`Unit One**

6 Rights of Medication Administration

1. Right patient 2. Right drug 3. Right dose 4. Right route 5. Right Time 6. Right documentation

Mobility

A state or quality of being mobile or movable.

Methods of identifying cultures of patients:

Acceptance, awareness, asking the patient directly, avoid making assumptions

Compare/Contrast recommended vaccinations for adults & elderly populations:

Adults 19-26: Regular flu, HPV, TDAP, Meningitis Adults 50 and older: Flu, shingles, pneumococcal, TDAP

Unique qualities of adult learning

Adults will learn as they develop needs that they believe learning will fulfill They use their lives as the point of reference for all learning, they learn best from and in relation to their experiences

Medical complications associated with obesity:

Affect primarily the cardiovascular and respiratory systems. Excess weight can also cause degeneration of the musculoskeletal system, especially the weight-bearing joints such as hips and knees (osteoarthritis). More susceptible to infections and infectious diseases than are thinner adults and tend to heal more slowly.

Sentinel event

An Unexpected occurrence involving death or serious injury

Nursing care to optimize mobility and minimize complications of immobility

Appropriate body alignment while in bed, skin care is important, coughing and deep breathing, bed exercises such as ROM

Apply knowledge of anatomy/physiology to perform patient-centered assessment for a patient with CAD, including spiritual & cultural considerations:

Assess blood pressure and heart rate, check for presence of dysrhythmias. Sinus tachycardia with premature ventricular contractions (PVCs) frequently occurs in the first few hours after an MI. Next assess distal peripheral pulses and skin temperature. The skin should be warm with all pulses palpable. In the patient with unstable angina or MI, poor cardiac output may be manifested by cool, diaphoretic ("sweaty") skin and diminished or absent pulses. Auscultate for an S3 gallop, which often indicates heart failure—a serious and common complication of MI. In adults, the S3 heart sound is heard over the apex of the heart Assess the respiratory rate and RR for signs of heart failure. An increased RR is common because of anxiety and pain, but crackles or wheezes may indicate left-sided heart failure. Assess for the presence of jugular venous distention and peripheral edema.

Smoking Cessation Care plan:

Assessment: Current smoking status and history, including # of cigs smoked daily, duration of smoking habit, and age of patient when first started smoking- record pack history in pack years Ex. Per day multiplied by years patient has smoked, willingness of patient to stop, nicotine dependence like how often do you wake up to smoke, identify negative consequences to continue and rewards if you stop Diagnoses: Alteration in the normal oxygenation mechanism of the body Planning: Patient will stop smoking Nursing Interventions: Set a quit date with patient within 2 weeks, teach patient nicotine replacement systems and other agents to assist them, help patient choose best route to quit, refer patient to support groups, teach withdrawal symptoms, advise to keep list of slips to smoke again, schedule FU apt. Patient Teaching: Make a list of reasons to quit, decide to go cold turkey or gradually decrease nicotine, ask for help from others around you that has done this before and had success, consult HCP, remove ash trays, think of rewards to help them, avoid smoking places, 8 glasses of water a day and keep snacks on hand Evaluation: Evaluate how well the patient is adapting to quitting, ask if patient is having relapse issues

Etiology and Genetic Risk

Atherosclerosis is the primary factor in the development of CAD. Numerous risk factors, both nonmodifiable and modifiable, contribute to atherosclerosis and subsequently to CAD.

RN Roles:

Authorized to execute medical orders from select authorized care providers & can function independently when giving care RN programs teach on the understanding of "why" Must complete & sign the nursing assessment portion of patients chart Utilize in care planning Have to be involved in overseeing the administration of IV medications High patient teaching skills Have to receive at least an associates in nursing 2-4 yrs of college

Health maintenance & promotion for patients, related to melanoma:

Avoid sun exposure between 11 AM and 3 PM, wear sunscreen • Examine your body monthly for possibly cancerous or precancerous lesions. • A change in the color of a lesion, especially if it darkens or shows evidence of spreading • A change in the size of a lesion, especially rapid growth • A change in the shape of a lesion, such as a sharp border becoming irregular or a flat lesion becoming raised • Redness or swelling of the skin around a lesion • A change in the character of a lesion, such as oozing, crusting, bleeding, or scaling

