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Dilate pupil – to aware of surroundings Release of norepinephrine (adrenaline – cathecolamine) - medriasis Adrenal medulla (potent vasoconstrictor) 2. Dry mouth Increases body activities VS = Increase 3. BP & HR= increased Except GIT – decrease GITmotility bronchioles dilated to take more oxygen 4. RR increased * Why GIT is not increased = GIT is not important! 5. Constipation & urinary retention Increase blood flow to skeletal muscles, brain & heart. I. Adrenergic Agents – Epinephrine (adrenaline) SE: SNS effect II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in –‘lol’) Blocks release of norepinephrine. Decrease body activities except GIT (diarrhea) Ex. Propanolol, Metopanolol SE: B – broncho spasm (bronchoconstriction) E – elicits a decrease in myocardial contraction T – treats HPN A – AV conduction slows down Given to angina & MI – beta-blockers to rest heart Anti HPN agents: Beta blockers (-lol) Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL Calcium antagonist ex CALCIBLOC or NEFEDIPINE Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic) Involved in fly or withdrawal response 1. Meiosis – contraction of pupils Release of acetylcholine (ACTH) 2. Increase salivation Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased 4. RR decrease – broncho constriction I Cholinergic agents 5. Diarrhea – increased GI motility ex 1. Mestinon 6. Urinary frequency Antidote – anti cholinergic agents Atropine Sulfate – S/E – SNS S/E- of anti-hpn drugs: orthostatic hpn transient headache & dizziness. -Mgt. Rise slowly. Assist in ambulation. CNS (brain & spinal cord) I. Cells – A. neurons Properties and characteristics Excitability – ability of neuron to be affected in external environment. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another Permanent cells – once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes) Regenerative capacity A. Labile – once destroyed cant regenerate - Epidermal cells, GIT cells, resp (lung cells). GUT B. Stable – capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver, kidney cells C. Permanent cells – retina, brain, heart, osteocytes can’t regenerate. 3.) Neuroglia – attached to neurons. Supports neurons. Where brain tumors are found. Types: Astrocyte Oligodendria Astrocytoma – 90 – 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte. Astrocyte – maintains integrity of blood brain barrier (BBB). BBB – semi permeable / selective -Toxic substance that destroys astrocyte & destroy BBB. Toxins that can pass in BBB: Ammonia-liver cirrhosis. 2. Carbon Monoxide – seizure & parkinsons. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia. 4. Ketones –DM. OLIGODENDRIA – Produces myelin sheath – wraps around a neuron – acts as insulator facilitates rapid nerve impulse transmission. No myelin sheath – degenerates neurons Damage to myelin sheath – demyellenating disorders DEMYELLENATING DSE 1.)ALZHEIMER’S DISEASE– atrophy of brain tissue due to a deficiency of acetylcholine. S&Sx: A – amnesia – loss of memory A – apraxia – unable to determine function & purpose of object A – agnosia – unable to recognize familiar object A – aphasia – - Expressive – brocca’s aphasia – unable to speak - Receptive – wernickes aphasia – unable to understand spoken words Common to Alzheimer – receptive aphasia Drug of choice – ARICEPT (taken at bedtime) & COGNEX. Mgt: Supportive & palliative. Microglia – stationary cells, engulfs bacteria, engulfs cellular debris. II. Compositions of Cord & Spinal cord 80% - brain mass 10% - CSF 10% - blood MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will increase ICP. Normal ICP: 0-15mmHg Brain mass 1. Cerebrum – largest - Connects R & L cerebral hemisphere - Corpus collusum Rt cerebral hemisphere, Lt cerebral hemisphere Function: Sensory Motor Integrative Lobes 1.) Frontal a. Controls motor activity b. Controls personality development c. Where primitive reflexes are inhibited d. Site of development of sense of umor e. Brocca’s area – speech center Damage - expressive aphasia 2.) Temporal – a. Hearing b. Short term memory c. Wernickes area – gen interpretative or knowing Gnostic area Damage – receptive aphasia 3.) Parietal lobe – appreciation & discrimation of sensory imp - Pain, touch, pressure, heat & cold 4.) Occipital - vision 5.) Insula/island of reil/ Central lobe- controls visceral fx Function: - activities of internal organ 6.) Rhinencephalon/ Limbec - Smell, libido, long-term memory Basal Ganglia – areas of gray matte located deep within a cerebral hemisphere Extra pyramidal tract Releases dopamine- Controls gross voluntary unit Decrease dopamine – (Parkinson’s) pin rolling of extremities & Huntington’s Dse. Decrease acetylcholine – Myasthenia Gravis & Alzheimer’s Increased neurotransmitter = psychiatric disorder Increase dopamine – schizo Increase acetylcholine – bipolar MID BRAIN – relay station for sight & hearing Controls size & reaction of pupil 2 – 3 mm Controls hearing acuity CN 3 – 4 Isocoria – normal size (equal) Anisocoria – uneven size – damage to mid brain PERRLA – normal reaction DIENCEPHALON- between brain Thalamus – acts as a relay station for sensation Hypothalamus – (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center, emotional responses, controls pituitary function. BRAIN STEM- a. Pons – or pneumotaxic center – controls respiration Cranial 5 – 8 CNS MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12 CEREBELLUM – lesser brain - Controls posture, gait, balance, equilibrium Cerebellar Tests: a.) R – Romberg’s test- needs 2 RNs to assist - Normal anatomical position 5 – 10 min (+) Romberg’s test – (+) ataxia or unsteady gait or drunken like movement with loss of balance. b.) Finger to nose test – (+) To FTNT – dymetria – inability to stop a movement at a desired point c.) Alternate pronation & supination Palm up & down . (+) To alternate pronation & supination or damage to cerebellum – dymentrium Composition of brain - based on Monroe Kellie Hypothesis Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP Normal ICP – 0 – 15 mmHg Foramen Magnum C1 – atlas C2 – axis (+) Projectile vomiting = increase ICP Observe for 24 - 48 hrs CSF – cushions the brain, shock absorber Obstruction of flow of CSF = increase ICP Hydrocephalus – posteriorly due to closure of posterior fontanel CVA – partial/ total obstruction of blood supply INCREASED ICP – increase ICP is due to increase in 1 of the Intra Cranial components. Predisposing factors: Head injury Tumor Localized abscess Hemorrhage (stroke) Cerebral edema Hydrocephalus Inflammatory conditions - Meningitis, encephalitis B. S&Sx change in VS = always late symptoms Earliest Sx: a.) Change or decrease LOC – Restlessness to confusion Wide pulse pressure: Increased ICP - Disorientation to lethargy Narrow pp: Cardiac disorder, shock - Stupor to coma Late sign – change in V/S BP increase (systolic increase, diastole- same) Widening pulse pressure Normal adult BP 120/80 120 – 80 = 40 (normal pulse pressure) Increase ICP = BP 140/80 = 140 – 80= 60 PP (wide) RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea) Temp increase Increased ICP: Increase BP Shock – decrease BP – Decrease HR Increase HR CUSHINGS EFFECT Decrease RR Increase RR Increase Temp Decrease temp b.) Headache Projectile vomiting Papilledima (edema of optic disk – outer surface of retina) Decorticate (abnormal flexion) = Damage to cortico spinal tract / Decerebrate (abnormal extension) = Damage to upper brain stem-pons/ c.) Uncal herniation – unilateral dilation of pupil. (Bilateral dilation of pupil – tentorial herniation.) d.) Possible seizure. Nursing priority: 1.) Maintain patent a/w & adequate ventilation a. Prevention of hypoxia – (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention). Hypoxia – cerebral edema - increase ICP Hypoxia – inadequate tissue oxygenation Late symptoms of hypoxia – B – bradycardia E – extreme restlessness D – dyspnea C – cyanosis Early symptoms – R – restlessness A – agitation T – tachycardia Increase CO2 retention/ hypercarbia – cerebral vasodilatation = increase ICP Most powerful respiratory stimulant increase in CO2 Hyperventilate decrease CO2 – excrete CO2 Respiratory Distress Syndrome (RDS) – decrease Oxygen Suctioning – 10-15 seconds, max 15 seconds. Suction upon removal of suction cap. Ambu bag – pump upon inspiration