Discuss 8 Aspects Of Mrs. Lee Pre-Cooperative Nursing Care
HLTEN512B Implement and monitor nursing care for clients with acute health problems NURS5286C
1. Identify and discuss 8 aspects of Mrs. Lee pre-operative nursing care?
It is an important role of a nurse to ensure that patients are prepared for surgery not only in a physical way but also in a psychological way so they have informed consent of the procedure being undertaken, have psychosocial support and are educated on the expected and unexpected outcomes.
For Mrs. Lee, these 8 aspects of pre-operative nursing care may include:
Providing psychological support: Because it is already stated that Mrs. Lee’s family is quite anxious, it may very well be also making her anxious about her surgery. Catering to the psychological support needs …show more content…
of a surgical patient will include being there for the patient and answering any questions relating to their fears and concerns regarding the surgery and the post operative period. The answers to these questions need to be honest and factual. If necessary, it may be arranged for Mrs. Lee’s spiritual adviser to come and speak with her also.
Providing pain management information: Following on from the psychosocial support needs, one of the reasons that Mrs. Lee may be anxious could be due to the amount of pain she thinks she will be in post surgery or she may be even scared of developing a drug addiction to analgesics. Educating the patient on the types of analgesics they may be given is important, as is how the medication may be administered. Mrs. Lee could be provided with pain management brochures if they are available.
Teaching techniques for preventing respiratory complications: As Mrs. Lee is having surgery and more than likely will be going under general anesthesia it is important to reduce any risk of potential respiratory complications by the use of deep breathing techniques, incentive spirometry and pursed lip breathing to assist and maintain an open clear airway. The patient should practice deep breathing exercises hourly with encouragement from the nurse for the first 2-3 days post surgery. Coughing exercises should also be done frequently to ensure the airways are free of secretions.
Promoting activity and exercise: It is important to promote exercise and activity as inactivity may cause thrombi and emboli’s as well as respiratory complications which will lead to a delayed recovery time post op. As a nurse, we need to ensure our patients are well informed on activity and exercise post surgery because we do not want a potential DVT. Mrs. Lee will need to be informed that she may be required and encouraged to be out of bed and walking at 8 to 12 hours post op and that the time out of bed will increase daily, and that she will be given analgesia if she requires it.
Preparing the surgical site: The nurse will be required to prepare the surgical site whether that be by shaving the area if the patient is rather hairy, washing the skin with antimicrobial soap, swabbing with antimicrobial solutions and wrapping the area in a sterile drape to protect from bacteria. Povidone-iodine is what is mostly used as an antimicrobial solution. The site for the surgery will be identified and marked with a texta (marker pen) which is usually done by the surgeon and verified by other staff e.g., the nurse and written in the documentation. It is important to identify right patient, right procedure and right site.
Carry out the pre-operative routine: The pre-operative routine involves: identifying the patient and procedure with the use of arm and leg bands as well as documentation; fasting for 6+ hours ensures that the GI tract will be empty and non active preventing the risk of aspirating on undigested food; elimination of the bowel will reduce the risk of constipation and distention post surgery; consent signature is extremely important as your patient is signing a legal document agreeing to the surgery and it means that they understand the procedure at full; valuables are to be taken from the patient and placed in a secure place which is generally a locker that is locked or a safe. Often wedding rings that are left on the finger will be taped with hypo allergenic tape however they must be removed if there is a risk of oedema in the hands post surgery; allergies must be identified prior to the surgery, generally this would be done in the pre-admission clinic. Allergies must be written in red and the patient must have a red armband on them identifying what the allergy is if it is related to the surgery, dressings, treatment or medications; personal hygiene care involves showering/bathing/mouth care including dental work and prosthesis which are removed because they may be a choking risk, cosmetics and nail polish; ted stockings may need to be applied and worn throughout the surgery to reduce the risk of a DVT. As a nurse we cannot put ted stockings on without a doctors order.
Administer the pre-operative medication: Medications may be ordered as per the medication chart and need to be given to a patient pre surgery must be ready in time and when it is needed. If the patient is on medications prior to surgery, they must be withheld the morning of the surgery if it is elective surgery. There are some exemptions however that may include routine medications, which may be given with minimal water at least 2 hours before the scheduled surgery.
