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  • Private or hospital-affilicated: Pediatric Urgent care Clinics fo
  • Discuss positive and negative attitudes and how they can affect a child’s experience.
  • Stress the importance of knowing the developmental stage of the child as it will guide the type of preparation needed. How would you involve the parents?
  • Discuss simple terms in which to explain procedures to the toddler. Give an example of a preprocedure situation and how the nurse can effectively communicate with the toddler. Give an example of a situation in which a choice is offered to the toddler. What are some methods of distraction?
  • Give an example of a situation in which the nurse allows the child to examine or play with a piece of equipment prior to using it. What are other rewards a child might enjoy?
  • Discuss how the nurse can provide privacy to a teen and involve him or her in the treatment or procedure. What are some coping techniques that are appropriate for a teen?
  • Give an example of a situation in which a child might need varied home health care and discuss the impact on the family and child. What is the home health care nurse’s role in coordinating these services?
  • How can the nurse assist the child and parents in maintaining their normal routine?
  • Discuss the varied reactions to hospitalization of an infant, toddler, preschooler, school-age child, and an adolescent. How can the nurse prepare the child for hospitalization? Discuss the issue of previous hospitalizations and how they will affect the child during this hospitalization.
  • Discuss the nurse’s role in attempts to decrease the child’s stress. How can the nurse involve the parents in decreasing the amount of stress the child is experiencing?
  • Discuss nursing interventions which can assist the child through these stages.
  • Discuss Figure 21-2, page 474. Audience Response Question #1 A 7-year-old is in the hospital following an appendectomy. The nurse assesses him for pain using the face scale. He points to the 0 face indicating no hurt, but the nurse notices he is grimacing and guarding the operative site. What would be the best action for the nurse to take? 1. Note that the child is pain free. 2. Reposition the child. 3. Attempt assessment using another tool. 4. Medicate immediately for pain as ordered.
  • What are examples of distraction, imagery, and relaxation techniques?
  • Discuss the importance of proper dosage calculations for the pediatric patient.
  • Discuss the nurse’s role in monitoring and relieving pain.
  • Discuss the proper administration method for naloxone. How is EMLA cream used? Discuss the use of PCAs and signs/symptoms to monitor in the child.
  • Give examples of regressive behavior.
  • How might the nurse adjust his or her approach when caring for the cultural needs of the child? Discuss positive and negative body language cues.
  • In what ways can a nurse support the family and involve them in the care of the hospitalized child?
  • Discuss communication techniques that can be used by the nurse to manage parents who exhibit anger or avoidance.
  • Give an example of a scenario in which a parent is providing too much and too detailed information to a child and how the nurse can manage this situation.
  • Discuss the nurse’s role and rationale for obtaining this information.
  • Discuss which disciplines can be involved in the clinical pathway.
  • Give an example of a nursing intervention involving play.
  • Discuss nursing interventions in which the nurse assists the parents and infant in sensorimotor activities. Discuss the importance and rationale for liberal visiting hours. What is the rationale for consistency of caregivers for this population?
  • Give an example of the difference between how a toddler might perceive a hospitalization versus a school-age child.
  • How can the nurse obtain the toddler’s trust? Give an example of a soothing technique and play intervention for a toddler who has experienced a threatening situation.
  • Discuss the rationale for preparing and explaining the procedure just prior to performing it. How can a toddler’s emotions be supported when restrained for a procedure?
  • Discuss the preschooler’s ability to think concretely and give an example. Give an example of how a preschool child might misinterpret what a nurse or physician has told him or her.
  • Give an example of behavior exhibiting industry and independence. Give an example of body language which exhibits fear while the child is attempting to be brave.
  • Discuss how body image is very important to this population.
  • Discuss a situation in which an adolescent is in a room with a toddler and the issues this could cause.
  • How might the nurse approach an adolescent and obtain his or her confidence? Discuss laws in your region regarding parental authority which might affect this population.
  • Discuss the rationale for documenting this information.