Facilitators & Blockers of communication

Blockers: making value judgments excessive questioning giving approval or disapproval Asking why questions Advising Not responding or changing the subject Facilitators: Responding directly to the patients statements nodding head or leaning toward patient staying on topic, toward the major concerns

Wellness & prevention activities with it:

Continually changing state ranging from high-level to low-level wellness Prevention activities: Nutrition, exercise, immunizations, avoid smoking

Evidence-based ways for adults to decrease their risk for CAD

Control your blood pressure. High blood pressure is a major risk factor for heart disease Keep your cholesterol and triglyceride levels under control Stay at a healthy weight Eat a healthy diet Get regular exercise Limit alcohol Don't smoke Manage stress

Cultural competence

Conveying acceptance of the patients health beliefs while sharing information, encouraging, and strengthening the patients coping resources

Attributes of the critical thinker:

Curiosity- drives the nurse to seek knowledge for the situation Diligent pursuit for information- seeks information for the process of decision making Rational thought- ruled by knowledge and experience, helps the nurse predict outcomes Reflection- look back on ideas, thoughts,beliefs. Evaluate the plan of care and critique what you did Creativity- linked to inductive reasoning, creative thinkers recognize patterns that are present but understand that outcomes are uncertain Intuitive Thought- Ones 6th sense, a "gut" feeling about something

Types of Reasoning based on critical thinking: Reasoned Thought

Discriminating and doesn't allow emotion, feelings,or prejudice to misguide decisions, Nurses using this recognize when negative factors are interfering with their ability to think clearly

Safety in nursing and healthcare

Focus is on teamwork to accomplish a goal of safe, high-quality care. when errors occur the focus is on what went wrong rather than who committed it. Focus shifts from focusing on fault to establish blame and determine discipline to improve the system and hold one accountable

2015-2020 Dietary Guidelines for Americans

Follow a healthy eating pattern across the lifespan. • Focus on variety, nutrient density, and amount. • Limit calories from added sugars and saturated fats and reduce sodium intake. • Shift to healthier food and beverage choices. • Support healthy eating patterns for all.

Concept of safety

Freedom from accidental injury- ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of intercepting them when they occur

LPN Roles:

Function under an RN or physician LPN programs teach "how to" of patient care Perform a basic nursing assement on patient identify patient problems and participate with assisting them Don't receive teaching on patient education Receive a diploma for a program at a tech school 1 yr

Disease & Prevention activities with it:

Functional or structural disturbance that results when a person adaptive mechanisms to counteract stimuli and stress fails

Scope of practice for LPN

Functions under an RN or , prepared to provide care in settings where patients experience common health problems, meet basic needs & doesn't not perform at the level of assessment that requires critical thinking and the nursing process

Discuss the importance of respecting patients cultural requests when delivering patient care:

Have self-awareness, ability to work past the language & communication barriers. Different cultures have different emotions as well as verbal & nonverbal behaviors

Strategies for communicating with a diverse group of peers in the health care setting

How your words are perceived depends on verbal and nonverbal congruence, your intention, and the manner in which you present your message. Possible ways are assertive>direct and honest & typically begin with "I" , aggressive>hostile , and passive-aggressive> aggressive in a passive way to manipulate the situation Communicate with DESC Describe Explain State Consequences

Indicators of Risk Factors for Metabolic Syndrome

Hypertension: Either blood pressure of 130/85 mm Hg or higher OR taking antihypertensive drug(s) Decreased HDL-C (usually with high LDL-C) levelEither HDL-C <45 mg/dL for men or <55 mg/dL for women OR taking an anticholesterol drug Increased level of triglyceridesEither 160 mg/dL or higher for men or 135 mg/dL or higher for women OR taking an anticholesterol drug Increased fasting blood glucose (caused by diabetes, glucose intolerance, or insulin resistance)Either 100 mg/dL or higher OR taking antidiabetic drug(s) Large waist size (excessive abdominal fat causing central obesity)40 inches (102 cm) or greater for men or 35 inches (89 cm) or greater for women

Measures to prevent medication errors:

Identify the right patient Ensure the right drug Check the drug handbook if needed Maintain clear communication Have a double check for high alert medications Clarify with patient any drug allergies