Documentation: Is required before and after the patient is wheeled into theatre and to the recovery area. The documentation must be accurate, timely, correct and signed with your designation as it is a legal document. Observation and medication charts must be filled in and signed. The patient is unable to give the healthcare team any information therefore it is extremely important for the charts to be complete.
(24 marks)
2. Identify and discuss the initial postoperative assessment and care required in this postoperative phase.
Mrs.
Lee has just returned to the ward from the operating theatre and recovery. As she has just returned to the ward, it is essential to do a full set of observations on her (vital signs, neurovascular and neurological). To get a clear understanding of the normal baseline results for this patient, checking the observations chart would be very helpful with identifying and preventing possible issues and complications relating to Mrs. Lee’s surgery. The initial perioperative assessment includes the level of consciousness (GCS), respiratory rate (depth, sounds, chest movement), blood pressure, pulse rate, temperature, oxygen saturation level, pain assessment, condition and colour of the skin, circulation (peripheral pulses and sensation), condition and location of dressings, condition of suture line, condition of drain tubes/catheters, muscle strength and response, pupil response (PEARL), level of comfort, level of activity and exercise and any postoperative instructions. If there were any abnormalities from the nursing assessment, interventions would be made. These observations will be taken every 15 minutes for the first hour then every half an hour for 2 hours, following once every 2 hours ultimately resulting in 4 times daily if there are no problems post
op.
Relating to the nursing care of Mrs. Lee, she has had a hip replacement so for her to achieve her normal level of ADL’s while she is in hospital will not be to the level that she is used to prior to her surgery. Mrs. Lee will be requiring assistance with personal hygiene including showering and toileting (both voiding and elimination). Encouragement for postoperative activity and exercise along with instruction from the physiotherapist may be needed as her surgery has affected the way she ambulates. Mrs. Lee may need to be positioned and turned every 3 to 4 hourly post surgery, as she may not feel up to getting out of bed yet due to her hip replacement. Positioning of Mrs. Lee may be painful for analgesia may be required when it comes to changing her position. Again, everything a nurse would be doing for Mrs. Lee requires documentation, whether that is in the nursing notes or the drug charts. Every nurse intervention needs to be documented signed and designated for legal purposes. (16 marks)
3. Identify and discuss the emergency management of this patient.
First and foremost in an emergency situation I would go back to what I have learnt in first aid regarding DRSABCD as well as a primary and secondary survey. Since I have found Mrs. Lee unconscious, I would send for help automatically by pressing the emergency button above the bed and then call a MET call.
There are no dangers and I have no response from Mrs. Lee as she is unconscious and I have already sent for help by pressing the emergency button and calling a MET Call. Mrs. Lee has a very low respiratory rate and is breathing very shallow so automatically I would put her on oxygen with a free flow mask with 8-15L of oxygen. Next I will assess her capillary refill, skin colour, blood pressure and pulse, which are also both on the low side. Mrs. Lee is unconscious so that brings her GCS from 15 down to 11; she is also febrile and has a high temperature.
The secondary survey will look at the head, neck, chest, abdomen back and limbs. There has been no evidence of a fall in hospital and the head and neck don’t appear to be lacerated, fractured or bleeding. There is a small hematoma on the left frontal region of the head due to a fall prior to admission. The chest is normal, breathing is shallow and there are no abnormal breathing sounds. There is oedema in the abdominal cavity, possibly related to the hip replacement surgery. It is tender. All the abdominal organs felt normal with palpation, no abnormalities found. There is bright red blood coming from the redivac drain from the hip joint, which has soaked through x2 combine, and there is blood on the patient’s bluey, which has leaked from the wound site. The limbs appear to be slightly cyanosed possibly relating to the blood loss and capillary refill is slow. Peripheral pulses are weak. As Mrs. Lee has suffered from blood loss, it will be essential for the doctor to order a blood transfusion as well as fluids to bring the patient back to a level of stability. Management of what appears to be Hypovolemic Shock will be to keep the patient warm to lower the risk of hypothermia. Medications such as dopamine may be given to increase blood pressure and cardiac output. An ECG will be given for cardiac monitoring due to the blood loss.
Mrs. Lee will then be sent off for the following tests: FBE (full blood exam), LFT (liver function test), CRP (C-reactive protein test), chest x-ray, ABG (arterial blood gas test).
