NUR 2092 – Health Assessment Essays, Exams and study guide
NUR 2092 – Health Assessment Essays, Exams and study guide.
NUR 2092 – Health Assessment
Written Assignment: HEENT/Skin/Nails
Purpose: To apply assessment and documentation skills utilized for physical health assessment.
Overview: After reading/viewing the module assignment and attending lab, conduct an assessment of the
Directions: Conduct a HEENT, skin and nails assessment on a fellow student, friend, or family member. Remember to secure their permission.
ORDER A PLAGIARISM-FREE PAPER HERE
Use the HEENT documentation assignment attached to this assignment module to document your findings. Formulate a SOAP note with both subjective and objective data as indicated on the HEENT attachment.
Submit your work to the Module 7 dropbox. Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates. NUR 2092 – Health Assessment Essays, Exams and study guide.
Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown: Jstudent_exampleproblem_101504
This assignment is worth 20 points and will be graded using the graded rubric below.
Does Not meet Expectations
Assessment Findings and documentation
An optimal and thorough assessment and summary is present for each system.
Poorly organized/or limited summary of pertinent assessment
Less than 50% of pertinent assessment information is addressed or is grossly incomplete and or inaccurate.
Complete and concise summary of pertinent SOAP information.
Poorly organized/or limited summary of pertinent SOAP information. NUR 2092 – Health Assessment Essays, Exams and study guide.
Less than 50% of pertinent information is addressed or is grossly incomplete and or inaccurate.
Spelling and Grammar
No grammar or spelling errors.
Errors in grammar or spelling.
Final Exam Study Guide
Geriatrics: functional assessment-what is being tested, best approach to testing; caregiver concerns; IADLs, ADLs; disability concerns; tools to assess
What is being tested
-Identify limitations – so interventions can be recognized
-Independence and prevention of functional decline
NUR 2092 – Health Assessment Essays, Exams and study guide
Best approach to testing
-Decrease in attention, memory, orientation, language, planning and making decisions
-Depression is not a normal change
-Persistent depression – is concerning if it interferes with ADL’s
Instrumental activities of daily living
-measures functional abilities necessary for independent community living
-includes shopping, meal preparation, house-keeping, laundry, managing finances, taking medications, and using transportation NUR 2092 – Health Assessment Essays, Exams and study guide.
Activities of daily living
-tasks necessary for self-care
-measure domains of eating/feeding, bathing, grooming, dressing, toileting, walking, using stairs, and transferring
Tools to assess
-Katz Activities of Daily Living
-The Lawton Instrumental Activities of Daily Living Scale
-Hospital Admission Risk Profile
-Geriatric Depression Scale (short form)
-Inspect for lesions and moles – irregular shapes, change in size or color
-Check for pressure ulcers especially sacrum, heels & trochanters
-Clubbing – cardiac or pulmonary disorder
-Pitting/transverse groves – peripheral vascular disease, arterial insufficiency, or diabetes
-Brittleness – decreased vascular supply
-Yellow or brown nails – fungal infection
-Look for limited range of motion – arthritis or muscle weakness causing pain and discomfort
-While assessing range of motion – watch for reports of pain, dizziness, jerky or abnormal movements: may indicate fractured vertebrae, Parkinson’s disease, transient ischemic attack, or stroke NUR 2092 – Health Assessment Essays, Exams and study guide.
-Look for facial symmetry (asymmetry may indicate a stroke)
-Bowel sounds; Look for hernias, pulsatile masses
-Evaluate muscles for atrophy, tremors, and involuntary movements
-Note warmth, swelling, tenderness, crepitus and deformities
Cultural assessment: culturally competent care; definition of ethnicity; spirituality; concepts such as assimilation, acculturation, etc.