  • Chapter 21 Power Point

    1. 1. Chapter 21Chapter 21 The Child’s Experience ofThe Child’s Experience of HospitalizationHospitalization
    2. 2. ObjectivesObjectives • Identify various health care delivery settings. • Describe three phases of separation anxiety. • List two ways in which the nurse can lessen the stress of hospitalization for the child’s parents. • Discuss the management of pain in infants and children. 2Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    3. 3. ObjectivesObjectives (cont.)(cont.) • Describe two milestones in the psychosocial development of the preschool child that contribute either positively or negatively to the adjustment to hospitalization. • Contrast the problems of the preschool child and the school-age child facing hospitalization. • Identify two problems confronting the siblings of the hospitalized child. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 3
    4. 4. ObjectivesObjectives (cont.)(cont.) • List three strengths of the adolescent that the nurse might use when formulating nursing care plans. • Organize a nursing care plan for a hospitalized child. • Recognize the steps in discharge planning for infants, children, and adolescents. • Interpret a clinical pathway for a hospitalized child. 4Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    5. 5. Outpatient ClinicOutpatient Clinic • Eliminates the need to separate the child from the family so that the treatment and the emotional impact of the illness are reduced • Types – Private office or hospital-affiliated – Satellite – Pediatric research centers – Outpatient surgery centers 5Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    6. 6. Outpatient ClinicOutpatient Clinic (cont.)(cont.) • Promoting a positive experience – Attitude of personnel child comes in contact with is of the utmost importance – For many children, the only exposure to health care is through brief clinic appointments 6Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    7. 7. Preparing the Child for a TreatmentPreparing the Child for a Treatment or Procedureor Procedure • Infants – Involve parents – Include familiar objects – Soothe, distract, and hug afterward 7Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    8. 8. Preparing the Child for a TreatmentPreparing the Child for a Treatment or Procedureor Procedure (cont.)(cont.) • Toddlers and preschoolers – Involve parents – Offer simple explanations – Give permission to express discomfort – Offer one direction at a time – Allow for choices, if possible – Use distraction – Hug after treatment or procedure 8Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    9. 9. Preparing the Child for a TreatmentPreparing the Child for a Treatment or Procedureor Procedure (cont.)(cont.) • School-age child – All of the previous preparations, plus • Let them examine equipment • Encourage child to verbalize fears • Offer small reward after treatment or procedure, a sticker, for example 9Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    10. 10. Preparing the Child for a TreatmentPreparing the Child for a Treatment or Procedureor Procedure (cont.)(cont.) • Adolescent – Provide privacy – Involve teen in treatment or procedure – Explain treatment or procedure and equipment – Suggest coping techniques 10Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    11. 11. HomeHome • Not only a matter of supplying appliances and nursing care • Includes assessment of the total needs of children and their families • Hospice care can also be provided in the home • Changes in health care delivery affect the role and responsibilities of the nurse • The various home and support groups that are available have the potential for improving life for the child and family and help reduce the cost of medical care 11Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    12. 12. Children’s Hospital UnitChildren’s Hospital Unit • Designed to meet the needs of the child and parents • Special treatment room for child to be examined or receive some form of treatment • Playrooms for the children are also available • Daily routine emphasizes parent rooming-in • Provision of consistent caregivers • Flexible schedules to meet the needs of the growing child 12Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    13. 13. The Child’s Reaction toThe Child’s Reaction to HospitalizationHospitalization • Depends on – Age – Amount of preparation given – Security of home life – Previous hospitalizations – Support of family and medical personnel – Child’s emotional health 13Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    14. 14. The Child’s Reaction toThe Child’s Reaction to HospitalizationHospitalization (cont.)(cont.) • The major causes of stress for children of all ages are – Separation – Pain – Fear of body intrusion • This is influenced by – Developmental age – Maturity of parents – Cultural and economics – Religious background – Past experiences – Family size – State of health on admission – Other factors 14Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    15. 15. Cultural ConsiderationsCultural Considerations • Familiar rituals and routines must be incorporated into the plan of care for a hospitalized child 15Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    16. 16. Separation AnxietySeparation Anxiety • Occurs in infants age 6 months and older • More pronounced in toddlers • Three stages – Protest – Despair – Denial or detachment Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 16
