Patient Assessment and Care Plan

   

                   

Nursing Clinical Packet

Patient Assessmentand Care Plan

Instructions to student:

1) Bring one copy of this packet with you to clinical each week.

2) Your instructor will inform you of the number of packets and the dates each packet is due. They may have you complete only portions of or all of the packet.

3) Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a Pass. Your instructor may ask you to resubmit packets that are incomplete or incorrect.

4) If your instructor asks you to submit the packet electronically, then please record your answers in bold or in a colored or lower case font. This helps us identify your answers more quickly.

 PATIENT ASSESSMENT FORM

  

STUDENT NAME:


DATE:

 

  

CLIENT INITIALS: 


ROOM #


DOB:


AGE


GENDER: 


ADMISSION DATE:

 

CODE STATUS:


ALLERGIES:


MARITAL STATUS:


OCCUPATION   (FORMER):

 

MEDICAL DX:


CHIEF   COMPLAINT:

 

PAST HISTORY   (SURGERY/PROCEDURES) WITH DATES

 


ORDERS


RATIONALE(Why is this ordered   for this client???)

 

EXAMPLE:DIET


2 g Sodium diet with nectar thick liquids only


Sodium is restricted due to edema in the bilateral   lower extremities and nectar thick liquids due to dysphagia from a past   stroke.

 

DIET



 

ACTIVITY



 

I/O



 

VS



 

BGM



 

FOLEY 



 

NG



 

PEG/PEJ TUBE



 

WOUND CARE 



 

RESPIRATORY TREATMENT



 

TRACHEOSTOMY 



 

SUCTIONING



 

CHEST TUBE



 

SPECIAL EQUIPMENT



 

LAB ORDERS



 

OTHER



 

REHAB   SERVICES


ACTIVITY OR   TREATMENT PLAN & SCHEDULE


RATIONALE

 

PHYSICAL THERAPY



 

SPEECH THERAPY



 

OCCUPATIONAL THERAPY



 



             

/ 5 pts

IVs

  

IV   FLUID AND RATE: 


SITE   LOCATION AND CONDITION:

 

LAST   DRESSING CHANGE:


LAST   TUBING CHANGE:

 

GAUGE:   


REASON   FOR IV ACCESS: 

  

DIAGNOSTIC   TESTS: 


DATE


RESULTS


REASON FOR   TESTING AND IMPLICATIONS FOR NURSING CARE

 




 




 




 




 




  

LAB TEST


DATE


RESULTS


NORMSREFERENCE   RANGES


IMPLICATIONS FOR NURSING CARE   (WHAT S&S I SHOULD BE AWARE OF AND WHAT YOU CAN DO TO HELP IMPROVE AN   ABNORMAL RESULT?)

 





 





 





 





 





 





 





 





 





 





 





 





 





GROWTH and DEVELOPMENT:(see pages 378-379 Taylor, Lillis and White) or (Erikson’s Stages of Development)

  

CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO   HAVIGHUSRT


TASKS OF THIS STAGE: 

 

ASSESSMENT OF CLIENT’S SUCESSFUL   ACHIEVEMENT OF TASKS 

/ 5 pts

MEDICATIONS

If your client has more than 12 medications, select the 12 medications that are most important, most frequently given or those that pertain to the client’s most significant medical problems. See the example below.

  

Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 

Coreg (carvedilol)


3.125 mg – 50 mg BID


Asthma, heart block

 

Pharmacotherapeutic Class


Dosage, Route & Frequency


Adverse Reactions

 

β-adrenergic blocker


6.25 mg p.o. BID


Bradycardia, CHF, thrombocytopenia, hyperglycemia, bronchospasm

 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 

He has a history of hypertension but has been taking   Coreg for 2 years to control his hypertension


BP’s   for past 3 days have been 128/78, 132/72, 138/80

How is this medication   impacting your client??B/P readings, lab results, pain management, etc……..