c. Assist in mechanical ventilation 1. Maintain patent a/w 2. Monitor VS & I&O 3. Elevate head of bed 30 – 45 degrees angle neck in neutral position unless contra indicated to promote venous drainage 4. Limit fluid intake 1,200 – 1,500 ml/day (FORCE FLUID means:Increase fluid intake/day – 2,000 – 3,000 ml/day)- not for inc ICP. 5. Prevent complications of immobility 6. Prevent increase ICP by: a. Maintain quiet & comfy environment b. Avoid use of restraints – lead to fractures c. Siderails up d. Instruct patient to avoid the ff: -Valsalva maneuver or bearing down, avoid straining of stool (give laxatives/ stool softener Dulcolax/ Duphalac) - Excessive cough – antitussive Dextrometorpham -Excessive vomiting – anti emetic (Plasil – Phil only)/ Phenergan - Lifting of heavy objects - Bending & stooping e. Avoid clustering of nursing activities 7. Administer meds as ordered: 1.) Osmotic diuretic – Mannitol./Osmitrol promotes cerebral diuresis by decompressing brain tissue Nursing considerations: Mannitol Monitor BP – SE of hypotension Monitor I&O every hr. report if < 30cc out put Administer via side drip Regulate fast drip – to prevent formation of crystals or precipitate 2.) Loop diuretic - Lasix (Furosemide) Nursing Mgt: Lasix Same as Mannitol except - Lasix is given via IV push (expect urine after 10-15mins) should be in the morning. If given at 7am. Pt will urinate at 7:15 Immediate effect of Lasix within 15 minutes. Max effect – 6 hrs due (7am – 1pm) S/E of Lasix Hypokalemia (normal K-3.5 – 5.5 meg/L) S&Sx Weakness & fatigue Constipation (+) “U” wave in ECG tracing Nursing Mgt: Administer K supplements – ex Kalium Durule, K chloride Potassium Rich food: ABC’s of K Vegetables Fruits A - asparagus A – apple B – broccoli (highest) B – banana – green C – carrots C – cantalope/ melon O – orange (highest) –for digitalis toxicity also. Vit A – squash, carrots yellow vegetables & fruits, spinach, chesa Iron – raisins, Food appropriate for toddler – spaghetti! Not milk – increase bronchial secretions Don’t give grapes – may choke S/E of Lasix: Hypokalemia Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml) or Tetany: S&Sx weakness Paresthesia (+) Trousseau sign – pathognomonic – or carpopedal spasm. Put bp cuff on arm=hand spasm. (+) Chevostek’s sign Arrhythmia Laryngospasm Administer – Ca gluconate – IV slowly Ca gluconate toxicity: Sx – seizure – administer Mg SO4 Mg SO4 toxcicity– administer Ca gluconate B – BP decrease U – urine output decrease R – RR decrease P – patellar reflexes absent Hyponatremia – Normal Na level = 135 – 145 meg/L S/Sx – Hypotension Signs of Dehydration: dry skin, poor skin turgor, gen body malaise. Early signs – Adult: thirst and agitation / Child: tachycardia Mgt: force fluid Administer isotonic fluid sol 4.) Hyperglycemia – increase blood sugar level P – polyuria P – polyphagia P – polydipsia Nsg Mgt: Monitor FBS (N=80 – 120 mg/dl) 5.) Hyperurecemia – increase serum uric acid. Tophi- urate crystals in joint.   Gouty arthritis kidney stones- renal colic (pain) Cool moist skin Sx joint pain & swelling usually at great toe. Nsg Mgt of Gouty Arthritis a.) Cheese (not sardines, anchovies, organ meat) (Not good if pt taking MAO) b.) Force fluid c.) Administer meds – Allopurinol/ Zyloprim – inhibits synthesis of uric acid – drug of choice for gout Colchicene – excretes uric acid. Acute gout drug of choice. Kidney stones – renal colic (pain). Cool moist skin Mgt: Force fluid Meds – narcotic analgesic Morphine SO4 SE of Morphine SO4 toxicity Respiratory depression (check RR 1st) Antidote for morphine SO4 toxicity –Narcan (NALOXONE) Naloxone toxicity – tremors Increase ICP meds: 3.) Corticosteroids - Dexamethsone – decrease cerebral edema (Decadrone) 4.) Mild analgesic – codeine SO4. For headache. 5.) Anti consultants – Dilantin (Phenytoin) Question: Increase ICP what is the immediate nsg action? Administer Mannitol as ordered Elevate head 30 – 45 degrees Restrict fluid Avoid use of restraints Nsg Priority – ABC & safety Pt suffering from epiglotitis. What is nsg priority? Administer steroids – least priority Assist in ET – temp, a/w Assist in tracheotomy – permanent (Answer) Apply warm moist pack? Least priority Rationale: Wont need to pass larynx due to larynx is inflamed. ET can’t pass. Need tracheostomy only- Magic 2’s of drug monitoring Drug N range Toxicity Classification Indication D – digoxin .5 – 1.5 meq/L 2 cardiac glycosides CHF L - lithium .6 – 1.2 meq/L 2 antimanic bipolar A – aminophylline 10 – 19 mg/100ml 20 bronchodilator COPD D – Dilantin 10 -19 mg/100 ml 20 anticonvulsant seizures A – acetaminophen 10 – 30 mg/100ml 200 narcotic analgesic osteoarthritis Digitalis – increase cardiac contraction = increase CO Nursing Mgt Check PR, HR (if HR below 60bpm, don’t giveDigoxin) Digitalis toxicity – antidote - Digivine Anorexia -initial sx. n/v GIT Diarrhea Confusion Photophobia Changes in color perception – yellow spots (Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.) L – lithium (lithane) decrease levels of norepinephrine, serotonine, acetylcholine Antimanic agent Lithium toxicity S/Sx - Anorexia n/s Diarrhea Dehydration – force fluid, maintain Na intake 4 – 10g daily Hypothyroidism (CRETINISM– the only endocrine disorder that can lead to mental retardation) A – aminophyline (theophylline) – dilates bronchioles. Take bp before giving aminophylline. S/Sx : Aminophylline toxicity: Tachycardia Hyperactivity – restlessness, agitation, tremors Question: Avoid giving food with Aminophylline Cheese/butter– food rich in tyramine, avoided only if pt is given MAOI Beer/ wine - Hot chocolate & tea – caffeine – CNS stimulant tachycardia Organ meat/ box cereals – anti parkinsonian MAOI – antidepressant m AR plan n AR dil can lead to CVA or hypertensive crisis p AR nate 3 – 4 weeks - before MAOI will take effect Anti Parkinsonian agents – Vit B6 Pyridoxine reverses effect of Levodopa D – dilatin (Phenytoin) – anti convulsant/seizure Nursing Mgt: Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate Do sandwich method Give NSS then Dilantin, then NSS! Instruct the pt to avoid alcohol – bec alcohol + dilantin can lead to severe CNS depression Dilantin toxicity: S/Sx: G – gingival hyperplasia – swollen gums Oral hygiene – soft toothbrush Massage gums H – hairy tongue A - ataxia N – nystagmus – abnormal movement of eyeballs A – acetaminophen/ Tylenol – non-opoid analgesic & antipyretic – febrile pts Acetaminophen toxicity : Hepato toxicity Monitor liver enzymes SGPT (ALT) – Serum Glutamic Piruvate Tyranase SGOT- Serum Glutamic Acetate Tyranase Monitor BUN (10 – 20) Crea (.8-1) Acetaminophen toxicity can lead to hypoglycemia T – tremors, Tachycardia I – irritability R – restlessness E – extreme fatigue D – depression (nightmares) , Diaphoresis Antidote for acetaminophen toxicity – Acetylcesteine = causes outporing of secretions. Suction. Prepare suctioning apparatus. Question: The following are symptoms of hypoglycemia except: Nightmares Extreme thirst – hyperglycemia symptoms Weakness d. Diaphoresis PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine producing cells in substancia nigra at mid brain & basal ganglia Palliative, Supportive Function of dopamine: controls gross voluntary motors. Predisposing Factors: 1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA 2. Hypoxia 3. Arteriosclerosis 4. Encephalitis High doses of the ff:  a. Reserpine (serpasil) anti HPN, SE – 1.) depression - suicidal 2.) breast cancer b. Methyldopa (aldomet) - promote safety c. Haloperidol (Haldol)- anti psychotic d. Phenothiazide - anti psychotic SE of anti psychotic drugs – Extra Pyramidal Symptom Over meds of anti psychotic drugs – neuroleptic malignant syndrome char by tremors (severe) S/Sx: Parkinsonism – Pill rolling tremors of extremities – early sign Bradykinesia – slow movement Over fatigue Rigidity (cogwheel type) Stooped posture Shuffling – most common Propulsive gait Mask like facial expression with decrease blinking eyes Monotone speech Difficulty rising from sitting position Mood labilety – always depressed – suicide Nsg priority: Promote safety Increase salivation – drooling type Autonomic signs: Increase sweating Increase lacrimation Seborrhea (increase sebaceous gland) Constipation Decrease sexual activity Nsg Mgt Anti parkinsonian agents Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel) Mechanism