Pediatric Nursing_Week 1_Spring 2025_120624_SV.pptx

N360 Hunter Pediatric Course PresentationA pediatric nursing course is designed to prepare nursing students to provide specialized care for infants, children, and adolescents. The course integrates developmental, physiological, and psychological aspects of pediatric health and illness, emphasizing family-centered care. Below is a detailed breakdown of what you can expect in a pediatric nursing course:
2. Key Topics Covered
A. Growth and Development
Neonates (0-28 days): Reflexes, feeding patterns, thermoregulation.
Infants (1 month - 1 year): Milestones, immunization schedule, nutrition.
Toddlers (1-3 years): Language development, toilet training, injury prevention.
Preschoolers (3-5 years): Cognitive and social development, school readiness.
School-age children (6-12 years): Psychosocial development, peer relationships.
Adolescents (13-18 years): Puberty, identity formation, risk-taking behaviors.
B. Pediatric Assessment
Head-to-toe assessment in children (differences from adults).
Vital signs (normal ranges vary by age).
Pain assessment using age-appropriate scales (FLACC, Wong-Baker, Numeric).
C. Pediatric Disease Conditions
Respiratory disorders: Asthma, bronchiolitis, pneumonia, cystic fibrosis.
Cardiac conditions: Congenital heart defects, Kawasaki disease.
Neurological disorders: Seizures, meningitis, cerebral palsy.
Gastrointestinal disorders: GERD, pyloric stenosis, intussusception.
Endocrine conditions: Diabetes mellitus type 1, congenital hypothyroidism.
Hematologic disorders: Sickle cell anemia, hemophilia, leukemia.
Infectious diseases: Measles, mumps, rubella, chickenpox.
Mental health concerns: Autism spectrum disorder, ADHD, eating disorders.
D. Pediatric Pharmacology
Medication administration (oral, IV, IM, subcutaneous).
Weight-based dosing calculations (mg/kg).
Common pediatric medications (antibiotics, analgesics, vaccines).
Parenteral nutrition and fluid management.
E. Pediatric Emergency & Critical Care
Pediatric Advanced Life Support (PALS) basics.
Recognizing signs of deterioration (early vs. late signs).
Shock, dehydration, respiratory distress management.
F. Family-Centered Care & Communication
Parental involvement in care decisions.
Therapeutic communication with children at different developmental stages.
Cultural considerations in pediatric care.
G. Ethical and Legal Issues in Pediatric Nursing
Informed consent for minors.
Mandatory reporting of abuse and neglect.
Palliative care and end-of-life considerations in pediatrics.
3. Clinical Component
Hands-on experience in pediatric hospital units, clinics, or community settings.
Performing assessments and interventions under supervision.
Case study discussions based on real pediatric patients.
Simulation labs to practice pediatric emergencies (CPR, airway management).
4. Teaching and Learning Methods
Lectures and online modules.
Case studies and group discussions.
Simulation labs for hands-on skills.
Clinical rotations in pediatric settings.
Exams, quizzes, and NCLEX-sty

1. Nursing Care of Infants, Children, & Adolescents Week 1 Ellen M. McCabe PhD, PNP-BC, RN, NCSN, FNASN

2. Let’s talk about the course Syllabus Assignments Please read through carefully and note important dates

3. Today’s Major Objective and Methods of instruction Methods of instruction: Lecture, dialogue, case studies, questions, and course reading.

4. Behavioral Assessment

5. Growth and Development

6. Pediatric Developmental Stages Infancy (1-12 months) Toddlerhood (1 – 3 years) Preschool (3 – 6 years) School-aged (6 – 12 years) Adolescence (13 – ≈21 years)

7. Newborn and infant objectives 1. Describe normal physical growth, physiologic changes, and sensory development in the newborn and infant. 2. Identify the gross and fine motor milestones of the newborn and infant. 3. Examine normal language development in the first year of life. 4. Examine common issues related to growth and development in infancy. 5. Demonstrate knowledge of appropriate anticipatory guidance for common developmental issues.

8. What are growth and development?

9. Basic Principles of Growth and Development

10. Major Developmental Theories Focusing on Piaget (Cognitive) & Erikson (Psychosocial) today. Specifics discussed in each of the developmental stages With each theory: Note how abilities change over time Consider how changes might affect illness presentation, self care, academic and social abilities How might you assess whether a child has met milestones? How might developmental stage affect your approach? How might developmental stage affect patient teaching?