Do   not discontinue abruptly or before surgery

Caution   with Upper airway dysfunction

Rise   slowly to minimize orthostatic hypotension, check B/P and heart rate prior to   administration

Take   before meals

  

#1 Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 



 

Pharmacotherapeutic Class


Dosage, Route & Frequency


Adverse Reactions

 



 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 



  

#2 Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 



 

#3 Pharmacotherapeutic Class


Dosage, Route and Frequency


Adverse Reactions

 



 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 



  

#4 Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 



 

Pharmacotherapeutic Class


Dosage, Route and Frequency


Adverse Reactions

 



 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 



  

#5 Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 



 

Pharmacotherapeutic Class


Dosage, Route and Frequency


Adverse Reactions

 



 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 



  

# 6 Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 



 

Pharmacotherapeutic Class


Dosage, Route and Frequency


Adverse Reactions

 



 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 



  

#7 Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 



 

Pharmacotherapeutic Class


Dosage, Route and Frequency


Adverse Reactions

 



 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 



  

#8 Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 



 

Pharmacotherapeutic Class


Dosage, Route and Frequency


Adverse Reactions

 



 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 



  

#9 Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 



 

Pharmacotherapeutic Class


Dosage, Route and Frequency


Adverse Reactions

 



 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 



  

#10 Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 



 

Pharmacotherapeutic Class


Dosage, Route and Frequency


Adverse Reactions

 



 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 



  

#11 Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 



 

Pharmacotherapeutic Class


Dosage, Route and Frequency


Adverse Reactions

 



 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 



  

#12 Brand Name and Generic Name


Normal Dosage Ranges


Contraindications

 



 

Pharmacotherapeutic Class


Dosage, Route and Frequency


Adverse Reactions

 



 

Why this Patient Receives this Med


Effects of the Med on the Client


Nursing Considerations and Teaching

 



/ 20 pts

NURSES NOTES FOR CLINICAL

For this clinical, we are having you write out your assessment findings in the form of a narrative nurse’s note. We have provided some samples of assessments.We have also provided a worksheet that you may use to take into a patient’s room to take notes during your assessment. Record your vital signs and type your physical assessment findings. This form will expand to fit your typing. A sample of charting for a long term care resident follows below. 

  

TEMP: 


APICAL HR: 


RESP: 


BP: 


HT:


WT:

  

DATE / TIME


(TYPE HERE)

Sample Narrative Note ---Head to Toe format

  

Temp: 98.6


Apical HR: 72


Resp: 16


BP 128/62


Ht: 5’10”


Wt: 145

  

12/22/2010 1400 


Resident in semi-fowlers position in bed. Pressure reduction mattress in place. Alert   and oriented x 3. Appropriate mood and affect. Well groomed.  Recent and remote memory intact. Facial   symmetry noted. Pupils are equal, reactive to light and accommodation. Oral   mucosa moist, pink. Frequent oral care   rendered with sponge toothette and toothbrush. Dentition intact. Hearing intact. Oropharynx clear without   erythema or exudate. No chewing or swallowing difficulties. 75% of general   diet taken at breakfast. Skin pink, warm, dry, free of lesions with elastic   turgor.Hair and nails unremarkable.Carotid and radial pulses present and   equal. Motor and sensory functions grossly intact.No weakness or   paralysis. Upper extremities equal   strength bilaterally, full ROM w/ capillary refill < 3 sec. Fine resting   tremor in the left hand” No involuntary movement or abnormal posture. Lungs clear bilaterally to auscultation.Tracheostomy   dressing clean, dry, and intact. Connected to ventilator with settings:   TV-550, Fio2-40%, Rate 10, and PEEP-5cm. Sao2-92%. Suctioned for moderate   amount of white, thin secretion. Apical pulse regular (rate) and rhythm.   Double lumen picc line note to left antecubital space. Tegaderm dressing is   clean, dry, and intact. Last dressing change on 11/28/16. Chlorhexadine caps   intact to all lumens.  Bowel sounds   active x 4. Abdomen soft,   non-distended, non-tender. Last bowel movement this morning, passed a large,   soft- formed brown stool and a moderate amount of clear yellow urine.   Bilateral lower extremities,no tenderness, swelling or joint deformities   noted. Denies numbness or tingling to   extremities. Toe nails thick and yellowed w/ capillary refill < 3 sec.  No peripheral edema noted, pedal pulses   palpable and equal bilaterally. 

PHYSICAL ASSESSMENT WORKSHEET (Use this sheet for jotting down your assessment findings.)