of action Increase levels of dopa – relieving tremors & bradykinesia S/E of anti parkinsonian Anorexia n/v Confusion Orthostatic hypotension Hallucination Arrhythmia Contraindication: Narrow angled closure glaucoma Pt taking MAOI (Parnate, Marplan, Nardil) Nsg Mgt when giving anti-parkinsonian Take with meals – to decrease GIT irritation Inform pt – urine/ stool may be darkened Instruct pt- don’t take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg Cause B6 reverses therapeutic effects of levodopa Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis. Anti cholinergic agents – relieves tremors Artane mech – inhibits acetylcholine Cogentin action , S/E - SNS Antihistamine – Diphenhydramine Hcl (Benadryl) – take at bedtime S/E: adult– drowsiness,– avoid driving & operating heavy equipt. Take at bedtime. Child – hyperactivity CNS excitement for kids. 4.) Dopamine agonist Bromotriptine Hcl (Parlodel) – respiratory depression. Monitor RR. Nsg Mgt – Parkinson 1.) Maintain siderails 2.) Prevent complications of immobility - Turn pt every 2h Turn pt every 1 h – elderly 3.) Assist in passive ROM exercises to prevent contractures 4.) Maintain good nutrition  CHON – in am  CHON – in pm – to induce sleep – due Tryptopan – Amino Acid 5.) Increase fluid in take, high fiber diet to prevent constipation 6.) Assist in surgery – Sterotaxic Thalamotomy Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis MULTIPLE SCLEROSIS (MS) Chronic intermittent disorder of CNS – white patches of demyelenation in brain & spinal cord. Remission & exacerbation Common – women, 15 – 35 yo cause – unknown Predisposing factor: Slow growing virus Autoimmune – (supportive & palliative treatment only) Normal Resident Antibodies: Ig G – can pass placenta – passive immunity. Short acting. Ig A – body secretions – saliva, tears, colostrums, sweat Ig M – acute inflammation Ig E – allergic reactions IgD – chronic inflammation S & Sx of MS: (everything down) 1. Visual disturbances a. Blurring of vision b. Diplopia/ double vision c. Scotomas (blind spots) – initial sx 2. Impaired sensation to touch, pain, pressure, heat, cold a. Numbness b. Tingling c. Paresthesia 3. Mood swings – euphoria (sense of elation ) 4. Impaired motor function: a. Weakness b. Spasiticity –“ tigas” c. Paralysis –major problem 5. Impaired cerebellar function Triad Sx of MS  I – intentional tremors N – nystagmus – abnormal rotation of eyes Charcots triad A – Ataxia & Scanning speech 6. Urinary retention or incontinence 7. Constipation 8. Decrease sexual ability Dx – MS 1. CSF analysis thru lumbar puncture - Reveals increase CHON & IgG 2. MRI – reveals site & extent of demyelination 3. Lhermitte’s response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord. Nsg Mgt MS Supportive mgt 1.) Meds a. Acute exacerbation ACTH – adenocorticotopic Steroids – to reduce edema at the site of demyelination to prevent paralysis Spinal Cord Injury Administer drug to prevent paralysis due to edema a. Give ACTH – steroids b. Baclopen (Lioresol) or Dantrolene Na (Dantrene) To decrease muscle spasticity c. Interferone – to alter immune response d. Immunosuppresants 2. Maintain siderails 3. Assist passive ROMexercises – promote proper body alignment 4. Prevent complications of immobility 5. Encourage fluid intake & increase fiber diet – to prevent constipation 6. Provide catheterization die urinary retention 7. Give diuretics Urinary incontinence – give Prophantheline bromide (probanthene)  Antispasmodic anti cholinergic 8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques. 9. Provide acid-ash diet – to acidify urine & prevent bacteria multiplication Grape, Cranberry, Orange juice, Vit C MYASTHENIA GRAVIS (MG) – disturbance in transmission of impulses from nerve to muscle cell at neuro muscular junction. Common in Women, 20 – 40 yo, unknown cause or idiopathic Autoimmune – release of cholenesterase – enzyme Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine Descending muscle weakness (Ascending muscle weakness – Guillain Barre Syndrome) Nsg priority: a/w aspiration immobility S/ Sx: Ptosis – drooping of upper lid ( initial sign) Check Palpebral fissure – opening of upper & lower lids = to know if (+) of MG. Diplopia – double vision Mask like facial expression Dysphagia – risk for aspiration! Weakening of laryngeal muscles – hoarseness of voice Resp muscle weakness – lead respiratory arrest. Prepare at bedside tracheostomy set Extreme muscle weakness during activity especially in the morning. Dx test Tensilon test (Edrophonium Hcl) – temporarily strengthens muscles for 5 – 10 mins. Short term- cholinergic. PNS effect. Nsg Mgt 1. Maintain patent a/w & adequate vent by: a.) Assist in mechanical vent – attach to ventilator b.) Monitor pulmonary function test. Decrease vital lung capacity. 2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc) 3. Siderails 4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every 1 hr. 5. NGT feeding Administer meds – Cholinergics or anticholinesterase agents Mestinon (Pyridostigmine) Neostignine (prostigmin) – Long term - Increase acetylcholine s/e – PNS Corticosteroids – to suppress immune resp Decadron (dexamethasone) Monitor for 2 types of Crisis: Myastinic crisisCholinergic crisisA cause – 1. Under medication 2. Stress 3. Infection B S&Sx 1. Unable to see – Ptosis & diplopia 2. Dysphagia- unable to swallow. 3. Unable to breath C Mgt – adm cholinergic agentsCause: 1 over meds S/Sx - PNS Mgt. adm anti-cholinergic Atropine SO4 SNS – dry mouth7. Assist in surgical proc – thymectomy. Removal of thymus gland. Thymus secretes auto immune antibody. 8. Assist in plasmaparesis – filter blood 9. Prevent complication – respiratory arrest Prepare tracheostomy set at bedside. GBS – Guillain Barre Syndrome Disorder of CNS Bilateral symmetrical polyneuritis Ascending paralysis Cause – unknown, idiopathic Auto immune r/t antecedent viral infection Immunizations S&Sx Initial : Clumsiness Ascending muscle weakness – lead to paralysis Dysphagia Decrease or diminished DTR (deep tendon reflexes) Paralysis Alternate HPN to hypotension – lead to arrhythmia - complication Autonomic changes – increase sweating, increase salivation. Increase lacrimation Constipation Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS) Nsg Mgt 1. Maintain patent a/w & adequate vent a. Assist in mechanical vent b. Monitor pulmonary function test 2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia 3. Siderails 4. Prevent compl – immobility 5. Assist in passive ROM exercises 6. Institute NGT feeding – due dysphagia 7. Adm meds (GBS) as ordered: – 1. Anti cholinergic – atropine SO4 2. Corticosteroids – to suppress immune response 3. Anti arrhythmic agents a.) Lidocaine /Xylocaine –SE confusion = VTach b.) Bretyllium c.) Quinines/Quinidine – anti malarial agent. Give with meals. - Toxic effect – cinchonism Quinidine toxicity S/E – anorexia, n/v, headache, vertigo, visual disturbances Assist in plasmaparesis (MG. GBS) Prevent comp – arrhythmias, respiratory arrest Prepare tracheostomy set at bedside. INFL CONDITONS OF BRAIN Meninges – 3-fold membrane – cover brain & spinal cord Fx: Protection & support Nourishment Blood supply 3 layers  1. Duramater sub dural space  2. Arachmoid matter  3. Pia matter sub arachnoid space where CSF flows L3 & L4. Site for lumbar puncture. MENINGITIS – inflammation of meningitis & spinal cord Etiology – Meningococcus Pneumococcus Hemophilous influenza – child Streptococcus – adult meningitis MOT – direct transmission via droplet nuclei S&Sx Stiff neck or nuchal rigidity (initial sign) Headache Projectile vomiting – due to increase ICP Photophobia Fever chills, anorexia Gen body malaise Wt loss Decorticate/decerebration – abnormal posturing Possible seizure Sx of meningeal irritation – nuchal rigidity or stiffness Opisthotonus- rigid arching of back Pathognomonic sign – (+) Kernig’s & Brudzinski sign Leg pain neck pain Dx: 1. Lumbar puncture – lumbar/ spinal tap – use of hallow spinal needle – sub arachnoid space L3 & L4 or L4 & L5 Aspirate CSF for lumbar puncture. Nsg Mgt for lumbar puncture – invasive Consent / explain procedure to pt RN – dx procedure (lab) MD – operation procedure Empty bladder, bowel – promote comfort Arch back – to clearly visualize L3, L4 Nsg Ngt post lumbar Flat on bed – 12 – 24 h to prevent spinal headache & leak of CSF Force fluid