    17. 17. PainPain • Pain is whatever the person says it is – May be verbally or nonverbally expressed • The fifth vital sign and is assessed and recorded with routine documentation • Patients in pain secrete higher levels of cortisol, have compromised immune systems, experience more infections, and show delayed wound healing 17Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    18. 18. Four Pain AssessmentFour Pain Assessment Tools for ChildrenTools for Children 18Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    19. 19. Two Additional PainTwo Additional Pain Assessment ScalesAssessment Scales • PICIC (Pain Indicator for Communicatively Impaired Children) – Crying with or without tears – Screaming or groaning – Distressed facial expression – Tense body – Irritability to touch • FLACC – Face: grimace – Legs: restless to kicking – Activity: quiet to arched – Crying: moan to scream – Consolability: touch to inconsolable Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 19
    20. 20. PainPain (cont.)(cont.) • Children sometimes refrain from reporting pain for fear they will receive an injection • Infants should be assessed according to a behavior scale • In toddlers, crying may be caused by anxiety and fear rather than pain • All factors related to pain should be considered 20Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    21. 21. Managing PainManaging Pain • Nonpharmacological techniques – Drawing – Distraction – Imagery – Relaxation – Cognitive (thinking) strategies – Backrub or hand massage 21Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    22. 22. Drug PhysiologyDrug Physiology • Elimination of the drug may be prolonged because of an immature liver enzyme system • Dosages are influenced by weight and differences in expected absorption, metabolism, and clearance 22Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    23. 23. Drugs Used for Pain ReliefDrugs Used for Pain Relief • Acetaminophen—mild to moderate pain – Can lead to liver failure if not dosed correctly • Nonsteroidal antiinflammatory drugs (NSAIDs)—mild to moderate pain • Opioids—moderate to severe pain – Used for long periods of time – Tolerance and respiratory depression can occur 23Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    24. 24. Drugs Used for Pain ReliefDrugs Used for Pain Relief (cont.)(cont.) • Providing adequate pain relief enables patients to focus on their surroundings and other activities • Inadequate pain relief causes the patient to focus on the pain and when more medications will be given to stop the pain • More effective pain relief at lower dosages of the analgesic around the clock, referred to as preventive pain control 24Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    25. 25. Drugs Used for Pain ReliefDrugs Used for Pain Relief (cont.)(cont.) • Fentanyl – Naloxone (Narcan)—used in case of opioid overdose • Local anesthetics (e.g., EMLA cream) • Patient-controlled analgesia (PCA) – Child must be 7 years of age or older 25Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    26. 26. Conscious SedationConscious Sedation • The administration of IV drugs to a patient to impair consciousness but retain protective reflexes, the ability to maintain a patent airway, and the ability to respond to physical and verbal stimuli • A 1:1 nurse-patient ratio is continued until there are stable vital signs, age-appropriate motor and verbal abilities, adequate hydration, and a presedation level of responsiveness and orientation 26Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    27. 27. FearFear • Intrusive procedures are fear-provoking • Disrupts child’s trust level • Threatens self-esteem and self-control • May require restriction of activity 27Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    28. 28. RegressionRegression • The loss of an achieved level of functioning to a past level of behavior that was successful during earlier stages of development • Can be minimized by an accurate nursing assessment of the child’s abilities and the planning of care to support and maintain growth and development • When the child is free from the stress that caused the regression, praise will motivate the achievement of appropriate behavior 28Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    29. 29. Cultural NeedsCultural Needs • Showing cultural sensitivity decreases anxiety • Effective utilization of health care service and compliance with treatment plans are enhanced when the nurse’s approach is compatible with cultural needs and beliefs • Nonverbal cues and body language are important in intercultural communication 29Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    30. 30. Cultural NeedsCultural Needs (cont.)(cont.) • Crying may be interpreted by some cultures as a signal of an organic upset of illness • One cultural group may prize autonomy and initiative while others may tolerate only complete obedience • Respecting cultural and religious beliefs will enhance compliance • Assess family through the eyes of its culture to avoid labeling a family who is “different” as dysfunctional 30Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    31. 