  

ROUTINE   FINDINGS


PATIENT   VARIATIONS/ABNORMALS

 

COGNITION/NEUROLOGICAL(SAMPLE) Alert and oriented x3, recent and remote memory intact. Denies any   numbness or tingling to extremities”


(SAMPLE) “Fine resting tremor of   left hand

 

SKIN


 

SENSORY


Wound measurements and complete description if   available at the very least Document dressing including the type of dressing   and description of condition!

 

BREASTS - 


DEFERRED.

 

RESPIRATORY – 


(Include ventilator settings as indicated in narrative   note)

 

CARDIOVASCULAR 


Include any vascular access device, IV lines, AV   fistulas, perma -cath lines, etc.

 

ABDOMEN – 

.


Include any enteral feedings here and route

BOWEL CONTINENCE? LAST BM? BOWEL PLAN?

 

MUSCULOSKELETAL - 


 

GENITOURINARY - 


URINARY CONTINENCE? TOILETING PLAN?

 

PELVIC -


DEFERRED.

 

RECTAL - 


DEFERRED.

/ 10 pts

   

NURSING CARE PLAN
Begin your NCP by listing ALL your clients individual problems (at least 10)and then identify an appropriate nursing diagnosis that you can think of that would apply to your client. Determine which 3problems/nursing diagnoses are of greatest priority and then add a #1, #2, and #3 to indicate which of the two have highest priority. Risks would not be priority 1, 2, or 3!!!!!

Expectation is to have at least 10 nursing diagnosis listed!

  

#


List the Client problem 


An appropriate Nursing Diagnosis stem 

(REFER TO   YOUR NURSING DIAGNOSIS LIST)


Related to part of the statement (This is individual to your client) 


As evidenced by part of the statement (This is   individual to your client) 

REMEMEBR THIS IS NOT USED IN A “Risk For” diagnosis

 

1


SAMPLE:Reports severe pain in the   right hip.


“Acute Pain”


“related to” fractured right hip


“as evidenced by” verbal report of pain   rated at an 8 on a scale of 0 –to 10.

 

2


SAMPLE: Complete bed rest


“Risk for Impaired skin integrity”


“related to “ immobility


NONE it is a “Risk for” diagnosis so   there is no evidence statement

 





 





 





 





 





 





 





 





 





From the list above your faculty member will give you direction regarding how many and which diagnoses they want you to develop for either a Nursing Care Plan and/or a Concept Map.

  

SAMPLE NCP

  

NANDA   DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT: Acute Pain related to right hip fracture as   evidenced by a verbal report of pain rated 8 on a scale of 0 -10. 

  

ASSESSMENT 

(Data   that directly pertains to the above nursing diagnosis)


OUTCOME STATEMENT

(Patient   centered, realistic, specific, measurable, target time)


INTERVENTIONS

(Individualized, specific,   frequency)

Minimum   of 4-5 interventions per plan


SCIENTIFIC RATIONALE

(Supporting   statement from text or other source, cite source)


EVALUATION OF OUTCOME

(Met,   partially met, unmet, unknown by target time)

 

SUBJECTIVE DATA: “My right hip hurts me so much every time I   move. I am so afraid to start physical   therapy” 


SHORT TERM: Client will report pain level rated at a 3   or lower 30 minutes after pain medication taken


1. Educate the client on the   importance of pain relief to enhance her rehabilitation efforts and include   education on various types of methods to relieve pain. 

2. Encourage client to   express any questions or concerns she may have regarding pain management   methods to alleviate anxiety and fears. 

3. Educate the client on her responsibility to   honestly report pain when it occurs as well as reporting if the current pain   management is effective or ineffective for providing her pain relief 

4. Provide for   alternative/complementary measures of pain relief, such as, reduce lighting   and noise, soothing music, pet therapy, massage, and hot/cold packs according   to client preferences.


1. “There are many ways to   manage pain. In addition to   pharmacologic and non-pharmacologic measures, simple nursing interventions   can alter patients’ pain experience and speed their recovery.” Taylor, Lillis   and White pg. 1168.

2. “Common fears include a   loss of control and embarrassment by being unable to deal with pain maturely…   The patient may view the need of for medication as a sign of weakness or may   fear addiction or loss of effectiveness at a later date.” Taylor, Lillis and   White pg. 1169. 