Nursing Care plan for a patient with OA

Impaired Physical Mobility: Nursing Diagnosis- Impaired Physical Mobility May be related to: Fatigue, Muscle weakness, Pain, Restricted joint movement, Stiffness Possibly evidenced by: Decreased muscle strength, Limited range of motion, Refusal to transfer and ambulate or perform ADLs, Reluctance to move Desired Outcomes: Client will perform physical activity independently or within limits of activity restrictions. Client will demonstrate the use of adaptive changes that promote ambulation and transferring. Client will be free of complications of immobility, as evidenced by intact skin, absence of thrombophlebitis, normal bowel pattern, and clear breath sounds Nursing Interventions: Assess the client's posture and gait. Rationale: It is important to assess for indicators of a decreased ability to ambulate and move purposefully Nursing Interventions: Assess the client's weight Rationale: Excessive weight may add stress to painful joints. Nursing Interventions: Assess range of motion (ROM) in all joints, comparing passive and active ROM Rationale: Pain or joint deformity may cause a progressive loss of ROM Nursing Interventions: Assess the client's comfort with and knowledge of how to use assistive devices Rationale: The correct use of assistive devices for ambulation can improve mobility and reduce the risk for falls

Specific needs for different cultural backgrounds:

In non-western cultures they believe bacteria & viruses, etc. can take blame from social problems or negative attitudes where as western cultures believe in disease causation Taboos- in many cultures illnesses that may be characterized as illness are highly stigmatized and the patient won't tell the healthcare worker and not seek treatment or deny symptoms such as ADD, depression, suicidal, etc.

Identify the priority nursing interventions in the care of a patient with infectious respiratory problems

Influenza: The antiviral drugs oseltamivir (Tamiflu) and zanamivir (Relenza) should be widely distributed. These drugs may reduce the severity of the infection and the mortality rate. Infected patients must be cared for in strict isolation. No effective treatment for this infection currently exists. Interventions are supportive to allow the patient's own immune system to fight the infection. Oxygen is given when hypoxia, breathlessness, or a sudden change in COGNITION is present. Respiratory treatments to dilate the bronchioles and move respiratory secretions are used. If hypoxemia is not improved with oxygen therapy, intubation and mechanical ventilation may be needed. Antibiotics are used to treat a bacterial pneumonia that may occur with H5N1. In addition to the need for respiratory support, the patient with H5N1 may have severe diarrhea and need fluid therapy. MERS: There is no specific treatment for MERS. Supportive care is used to manage and prevent complications. The patient may need mechanical ventilation and fluids. If kidney function is severely reduced, dialysis is performed. Hemorrhage from disseminated intravascular coagulation is managed with blood products. "Convalescent serum," which is the serum taken from a patient who has recovered from the disease, is a potential treatment but requires that the patient have the same blood type as the convalescent patient. This therapy was used successfully with a few patients during the 2014 Ebola outbreak. Patients being treated for MERS must be maintained in Contact and Airborne Precautions Pneumonia: Patient education about vaccination is important in the prevention of pneumonia. The Joint Commission National Patient Safety Goals recommend that nurses especially encourage adults older than 65 years and those with a chronic health problem to receive immunization against pneumonia. There are two pneumonia vaccines: pneumococcal polysaccharide vaccine (PPSV 23), known as Pneumovax; and pneumococcal conjugate vaccine (PCV-13), known as Prevnar 13. The CDC recommends that adults older than 65 years be vaccinated with both, first with Prevnar 13 followed by Pneumovax about 6 to 12 months later. Adults who have already received the Pneumovax should have Prevnar 13 about a year or more later. These recommendations also apply to adults between 19 and 64 years of age who have specific risk factors such as chronic illnesses. HAND-WASHING & Respiratory therapy equipment must be well maintained and decontaminated or changed as recommended. Use sterile water rather than tap water in GI tubes and institute Aspiration Precautions as indicated, including screening patients for aspiration risk.

Clinical Judgment

Interpretation or conclusion about a patients needs, concerns, or health problems and/or decision to take action

Purpose of developing a therapeutic patient-nurse relationship

It is a planned and goal-directed process that focuses on the patients feelings, problems, and needs

Underlying theory of safety

Keeping patients safe to the unfortunate reality that errors can lead to accidental death. Diagnostic errors- delay in diagnosis, test results Treatment errors- performance of operations, administering a drug, delay in responding to abnormal test result Preventive errors- failure of monitoring or following up with treatment Communication failure- lack of communication can lead to many errors

Preventing OA teaching for patients

Maintain proper nutrition to prevent obesity. • Take care to avoid injuries, especially those that can occur from professional or amateur sports. • Take adequate work breaks to rest joints in jobs where repetitive motion is common. • Stay active and maintain a healthy lifestyle.