31. Fostering InterculturalFostering Intercultural CommunicationCommunication • Approaches to various cultures involve knowing what is and is not acceptable as it relates to – Personal space – Smiling – Eye contact – Touch – Focus • It is important for the nurse to take the time to become familiar with culturally acceptable behaviors 31Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    32. 32. The Parents’ Reactions to theThe Parents’ Reactions to the Child’s HospitalizationChild’s Hospitalization • May believe they are to blame for their child’s illness • Immunizations may have been neglected • Guilt, helplessness, and anxiety • Parents are seldom the direct cause for hospital admission • The nurse listens carefully to parental concerns and acknowledges the legitimacy of their feelings • Encourages and supports parents and other family members, stresses their importance to the child’s recovery • Encourages their participation in the care of the child 32Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    33. 33. The Parents’ Reactions to the Child’sThe Parents’ Reactions to the Child’s HospitalizationHospitalization (cont.)(cont.) • Parents may ventilate their feelings and stresses through anger, crying, or body language • Behavior often involves attitudes resulting from early childhood experiences • An understanding and acceptance of people and their problems is essential for the successful pediatric nurse • Poor communication can result in unnecessary fear 33Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    34. 34. The Nurse’s Role in HospitalThe Nurse’s Role in Hospital AdmissionAdmission • Must be prepared to meet the emotional needs of those involved • Parents should try to be as matter-of-fact as possible about this new experience for their child • It is not necessary to go into great detail with the child about what is going to happen as it may increase the child’s anxiety 34Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    35. 35. Developmental HistoryDevelopmental History • Family relationships and support systems • Cultural needs that may affect care and hospital routine • Nicknames, rituals, routines • Developmental level and abilities • Communication skills • Personality, adaptability, coping skills • Past experiences, divorces, new siblings, extended family • Previous separation experiences • Impact of current health problem on growth and development • Preparation given to the child • Previous contact with health care personnel 35Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    36. 36. Developing a PediatricDeveloping a Pediatric Nursing Care PlanNursing Care Plan • Result of nursing process • States specifically what is to be done for each child • Keeps the focus on the child and not on the condition or therapy • Involves growth and development process; evaluation of the primary caregiver, who has a direct role in the safety and maintenance of the child’s health 36Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    37. 37. Clinical PathwaysClinical Pathways • Interdisciplinary plan of care • Displays progress of entire treatment plan • Nursing care plan focuses on the nurse’s role • Clinical pathway focuses on the team’s approach to outcomes of care 37Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    38. 38. Developmental Nursing TipsDevelopmental Nursing Tips • Play is an important part of a nursing care plan for children • The achievement of developmental tasks should be part of the plan of care for the hospitalized child 38Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    39. 39. Needs of the Hospitalized ChildNeeds of the Hospitalized Child 39Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    40. 40. The Hospitalized InfantThe Hospitalized Infant • Can be frustrating for the infant • Used to getting what they want when they want it • May miss continuous affection of their parents • Daily schedules are disrupted • Nurse must try to meet the needs of the infant while preventing excess frustration • Major goal is to assist parent-infant attachment process and promote sensorimotor activities • Liberal visiting hours are essential • Consistency in caregivers is important at this stage of development 40Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    41. 41. The Hospitalized ToddlerThe Hospitalized Toddler • Their world revolves around their parents, especially their primary caregiver • Cannot understand why they are separated from their caregiver and become distressed • Cohesive staff is essential to meet the needs of the children and their parents 41Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    42. 42. Nursing Goals of the HospitalizedNursing Goals of the Hospitalized ToddlerToddler • Reassure parents, particularly the child’s primary caregiver • Maintain the toddler’s sense of trust • Incorporate home habits into care plans • Allow the child to work through or master threatening experiences through soothing techniques and play • Provide individualized, flexible nursing care plans in accordance with the child’s development and diagnosis Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 42