Check punctured site for drainage, discoloration & leakage to tissue Assess for movement & sensation of extremeties Result 1. CSF analysis: a. increase CHON & WBC Content of CSF: Chon, wbc, glucose b. Decrease glucose Confirms meningitis c. increase CSF opening pressure N 50 – 160 mmHg d. (+) Culture microorganism 2. Complete blood count CBC – reveals increase WBC Mgt: 1. Adm meds a.) Broad-spectrum antibiotic penicillin S/E GIT irritation – take with food Hepatotoxicity, nephrotoxcicity Allergic reaction Super infection – alteration in normal bacterial flora N flora throat – streptococcus N flora intestine – e coli Sx of superinfection of penicillin = diarrhea b.) Antipyretic c.) Mild analgesic 2. Strict resp isolation 24h after start of antibiotic therapy A – Cushing’s synd – reverse isolation - due to increased corticosteroid in body. B – Aplastic anemia – reverse isolation - due to bone marrow depression. C – Cancer anytype – reverse isolation – immunocompromised. D – Post liver transplant – reverse isolation – takes steroids lifetime. E – Prolonged use steroids – reverse isolation F – Meningitis – strict respiratory isolation – safe after 24h of antibiotic therapy G – Asthma – not to be isolated 3. Comfy & dark room – due to photophobia & seizure 4. Prevent complications of immobility 5. Maintain F & E balance 6. Monitor vs, I&O , neuro check 7. Provide client health teaching & discharge plan a. Nutrition – increase cal & CHO, CHON-for tissue repair. Small freq feeding b. Prevent complication hydrocephalus, hearing loss or nerve deafness. 8. Prevent seizure. Where to bring 2 yo post meningitis Audiologist due to damage to hearing- post repair myelomeningocele Urologist -Damage to sacral area – spina bifida – controls urination 9. Rehab for neurological deficit. Can lead to mental retardation or a delay in psychomotor development. CEREBRO VASCULAR ACCIDENT – stroke, brain attack or cerebral thrombosis, apoplexy Partial or complete disruption in the brains blood supply 2 largest & common artery in stroke Middle cerebral artery Internal carotid artery Common to male – 2 – 3x high risk Predisposing factor: Thrombosis – clot (attached) Embolism – dislodged clot – pulmo embolism S/Sx: pulmo embolism Sudden sharp chest pain Unexplained dyspnea, SOB Tachycardia, palpitations, diaphoresis & mild restlessness S/Sx: cerebral embolism Headache, disorientation, confusion & decrease in LOC Femur fracture – complications: fat embolism – most feared complication w/in 24hrs Yellow bone marrow – produces fat cells at meduallary cavity of long bone Red bone marrow – provides WBC, platelets, RBC found at epiphisis 2.) Hemorrhage 3.) Compartment syndrome – compression of nerves/ arteries Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery – mitral valve replacement Lifestyle: 1. Smoking – nicotine – potent vasoconstrictor 2. Sedentary lifestyle 3. Hyperlipidemia – genetic 4. Prolonged use of oral contraceptives - Macro pill – has large amt estrogen - Mini pill – has large amt of progestin - Promote lipolysis (breakdown of lipids/fats) – artherosclerosis – HPN - stroke 5. Type A personality a. Deadline driven person b. 2 – 5 things at the same time c. Guilty when not dong anything 6. Diet – increase saturated fats 7. Emotional & physical stress 8. Obesity S & Sx 1. TIA- warning signs of impending stroke attacks Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or plegia (monoplegia – 1 extreme) Increase ICP 2. Stroke in evolution – progression of S & Sx of stroke 3. Complete stroke – resolution of stroke a.) Headache b.) Cheyne-Stokes Resp c.) Anorexia, n/v d.) Dysphagia e.) Increase BP f.) (+) Kernig’s & Brudzinski – sx of hemorrhagic stroke g.) Focal & neurological deficit 1. Phlegia 2. Dysarthria – inability to vocalize, articulate words 3. Aphasia 4. Agraphia diff writing 5. Alesia – diff reading 6. Homoninous hemianopsia – loss of half of field of vision Left sided hemianopsia – approach Right side of pt – the unaffected side Dx CT Scan – reveals brain lesion Cerebral arteriography – site & extent of mal occlusion Invasive procedure due to inject dye Allergy test All – graphy – invasive due to iodine dye Post Force fluid – to excrete dye is nephrotoxic Check peripheral pulses - distal Nsg Mgt 1. Maintain patent a/w & adequate vent - Assist mechanical ventilation - Administer O2 2. Restrict fluids – prevent cerebral edema 3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver. 4. Monitor vs., I&O, neuro check 5. Prevent compl of immobility by: a. Turn client q2h Elderly q1h To prevent decubitus ulcer To prevent hypostatic pneumonia – after prolonged immobility. b. Egg crate mattress or H2O bed c. Sand bag or foot board- prevent foot drop 6. NGT feeding – if pt can’t swallow 7. Passive ROM exercise q4h 8. Alternative means of communication - Non-verbal cues - Magic slate. Not paper and pen. Tiring for pt. - (+) To hemianopsia – approach on unaffected side 9. Meds Osmotic diuretics – Mannitol Loop diuretics – Lasix/ Furosemide Corticosteroids – dextamethazone Mild analgesic Thrombolytic/ fibrolitic agents – tunaw clot. SE-Urticaria, pruritus-caused by foreign subs. Streptokinase Urokinase Tissue plasminogen activating Monitor bleeding time Anticoagulants – Heparin & Coumadin” sabay” Coumadin will take effect after 3 days Heparin – monitor PTT partial thromboplastin time if prolonged – bleeding give Protamine SO4- antidote. Coumadin –Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K – Aquamephyton- antidote. Antiplatelet – PASA – aspirin paraanemo aspirin, don’t give to dengue, ulcer, and unknown headache. Health Teaching 1. Avoidance modifiable lifestyle - Diet, smoking 2. Dietary modification - Avoid caffeine, decrease Na & saturated fats Complications: Subarachnoid hemorrhage Rehab for focal neurological deficit – physical therapy Mental retardation Delay in psychomotor development CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or without loss of consciousness, abnormal motor activity, alteration in sensation & perception & change in behavior. Can you outgrow febrile seizure? Difference between: Seizure- 1st convulsive attack Febrile seizure Normal if < 5 yo Epilepsy – 2nd and with history of seizure Pathologic if > 5 yo Predisposing Factor Head injury due birth trauma Toxicity of carbon monoxide Brain tumor Genetics Nutritional & metabolic deficit Physical stress Sudden withdrawal to anticonvulsants will bring about status epilepticus Status epilepticus – drug of choice: Diazepam & glucose S & Sx I. Generalized Seizure – a.) Grand mal / tonic clonic seizures With or without aura – warning symptoms of impending seizure attack- Epigastric pain- associated with olfactory, tactile, visual, auditory sensory experience Epileptic cry – fall Loss of consciousness 3 – 5 min Tonic clonic contractions Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic b.) Petimal seizure – (same as daydreaming!) or absent seizure. - Blank stare - Decrease blinking eye - Twitching of mouth - Loss of consciousness – 5 – 10 secs (quick & short) II. Localized/partial seizure Jacksonian seizure or focal seizure – tingling/jerky movement of index finger/thumb & spreads to shoulder & 1 sideof the body with janksonian march Psychomotor/ focal motor - seizure -Automatism – stereotype repetitive & non-purposive behavior - Clouding of consciousness – not in control with environment - Mild hallucinatory sensory experience HALLUCINATIONS Auditory – schitzo – paranoid type Visual – korsakoffs psychosis – chronic alcoholism Tactile – addict – substance abuse III. Status epilecticus – continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia – coma – death Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and O2=dec glucose, dec O2. Tx:Diazepam (drug of choice), glucose Dx-Convulsion- get health history! CT scan – brain lesion EEG electroencephalography Hyperactivity brain waves Nsg Mgt Priority – Airway & safety Maintain patent a/w & promote safety Before seizure: Remove blunt/sharp objects Loosen clothing Avoid restraints Maintain siderails Turn head to side to prevent aspiration Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can use spoon at home. Avoid precipitating stimulus – bright glaring lights & noises Administer meds Dilantin (Phenytoin) –( toxicity level – 20 ) SE Ginguial hyperplasia H-hairy tongue A-ataxia N-nystagmus A-acetaminophen- febrile pt Mix with NSS - Don’t give alcohol – lead to CNS depression b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia c. Phenobarbital (Luminal)- SE: hallucinations 2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside 3. Monitor onset & duration - Type of seizure - Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having status epilepticus! 