Etiology & Risk factors for melanoma

Melanomas are pigmented cancers arising in the melanin-producing epidermal cells, often they start as the benign growth of a nevus (mole) Risk factors include genetic predisposition, excessive exposure to UV light, and the presence of one or more precursor lesions that resemble unusual moles. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment.

Modifiable & Non-modifiable risk factors for CAD:

Modifiable: High blood cholesterol levels High Blood Pressure 139/89 Cigarette Smoking Diabetes Mellitus Lack of physical activity Metabolic syndrome Mental stress, depression, cardiovascular risk Non-modifiable: Age Gender-males are more at risk Family History of MI

Motivators of learning: Facilitators of learning: Barriers of learning:

Motivators of learning: life changing event such as childbirth Facilitators of learning: motivated to make a change in life, low level of stress, patient needs positive reinforcement, Barriers of learning: myths about healthcare, denial, patient values influence the willingness to accept the need to change moderate to sever anxiety

Qualities of an effective teacher:

Nurse credibility- has license, is always honest Confidence- self-evaluation helpful Clear and effective communication- use of terms patient can understand

Nutrition screening to determine if patients are at risk for nutrition health problems:

Nutritional intake, diet restrictions, changes in appetite, weight change, medical history, family history Mentioning potential nutritional complications allows for focusing interviewing. Most important presenting symptoms include: unplanned changes in weight, nausea/vomiting, trouble swallowing, and pain, changes in bowels, diarrhea *Measure BMI

Community Resources to help patients achieve or maintain ADLs independence and mobility

Occupational therapy, assistive devices such as canes, wheel chairs, crutches

Illness and prevention activities with it:

Physical manifestations and the subjective experience of the individual, it can be present in the abcense of disease Prevention activities: Screening, identify early state of diseases, regular maintenance health care checkups

Risk factors for impaired mobility

Populations at risk, regardless of culture, ethnicity, gender Greatest population is elderly people from age 90% of falling is from hip fractures & 76% are elderly women Individual risk factors such as chronic conditions, orthopedic injuries, head and spinal injuries, nutritional deficiencies & genetics, as well as end stage cancer

Risk Factors for Cancer

Populations at risk: certain racial & ethnic minorities are greater at risk due to poor healthcare Age 40-59 yrs. Smoking/Tobacco,Infectious agents like Hep C, HPV, Hep B, Helicobacter Genetics, BRCA1 for women is 70% Radiation, Carcinogens, overweight and poor diet

Compare/Contrast 3 levels of preventative care:

Primary Prevention Primary prevention aims to avoid the development of a disease or disability in healthy individuals.2 Most population-based health promotion activities, such as encouraging less consumption of sugars to reduce caries risk, are primary preventive measures. Other examples of primary prevention in medicine and dentistry include the use of fluoridated toothpaste, and vaccinations for infectious diseases like measles, mumps, rubella, and polio. Secondary Prevention The focus of secondary prevention is early disease detection, making it possible to prevent the worsening of the disease and the emergence of symptoms, or to minimize complications and limit disabilities before the disease becomes severe.2 Secondary prevention also includes the detection of disease in asymptomatic patients with screening or diagnostic testing and preventing the spread of communicable diseases. Examples in dentistry and medicine include screening for caries, periodontal screening and recording for periodontal disease, and screening for breast and cervical cancer. Tertiary Prevention The goal of tertiary prevention is to reduce the negative impact of an already-established disease by restoring function and reducing disease-related complications.2 Tertiary prevention also aims to improve the quality of life for people with disease. In medicine and dentistry, tertiary prevention measures include the use of amalgam and composite fillings for dental caries, replacement of missing teeth with bridges, implants, or dentures, or insulin therapy for Type II diabetes.