11. Nursing Process Related to Growth and Development

12. Developmental Disabilities Include cerebral palsy, autism spectrum disorders, down syndrome (aka Trisomy 21), and many others Are common (approximately 1 in 6 children) Can be subtle in their presentation Respond to early intervention Require surveillance and screening for early identification and intervention Check out this video from the American Academy of Pediatrics

13. CDC’s: Learn the Signs. Act Early.

14. If developmental delay suspected or parents are concerned or if they have an infant with special needs Refer to local early intervention from birth to 36 months In NYC parents can call 311 to request an EI (early intervention) assessment

15. Temperament Person’s typical way of reacting. Relatively constant through life (i.e., doesn’t change with developmental stages)

16. Infancy (1 – 12 Months) More change in physical size, motor abilities, and cognitive skills than any other period of life!

17. Infant Growth

18. Premature Infants

19. Nutrition Nutrition is the single most important influence on growth in infancy! Use this cite to review current recommendations regarding prescription medications and breastfeeding: Updated February 2024

20. Nutrition Introduction of solid foods: When is this supposed to happen? Loss of extrusion reflex ≈ 4 months- What does that mean? In helping parents choose foods, consider choking safety and nutritional density over strict rules on food types and which order. Old school rules recommend starting this way: Cereal to fruit/vegetables to meat NO SOLIDS IN BOTTLE!

21. Crying It’s what babies do Most pronounced 2 weeks to 3-5 months Frustrating but can be completely normal Parents need lots of reassurance. http://www.purplecrying.info Period of Purple Crying

22. Development: Cognitive and Psychosocial Piaget’s Sensorimotor Period (Cognitive): Begin life by reflexively responding to the world, then gradually develop more complex, focused responses. Develop object permanence- what does this mean? Erikson’s Trust vs Mistrust (Psychosocial): Developing a sense that the self and the world is good . Do all babies develop trust? If not, why might some babies develop mistrust?

23. Attachment Development is relational. Our view of the world is shaped by the care we receive in infancy Infants are 100% dependent on their caregivers. Caregivers must meet physical and emotional needs in a timely, consistent, and loving way. Nurses support the caregiver’s ability to relate to child and child’s needs, and to meet those needs.

24. Nursing Implications of Attachment Consider impaired parenting, Risk for impaired parent-child attachment: Parents reluctant to touch or hold the child; only do so when feeding or changing the child's diaper Parents do not readily comfort the child Parents are reluctant to talk to or interact with the child Parents have minimal eye contact with the child

25. Infancy Milestones Let’s talk about sleep! Include SIDS

26. By 2 Months Social/Emotional: Smiles at people Tries to look at parent Language/Communication: Coos, makes gurgling sounds Turns head toward sounds Cognitive: Pays attention to faces Begins following things with eyes, recognizes people Motor: Can hold head up and begin pushing up when lying prone Making smoother movements with extremities

27. When to Seek Further Assessment 2 Months Seek further assessment if the baby: Doesn’t respond to loud sounds (e.g., a clap) Doesn’t watch things as they move Doesn’t smile at people Doesn’t bring hands to mouth Can’t hold head up up when pushing up from a prone position

28. Communicating with Infants Share some suggested communication approaches recommended by our text For example, do we talk to babies? Why or why not? When do we prepare infants for procedures?

29. By 4 Months Social/Emotional: Smiles spontaneously, especially at people Likes to play with people Copies facial expressions, movements Language/Communication: Begins babbling Different cries for hunger, pain, fatigue

30. By 4 Months Cognitive: Lets you know they are happy or sad Responds to affection Reaches for toy with one hand Follows moving things with eyes from side to side Recognizes familiar people and things (e.g., fave toy!) at a distance Motor: Head is steady, No head lag Pushes down on legs when feet are on a hard surface Rolls tummy to back Brings hands and objects to mouth

31. When to Seek Further Assessment 4 Months Seek further assessment if the baby: Still can’t do things on the prior list Can’t hold head steady Doesn’t coo or make sounds Doesn’t bring things to mouth Doesn’t push down with legs when feet on hard surface Has trouble moving one or both eyes in all directions