4. Assist in surgical procedure. Cortical resection 5. Complications: Subarachnoid hemorrhage and encephalitis Question: 1 yo grand mal – immediate nursing action = a/w & safety a. Mouthpiece – 1 yr old – little teeth only b. Adm o2 inhalation – post! c. Give pillow – safety (answer) d. Prepare suction Neurological assessment: Comprehensive neuro exam GCS - Glasgow coma scale – obj measurement of LOC or quick neuro check 3 components of ECS M – motor 6 V – verbal resp 5 E – eye opening 4 15 15 – 14 – conscious 13 – 11 – lethargy 10 – 8 – stupor 7 – coma 3 – deep coma – lowest score Survey of mental status & speech (Comprehensice Neuro Exam) LOC & test of memory Levels of orientation CN assessment Motor assessment Sensory assessment Cerebral test – Romhberg, finger to nose DTR Autonomics Levels of consciousness (LOC) – Conscious (conscious) – awake – levels of wakefulness Lethargy (lethargic) – drowsy, sleepy, obtunded Stupor (stuporous) – awakened by vigorous stimulation Pt has gen body weakness, decrease body reflex Coma (Comatose) light – (+) all forms of painful stimulations Deep – (-) to painful stimulation Question: Describe a conscious pt ? Alert – not all pt are alert & oriented to time & place Coherent Awake- answer Aware Different types of pain stimulation Don’t prick Deep sternal stimulation/ pressure 3x– fist knuckle With response – light coma Without response – deep coma Pressure on great toe – 3x Orbital pressure – pressure on orbits only – below eye Corneal reflex/ blinking reflex Wisp of cotton – used to illicit blinking reflex among conscious patients Instill 1-drop saline solution – unconscious pt if (-) response pt is in deep coma Test of memory – considered educational background Short term memory – What did you eat for breakfast? Damage to temporal lobe – (+) antero grade amnesia Long term memory (+) Retrograde amnesia – damage to limbic system Levels of orientation Time Place Person Graphesthesia- can identify numbers or letters written on palm with a blunt object. Agraphesthesia – cant identify numbers or letters written on palm with a blunt object. CN assessment: I – Olfactory s II – Optic s III – Oculomotor m IV – Trocheal m smallest CN V – Trigeminal b largest CN VI – Abducens m VII – Facial b VIII – Acustic/auditory s IX – Glassopharyngeal b X – Vagus b longest CN XI– Spinal accessory m XII – Hypoglossal m I. Olfactory – don’t use ammonia, alcohol, cologne irritating to mucosa – use coffee, bar soap, vinegar, cigarette tar - Hyposmia – decrease sensitivity to smell - Diposmia – distorted sense of smell - Anosmia – absence of sense of smell Either of 3 might indicate head injury – damage to cribriform plate of ethmoid bone where olfactory cells are located or indicate inflammation condition – sinusitis II optic- test of visual acuity – Snellens chart – central or distance vision Snellens E chart – used for illiterate chart N 20/20 vision distance by w/c person can see letters- 20 ft Numerator – distance to snellens chart Denominator – distance the person can see the letters OD – Rt eye 20/20 20/200 – blindness – cant read E – biggest OS – left eye 20/20 OU – both eye 20/20 Test of peripheral vision/ visual field Superiority Bitemporally Inferiorly Nasally Common Disorders – see page 85-87 for more info on glaucoma, etc. 1. Glaucoma – Normal 12 – 21 mmHg pressure - Increase IOP - Loss of peripheral vision – “tunnel vision” 2. Cataract – opacity of lens - Loss of central vision, “Blurring or hazy vision” 3. Retinal detachment – curtain veil – like vision & floaters 4. Macular degeneration – black spots III, IV, VI – tested simultaneously Innervates the movementt of extrinsic ocular muscle 6 cardinal gaze EOM  Rt eye N left eye IO SO O S LR MR E SR 3 – 4 EOM IV – sup oblique VI – lateral rectus Normal response – PERRLA (isocoria – equal pupil) Anisocoria – unequal pupil Oculomotor Raising of eyelid – Ptosis Controls pupil size 2 -3 cm or 1.5 – 2 mm V – Trigeminal – Largest – consists of - ophthalmic, maxillary, mandibular Sensory – controls sensation of the face, mucus membrane; teeth & cornea reflex Unconscious – instill drop of saline solution Motor – controls muscles of chewing/ muscles of mastication Trigeminal neuralgia – diff chewing & swallowing – extreme food temp is not recommended Question: Trigeminal neuralgia, RN should give Hot milk, butter, raisins Cereals Gelatin, toast, potato – all correct but Potato, salad, gelatin – salad easier to chew VI Facial: Sensory – controls taste – ant 2/3 of tongue test cotton applicator put sugar. -Put applicator with sugar to tip to tongue. -Start of taste insensitivity: Age group – 40 yrs old Motor- controls muscles of facial expression, smile frown, raise eyebrow Damage – Bells palsy – facial paralysis Cause – bells palsy pedia – R/T forcep delivery Temporary only Most evident clinical sign of facial symmetry: Nasolabial folds VIII Acoustic/ vestibule cochlear (controls hearing) – controls balance (kenesthesia or position sense) Movement & orientation of body in space Organ of Corti – for hearing – true sense organ of hearing Outer – tympanic membrane, pinna, oricle (impacted cerumen), cerumen Middle – hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media Eustachean ear Inner ear- meniere dse, sensory hearing loss (research parts! & dse) Remove vestibule – meniere’s dse – disease inner ear Archimedes law – buoyancy (pregnancy – fetus) Daltons law – partial pressure of gases Inertia – law of motion (dizziness, vertigo) 1.) Pt with multiple stab wound - chest - Movement of air in & out of lungs is carried by what principle? - Diffusion – Dalton’s law 2.) Pregnant – check up – ultrasound reveals fetus is carried by amniotic fluid - Archimedes 3.) Severe vertigo due- Inertia Test for acoustic nerve: Repeat words uttered IX – Glossopharyngeal – controls taste – posterior 1/3 of tongue X – Vagus – controls gag reflex Test 9 – 10 Pt say ah – check uvula – should be midline Damage cerebral hemisphere is L or R Gag reflex – place tongue depression post part of tongue Don’t touch uvula XI – Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back) Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia XII – Hypoglossal – controls movement of tongue – say “ah”. Assess tongue position=midline L or R deviation - Push tongue against cheek - Short frenulum lingue – Tongue tied – “bulol” ENDOCRINE Fx of endocrine – ductless gland Main gland – Pituitary gland – located at base of brain of Stella Turcica Master gland of body Master clock of body Anterior pituitary gland – adenohypophysis Posterior pituitary gland – neurohypophysis Posterior pituitary: 1.) Oxytocin – a.) Promotes uterine contraction preventing bleeding/ hemorrhage. - Give after placental delivery to prevent uterine atony. b.) Milk letdown reflex with help of prolactin. 