Identify the priority nursing interventions in the care of a patient with noninfectious lower respiratory problems

Priority nursing actions focus on patient education about using his or her personal asthma action plan, which includes drug therapy and lifestyle management strategies to help him or her understand the disease and its management Use a peak flow meter Avoid potential environmental asthma triggers, such as smoke, fireplaces, dust, mold, and weather changes of warm to cold. Avoid drugs that trigger your asthma (e.g., aspirin, NSAIDs, beta blockers). Avoid food that has been prepared with monosodium glutamate (MSG) or metabisulfite. If you have exercise-induced asthma, use your bronchodilator inhaler 30 minutes before exercise to prevent or reduce bronchospasm Control therapy drugs are used to reduce airway sensitivity (responsiveness) to prevent asthma attacks from occurring to maintain GAS EXCHANGE. They are used every day, regardless of symptoms. Reliever drugs (also called rescue drugs) are used to actually stop an attack once it has started Regular exercise is a recommended part of asthma therapy to maintain cardiac health, strengthen muscles, and promote GAS EXCHANGE and PERFUSION.

Health care goals established by Govt. agencies

Promote affordable healthcare, while balancing spending on premiums, deductibles, and out-of-pocket costs Expand safe, high-quality healthcare options, and encourage innovation and competition Improve Americans' access to healthcare and expand choices of care and service options Strengthen and expand the healthcare workforce to meet America's diverse needs

8 Elements of Reasoning & Critical Thought

Purpose- what are you trying to accomplish Question at issue- defines the purpose clearly and accurately Point of view- All thinking stems from the point of view, the nurse will recognize that a routine treatment may seem strange & frightening from the patients point of view Available Information- The thought process must be based on available information which is data that is at hand, assessment data Concepts- Explains the problem at hand. It is an idea, theory, or mental image of something that doesn't yet have accurate representation Assumptions- Mental images that help the thinker draw assumptions about events, objects, actions that are taking place- An educated guess, hypothesis, or belief Implications & Consequences- Defined through outcomes. Implications or consequences can always be considered. For example: the expected consequence for bathing a patient is clean, intact skin but they can also get chilled and upset...... if I continue on this path what will be the consequence??? Inferences- The conclusion that results from the summary of the process

Critical Thinking

Purposeful, goal-directed process of inquiry that utilizes available facts, principles, theories, and solve problems/make a decision *sets out to accomplish a specific goal

cultural diversity

Recognizing the presence of all diverse groups in an organization or society

Clinical judgment to prioritize evidence-based interventions for patients with osteoarthritis (OA)

Rest balanced with exercise, joint positioning, heat or cold applications, weight control Teach the patient to position joints in their functional position. For example, when in a supine position (recumbent), use a small pillow under the head or neck but avoid the use of other pillows. The use of large pillows under the knees or head may result in flexion contractures. Use proper posture when standing and sitting to reduce undue strain on the vertebral column, wear supportive shoes Apply heat or cold for temporary relief of pain. Heat may help decrease the muscle tension around the tender joint and thereby decrease pain and stiffness. Suggest hot showers and baths, hot packs or compresses, and moist heating pads.

Utilize SBAR to assertively communicate with co-workers within the healthcare team to minimize risks associated with hand-offs

SBAR S: Situation- identify self, unit, patient & room # Briefly state the problem-what it is, when it happened, how severe it is B: Background- Admitting diagnoses of patient, Current meds, allergies, IV fluids, Lab results Recent vitals Lab results-provide date and time tests were done & previous results for comparison Code status A: Assessment- what is the nurses assessment of the situation? R: Recommendation- What is the nurses recommendation of what he/she thinks? Examples: Patient needs to be seen now, order change, notify that patient has been admitted

Nicotine & its side effects, adverse reactions, & treatment for addiction

Side effects: Nicotine is both a sedative and a stimulant. Nicotine stimulates the adrenal glands, which results in the release of adrenaline. There is then an immediate release of glucose. Nicotine makes the pancreas produce less insulin, causing a slight increase in blood sugar or glucose. Indirectly, nicotine causes the release of dopamine in the pleasure and motivation areas of the brain. Adverse reactions: Increased clotting tendency, atherosclerosis, dizziness and lightheadedness irregular sleep, possible blood restriction, nausea and vomiting, dry mouth, indigestion, peptic ulcers, diarrhea, heartburn, changes in heart rate and rhythm, an increase in blood pressure Treatment: Nicotine replacement therapy (NRT) This is available in skin patches, nasal sprays, inhalers, and solutions that can be rubbed into the gums. Varenicline, sold as Chantix: This medication partially triggers a certain receptor in the brain that usually responds only to nicotine. Bupropion is another drug Clonidine, an anti-hypertensive drug that has also shown to reduce symptoms of nicotine withdrawal but can also cause low blood pressure Nortryptyline, a tricyclic antidepressant whose effects can replace those of nicotine but has many of the major side effects of antidepressants