32. By 6 Months Social/Emotional: Knows familiar face, knows if someone’s a stranger Responds to other people’s emotions, often seems happy Likes looking at self in mirror Language/Communication: Responds to sounds by making sounds, copying sounds Begins stringing vowel sounds together Responds to own name Makes sounds to show joy, pleasure Begins saying consonant sounds (jabbering with m, b, or d sounds)

33. By 6 Months Cognitive: Looks around at nearby things- follows 180 degrees Shows curiosity about things and tries to get things out of reach Begins passing things from one hand to other Motor: Rolls over in both directions Sits without support, leaning forward on hands When standing, supports weight on legs and might bounce

34. When to Seek Further Assessment 6 Months Seek further assessment if the baby: Still can’t do things on the prior list Doesn’t try to get things out of reach Shows no affection for caregivers Doesn’t respond to sounds, activity around them Trouble getting things to mouth Doesn’t make vowel sounds, laugh, or make squealing sounds Doesn’t roll over in either direction Seems stiff, tight muscles Seems floppy, like a rag doll

35. By 9 Months Social/Emotional: “Height” of stranger anxiety Increased separation anxiety, may be clingy with familiar adults Has favorite toys Language/Communication: Understands “no” First words with meaning (Dada, Mama, bye-bye, baby) Uses finger to point at things Can obey simple commands (Wave bye-bye)

36. By 9 Months Cognitive: Looks for things he sees you hide (Object Permanence!) Plays peek a boo Puts things in mouth Can smoothly move things from one hand to the other Motor: Picks up things like cereal o’s between thumb and index finger (pincer) Stands, holding on Pulls to stand Can get into sitting position & Sit without support Crawls

37. When to Seek Further Assessment 9 Months Seek further assessment if the baby: Still can’t do things on the prior list Doesn’t bear weight on legs with support Doesn’t sit with help Doesn’t babble, hasn’t said first words (Dada, mama) Doesn’t play back and forth games, like peek a boo Doesn’t recognize their name or familiar people Doesn’t look where you point Doesn’t transfer toys from one hand to the other

38. By 12 Months Social/Emotional: Shy or nervous with strangers Cries when caregiver leaves Favorite things and people Hands you a book when wants to hear a story Repeats sounds or actions to get attention Puts out arm or leg to help when dressing Language/Communication: Responds to simple spoken requests Uses simple gestures, like shaking head “no” or waving ”bye” Has 2 or more words + Dada, Mama Tries to imitate words you say

39. By 12 Months Cognitive: Explores things in different ways (shake, bang, throw) Finds hidden things easily Looks at the right picture or thing when it’s named Can let things go without help Can put things in and take things out of a container Motor: Pulls up to stand, walks holding on (Cruises), may stand or take a few steps without holding on. DOES NOT NEED TO WALK BY 12 MONTHS! Can feed self with fingers and spoon Can hold crayon to mark on paper

40. When to Seek Further Assessment 12 Months Seek further assessment if the baby: Still can’t do things on the prior list Doesn’t crawl Can’t stand when supported Doesn’t search for things he sees you hide Doesn’t learn gestures (waving, giving 5, shaking hand) Doesn’t point to things Loses skills he once had

41. Health Promotion Continuing Assessment Questions Nutrition: How much is the child eating, how often, what? Elimination: How many wet diapers, stools? Consistency of stools? How is the family adjusting to the baby? Has there been any change in the household or family’s lifestyle? Are there any financial or other concerns making it difficult to meet the family’s needs? Offer tips/advice on approaching child for physical exam

42. Anticipatory Guidance for Safety Aspiration/choking prevention- babyproofing, no bottle propping Falls- Babies can’t even walk. Why is this a big deal? Smoking- never around baby or in the home Motor vehicle accidents: Car seat 100% of time Poisoning- Med inaccessible location, in child-proof bottles Drowning- Never alone in bathtub even for 1 second Burns- test food and water, extra care with microwave Managing caregiver frustration and anger- Putting baby in crib and walking out of the room for a few minutes when needed

43. Toddler Objectives

44. Toddler (1 to 3 Years) Physical growth slows Rapid advances in psychosocial and cognitive development Growing sense of autonomy, developing point of view

45. Toddler Growth Growth in spurts, not linear Affects appetite, which can be highly variable Average weight gain1.4-2.3 kg (3-5#) per year Length/height increases average 3 inches per year Pillitteri, 2009 No! Want that! Mine!