(15 marks)
4. A) Discuss the nursing care of a patient on a blood transfusion with rationales to support your answers.
Mrs. Lee had a FBE (full blood exam) and the results have come back indicating that she has a hemoglobin level of 50, which is extremely low so the doctor has ordered a blood transfusion.
First and foremost for the blood transfusion to go ahead, we need patient consent, identification and cross matching. Prior to collecting the blood from the blood bank, Mrs. Lee would already need IV access set up as the blood can only be out of the fridge for 30 minutes. Before the transfusion is set up, checks must be made at the bedside in the presence of another nurse. These checks include right patient identification on the patient tag, blood pack and documentation; blood product identification; and right blood group. It is also necessary to check the blood pack for any leakage, clots or abnormal colour.
Before starting the transfusion you will need to do a full set of observations on Mrs. Lee to get a baseline incase there are any adverse reactions. Then you will need to prime the line with normal saline at 0.9% before you start with the blood transfusion. Once this is done and all documentation and checks are in place, you may start the blood transfusion.
The nurse will start the transfusion off slowly and they will need to sit with Mrs. Lee for the first 15 minutes as that is when most adverse reactions occur and if everything is running smoothly and her vital signs are within her normal ranges, the nurse will be able to speed up the transfusion which generally will run over 2 to 3 hours. Observations will need to be done every 15 minutes for the first hour.
(8 marks)
B) Identify 2 complications that can arise from a blood transfusion.
Two complications, which can arise from a blood transfusion, may be a febrile reaction (fever) or a severe allergic reaction (anaphylaxis).
(2 marks)
5. Discuss the aspects relevant to Mrs. Lee’s discharge and provide rationales to support your response.
Aspects that would be relevant to Mrs. Lee’s discharge are a continuity of care not only for Mrs. Lee herself but for her husband also since she is his primary career. To ensure the best care for Mrs. Lee, discharge planning would include Mrs. Lee herself, her family, doctor, nurses, physiotherapist as well as an occupational therapist. In order for Mrs. Lee to be discharged home, I would have an occupational therapist go out to her home and see if there were any necessary changes there would need to be made to ensure Mrs. Lee would have a lower risk of falling and be able to ambulate within her own home with the use of mobility aids.
Help in the home could be contacted to come into Mrs. Lee’s home 3 times a week to help with ADL’s while also encouraging Mrs. Lee to be independent. If it were also possible, the daughter could temporarily stay at her parent’s home for a few weeks to assist with shopping, cooking, cleaning and making sure her mother was taking her medications as well as her father. If her daughter were unavailable to do this, help in the home would be able to look after the cleaning side of things and meals on wheels may be able to be arranged for Mrs. Lee and her husband.
The physiotherapist could make home visits in order to help Mrs. Lee with her exercises and to ensure her range of motion is getting stronger so she can ambulate, as she would have post hip replacement surgery.
The royal district nursing service could be contacted to change the dressings on Mrs. Lee’s incision post discharge which would be more convenient to her as well as her family as they wouldn’t be having to arrange transport to go to the GP or clinic every few days to get the dressing checked and changed if need be.
Prior to discharge from hospital, Mrs. Lee would need to be educated on the exercises she would need to do to regain strength in her hip, which the physiotherapist would explain and show to her.
(15 marks)
References:
Books
- Tollefson, J, 2012. Clinical Psychomotor Skills: Assessment tools for nursing students. 5th ed. Australia: Cengage Learning Australia Pty Limited.
- Kozier and Erbs ‘ Fundamentals of Nursing’. (2012). 2nd edition. Pearson
Internet
- Hypovolemic Shock: An Overview, Dorothy M. Kelley https://elibrary.utas.edu.au/utas/file/05409184-2b96-23be-1aff-43a5cf934b31/1/15826962.pdf [Accessed 21st April 2014]
- Hypovolemic Shock http://www.nlm.nih.gov/medlineplus/ency/article/000167.htm [Accessed 18th April 2014]
- Principles of monitoring postoperative patients http://www.nursingtimes.net/nursing-practice/clinical-zones/critical-care/principles-of-monitoring-postoperative-patients/5059272.article [Accessed 18th April 2014]
Journals
- Paul Froom, Tayser Mahameed, Rosa Havis, Mira Barak. 2001. Effect of Urgent Clinician Notification of Low Haemoglobin Values. [ONLINE] Available at: http://www.clinchem.org/content/47/1/63.full. [Accessed 18 April 14].