Recognizing when an individual has compromised mobility

Symptoms Associated with Altered Mobility: Pain Reduced joint movement Reduced sensation or loss of sensation Falls Fatigue Altered gait or imbalance Reduced functional ability History: Past medical history Family history Current medications Lifestyle behaviors Occupation Social environment Problem-based history

Concept based nursing

Teaching nurses to organize and categorize information, concept focuses on making sense of facts- challenging the student nurse to use critical thinking

Role of a nursing leader:

Team leader, charge nurse, nurse manager are duties assigned to nurses who make decisions inherent in such positions

Specialty Nursing Certification

The American Nurses Credentialing Center (ANCC) provides opportunities to receive certifications in certain topics such as Pediatrics, Med Surg, OBGYN The nurse must take a comprehensive exam in their area & provide letters of recommendation or experience It builds confidence for the nurse, they learn more, and have better job opportunities

Laboratory Findings for patients with OA

The erythrocyte sedimentation rate (ESR) and high-sensitivity C-reactive protein (hsCRP) may be slightly elevated when secondary synovitis occurs. The ESR also tends to rise with age, infection, and other inflammatory disorders.

Healthy People 2020

The major goal is the Elimination of health care disparities, provide culturally competent health care services and improve health literacy and health education among non-english speaking populations

Deductive Reasoning

The nurse must analyze situations everyday, The nursing process is an example of deductive reasoning because it goes from specifics to generalities and conclude the likely outcomes based on supporting data

Health Promotion & Prevention activities with it:

The process of enabling people to increase control over and to improve their health

Types of Reasoning based on critical thinking: Clinical Judgment

Understanding of a situation based on knowledge-emperical data. (data that can't be observed) The nurse will make a decision on whether to proceed with or revise a course of action

Principles of communication:

Verbal & nonverbal communication- Verbal is tone, pitch, inflection, & intensity of how we speak. Non-verbal is posture, body movements, eye contact, grooming and dressed. Estimated that 10% is verbal and 70-90% is non-verbal communication Therapeutic communication- Empathy, positive regard, and self-awareness. Respect and willingness to work with the patient & communicate through your actions that the patient is worthy of caring about Communication facilitations- Factors enhancing effective communication. The nurse must project warmth, acceptance, friendliness, openness Active listening- Establishes trust. Requires an open mind & full concentration to hear what the patient is saying. Use questions that seek clarifications such as, " what more can you tell me? I'm not sure I understand? Would you please explain a little more? Communication blockers- Questioning a patients reasonings rather than accepting them DOn't use Why as a questions, such as why did you do that?

Inductive Reasoning

When a patient presents with symptoms or problems the nurse has seen before Mainly based on the nurses knowledge and experience

Culture

a pattern of shared attitudes, beliefs, self-definitions, norms, roles, and values that can occur among those who speak a particular language or live in a defined geographic region.

(CSA) Chronic Stable Angina

is chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the patient. The frequency, duration, and intensity of symptoms remain the same over several months. CSA results in only slight limitation of activity and is usually associated with a fixed atherosclerotic plaque. It is usually relieved by nitroglycerin or rest and often is managed with drug therapy. Rarely does CSA require aggressive treatment.

Teaching on overweight & obese patients & the importance of lifestyle changes to be made:

teach the importance of weight management and exercise to improve health. Even a 5% weight loss can drastically decrease the risk for coronary artery disease (CAD) and diabetes mellitus. Eat a variety of foods, especially grain products, vegetables, and fruits." don't eat out as much. "Consume a diet that is moderate in salt and sugar and low in fats and cholesterol." "Engage in moderate physical activity for at least 30 minutes each day."

Calculate BMI:

weight ___________ x 703 height 2 (in inches)