Culturally competent care
-Know self, understand own heritage
-Identify meaning of health to someone else
-Understand health care delivery system
-Gain knowledge re social backgrounds of clients
-Be familiar with language, resources for interpreters, resources within community
Associated with culture; NUR 2092 – Health Assessment Essays, Exams and study guide . awareness of belonging to a group in which certain characteristics differentiate from one group to another
-Includes nationality, regional culture, language, ancestry
-Ex: Egyptian, Swedish, Mexican, Jewish, etc.
-Borne out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life.
-Comes from person’s life experiences
-Attempt to find meaning and purpose of life
-Relationship of self and something larger
To believe one’s own beliefs or way of life is ‘superior’; will interfere with collection and interpretation of data, your development of a plan of care may be skewed; must be aware of your own biases
Adapting to and acquiring another culture
Developing new cultural identity and becoming like the dominant culture
Divided loyalty, identifies with two cultures
Final Exam Study Guide
Geriatrics: functional assessment-what is it, what is being tested, best approach to testing; caregiver concerns/burnout; IADLs, ADLs; disability concerns; expected changes in the elderly;
Cultural assessment: culturally competent care; religion vs spirituality;
Therapeutic communication: examples of effective and ineffective (barriers) techniques e.g. clarification, reflection, blaming, etc.;
General survey – what is included?
Nutrition: Dietary assessment methods; abnormal eating patterns, for example, anorexia.
Skin: staging of decubitus ulcers, primary skin lesions like nodules, pustules, etc.; common skin lesions, for ex. Psoriasis, contact dermatitis; signs of malignant skin lesions; color differences seen in dark skinned individuals; lesion configurations;
Musculoskeletal – range of motion techniques; points for comparison; osteoporosis risk factors; spinal assessment findings; testing various joints including jaw; types of fractures; problems such as rheumatoid arthritis, gout, etc.
Thorax/Respiratory assessment – auscultation, palpation; normal sounds and locations; abnormal sounds & when you might hear them; proper method of auscultation; methods- e.g. voice sounds such as egophony, thoracic expansion, etc.; chest shapes
Heart: cardiac cycle; auscultation sites; what causes the heart sounds;
HEENT: eye examination techniques; PERRLA; hearing tests; lymph nodes; problems seen in head, ears, eyes, nose, and throat;
Breasts: Risk factors for cancer
GU: testicular cancer; assessing
Pulses- where are they, how do you document information about them, including rate, amplitude, rhythm; peripheral vascular assessment, edema – appearance, scale; arterial vs venous insufficiency NUR 2092 – Health Assessment Essays, Exams and study guide.
Neuro – Glasgow coma scale; reflexes; cranial nerves – how do you test each one; testing for cerebellar function; tests such as graphesthesia, position sense, stereognosis, etc., part of the brain being tested?; headache types
Vital signs: BP – proper method, findings if not done properly; normal ranges; terminology used, e.g. bradycardia, tachypnea, etc.
Abdomen – methods and order of assessment, anatomy, expected findings; colon cancer risk factors
Pain assessment techniques
History taking/symptom analysis – components of a health history (what is in each component, for ex. Past medical history); subjective vs objective data; examples of open and closed ended questions; history first; signs vs symptoms; health promotion levels
Pediatrics – best methods for assessing; pain assessment
Health Assessment – NUR 2092 Exam 1
What are the 6 steps of the nursing process?
Assessment Definition (nursing process)
Use evidence-based assessment techniques
Document relevant data
Diagnosis Definition (nursing process)
Compare clinical findings with normal and abnormal variation and developmental events
Interpret data– make & test hypotheses
Outcome Identification Definition (nursing process)
Identify expected outcomes
Individualize to the person
Realistic and measurable
Include a timeline
Planning Definition (nursing process)
Set timelines for outcomes
Integrate evidence-based trends and research
Document plan of care
Implementation Definition (nursing process)
Implement in a safe and timely manner
Use evidence-based interventions
Collaborate with colleagues
Use community resources
Coordinate care delivery
Provide health teaching and health promotion
Document implementation and any modifications.