2.) ADH – antidiuretic hormone – (vasopressin) -Prevents urination – conserve H2O A. DIABETIS INSIPIDUS (DI- dalas ihi) – hyposecretion of ADH Cause: idiopathic/ unknown Predisposing factor: Pituitary surgery Trauma/ head injury Tumor Inflammation * alcohol inhibits release of ADH S & Sx: 1. Polyuria 2. Sx of dehydration (1st sx of dehydration in children-tachycardia) - Excessive thirst (adult) - Agitation - Poor skin turgor - Dry mucus membrane 3. Weakness & fatigue 4. Hypotension – if left untreated - 5. Hypovolemic shock Anuria – late sign hypovolemic shock Dx Proc: Decrease urine specific gravity- concentrated urine N= 1.015 – 1.035 Serum Na = increase (N=135 -145 meq/L) Hypernatremia Mgt: Force fluid 2,000 – 3,000ml/day Administer IV fluid replacement as ordered Monitor VS, I&O Administer meds as ordered a.) Pitresin (vasopressin) IM 5. Prevent complications Most feared complication – Hypovolemic shock B.) SIADH - Syndrome of Inappropriate Anti-Diuretic Hormone - Increase ADH - Idiopathic/ unknown Predisposing factor Head injury Related to Bronchogenic cancer or lung caner- Early Sign of Lung Ca - Cough –1. non productive 2. productive 3. Hyperplasia of Pit gland Increase size of organ S&Sx Fluid retention Increase BP – HPN Edema Wt gain Danger of H2O intoxication –Complications: 1. cerebral edema – increase ICP – 2. seizure Dx Proc: Urine specific gravity increase – diluted urine Hyponatremia – Decreased Na Nsg Mgt: Restrict fluid Administer meds as ordered eg. Diuretics: Loop and Osmotic Monitorstrictly V/S, I&O, neuro check – increase ICP Weigh daily Assess for presence edema Provide meticulous skin care Prevent complications – increase ICP & seizures activity Anterior Pituitary Gland – adeno Growth hormone (GH) (Somatotropic hormone) Fx: Elongation of long bones Decrease GH – dwarfism children Increase GH – gigantism Increase GH – acromegaly – adult Puberty 9 yo – 21 yo Epiphyseal plate closes at 21 yo Square face Square jaw Drug of choice in acromegaly: Ocreotide (Sandostatin) SE dizziness Somatostatin Hormone – antagonizes the release of of GH Melanocytes stimulating hormone - MSH Skin pigmentation Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes development of mammary gland (Oxytocin-Initiates milk letdown reflex) Adrenocorticotropic hormone – ACTH - Development & maturation of adrenal cortex Luteinizing hormone – produces progesterone. FSH- produces estrogen PINEAL GLAND Secretes Melatonin – inhibits lutenizing hormone (LH) secretion THYROID GLAND (TG) Question: Normal physical finding on TG: a. With tenderness – thyroid never tender b. With nodular consistency- answer c. Marked asymmetry – only 1 TG d. Palpable upon swallowing - Normal TG never palpable unless with goiter TG hormones: T3 T4 Thyrocalcitonin - Triodothyronine -Tetraiodothyronine/ Tyroxine FX – antagonizes effects of parathormone - 3 molecules of iodine - 4 molecules of iodine Metabolic hormone Increase metabolism brain –inc cerebration, inc v/s all v/s down, constipation Hypo T3 T4 - lethargy & memory impairment – Hyper T3 T4 - agitation, restlessness, and hallucination Increase VS, increase motility HYPOTHYROIDISM – all decreased except wt & menstruation, loss of appetite but with wt gain menorrhagia – increase in mens HYPERTHYROIDISM - Increase appetite – wt loss, amenorrhea SIMPLE GOITER – enlarged thyroid gland - iodine deficiency Predisposing factors Goiter belt area - Place far from sea – no iodine. Seafood’s rich in iodine Mountainous area – increase intake of goitrogenic foods (US: Midwest, NE, Salt Lake) Cabbage – has progoitrin – an anti thyroid agent with no iodine Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root crops), all nuts. 3. Goitrogenic drugs: Anti thyroid agents :(PTU) prephyl thiupil Lithium carbonate, Aspirin PASA Cobalt, Phenyl butasone Endemic goiter – cause # 1 Sporadic goiter – caused by #2 & 3 S & Sx – enlarged TG Mild restlessness Mild dysphagia Dx Proc. Thyroid scan – reveals enlarged TG Serum TSH – increase (confirmatory) Serum T3, T4 – N or below N Nsg Mgt: 1. Administer meds a.) Iodine solution – Logol’s solution or saturated sol of K iodide SSKI Nsg Mgt Lugol’s sol – violet color use straw – prevent staining teeth Prophylaxis 2 -3 drops Treatment – 5 to 6 drops Use straw – to prevernt staining of teeth 1. Lugol’s sol., 2. tetracycline 3. nitrofurantin (macrodantin)-urinary anticeptic-pyelonephritis. 4. Iron solution. B. Thyroid h / Agents 1. Levothyroxine (Synthroid) 2. Liothyronine (cytomel) 3. Thyroid extract Nsg Mgt: for TH/agents Monitor vs. – HR due tachycardia & palpitation Take it early AM – SE insomnia Monitor s/e  Tachycardia, palpitations Signs of insomnia Hyperthyroidism restlessness agitation Heat intolerance HPN Encourage increase intake iodine – iodine is extracted from seaweeds (!) Seafood- highest iodine content oysters, clams, crabs, lobster Lowest iodine – shrimps Iodized salt –easily destroyed by heat take it raw not cooked Assist surgery- Sub total thyroidectomy- Complication: 1. Tetany 2. laryngeal nerve damage 3.Hemorrhage-feeling of fullness at incision site.Check nape for wet blood. 4.Laryngeal spasm – DOB, SOB – trache set ready at bedside. 2.) HYPOTHYROIDISM – decrease secretion of T3, T4 – can lead to MI / Atherosclerosis Adult – myxedema Child- cretinism – only endocrine dis lead to mental retardation Predisposing factor: `Iatrogenic causes – caused by surgery Atrophy of TG due to: Irradiation Trauma Tumor, inflammation Iodine def Autoimmune – Hashimoto disease S&Sx everything decreased except wt gain & mens increase) Early signs – weakness and fatigue Loss of appetite – increased lypolysis – breakdown of fats causing atherosclerosis = MI Wt gain Cold intolerance – myxedema - coma Constipation Late Sx – brittle hair/ nails Non pitting edema due increase accumulation of mucopolysacharide in SQ tissue -Myxedema Horseness voice Decrease libido Decrease VS – hypotension bradycardia, bradypnea, and hypothermia Lethargy Memory impairment leading to psychosis-forgetfulness Menorrhagia Dx: Serum T3 T4 decrease Serum cholesterol increase – can lead to MI RA IU – radio iodine uptake – decrease Nsg Mgt: Monitor strictly V/S. I&O – to determine presence of myxedema coma! Myxedema Coma - Severe form of hypothyroidism Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia Might lead to progressive stupor & coma Impt mgt for Myxedema coma Assist mech vent – priority a/w Adm thyroid hormone Adm IVF replacement – force fluid Mgt myxedema coma Monitor VS, I&O Provide dietary intake low in calories – due to wt gain Skin care due to dry skin Comfortable & warm environment due to cold intolerance Administer IVF replacements Force fluid Administer meds – take AM – SE insomia. Monitor HR. Thyroid hormones Levothyroxine(Synthroid), Liothyronine (cytomel) Thyroid extracts Health teaching & discharge plan Avoidance precipitating factors leading to myxedema coma: Exposure to cold environment Stress 3. Infection 4. Use of sedative, narcotics, anesthetics not allowed – CNS depressants V/S already down Complications: Hypovolemic shock, myxedema coma Hormonal replacement therapy - lifetime Importance of follow up care HYPERTHYROIDISM - Graves dse or thyrotoxicosis ( everything up except wt and mens) -Increased T3 & T4 Predisposing factors: Autoimmune disease – release of long acting thyroid stimulator (LATS) Exopthalmos Enopthalmos – severe dehydration depressed eye Excessive iodine intake Hyperplasia of TG S&Sx: Increase in appetite – hyperphagia – wt loss due to increase metabolism Skin is moist - perspiration Heat intolerance Diarrhea – increase motility All VS increase = HPN, tachycardia, tachypnea, hyperthermia CNS changes Irritability & agitation, restlessness, tremors, insomnia, hallucinations Goiter Exopthalmos – pathognomonic sx Amenorrhea Dx: Serum T3 & T4 - increased Radio iodine uptake – increase Thyroid scan – reveals enlarged TG Nsg Mgt: 1. Monitor VS & I & O – determine presence of thyroid storm or most feared complication: Thyrotoxicosis Administer meds Antithyroid agents Prophylthiuracil (PTU) Methymazole (Tapazole) Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab culture Most feared complication : Thrombosis – stroke CVS Diet – increase calorie – to correct wt loss Skin care – Comfy & cool environment Maintain siderails- due agitation/restlessness Provide bilateral eye patch – to prevent drying of eyes- exopthalmos Assist in surgery – subtotal thyroidectomy Nsg Mgt: pre-op Adm Lugol’s solution (SSKI) K iodide To decrease vascularity of TG To prevent bleeding & hemorrhage Mgt post op: Complication: 1. Watch out for signs of thyroid storm or thyrotoxicosis Triad signs of thyroidstorm; Tachycardia /palpitation Hyperthermia Agitation Nsg Mgt Thyroid Storm: Monitor VS & neuro check Agitated might decrease LOC Antipyretic – fever Tachycardia - ( blockers (-lol) Siderails – agitated Comp 2. Watch for inadvertent (accidental) removal of parathyroid gland  Secretes Para hormone If removed, hypocalcemia - classic sign tetany – 1. .(+) Trousseau sign/ 2. Chvosteck’s sign Nsg Mgt: Adm calcium gluconate slowly – to prevent arrhythmia Ca gluconate toxicity – antidote – MgSO4 3.Laryngeal (voice box) nerve damage (accidental) Sx: hoarseness of voice ***Encourage pt to talk or speak post operatively asap to determine laryngeal nerve damage Notify physician! 