standards Growth and Development patterns Normal vital signs Laboratory values
B. CLUSTER CUES It is a process of determining the relatedness of facts and determining whether data are significant.
C. IDENTIFY GAPS & INCONSISTENCIESSkillful assessment minimizes the gaps & inconsistencies,conflicting datas.Possible sources are measurement error, expectation andunreliable report.It helps to have final check to ensure the data are complete andcorrect. Eg. Patient reports not having seen a Doctor in 15 years, yet during Physical Examination he states “My doctor takes my BP every year”. All inconsistencies must be clarified before valid pattern “Validating data”.
2] IDENTIFYING HEALTH PROBLEMS, RISKS & STRENGTHS After data are analyzed, the nurse and client can together identify strengths & problems. That is after gaping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible diagnoses.
EG. OF A CLIENT WITH PNEUMONIASlNo. Client cue clusters1 a) No appetite since Imbalanced Nutrition: Less that having “Cold” Body Requirements related to b) Has not eaten decreased appetite & Nausea, & today, Last fluids increased metabolism at noon today (Strength: - Normal Weight for c) Nauseated x 2 Height.) days
EG. OF A CLIENT WITH PNEUMONIASlNo. Client cue clusters2 a) Last fluids at noon today Deficient fluid volume related to b) Oral temperature intake insufficient to replace 39.40c (1030 F) fluid loss secondary to fever, c) Skin lot & pale, diaphoresis, anorexia checks flushed d) Dry mucous membrane e) Poor skin turgor f) Decreased Urinary frequency x 2 days
EG. OF A CLIENT WITH PNEUMONIA Sl Client cue clustersNo.3 Difficulty in Disturbed sleep pattern related to sleeping because cough, pain, orthopnea, fever, of cough, and diaphoresis. “Can’t breathe while lying down”
EG. OF A CLIENT WITH PNEUMONIASlNo. Client cue clusters4 a) States “I feel Weak” b) Short of breath on Activity Intolerance related to exertion general weakness imbalance between c) Radial pulses weak, O2 supply / demand regular Strength: - No musculoskeletal d) Pulse rate – 92 bt/mt impairment, normal energy level is e) States “I can think Satisfactory, exercises regularly. ok, just weak”
EG. OF A CLIENT WITH PNEUMONIASlNo. Client cue clusters5 Reports pain in Acute pain related to cough chest especially secondary to inflammation of when coughing lung parenchyma. Strength:-No cognitive or sensory deficits.
EG. OF A CLIENT WITH PNEUMONIASlNo. Client cue clusters6 a) Husband out of Interrupted family processes town; will be back related to mother’s illness & tomorrow temporary unavailability of afternoon father to provide child care. b) Child with Strength :- Neighbors available neighbor until & willing to help. husband returns.
EG. OF A CLIENT WITH PNEUMONIASl Client cue clustersNo.7 a) Anxious :- “I can’t breathe” Anxiety related to difficulty breathing, b) Facial muscles tense, inability to work, and child care. c) Trembling d) States “I’ll never get caught up” e) Husband out of town; will be back tomorrow afternoon. f) Child with neighbor house g) Express “concern” & “Worry”
EG. OF A CLIENT WITH PNEUMONIASl Client cue clustersNo.8 a) Radial pulse weak, regular pulse rate 92 Ineffective Airway clearance related to b) Skin hot, pale, and moist viscous secretions & shallow chest c) Respirations shallow, chest expansion secondary to pain, fluid expansion, 3cm volume deficit & fatigue. d) Productive cough e) Thick pale pink sputum f) Inspiratory crackles auscultated through out. Right upper & lower lungs. g) Diminished breath sounds an ® side h) Mucous membranes pale, dry
DETERMINING STRENGTHS Eg. of strengths Weight is with in normal as per age & Height – Enables client to cope with surgery. Absence of allergies & Non smoker. It can be found in the nursing assessment record (health, home life, Education, recreation, exercise, work, family & friends religious beliefs, sense of humour)
3] FORMULATING DIAGNOSTIC STATEMENTS Most Nursing Diagnoses are written as two part or three part statements, but there are variations of these.1. Basic two part statements2. Basic three part statements3. One part statements4. Variations of Basic formats.5. Collaborative problems.
BASIC TWO PART STATEMENTS The basic two part statement includes the following.1] Problem (P) :- Statement of the client’s response (NANDA Label)2] Etiology (E) :- Factors contributing to or probable cause of responses. The two parts are joined by the words related to rather than due to. The phrase due to implies that one part causes or is responsible for the other part. By contrast, the phrase related to merely implies a relationship.
EG. OF TWO PART STATEMENTS Problem Related to Etiology Constipation Related to Prolonged Laxative use Ineffective Related to BreastBreast Feeding engorgement
Some NANDA Labels contain the word specify. For these the nurse must add words to indicate the problem more specifically. Eg. Noncompliance (specify) Noncompliance (Diabetic Diet) related to denial of having disease. For ease in alphabetizing, many NANDA lists are arranged with qualifying words after the main word (Eg. Infection, Risk For). Avoid writing Diagnostic statements in that manner instead, write them as they would be stated in normal conversation (Eg. Risk for infection)
BASIC THREE PART STATEMENTS The three part Diagnostic Statements called the PES format and includes the following:1] Problem (P) :- Statement of the client’s response (NANDA Label)2] Etiology (E) :- Factors contributing to or probable cause of the response.3] S/S (S) :- Defining characteristics manifested by the client.
Actual nursing diagnoses can be documented by using the three part statement because the signs & symptoms have been identified. This format cannot be used for risk diagnoses because the client doesn’t have signs & symptoms of the diagnosis.