Evaluation Definition (nursing process)
Progress toward outcomes
Conduct systematic, ongoing, criterion-based evaluation.
Include patient and significant others
Use ongoing assessment to revise diagnoses, outcomes, and plan
Distribute results to patient and family
Is short term and self-limiting, often follows a predictable trajectory, and dissipates after an injury heals.
Self-protective purpose; it warns the individual of actual or threatened tissue damage.
Over 6 months in duration
Pain where limb used to exist
Malignant pain Vs nonmalignant pain
Malignant pain is cancer-related and is caused by tumor cells that cause necrosis or stretching.
Nonmalignant pain is often associated with musculoskeletal conditions.
Originates from internal organs.
Somatic pain and deep somatic pain
Somatic pain originates from musculoskeletal tissues or the body surface
Deep somatic pain comes from sources such as blood vessels, joints, tendons, muscles, and bone NUR 2092 – Health Assessment Essays, Exams and study guide.
Pain that is felt at a particular site but originates from another location.
Develops when functioning and intact nerve fibers in CNS are stimulated.
They are triggered by events outside nervous system from actual or potential tissue damage.
Nociception can be divided into four phases:
(2) Transmission: the pain impulse moves from the level of the spinal cord to the brain.
(3) Perception: signifies the conscious awareness of a painful sensation
(4) Modulation: a built-in mechanism that will eventually slow down and stop the processing of a painful stimulus
Pain caused by a lesion or disease of the somatosensory nervous system.
This implies an abnormal processing of pain message from an INJURY to the NERVE FIBERS.
This pain is very difficult to treat and assess.
Pain is always subjective. What the patient is complaining of; SYMPTOM
What the nurse observes; SIGN
This balance is affected by many factors, including physiologic, psychosocial, developmental, cultural, and economic factors
24 hour recall
Swallowing assessment prn
Pain assessment tools
Brief pain inventory: asks the patient to rate the pain within the past 24 hours using graduated scales (0 to 10) with respect to its impact on areas such as mood, walking ability, and sleep
McGill Pain Questionnaire: The short-form McGill Pain, asks the patient to rank a list of descriptors in terms of their intensity and to give an overall intensity rating to his or her pain
Initial Pain assessment: asks the patient to answer 8 questions concerning location, duration, quality, intensity, and aggravating/relieving factors. NUR 2092 – Health Assessment Essays, Exams and study guide.
Pain rating scales
Wong-Baker Faces pain rating scale
How to assess domestic violence
“Abuse assessment screen” is a tool used by many healthcare providers.
Estimate arterial oxygen saturation in blood
Normal Resp. Rate for adult
Normal BP for Adult
BMI requirements for being underweight, normal weight, overweight, obese.
Underweight = 18.5 BMI
Normal weight = 18.5- 24.9 BMI
Overweight= 25-29.9 BMI
Obese= 30+ BMI
How to document pulse
Definition of Eupnea
Definition of Apnea
Breathing has stopped
What does the acronym PQRSTU stand for?
P= Precipitating/palliative/provocative, what brings it on? What were you doing when you noticed it?
Q= Quality or Quantity, how does it feel, sound? How intense/severe is it?
R=Region or Radiation, Where is it? Does it spread anywhere?
S= Severity Scale, Scale of 1-10. Is it getting better/worse?
T= Timing/ onset. When did it first occur? Duration? How long did it last? Frequency?
U= Understand patient’s perception of the problem. What do you think it means? NUR 2092 – Health Assessment Essays, Exams and study guide.
Vital Signs Influences
Exercise and anxiety
Heart Rate (Pulse)
Exercise, age, gender, anxiety, pain
Diurnal variations – Lowest early AM, highest late afternoon/early evening
Exercise – rises
Menstrual cycle – increase mid cycle ovulation to menses
Age – very young wider variation; older typically lower
Drinks hot or cold
Normal pulse rate for adult
What happens to BP if cuff is too small or big?