3. “As a patient advocate,   ensure that a strong emphasis on the need for aggressive, individualized   strategies that can minimize or eliminate acute pain and improve patient   outcomes. Preventing pain is easier   then treating it once after it occurs.” Taylor, Lillis and White pg. 1178. 

4. Alternative/complementary   measures will provide an added benefit of distraction from pain experience   and augment analgesic effect. Cold/hot therapy can provide constriction and   or dilation which will reduce pain inflammation in each specific circumstance   Daniels. Pg 378


Short Term Goal: Met; pain   was rated at a 2 on a scale of 0 to 10 after administration of Vicodin. 

Long Term Goal. In progress

 

OBJECTIVE DATA:

Alert and oriented 70 year   old widowed female. Lives in an   apartment independently. 2 daughter live nearby and visit often. 

History of a fall while out   shopping 1 ½ weeks ago. Right hip surgically   repaired 7 days ago. Surgical dressing   to right hip is clean, dry and intact. Circulation, motion and sensation   intact to right lower extremity.

Afebrile; BP 124/80; R-18 AP   84 and regular. 5 foot 7 inches weighs 142 pounds. No hearing deficits; wears   eye glasses 

Medical history positive for   osteoarthritis and osteoporosis

Non weight bearing to right   leg and to use a walker for ambulation

To start physical therapy   for gait and strength training BID times 7 days and occupational therapy to   develop upper body strength once daily times 7 days

Reports pain level is at 8   on a scale of 0 to 10.

Has Vicodin 5mg/325 mg po 2   tabs every 4 hours prn for severe pain

Ibuprofen 400 mg every 6   hours prn for moderate pain.


LONG TERM: Client will report pain level of 2 or less   using ibuprofen with alternative pain control methods by discharge.

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

  

NANDA   DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT:

  

ASSESSMENT 

(Data that directly   pertains to the above nursing diagnosis)


OUTCOME STATEMENT

(Patient centered, realistic,   specific, measurable, target time)


INTERVENTIONS

(Individualized,   specific, frequency)


SCIENTIFIC RATIONALE

(Supporting statement   from text or other source, cite source)


EVALUATION OF OUTCOME

(Met, partially met,   unmet, unknown by target time)

 

SUBJECTIVE DATA: 


SHORT TERM:




 

OBJECTIVE DATA:


LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

/30

  

NANDA   DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT:

  

ASSESSMENT 

(Data that directly   pertains to the above nursing diagnosis)


OUTCOME STATEMENT

(Patient centered, realistic,   specific, measurable, target time)


INTERVENTIONS

(Individualized,   specific, frequency)


SCIENTIFIC RATIONALE

(Supporting statement   from text or other source, cite source)


EVALUATION OF OUTCOME

(Met, partially met,   unmet, unknown by target time)

 

SUBJECTIVE DATA:


SHORT TERM:




 

OBJECTIVE DATA:


LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. . Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

/30

  

NANDA   DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT:

  

ASSESSMENT 

(Data that directly   pertains to the above nursing diagnosis)


OUTCOME STATEMENT

(Patient centered, realistic,   specific, measurable, target time)


INTERVENTIONS

(Individualized,   specific, frequency)


SCIENTIFIC RATIONALE

(Supporting statement   from text or other source, cite source)


EVALUATION OF OUTCOME

(Met, partially met,   unmet, unknown by target time)

 

SUBJECTIVE DATA:


SHORT TERM:




 

OBJECTIVE DATA:


LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. . Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

/30

   

   

3

        

Key Problem: Impaired urinary elimination

Data:

Intake=3800 Output=3200

Polyuria

3+ glucose in     urine

AEB: Polydipsia and     polyuria

Outcomes:

Pt. will have     urine output of 1000 – 2000 ml/24 hours.

Interventions:

Monitor I     & O q shift.

Monitor BGM     a.c. and h.s.

Monitor     kidney function tests

Administer antihyperglycemics     as ordered.

   

   

Key Problem:Knowledge deficit

Data:Pt verbalizes confusion about diagnosis,new     meds,diet, exercise routine

AEB: Verbal     statements and questions.

Outcomes:

Pt will     verbalize understanding of ADA diet and administer insulin using     appropriate technique by discharge.