1. Identify and discuss 8 aspects of Mrs. Lee pre-operative nursing care?
It is an important role of a nurse to ensure that patients are prepared for surgery not only in a physical way but also in a psychological way so they have informed consent of the procedure being undertaken, have psychosocial support and are educated on the expected and unexpected outcomes.
For Mrs. Lee, these 8 aspects of pre-operative nursing care may include:
Providing psychological support: Because it is already stated that Mrs. Lee’s family is quite anxious, it may very well be also making her anxious about her surgery. Catering to the psychological support needs …show more content…
of a surgical patient will include being there for the patient and answering any questions relating to their fears and concerns regarding the surgery and the post operative period. The answers to these questions need to be honest and factual. If necessary, it may be arranged for Mrs. Lee’s spiritual adviser to come and speak with her also.
Providing pain management information: Following on from the psychosocial support needs, one of the reasons that Mrs. Lee may be anxious could be due to the amount of pain she thinks she will be in post surgery or she may be even scared of developing a drug addiction to analgesics. Educating the patient on the types of analgesics they may be given is important, as is how the medication may be administered. Mrs. Lee could be provided with pain management brochures if they are available.
Teaching techniques for preventing respiratory complications: As Mrs. Lee is having surgery and more than likely will be going under general anesthesia it is important to reduce any risk of potential respiratory complications by the use of deep breathing techniques, incentive spirometry and pursed lip breathing to assist and maintain an open clear airway. The patient should practice deep breathing exercises hourly with encouragement from the nurse for the first 2-3 days post surgery. Coughing exercises should also be done frequently to ensure the airways are free of secretions.
Promoting activity and exercise: It is important to promote exercise and activity as inactivity may cause thrombi and emboli’s as well as respiratory complications which will lead to a delayed recovery time post op. As a nurse, we need to ensure our patients are well informed on activity and exercise post surgery because we do not want a potential DVT. Mrs. Lee will need to be informed that she may be required and encouraged to be out of bed and walking at 8 to 12 hours post op and that the time out of bed will increase daily, and that she will be given analgesia if she requires it.
Preparing the surgical site: The nurse will be required to prepare the surgical site whether that be by shaving the area if the patient is rather hairy, washing the skin with antimicrobial soap, swabbing with antimicrobial solutions and wrapping the area in a sterile drape to protect from bacteria. Povidone-iodine is what is mostly used as an antimicrobial solution. The site for the surgery will be identified and marked with a texta (marker pen) which is usually done by the surgeon and verified by other staff e.g., the nurse and written in the documentation. It is important to identify right patient, right procedure and right site.
Carry out the pre-operative routine: The pre-operative routine involves: identifying the patient and procedure with the use of arm and leg bands as well as documentation; fasting for 6+ hours ensures that the GI tract will be empty and non active preventing the risk of aspirating on undigested food; elimination of the bowel will reduce the risk of constipation and distention post surgery; consent signature is extremely important as your patient is signing a legal document agreeing to the surgery and it means that they understand the procedure at full; valuables are to be taken from the patient and placed in a secure place which is generally a locker that is locked or a safe. Often wedding rings that are left on the finger will be taped with hypo allergenic tape however they must be removed if there is a risk of oedema in the hands post surgery; allergies must be identified prior to the surgery, generally this would be done in the pre-admission clinic. Allergies must be written in red and the patient must have a red armband on them identifying what the allergy is if it is related to the surgery, dressings, treatment or medications; personal hygiene care involves showering/bathing/mouth care including dental work and prosthesis which are removed because they may be a choking risk, cosmetics and nail polish; ted stockings may need to be applied and worn throughout the surgery to reduce the risk of a DVT. As a nurse we cannot put ted stockings on without a doctors order.
Administer the pre-operative medication: Medications may be ordered as per the medication chart and need to be given to a patient pre surgery must be ready in time and when it is needed. If the patient is on medications prior to surgery, they must be withheld the morning of the surgery if it is elective surgery. There are some exemptions however that may include routine medications, which may be given with minimal water at least 2 hours before the scheduled surgery.
Documentation: Is required before and after the patient is wheeled into theatre and to the recovery area. The documentation must be accurate, timely, correct and signed with your designation as it is a legal document. Observation and medication charts must be filled in and signed. The patient is unable to give the healthcare team any information therefore it is extremely important for the charts to be complete.