If too small it will increase BP
If too big it will lower BP
Normal Oral temp + range
98.6. Range of 96.4 to 99.1
Is it normal for new born infant’s rectal temps to be higher?
Yes, average is 100
How do you measure BP cuff size?
With of bladder should equal 40% of circumference of persons arm.
Length of bladder should equal 80% of circumference.
What is the working phase of the interview?
The working phase is the data-gathering phase.
What are the steps to the “Tools of a physical Assessment”, 4 Steps
Inspection—Visual examination of body
Palpation—texture, temp., rigidity, lumps, masses
Percussion—to evaluate size, borders, consistency, tenderness, extent of fluid
Auscultation—listening to sounds body produces; pitch, loud or soft, duration, and quality
Delirium Vs Dementia
Delirium is an ACUTE confusion state
Dementia is a CHRONIC progressive loss of cognitive & intellectual functions. Disorientation, judgment loss, memory loss, impaired. NUR 2092 – Health Assessment Essays, Exams and study guide.
Complete total health database
Includes complete health history and full physical examination
Describes current and past health state and forms baseline to measure all future changes
Yields first diagnoses
Episodic or problem-centered database
For limited or short-term problems
Concerns mainly one problem, one cue complex, or one body system
History and examination follow direction of presenting concern
Status of all identified problems should be evaluated at regular and appropriate intervals
Note changes that have occurred
Evaluate whether problem is getting better or worse
Identify coping strategies being used
Rapid collection of data, often compiled concurrently with lifesaving measures
Diagnosis must be rapid and comprehensive in nature
Two primary components of health assessment
Health history = Subjective data
Physical Assessment – Objective Data
Open ended questions: narrative information; tell me about you, how are you doing today?
Closed ended questions: specific information; do you have pain
BARRIERS TO COMMUICATION
Lack of interest or attention/ lack of respect
Physical barriers – a curtain, a door, a computer, a monitor, pain, room temperature
The patient’s inability to hear you, hearing deficit, or language barrier
Language/ use of jargon, or speaking above someone’s educational level
Safety – fear
Psychological barriers – embarrassment, disbelief, shock, anger, fear, grief, fatigue, hostility
Nonphysical traits – values, attitudes, beliefs, customs
Race – Identification of individuals or groups by shared genetic heritage and biological or physical characteristics
Ethnicity – associated with culture; awareness of belonging to a group in which certain characteristics differentiate from one group to another
Material – dress, tools, art and ways they are used
NON material – verbal and nonverbal language, beliefs, customs, social structures.
Ethnocentrism – to believe one’s own beliefs or way of life as ‘superior’
Acculturation– Adapting to and acquiring another culture NUR 2092 – Health Assessment Essays, Exams and study guide
Assimilation– Developing new cultural identity and becoming like the dominant culture; more two way; new affecting old
Biculturalism– Divided loyalty, identifies with two cultures
Causes of illness
Disease caused by bacteria, viruses, etc.
Involves scientific theories for cause of illness
Illness caused when there is loss of natural balance
May align with yin/yang, hot & cold theory
Illness caused by supernatural force
May use folk remedies
Know self, understand own heritage
Identify meaning of health to someone else
Understand health care delivery system
Gain knowledge re social backgrounds of clients
Be familiar with language, resources for interpreters, and resources within community
6 steps of nursing process
Interview, health history, ROS, physical examination, functional assessment, spiritual and cultural assessment
What patient SAYS
What you OBSERVE
SMART component in outcome identification
First level priority
Emergent situations, life threading and needs immediate attention
Second level priority
Requires attention to avoid further deterioration
Third level priorirty
Can be addressed after more important problems are addressed
Complete total health Database
Full health history, and physical exam
Yields first diagnosis
Current and past health state
Focused or problem centered database
Limited and short term problems
Concerned with mainly one problem, or one body system
Follow up database
Follow up care to evaluate if problem is getting better or worse
Rapid urgent collection of data
Preventing health problems
Ex: vaccines, safety glasses
Timely screenings to catch a problem early and reduce impact
Decrease impact of ongoing problem
Example: cardiac rehab, support group.