    43. 43. Nursing Goals of the HospitalizedNursing Goals of the Hospitalized ToddlerToddler (cont.)(cont.) • Children should be forewarned about any unpleasant or new experience that they may need to undergo • Preparation and explanation are done immediately before the procedure – Crying and protestations are healthy expressions and relieve tension • When restraint is indicated (splints, IV therapy, large dressings), increased emotional support should be provided Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 43
    44. 44. The Hospitalized PreschoolerThe Hospitalized Preschooler • Fear of bodily harm • Magical thinking and fantasy • Concrete thinking, may be better able to understand what is happening • Explanations must be realistic, clear, understandable, and truthful • Children who ask questions should be complimented and listened to; any misinterpretations should be corrected • Teach parents that upon discharge that the child may be demanding and irritable Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 44
    45. 45. The Hospitalized School-Age ChildThe Hospitalized School-Age Child • Stage of industry and independence • Forced dependency in the hospital can result in a feeling loss of control and security • Can participate in own care and make simple choices to foster their feelings of independence • Common for this age to be “brave” and to show little, if any, fear in situations that are actually quite upsetting • Observe body language Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 45
    46. 46. Safety AlertSafety Alert • Observation of nonverbal clues such as facial grimaces, squirming, and finger tapping is important in determining the need for pain relief and support for the child 46Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    47. 47. The Hospitalized AdolescentThe Hospitalized Adolescent • Experience feelings of loss of control during hospitalization • May cause adolescent to withdraw, be noncompliant, or display anger • May be concerned with how the illness will affect their appearance • Incorporating choice, privacy, and the opportunity for peer visitors is important 47Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    48. 48. Adjustment to IllnessAdjustment to Illness • Can understand the implications of their disease • Are capable of participating in decisions related to treatment and care • The nurse who recognizes these skills and encourages their practice helps the adolescent gain confidence 48Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    49. 49. Roommate SelectionRoommate Selection • Adolescents usually do better with one or more roommates • It is not a good choice to have a senile patient or infant as a roommate for the adolescent patient • Location of adolescent’s room is important 49Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    50. 50. Confidentiality and LegalityConfidentiality and Legality • Many problems can be avoided if the confidentiality of the relationship is clearly defined during initial meetings • An emancipated minor is no longer under the parent’s authority • Be familiar with state law as it applies to adolescent patients 50Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    51. 51. Discharge PlanningDischarge Planning • Ideally begins at the moment of admission to hospital • Written instructions should be given for any home treatments • Parents also must be prepared for behavioral problems that may arise after hospitalization 51Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    52. 52. Guidance for ParentsGuidance for Parents • Anticipating behaviors such as clinging or regression • Allowing the child to become a participating family member as soon as possible • Taking the focus off the illness • Being kind, firm, and consistent with misbehavior • Building trust by being truthful • Allowing time for free play 52Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    53. 53. Legal and Ethical ConsiderationsLegal and Ethical Considerations • Discharge charting should include who accompanied the child (and identification given), time of discharge, behavior and condition of the child, method of transportation, vital signs and weight, medications, and instructions given to the parents or caregiver 53Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    54. 54. Home CareHome Care • Children with acute or chronic conditions are cared for in the home • Home health care and other community agencies work with the family to provide holistic care • Respite care can be provided for the primary caregivers 54Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
    55. 55. Home CareHome Care (cont.)(cont.) • The health care worker in the home should – Observe how the parents interact with the child – Observe facial expressions and body language – Listen to the parents and observe how they attend to the physical needs of the child – Ask questions or discuss apprehensions the parents may have – Be attuned to the needs of other children in the home – Explore community facilities or support groups available Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc. 55
    56. 56. Question for ReviewQuestion for Review • What is the difference between a nursing care plan and a clinical pathway? 56Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.
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