Interventions:

Assess level     of knowledge regarding diabetes/ treatment and client’s preferred learning     style.

Provide     information q shift according to teaching plan recorded in EMR and document     pt’s response. 

Reassess     level of knowledge daily.

Provide     written information.

Provide     educational resources available in the community.

        

4

                      

Medical Problems     (Pathophysiology)/Surgical Procedures:

Newly     diagnosed diabetic

Key Assessments:

S/S of hyper and hypoglycemia, good     intake, I/O, glucose level, vitals

Tests: FBS, hemoglobin A1C

       

“I don’t know     how this fits”

Recent widow

Kids live out     of state

? support     system

   

   

1

        

Key Problem: Acute anxiety

Data: Restless, verbally states she     is anxious.

AEB: Pt states “I don’t know what I     will do with diabetes, this is too much.”

Outcomes: Pt. will verbalize under-standing     of resources available by discharge.

Interventions: 

Provide pt. with an opportunity each     shift to verbalize anxiety by asking open ended questions.

Demonstrate progressive relaxation     exercises and have pt. return demonstrate.

Provide pt. with a list of community     resources for newly diagnosed diabetics.

Identify client’s perception of anxiety

Utilize empathy.

       

2

       

Past     Medical History: Hypertension x 20 years; appendectomy at     age 9.

Risk     Factors: Mother had Type 2 diabetes;     hypertension; Native American descent; sedentary lifestyle; 290 pounds, age     52

       

Key Problem:

Imbalanced nutrition, more than

Data:

BMI:35.0–39.9; Ht: 5”9; Wt: 290 lbs

AEB: Anthropometric measurements.

Outcomes: Client will verbalize a     realistic weight loss goal and three strategies to reach it prior to     discharge.

Interventions:

Assess client’s knowledge of nutrition     and its relationship to diabetes.

Arrange for dietary consultation.

Reinforce teaching  by dietician.

Encourage physical activity as a     weight loss strategy.

Provide pt with community resources     that can assist her with weight loss goal.

         

“I DON’T KNOW HOW THIS FITS”

       

       

       

       

                   

PAST MEDICAL HISTORY

RISK FACTORS

          

MEDICAL PROBLEMS     (PATHOPHYSIOLOGY)/SURGICAL PROCEDURES:

KEY ASSESSMENTS:

Key Assessments:

Tests:

       

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

       

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

     

   

/60pts

        

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

       

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

RUBRIC for Grading Packets

  

Student   Name:


Clinical   Date:


Site:

  

Section


Grading Criteria


SatisfactoryOrUnsatisfactory


Comments, Kudos,

Things to Improve for Next Time

 

10 points

Patient Demographics,

Diagnoses, Surgeries, Orders,   Rehab, IV, Imaging and Lab


Page 1 fully and correctly completed  5   pts

Page 2 fully and   correctly completed 5 pts 


_/5___

_/5___


 

20   points

Medications


Medication Trade   Name  2   pts

Medication Generic   Name 2 pts

Pharmacological   Classification 2 pts

Normal Dosage Range  2   pts

Dose ordered 2 pts

Route and Frequency 2 pts

Contraindications 2 pts

Adverse   Effects/Reactions 2 pts

Nursing Considerations   & Teaching 2 pts

(Legible or typed) 2 pts


/ 2

/ 2

/ 2

/ 2

/ 2

/ 2

/ 2

/ 2

/ 2

 /   2 

_/20__


 

10 points

Narrative Notes

Head-to-Toe Assessment


Narrative note is in Head   to Toe order 

Head-to-toe assessment   documented Abnormal results noted10   pts


___/10_


 

60   points (either a Concept Map or a Patient Care Plan)

Concept   Map


Correct Medical   Diagnosis 15 pts

Pathophysiology 15 pts

Key Assessments 15 pts

At least 3 problems   identified 15 pts


____/60

OR


 

60   points (either a Concept Map or a Patient Care Plan)

Patient   Care Plan


3nursing diagnoses Related to” “As evidenced by”18 pts

2 Outcomes specific,   measurable, timed 8 pts

4-5Interventions are   logical, appropriate 15 pts

4-5Scientific Rationales   supporting each intervention15 pts2Evaluations4 pts


____/60


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    Patient Assessment and Care Plan

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