2 primary components of health assessment
Health history= subjective
Physical examination = objective
PQRSTU method of pain assessment
Understand patient perception of the problem
Disorder of the brain
Not yet determined to be organic
More complete mental assessment maybe necessary if:
Patients has anxiety/depression
If family is concerned
Deterioration in status from last visit
Acute psychiatric illness
Objective cues of mental health
Rapid mood swings
Rapid, inappropriate, rambling speech
Can be reversed
Can cause fever, pain, low blood glucose, infection
Slow and gradual onset
Consciousness not altered
Can’t be reverse
Can cause HIV, chronic alcoholism, Alzheimer’s
belief in the superiority of one’s own ethnic group
Associated with culture
Awareness of belonging to a group in which certain characteristics differentiate from one group to another NUR 2092 – Health Assessment Essays, Exams and study guide
Identification of individual groups by shared genetic heritage and biological or physical characteristics
Adapting to and acquiring another culture
Developing a new culture identity and becoming like the dominant culture
Identifies with two cultures
Biomedical cause of illness
Disease caused by bacteria, viruses
Involves scientific theories
Naturalistic cause of illness
Illness caused due to loss of natural balance
Yin/yang or hot and cold theory
Illness caused by supernatural forces
The sharp striking of one thing against another.
Used to evaluate the size, borders, consistency, tenderness, extent of fluid
Striking produces vibration
Sinuses, CVA tenderness
Bone or muscle
Heart, liver, spleen
Air filled lungs. Hollow
an abnormal booming sound produced during percussion of the lungs. Emphysematous lung
Air filled stomach (drumlike)
Listening to sound produced by body
Estimates oxygen saturation in blood
Normal value: 95-100%
COPD patients might have high 80s
Normal range: 96.4 to 99.1 F
Most accurate temperature
Normal range 50-95 bpm
Ear canal in older
Pull and up
Ear canal in children
Pull and down
Pulse and respiration rate is _________ in infants
Acute pain starts outside the nervous system
Responsive to anti-inflammatory and opiates
Numbness, tingling, shooting, burning, phantom pain
From injury to nerve fibers or CNS
Pain felt in a body part that is no longer there
Felt at a site different from organ affected
Pain restarts or escalates before next scheduled analgesic dose
What does OLDCARTS stand for?
Treatments thus far
Significance of symptoms
When do you use “old carts”?
Whenever a patient reports a symptom, it needs to be explored
What does IPPA stand for?
-perform in that order
What is an assessment?
Collection of data about the individual’s health state
Compare subjective and objective data.
Subjective data is what the person says about themselves during history taking; objective data is data you observe by inspecting, percussing, palpating, and auscultating during the physical exam
What elements form the database?
-subjective data (in pt. history)
-objective data (in physical)
What is the purpose of assessment?
Make a judgement or diagnoses
What is diagnostic reasoning?
Process of analyzing health data and drawing conclusions to identify diagnoses
What are the six phases of the nursing process?
What are the six parts of a health assessment?
-review of the clinical record
-review of the literature
What is a nursing diagnosis?
A clinical judgement about a person’s response to an actual or potential health state NUR 2092 – Health Assessment Essays, Exams and study guide
What are the three types of nursing diagnoses?
What is a medical diagnosis?
Diagnosis that evaluates the cause or etiology of the disease
What are the four different types of databases?
-focused or problem centered
What is a complete database?
Complete health history and full physical exam
What is a focused or problem centered database?
For a limited or a short term problem
What is a follow up database?
When the status of identified problems are evaluated at regular and appropriate intervals
What is an emergency database?