46. Development: Cognitive and Psychosocial Piaget’s Preoperational Thought (extends through preschool) Egocentric Thinking- Unable to take another’s point of view Magical thinking and animism- What do these mean? Erikson’s Autonomy vs Shame and Doubt : Sense of control over self/bodily functions, exerts own point of view How does this relate to what many toddlers learn to do during this period?

47. Toddler Milestones

48. By 18 months Social/Emotional: Likes to hand things to others as play May develop temper tantrums Shows affection to familiar people Simple pretend play, like feeding a doll May cling to caregiver in new situations Points to show others something interesting Explores alone but with parent close by Language/Communication: Says several single words Says and shakes head “no” Points to indicate what he wants

49. By 18 months Cognitive: Knows what ordinary objects are for (phones, spoons, brushes) Shows interest in doll or stuffy by pretending to feed it Points to at least one body part Scribbles on own Can follow 1 step verbal command (like “sit down”) without gestures Motor (consider fine and gross motor) Walks alone May walk up steps May run Can pull toys while walking Can undress self

50. When to Seek Further Assessment 18 Months Seek further assessment if the baby: Can’t walk Doesn’t point to show things to others Doesn’t know what familiar things are for Doesn’t copy others Doesn’t gain new words or have >=6 words Doesn’t notice or seem to mind when caregiver leaves or returns Loses skill he once had

51. By 24 months Social/Emotional: Copies others, esp. adults and older kids Gets excited around other kids More and more independence Shows defiant behavior Language/Communication: Points to things or pictures when named Knows names of familiar people and body parts Says 2-4 word sentences Follows simple instructions

52. By 24 months Cognitive: Begins to sort shapes and colors Completes sentences and rhymes in familiar books Plays simple make-believe games Builds towers of 4 or more blocks Follows two-step instructions such as “Pick up your shoes and put them in the closet.” Motor: Runs, Kicks a ball, climbs stairs, climbs on and off chairs/couches without help Fine: Utensils- yes!

53. When to Seek Further Assessment 24 Months Seek further assessment if the baby: Doesn’t use 2-word phrases Doesn’t know what to do with common things Doesn’t copy actions or words Doesn’t follow simple commands Doesn’t walk steadily Loses skills he once had

54. Play Children relate to and learn about the world through play Infants: Play alone or with caregiver Toddlers: Parallel play Preschoolers: More interactive; no group goals or rigid rules. Each child acts according to own wishes. May have an imaginary friend. Toddlers and Preschoolers enjoy imitating household chores and adult actions

55. Communicating with toddlers These tricks work for preschoolers too 

56. (Pillitteri, 2009)

57. Toddler Health Promotion Daily activities Routines offer a sense of control over a big world Encouragement of appropriate levels of independence: Invest time in helping kids learn self care- feeding, dressing Sleep- 1-2 naps a day Meals Appetite slows Small frequent meals What foods to avoid (think about choking)?

58. Health Promotion: Common Parental Concerns Normal Negativism: I am an individual! Refusing to accept help is not refusing love Separation anxiety Temper tantrums- assess patterns, prevention (routine, adequate sleep and food), management DISCIPLINE: Important from now through adolescence! What’s the difference between discipline & punishment? Consistency, positive reinforcement, redirection Provide limited choices in which all answers are ok. Do not give a choice if there is not one.

59. Anticipatory Guidance Encourage autonomy while maintaining consistent safety rules & constant supervision! Accidental ingestions Burn prevention Drowning Car seat use Animal safety Toilet training Screen time limits

60. Lead Poisoning What are common causes of lead poisoning? Who is most at risk? Can be inhaled or ingested As low as 10 mcg/dL can cause learning/behavioral problems New York State law: Blood test at 12 & 24 months; risk assessment 6 months - 6 years Venous blood sample preferred

61. Preschooler objectives 1. Describe normal physical growth, physiologic changes, and sensory development in the preschooler. 2. Examine psychosocial, cognitive, social/emotional, and moral/spiritual development in the preschooler. 3. Identify the gross and fine motor milestones of the preschooler. 4. Explain normal language development in the preschool years. 5. Provide appropriate anticipatory guidance for common developmental issues that arise in the preschool period.