(24 marks)
2. Identify and discuss the initial postoperative assessment and care required in this postoperative phase.
Mrs.
Lee has just returned to the ward from the operating theatre and recovery. As she has just returned to the ward, it is essential to do a full set of observations on her (vital signs, neurovascular and neurological). To get a clear understanding of the normal baseline results for this patient, checking the observations chart would be very helpful with identifying and preventing possible issues and complications relating to Mrs. Lee’s surgery. The initial perioperative assessment includes the level of consciousness (GCS), respiratory rate (depth, sounds, chest movement), blood pressure, pulse rate, temperature, oxygen saturation level, pain assessment, condition and colour of the skin, circulation (peripheral pulses and sensation), condition and location of dressings, condition of suture line, condition of drain tubes/catheters, muscle strength and response, pupil response (PEARL), level of comfort, level of activity and exercise and any postoperative instructions. If there were any abnormalities from the nursing assessment, interventions would be made. These observations will be taken every 15 minutes for the first hour then every half an hour for 2 hours, following once every 2 hours ultimately resulting in 4 times daily if there are no problems post
op.
Relating to the nursing care of Mrs. Lee, she has had a hip replacement so for her to achieve her normal level of ADL’s while she is in hospital will not be to the level that she is used to prior to her surgery. Mrs. Lee will be requiring assistance with personal hygiene including showering and toileting (both voiding and elimination). Encouragement for postoperative activity and exercise along with instruction from the physiotherapist may be needed as her surgery has affected the way she ambulates. Mrs. Lee may need to be positioned and turned every 3 to 4 hourly post surgery, as she may not feel up to getting out of bed yet due to her hip replacement. Positioning of Mrs. Lee may be painful for analgesia may be required when it comes to changing her position. Again, everything a nurse would be doing for Mrs. Lee requires documentation, whether that is in the nursing notes or the drug charts. Every nurse intervention needs to be documented signed and designated for legal purposes. (16 marks)
3. Identify and discuss the emergency management of this patient.
First and foremost in an emergency situation I would go back to what I have learnt in first aid regarding DRSABCD as well as a primary and secondary survey. Since I have found Mrs. Lee unconscious, I would send for help automatically by pressing the emergency button above the bed and then call a MET call.
There are no dangers and I have no response from Mrs. Lee as she is unconscious and I have already sent for help by pressing the emergency button and calling a MET Call. Mrs. Lee has a very low respiratory rate and is breathing very shallow so automatically I would put her on oxygen with a free flow mask with 8-15L of oxygen. Next I will assess her capillary refill, skin colour, blood pressure and pulse, which are also both on the low side. Mrs. Lee is unconscious so that brings her GCS from 15 down to 11; she is also febrile and has a high temperature.
The secondary survey will look at the head, neck, chest, abdomen back and limbs. There has been no evidence of a fall in hospital and the head and neck don’t appear to be lacerated, fractured or bleeding. There is a small hematoma on the left frontal region of the head due to a fall prior to admission. The chest is normal, breathing is shallow and there are no abnormal breathing sounds. There is oedema in the abdominal cavity, possibly related to the hip replacement surgery. It is tender. All the abdominal organs felt normal with palpation, no abnormalities found. There is bright red blood coming from the redivac drain from the hip joint, which has soaked through x2 combine, and there is blood on the patient’s bluey, which has leaked from the wound site. The limbs appear to be slightly cyanosed possibly relating to the blood loss and capillary refill is slow. Peripheral pulses are weak. As Mrs. Lee has suffered from blood loss, it will be essential for the doctor to order a blood transfusion as well as fluids to bring the patient back to a level of stability. Management of what appears to be Hypovolemic Shock will be to keep the patient warm to lower the risk of hypothermia. Medications such as dopamine may be given to increase blood pressure and cardiac output. An ECG will be given for cardiac monitoring due to the blood loss.
Mrs. Lee will then be sent off for the following tests: FBE (full blood exam), LFT (liver function test), CRP (C-reactive protein test), chest x-ray, ABG (arterial blood gas test).
(15 marks)
4. A) Discuss the nursing care of a patient on a blood transfusion with rationales to support your answers.
Mrs. Lee had a FBE (full blood exam) and the results have come back indicating that she has a hemoglobin level of 50, which is extremely low so the doctor has ordered a blood transfusion.