EG. OF 3 PART STATEMENT Problem Related Etiology As manifested Signs & symptoms To bySituational Related to Rejection by As manifested by States that “I don’t know if I canLow Self husbandEsteem manage by myself” Rejects positive feed back.Hyperthermia Related to Bacterial infection As manifested by Elevated body temperature. 1000F Increased pulse rate 92bt/mt Increased R.R 30br/mt Dry lips . States Fatigue, tired. Feels so Hot Reduced Skin turgor.Ineffective Related to Viscious secretions As manifested by Viscious secretions, shallow chestbreathingpattern expansion.
ONE PART STATEMENTS Wellness diagnoses and Syndrome nursing diagnoses. As the diagnostic labels are refined they tend to become more specific, so that nursing interventions can be derived from the label itself. Therefore an etiology may not be needed. The wellness diagnoses statement begins with words Readiness for Enhanced (Parenting, Spiritual well being, Effective breast feeding, Health seeking behaviors, Anticipatory Grieving Low fat Diet.)
GUIDELINES FOR WRITING A NURSING DIAGNOSTIC STATEMENTSl Correct statement IncorrectNo.1 State in terms of Deficient fluid volume Fluid replacement problem, not a related to fever (need) related to fever. need.2 Word the statement Impaired skin integrity Impaired skin integrity so that it is legally related to immobility related to improper advisable (legally acceptable) positioning (implies legal liability)3 Use nonjudgmental Spiritual distress related Spiritual distress statements to inability to attend related to strict rules church services necessitating church secondary to immobility attendance (Nonjudgmental)
GUIDELINES FOR WRITING A NURSING DIAGNOSTIC STATEMENTSl Correct IncorrectNo. statement 4 Make sure that both Impaired skin Impaired skin elements of the statement integrity (ulcer integrity don’t say the same thing. in sacral area) related to related to ulceration of immobility. sacral area. 5 Be sure that cause and Pain severe Pain related to effect are correctly stated head ache severe head (that is the etiology related to fear ache. causes the problem) of addiction to narcotics
GUIDELINES FOR WRITING A NURSING DIAGNOSTIC STATEMENTSl Correct statement IncorrectNo. 6 Word the diagnosis Impaired oral Impaired oral specifically and mucus membrane mucus precisely to provide related to membrane direction for decreased related to planning nursing salivation noxious agent intervention secondary to (vague) radiation of neck. (specific)
GUIDELINES FOR WRITING A NURSING DIAGNOSTIC STATEMENTSl Correct statement IncorrectNo.7 Use nursing Risk for Risk for terminology rather ineffective airway pneumonia than medical clearance related (Medical terminology to to accumulation Terminology) describe the client of secretions in response & its lungs (nursing cause. terminology)
CONCLUSION Definition Types of Nursing Diagnoses –Actual, Risk, Wellness, Possible and Syndrome Components of NANDA nursing diagnosis- Problem, Etiology, Defining characteristics Difference between medical and nursing diagnoses Diagnostic process- Analyzing data - Compare data against standards (identify significant cues), Cluster cues (generate tentative hypotheses) , Identify gaps & inconsistencies. Identifying health problems risk and its strengths Formulating diagnostic statements - Basic two part, Basic three part, One part, Variations of Basic formats, Collaborative problems. Guidelines for writing a nursing diagnostic statement
COMPONENTS OF NANDA NURSING DIAGNOSIS A nursing Diagnosis has 3 components.1. The problem and its definition2. The etiology3. The defining characteristics. Each component serves a specific purpose.
1] THE PROBLEM (DIAGNOSTIC LABEL) AND ITS DEFINITION Describes the clients health problem or response for which nursing therapy is given. It describes the client’s health status clearly & concisely in few words. Purpose is to direct the formation of client goals and desired outcomes. It may also suggest some nursing interventions.
To be clinically useful, diagnostic labels need to be specific; when the words specify follows a NANDA Label, the nurse states the area in which the problem occurs. For eg. Deficient knowledge (specify) Medication Deficient knowledge (Dietary adjustments).
Qualifiers are words that have been added to some NANDA Labels to give additional meaning to the diagnostic statement; for eg. Deficient (inadequate in amount quality or degree not sufficient, incomplete) Impaired (Made worse, weakened, damaged, reduced, deteriorated) Decreased (lesser in size amount or degree) Ineffective (not producing the desired coping) Compromised (to make Vulnerable to threat) Each Diagnostic label approved by NANDA carries a definition that clarifies its meaning.
2] ETIOLOGY The etiology component of a nursing diagnosis identifies one or more probable cause of the health problem, gives direction to the required nursing therapy and enables the nurse to individualize the client’s care. Eg. of problems having different etiologies and different interventions
Problem Client Etiology Nursing Intervention A Long term Gradual withdraw of laxatives laxative use - teach components of high fiber diet.Constipati B Inactivity & - exercise information about daily schedule on insufficient - types of fluid he likes - Plan to include sufficient amount of fluid in fluid intake his diet.Ineffective A Breast -massage of breast before feedingBreast engorgement - use hot packs - hot shower before nursing infantFeeding B Inexperience - Advice to feed infant on demand and lack of - Show her how infant is sucking & swallowing knowledge - demonstrate different holding positions for feedings.
D. DEFINING CHARACTERISTICS Defining Characteristics are the client’s signs & symptoms. That indicates the presence of a particular diagnostic label. For Actual Nursing Diagnosis the defining characteristics are the client’s signs & symptoms. For Risk Nursing Diagnosis no subjective & objective signs are present.