62. The Preschooler (3 to 6 years) Slowed physical growth Rapid personality and cognitive growth Language explodes!

63. Preschool Growth Average weight and height gains similar to toddlerhood Average weight gain 2.25 kg (5#) per year Length/height increases average 3 inches per year (Pillitteri, 2009)

64. Development: Psychosocial Erikson’s Initiative vs Guilt: Develops a “can do” attitude; behavior becomes goal directed, competitive, and imaginative What might you see in a child who is not mastering this stage? How can parents and health care providers promote mastery of this stage?

65. Preschool Milestones

66. By 3 Years Social/Emotional: Copies adults and friends Shows affection for friends without prompting, concern for crying friends Takes turns in games Wide range of emotions Separates easily from caregiver (such as at pre-K drop off) May get upset with major routine changes Dresses and undresses self

67. By 3 Years Language/Communication: Follows 2 or 3 step instructions Can name most familiar things Understands location words, like in, on, under Says first name, age, sex Names a friends Speaks clearly enough for strangers to understand most of the time Carries on conversations of 2 or 3 sentences

68. By 3 Years Cognitive: Can work toys with buttons, levers or moving parts, large jars lids, door handles Plays make-believe with dolls, animals, people Can do puzzles with 3 or 4 pieces Copies a circle Turns book pages one at a time Builds a tower of >6 blocks Motor: Climbs well, runs easily, pedals trike

69. By 5 Years Social/Emotional: Wants to please friends, be like friends Likes to sing, dance, act Is aware of gender Can tell what’s real and make believe More independence (though still need a lot of supervision) Language/Communication: Can tell simple stories Can say full name and address

70. By 5 Years Cognitive: Counts 10 or more things Can draw a person with >=6 body parts Can print some letters and numbers Copies triangles and other shapes Motor: Can stand on one foot for 10 sec or longer Hops, may be able to skip (even by age 4 the child will try and kick ball forward and hop on one foot) Can independently toilet Swings, climbs

71. When to Seek Further Assessment 5 Years Seek further assessment if the child: Doesn’t show wide range of emotions Extreme behavior (unusually fearful, aggressive, shy, sad, withdrawn) Easily distracted, trouble focusing on non-screen activity for >5 min Doesn’t respond to people or responds only superficially Can’t tell what’s real and make-believe Can’t give first and last name Doesn’t draw pictures Can’t do basic self care (brush teeth, wash hands, get dressed) Loses skills he once had

72. If you suspect a delay in child greater than 3 years Refer for services through the local school district In NYC: NYC Department of Education

73. Communicating with Preschoolers

74. School age child objectives 1. Identify normal physiologic, cognitive, and moral changes occurring in the school-age child. 2. Describe the role of peers and schools in the development and socialization of the school-age child. 3. Identify the developmental milestones of the school-age child. 4. Identify common developmental concerns in the school-age child. 5. Demonstrate knowledge of the appropriate nursing guidance for common developmental concerns.

75. The School-Age Child (6-12 years)

76. Growth Gain an average of 2.5kg (5.5#) year Grow an average of 1-2 inches/year Boys and girls begin this stage approximately the same size By approx. 10-12 years, girls have begun pubertal growth spurt. Generally thinner and more graceful than preschoolers More mature respiratory system = fewer URIs! When examining kids this age include them in all aspects of the physical examination

77. Development: Cognitive Piaget’s Concrete Operations (starts around 7 yrs.) Thinking becomes more systematic and logical, less magical Reduced egocentrism ; Understand others have own point of view Concrete objects and activities are needed for learning, still unable to handle abstraction Better concept of time Increased language and logical ability can lead to great sense of humor!

78. Development: Psychosocial Erikson’s Industry vs. Inferiority Mastering useful skills, learning how to play and work with others, competence in age-appropriate tasks across contexts (Home, School, Extracurricular activities) Why do we need to care about this as nurses? How can we support industry?