First and foremost for the blood transfusion to go ahead, we need patient consent, identification and cross matching. Prior to collecting the blood from the blood bank, Mrs. Lee would already need IV access set up as the blood can only be out of the fridge for 30 minutes. Before the transfusion is set up, checks must be made at the bedside in the presence of another nurse. These checks include right patient identification on the patient tag, blood pack and documentation; blood product identification; and right blood group. It is also necessary to check the blood pack for any leakage, clots or abnormal colour.
Before starting the transfusion you will need to do a full set of observations on Mrs. Lee to get a baseline incase there are any adverse reactions. Then you will need to prime the line with normal saline at 0.9% before you start with the blood transfusion. Once this is done and all documentation and checks are in place, you may start the blood transfusion.
The nurse will start the transfusion off slowly and they will need to sit with Mrs. Lee for the first 15 minutes as that is when most adverse reactions occur and if everything is running smoothly and her vital signs are within her normal ranges, the nurse will be able to speed up the transfusion which generally will run over 2 to 3 hours. Observations will need to be done every 15 minutes for the first hour.
(8 marks)
B) Identify 2 complications that can arise from a blood transfusion.
Two complications, which can arise from a blood transfusion, may be a febrile reaction (fever) or a severe allergic reaction (anaphylaxis).
(2 marks)
5. Discuss the aspects relevant to Mrs. Lee’s discharge and provide rationales to support your response.
Aspects that would be relevant to Mrs. Lee’s discharge are a continuity of care not only for Mrs. Lee herself but for her husband also since she is his primary career. To ensure the best care for Mrs. Lee, discharge planning would include Mrs. Lee herself, her family, doctor, nurses, physiotherapist as well as an occupational therapist. In order for Mrs. Lee to be discharged home, I would have an occupational therapist go out to her home and see if there were any necessary changes there would need to be made to ensure Mrs. Lee would have a lower risk of falling and be able to ambulate within her own home with the use of mobility aids.
Help in the home could be contacted to come into Mrs. Lee’s home 3 times a week to help with ADL’s while also encouraging Mrs. Lee to be independent. If it were also possible, the daughter could temporarily stay at her parent’s home for a few weeks to assist with shopping, cooking, cleaning and making sure her mother was taking her medications as well as her father. If her daughter were unavailable to do this, help in the home would be able to look after the cleaning side of things and meals on wheels may be able to be arranged for Mrs. Lee and her husband.
The physiotherapist could make home visits in order to help Mrs. Lee with her exercises and to ensure her range of motion is getting stronger so she can ambulate, as she would have post hip replacement surgery.
The royal district nursing service could be contacted to change the dressings on Mrs. Lee’s incision post discharge which would be more convenient to her as well as her family as they wouldn’t be having to arrange transport to go to the GP or clinic every few days to get the dressing checked and changed if need be.
Prior to discharge from hospital, Mrs. Lee would need to be educated on the exercises she would need to do to regain strength in her hip, which the physiotherapist would explain and show to her.
(15 marks)
References:
Books
- Tollefson, J, 2012. Clinical Psychomotor Skills: Assessment tools for nursing students. 5th ed. Australia: Cengage Learning Australia Pty Limited.
- Kozier and Erbs ‘ Fundamentals of Nursing’. (2012). 2nd edition. Pearson
Internet
- Hypovolemic Shock: An Overview, Dorothy M. Kelley https://elibrary.utas.edu.au/utas/file/05409184-2b96-23be-1aff-43a5cf934b31/1/15826962.pdf [Accessed 21st April 2014]
- Hypovolemic Shock http://www.nlm.nih.gov/medlineplus/ency/article/000167.htm [Accessed 18th April 2014]
- Principles of monitoring postoperative patients http://www.nursingtimes.net/nursing-practice/clinical-zones/critical-care/principles-of-monitoring-postoperative-patients/5059272.article [Accessed 18th April 2014]
Journals
- Paul Froom, Tayser Mahameed, Rosa Havis, Mira Barak. 2001. Effect of Urgent Clinician Notification of Low Haemoglobin Values. [ONLINE] Available at: http://www.clinchem.org/content/47/1/63.full. [Accessed 18 April 14].