A rapid collection of data, diagnosis must be swift and sure
After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be:
A patient tells the nurse that he is very nervous, is nauseated, and “feels hot.” These types of data would be:
The patient’s record, laboratory studies, objective data, and subjective data combine to form the:
When listening to a patient’s breath sounds, the nurse is unsure of a sound that is heard. The nurse’s next action should be to:
Validate the data by asking a coworker to listen to the breath sounds
The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using:
A set of rules
Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as:
Intuition NUR 2092 – Health Assessment Essays, Exams and study guide
The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP?
EBP emphasizes the use of best evidence with the clinician’s experience
The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem?
Individual with shortness of breath and respiratory distress
When considering priority setting problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
Abnormal laboratory values
Which critical thinking skill helps the nurse see relationships among the data?
Clustering related cues
The nurse knows that developing appropriate nurse interventions for a patient relies on the appropriateness of the ________ diagnosis
The nursing process is a sequential method of problem solving that nurses use and includes which steps?
Assessment, diagnosis, outcome identification, planning, implementation, and evaluation
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
Breathing, pain, sleep
Which of these would be formulated by a nurse using diagnostic reasoning?
Barriers to incorporating EBP include:
Nurses’ lack of research skills in evaluating the quality of research studies NUR 2092 – Health Assessment Essays, Exams and study guide
What step of the nursing process includes data collection by health history, physical examination, and interview?
During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems?
Teach the nurses how to conduct electronic searches for research studies
When reviewing the concepts of health, the nurse recalls that the components of holistic health include with of these?
Holistic health views the mind, body, and spirit as interdependent
The nurse recognizes that the concept of prevention in describing health is essential because:
Prevention places the emphasis on the link between health and personal behavior
The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:
2×5 cm scar on the right lower forearm
A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is more appropriate to collect in this setting?
A complete health data base because of the nurse’s primary responsibility for monitoring the patient’s health
Which situation is more appropriate during which the nurse performs a focused or problem centered history?
Patient in an outpatient clinic has cold and influenza-like symptoms
A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should:
Collect a follow-up data base and then check her blood pressure
A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?
Simultaneously ask history questions while performing the examination and initiating life-saving measures
A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to:
Provide culturally sensitive and appropriate care
In the health promotional model, the focus of the health professional includes:
Helping the consumer choose a healthier lifestyle
The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?
Evaluate the individual’s condition, and compare actual outcomes with expected outcomes
Which statement best describes a proficient nurse? A proficient nurse is one who:
Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient
The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply.
Inspiratory wheezes noted in left lower lobes
Patient reports dyspnea upon exertion
Rate of respirations 16 breaths per minute
Put the following patient situations in order according to the level of priority.
1st: A teenager who was stung by a bee during a soccer match is having trouble breathing.
2nd: An older adult with a urinary tract infection is also showing signs of confusion and agitation.
3rd: A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer.
A teenager who was stung by a bee during a soccer match is having trouble breathing.
First level priority problems
An older adult with a urinary tract infection is also showing signs of confusion and agitation
Second level priority problems
A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer.
Third level priority problems
The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis?
Inspiratory wheezes notes in the left lower lobes, Nonproductive cough, Patient reports dyspnea upon exertion, Rate of respirations 16 breaths per minute
Exam 2 review
Function of the Skin
The skin is a waterproof, almost indestructible covering that has protective and adaptive properties:
Protection. Skin minimizes injury from physical, chemical, thermal, and light-wave sources.
Prevents penetration. Skin is a barrier that stops invasion of microorganisms and loss of water and electrolytes from within the body.
Perception. Skin is a vast sensory surface holding the neurosensory end-organs for touch, pain, temperature, and pressure.
Temperature regulation. Skin allows heat dissipation through sweat glands and heat storage through subcutaneous insulation.
Identification. People identify one another by unique combinations of facial charac
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