79. Pillitteri, 2009

80. School-Aged Milestones

81. School-Aged Milestones Social/Emotional: Develops positive self-esteem through skill acquisition Peer group becomes primary socializing force. Loves cooperative play, group games. Strong sense of fairness and justice Language & Cognition: Vocabulary expands Appreciates play on words, puns, jokes Improved long-term memory; can use memory strategies to support schoolwork Organizes and classifies concepts mentally Motor: Ties shoelaces, buttons and zips clothing independently; can print, draw and color well, cuts with scissors; improved muscle mass and coordination allows for expanded sports participation

82. Communicating with School-Aged Children Explain using photographs, books, diagrams, charts, videos Explanations can be longer due to longer attention span Engage in conversations that encourage critical thinking Introduce preparatory materials 1-5 days in advance of the event Video https://kidshealth.org/en/kids/asthma.html?WT.ac=ctg#catallergy

83. Online Resources for Pediatric Patient Education Kids Health Pediatric Patient Education_AAP American Academy of Pediatrics Bright Futures

84. Health Promotion Safety Being alone- when is this ok? Street safety, Seat belts, helmets Encourage family conversations around: Screen time & Computer safety Smoking, ETOH, drugs Sexual self care, reproductive physiology, puberty and menstruation, Reinforce: Your body is your own; issues of consent- tell a parent or trusted adult if someone touches you in a way you don’t like, even if they tell you it is a secret Nutritional health: Establishing lifelong healthy eating patterns, Fostering independence in food choices

85. Health Promotion Reassess discipline: How do you correct Johnny when he does something wrong? School functioning is a critical health indicator: How is Johnny doing in school? Have the teacher or principal ever called to discuss anything? Can Johnny read? Fostering independence: What does the child do for his or herself? Does the child have chores?

86. Adolescent objectives

87. Adolescence (13–21 years…)

88. Physical Growth Puberty starts or continues Wisdom teeth- ouch!

89. Sexual Maturation Timing and onset of puberty varies widely Girls 8 – 13 years (average age 11). Average menarche 12.4 years but can be as early as 9 Boys 9 – 14 years (average age 12) Tanner Stages- secondary sex characteristic development

90. Development Psychosocial: Erikson’s Identity vs Role confusion Who am I? What kind of person am I going to be? Major challenges: Body image, Values, Self esteem, Career decisions, Independence from parents, Forming intimate relationships Cognitive: Piaget’s Formal Operational Thought What are they now able to do?

91. Communicating with Adolescents

92. Health Promotion Help parents balance child’s need for independence BUT not check out. Supervision and supportive guidance still needed! Sexual health: Support for healthy sexual expression, Sexual decision making, STI prevention, and contraception prn Self-expression: Gender, body piercing, tattoos Mental health ( Covered in your MH course as well ): Important note: Serious mental illness often first emerges during adolescence

93. Drugs, Alcohol, Tobacco Assessment of problem drug and ETOH use: 2 “Yeses” indicates problem use C - Have you ever ridden in a car driven by someone who had used alcohol or drugs? R - Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? A - Do you ever use alcohol or drugs while you are by yourself or alone ? F - Do you ever forget things you did while using drugs or alcohol? F - Do your friends or family ever tell you that you should cut down on your drinking or drug use? T - Have you ever gotten into trouble while you were using drugs or alcohol? Drugs- Illicit, RX, OTC Drinking (ETOH)- Any, Binge Tobacco- e-cigs, regular cigs, smokeless

94. Violence Prevention Dating Violence Prevention: Help set healthy expectations of dating relationships Listen to/Trust their inner voices instead of external pressure Define their own boundaries and comfort levels Sexual assault prevention: Affirmative consent & respect for partner’s wishes Limit ETOH and drug use Resource- About Teen Dating Violence (CDC, 2020)

95. Critical Thinking You are caring for a 15-year-old girl who has been admitted to the hospital with dehydration. She is quiet and answers questions with a simple “yes” or “no.” On the day she is to be discharged, she says, “I'll tell you something, but you can't tell anyone else.” What should you consider in this situation? What is your best response to her?

96. YIKES! This is a lot of information! How are we supposed to memorize all of it?

97. Coming Up Next week 2 weeks Getting a history on your patient: OLDCARTS- please review this for future classes when we will have break out sessions and practice Onset (when did it begin) Location (where do you feel the symptoms) Duration (how long has it lasted, does it come and go) Characteristics (describe the symptoms) Aggravating factors (what makes them worse) Alleviating factors (what makes them better) Related symptoms (any other symptoms) Treatment by patient (what have you tried, has it worked) Severity (how bad is it – 0-10 scale if pain involved)