4. Signs of bleeding post subtotal thyroidectomy - “Feeling of fullness” at incision site Nsg mgt: Check soiled dressing at nape area 5. Signs of laryngeal spasm a. DOB b. SOB Prepare at bedside tracheostomy 6. Hormonal replacement therapy - lifetime 7. Importance of follow up care (Liver cirrhosis – bedside scissor – if pt complaints of DOB)  (Cut cystachean tube to deflate balloon) Parathyroid gland – pair of small nodules located behind the TG Secrets parathyroid hormone – promotes Ca reabsorption Thyrocalcitonin – antagonises secretion of parathyroid hormone Hypoparthroidism – decrease of parathyroid hormone Hyperparathroidsm HYPOPARATHYROIDISM – decreased parathormone  Hypocalcemia Hyperphosphatemia (Or tetany) [If Ca decreases, phosphate increases] A. Predisposing, factors: 1. Following subtotal thyroidectomy 2. Atrophy of parathyroid gland due to a. Irradiation b. Trauma S&Sx: Acute tetany Tingling sensation Paresthesia Dysphagia Laryngospasm Bronchospasm Pathognomonic Sign of tetany: (+) Trousseau’s or carpopedial spasm (+) Chvosteck’s sign f. Seizure most feared complication g. Arrhythmia Chronic tetany Loss of tooth enamel Photophobia & cataract formation GIT changes – anorexia, n/v, general body malaise CNS changes – memory impairment, irritability Dx: Serum calcium – decrease (N 8.5 – 11 mg/100ml) Serum phosphate increase (N 2.5 – 4.5 mg/100ml) X-ray of long bone – decrease bone density CT Scan – reveals degeneration of basal ganglia Nsg Mgt: Administration of meds: Acute tetany – Ca gluconate – IV, slowly Chronic tetany Oral Ca supplements Ex. Ca gluconate Ca carbonate Ca lactate  Vit D (Cholecalceferol) Drug diet sunlight  Cholecalceferol calcidiol calcitriol 7am – 9am Phosphate binder Alumminum DH gel (ampho gel) SE constipation Antacid AAC MAD Aluminum containing acids Mg containing antacids  Ex. Milk or magnesia Aluminum OH gel Diarrhea Constipation Maalox – magnesium & aluminum - Less s/e 2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure 3. Diet – increase Ca & decrease phosphorus - Don’t give milk – due to increase phosphorus Good = anchovies – increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnips- Inc Ca. 4. Bedside – tracheostomy set –due to laryngospasm 5. Encourage to breath with paper bag in order to produce mild respiratory acidosis – to promote increase ionized Ca levels 6. Most feared complication : Seizure & arrhythmia 7. Hormonal replacement therapy - lifetime 8. Important fallow up care HYPERPARATHYROIDISM - increase parathormone. Complication: Renal failure Hypercalcemia can lead to Hypophosphatemia  Bone dse - kidney stones Mineralization  Leading to bone fracture Ca – 99% bones 1% serum blood Predisposing Factors: Hyperplasia parathyroid gland (PTG) Over compensation of PTG due to Vit D deficiency Children – Rickets Vit D Adults – Osteomalacia deficiency Sippy’s diet – Vit D diet – not good for pt with ulcer 2 -4 cups of milk & butter Karrel’s diet – Vit D diet – not good for pt with ulcer 6 cups of milk & whole cream Food rich in CHON – eggnog – combination of egg & milk S/Sx: Bone fracture Bone pain (especially at back), bone fracture Kidney stone – Renal colic Cool moist skin GIT changes – anorexia, n/v, ulcerations CNS involvement– irritability, memory impairment Dx Proc: Serum Ca increase Serum phosphorus decreases X-ray long bones – reveals bone demineralization Nsg Mgt: Kidney Stone Force fluids – 2,000 – 3,000/day or 2-3L/day Isotonic solution Warm sitz bath – for comfort Strain all urine with gauze pad Acid ash diet – cranberry, plum, grapefruit, vit C, calamansi – to acidify urine Adm meds Narcotic analgesic – Morphine SO4, Demerol (Meperidine Hcl) S/E – resp depression. Monitor RR) Narcan/ Naloxone – antidote Naloxone toxicity – tremors Siderails Assist in ambulation Diet – low in Ca, increase phosphorus lean meat Prevent complication Most feared – renal failure Assist surgical procedure – parathyroidectomy Impt ff up care Hormonal replacement- lifetime ADRENAL GLAND Atop of @ kidney 2 parts Adrenal cortex – outermost layer Adrenal medulla - innermost layer Secrets cathecolamines Epinephrine / Norephinephrine – potent vasoconstrictor – adrenaline=Increase BP Adrenal Medulla’s only disease: PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla -increase nor/epinephrine -with HPN and resistant to drugs -drug of choice: beta blockers -complication: HPN crisis = lead to stroke -no valsalva maneuver Adrenal Cortex – Zona fasiculata – secrets glucocorticoids Ex. Cortisol - Controls glucose metabolism (SUGAR) Zona reticularis – secrets traces of glucocorticoids & androgenic hormones M – testosterone F – estrogen & progesterone Fx – promotes development of secondary sexual characteristics 3. Zona glomerulosa - secretes mineralcortisone Ex. Aldosterone Fx: promotes Na & H2O reabsorption & excretion of potassium (SALT) ADDISON’S DISEASE – Steroids-lifetime Decreased adrenocortical hormones leading to: Metabolic disturbances (sugar) F&E imbalances- Na, H2O, K Deficiency of neuromuscular function (salt & sex) Predisposing Factors: Atrophy of adrenal gland Fungal infections Tubercular infections S/Sx: Decrease sugar – Hypoglycemia – Decreased glucocorticoids - cortisol T – tremors, tachycardia I - irritability R - restlessness E – extreme fatigue D – diaphoresis, depression Decrease plasma cortisol Decrease tolerance to stress – lead to Addisonian’s crisis Decrease salt – Hyponatermia – Decreased mineralocorticoids - Aldosterone Hypovolemia Hypotension Signs of dehydration – extreme thirst, agitation Wt loss Hyperkalemia Irritability Diarrhea Arrhythmia Decrease sexual urge or libido- Decreased Androgen Loss of pubic and axillary hair To Prevent STD Local – practice monogamous relationship CGFNS/NCLEX – condom Pathognomonic sign– bronze like skin pigmentation due to decrease cortisol will stimulate pituitary gland to release melanocyte stimulating hormone. Dx Proc: FBS – decrease FBS (N 80 – 120 mg/dL) Plasma cortisol – decreased Serum Na – decreased (N 135 – 145 meg/L) Serum K – increased (N 3.5 – 5.5 meg/L) Nsg Mgt: Monitor VS, I&O – to determine presence of Addisonian crisis Complication of Addison’s dse : Addisonian crisis Results the acute exacerbation of Addison’s dse characterized by : Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia Lead to progressive stupor & coma Nsg Mgt Addisonian Crisis (Coma) Assist in mechanical ventilation Adm steroids Force fluids Administer meds a.) Corticosteroids - (Decadron) or Dexamethazone - Hydrocortisone (cortisone)- Prednisone Nsg Mgt with Steroids Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm. Taper the dose (w/draw, gradually from drug) – sudden withdrawal can lead to addisonian crisis Monitor S/E (Cushing’s syndrome S/Sx) HPN Hirsutism Edema Moon face & buffalo hump Increase susceptibility to infection sue to steroids- reverse isolation b.) Mineralocorticoids ex. Flourocortisone Diet – increase calorie or CHO Increase Na, Increase CHON, Decrease K Force fluid Administer isotonic fluid as ordered Meticulous skin care – due to bronze like HT & discharge planning a) Avoid precipitating factors leading to Addisonian crisis Sudden withdrawal crisis Stress Infection Prevent complications Addisonian crisis & Hypovolemic shock Hormonal replacement therapy – lifetime Important: follow up care CUSHING’S SYNDROME – increase secretion of adrenocortical hormone Predisposing Factors: Hyperplasia of adrenal gland Tubercular infection – milliary TB S/Sx Increase sugar – Hyperglycemia 3 P’s 1. Polyuria 2. Polydipsia – increase thirst 3. Polyphagia – increase appetite Classic Sx of DM – 3 P’s & glycosuria + wt loss Increase susceptibility to infection – due to increased corticosteroid Hypernatrermia HPN Edema Wt gain Moon face Buffalo hump Obese trunk classic signs Pendulous abdomen Thin extremities Hypokalemia Weakness & fatigue Constipation ECG – (+) “U” wave Hirsutism – increase sex Acne & striae Increase muscularity of female Dx: FBS  increase‘! (N: 80-120mg/dL) Plasma cortisol increase Na  increase (135-145 meq/L) K- decrease (3.5-5.5 meq/L) Nsg Mgt: Monitor VS, I&O Administer meds a. K- sparing diuretics (Aldactone) Spironolactone - promotes excretion of NA while conserving potassium Not lasix due to S/E hypoK & Hyperglycemia! Restrict Na Provide Dietary intake – low in CHO, low in Na & fats High in CHON & K Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc. Reverse isolation Skin care – due acne & striae Prevent complication - Most feared – arrhythmia & DM (Endocrine disorder lead to MI – Hypothyroidism & DM) Surgical bilateral Adrenolectomy Hormonal replacement therapy – lifetime due to adrenal gland removal- no more corticosteroid! PANCREAS – behind the stomach, mixed gland – both endocrine and exocrine gland Acinar cells (exocrine gland) Islets of Langerhans (endocrine gland ductless)  Secrete pancreatic juices at pancreatic ducts. ( cells  Aids in digestion (in stomach) secrets glucagon  Fxn: hyperglycemia (high glucose)   ( Cells Secrets insulin   Fxn: hypoglycemia Delta Cells  Secrets somatostatin  Fxn: antagonizes growth hormone 3 disorders of the Pancreas DM Pancreatic Cancer Pancreatitis Overview only: PANCREATITIS (check page 72)– acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to Autodigestion – self-digestion Cause: unknown/idiopathic Or alcoholism Pathognomonic sign- (+) Cullen’s sign - Ecchymosis of umbilicus (bluish color)- pasa  (+) Grey turner’s sign – ecchymosis of flank area  Both sx means hemorrhage CHRONIC HEMORRHAGIC PANCREATITIS- “bangugot” Predisposing factors - unknown Risk factor: History of hepatobiliary disorder Alcohol Drugs – thiazide diuretics, oral contraceptives, aspirin, penthan Obesity Hyperlipidemia Hyperthyroidism High intake of fatty food – saturated fats DIABETES MELLITUS - metabolic disorder characterized by non utilization of CHO, CHON,& fat metabolism Classification: Type I DM (IDDM) – “Juvenile “ onset, common in children, non-obese “brittle dse” -Insulin dependent diabetes mellitus Incidence rate 10% of population with DM have Type I Predisposing Factor: 90% hereditary – total destruction of pancreatic dells Virus Toxicity to carbon tetrachloride Drugs – Steroids both cause hyperglycemia Lasix - loop diuretics S/Sx: 3 P’S + G 1.) Polyuria 2.) Poydipsia 3.) Polyphagia 4.) Glycosuria 5.) Weight loss 6.) Anorexia 7.) N/V 8.) Blurring of vision 9.) Increase susceptibility to infection 10.) Delayed/ poor wound healing Mgt: Insulin Therapy Diet Exercise Complications – Diabetic Ketoacidosis (DKA) Diabetic Ketoacidosis (DKA) – due to increase fat catabolism or breakdown of fats DKA –(+) fruity or acetone breath odor Kassmaul’s respiration – rapid, shallow breathing  Diabetic coma (needs oxygen) Type II DM – (NIDDM) Adult/ maturity onset type – age 40 & above, obese Incidence Rate 90% of pop with DM have Type II Mid 1980’s marked increase in type II because of increase proliferation of fast food chains! Predisposing Factor: Obesity – obese people lack insulin receptors binding site Hereditary S/Sx: Asymptomatic 3 P’s and 1G Tx: Oral Hypoglycemic Agents (OHA) Diet Exercise Complication: HONKC H – hyper O – osmolar N – non K – ketotic C – coma III. GESTATIONAL DM – occurs during pregnancy & terminates upon delivery of child Predisposing Factors: Unknown/ idiopathic Influence of maternal hormones S/Sx : Same as type II – Asymptomatic 3 P’s & 1G Type of delivery – CS – due to large baby Sx of hypoglycemia on infant High pitched shrill cry Poor sucking reflex IV. DM ASSOCIATED WITH OTHER DISORDER Pancreatic tumor Cancer Cushing s syndrome 3 MAIN FOOD GROUPS Anabolism Catabolism 1. CHON glucose glycogen 2. CHON amino acids nitrogen 3. Fats fatty acids free fatty acids (FFA)  Cholesterol & Ketones Pancreas ’! glucose ’! ATP (Main fuel/energy of cell ) Reserve glucose – glycogen Liver will undergo – glucogenesis – synthesis of glucagons & Glycogenolysis – breakdown of glucagons & Gluconeogenesis – formation of glucose form CHO sources – CHON & fats Hyperglycemia – pancreas will not release insulin. Glucose can’t go to cell, stays at circulation causing hyperglycemia. increase osmotic diuresis – glycosuria  Lead to cellular starvation  Lead to wt loss stimulates the appetite/ satiety center polyuria (Hypothalamus) Cellular dehydration  Polyphagia  Stimulates thirst center (hypothalamus) Polydipsia Increased CHON catabolism Lead to (-) nitrogen balance  Tissue wasting (cachexia) Increase fat catabolism Free fatty acids  Cholesterol ketones DKA  Atherosclerosis coma  HPN death  MI stroke DIABETIC KETOACIDOSIS (DKA) Acute complication of Type I DM due to severe hyperglycemia leading to CNS depression & Coma. Ketones- a CNS depressant Predisposing factor: Stress – between stress and infection, stress causes DKA more. Hyperglycemia Infection S/Sx: 3 P’s & 1G Polyuria Polydipsia Polyphagia Glycosuria Wt loss Anorexia, N/V (+) Acetone breath odor- fruity odor pathognomonic DKA Kussmaul's resp-rapid shallow respiration CNS depression Coma Dx Proc: FBS increase, Hct – increase (compensate due to dehydration) N =BUN – 10 -20 mg/100ml --increased due to severe dehydration Crea - .8 – 1 mg/100ml Hct 42% (should be 3x high)-nto hgb Nsg Mgt: Can lead to coma – assist mechanical ventilation Administer .9NaCl – isotonic solution Followed by .45NaCl hypotonic solution To counteract dehydration. Monitor VS, I&O, blood sugar levels Administer meds as ordered: Insulin therapy – IV push Regular Acting Insulin – clear (2-4hrs, peak action) To counteract acidosis – Na HCO3 Antibiotic to prevent infection Insulin Therapy Sources: Animal source – beef/ pork-rarely used. Causes severe allergic reaction. Human – has less antigenecity property Cause less allergic reaction. Humulin If kid is allergic to chicken – don’t give measles vaccine due it comes from chicken embryo. Artificially compound Types of Insulin Rapid Acting Insulin - Ex. Regular acting I Intermediate acting I - Ex. NPH (non-protamine Hagedorn I) Long acting I - Ex. Ultra lente Types of Insulin color & consistency onset peak duration 1. Rapid clear - 2-4h - 2. Intermediate cloudy - 6-12h - 3. Long acting cloudy - 12-24h - Ex. 5am Hemoglucose test (HGT)  250 mg/dl Adm 5 units of RA I Peak 7-9am – monitor hypoglycemic reaction at this time- TIRED Nsg Mgt: upon injection of insulin: 1.Administer insulin at room temp! – To prevent lipodystrophy = atrophy/ hypertrophy of SQ tissues 2. Insulin is only refrigerated once opened! 3. Gently roll vial bet palms. Avoid shaking to prevent formation of bubbles. 4. Use gauge 25 – 26needle – tuberculin syringe 5. Administer insulin at either 45(for skinny pt) or 90( (taba pt)depending on the client tissue deposit. 6. Don’t aspirate after injection 7. Rotate injection site to prevent lipodystrophy 8. Most accessible site – abdomen 9. When mixing 2 types of insulin, aspirate 1st regular/ clear – before cloudy to prevent contaminating clear insulin & to promote accurate calibration. 10. Monitor signs of complications: a. Allergic reactions – lipodystrophy b. Somogyi’s phenomenon – hypoglycemia followed by periods of hyperglycemia or rebound effect of insulin. 11. 1ml or cc of tuberculin = 100 units of insulin  - - 1 cc = 100 units - - .5cc = 50 units - - .1 cc = 10 units   6 units RA Most Feared Complication of Type II DM  Hyper ‘! osmolarity = severe dehydration Osmolar  Non - absence of lipolysis Ketotic - no ketone formation Coma  S/Sx: headache, restlessness, seizure, decrease LOC = coma Nsg Mgt; - same as DKA except don t give NaHCO3! 1.Can lead to coma – assist mechanical ventilation 2. Administer .9NaCl – isotonic solution Followed by .45NaCl hypotonic solution To counteract dehydration. 3.Monitor VS, I&O, blood sugar levels 4.Administer meds Insulin therapy – IV Antibiotic to prevent infection Tx: O ral H ypoglycemic A gents Stimulates pancreas to secrete insulin Classifications of OHA First generation Sulfonylurear Chlorpropamide (diabenase) Tolbutamide (orinase) Tolazamide (tolinase) 2nd generation sulfonylurear Diabeta (Micronase) Glipside (Glucotrol) Nsg Mgt or OHA Administer with meals – to lessen GIT irritation & prevent hypoglycemia Avoid alcohol (alcohol + OHA = severe hypoglycemic reaction=CNS depression=coma) Antabuse-Disufram Dx for DM FBS – N 80 – 120 mg/dl = Increased for 3 consecutive times =confirms DM!! + 3 P’s & 1G Oral glucose tolerance (OGTT) - Most sensitive test Random blood sugar – increased Alpha Glucosylated Hgb – elevated Nsg Mgt; Monitor for PEAK action of OHA & insulin Notify Doc Monitor VS, I&O, neurocheck, blood sugar levels. Administer insulin & OHA therapy as ordered. Monitor signs of hyper & hypoglycemia. Pt DM –“ hinimatay” You don’t know if hypo or hyperglycemia. Give simple sugar (Brain can tolerate high sugar, but brain can’t tolerate low sugar!) Cold, clammy skin – hypo – Orange Juice or simple sugar / warm to touch – hyper – adm insulin Provide nutritional intake of diabetic diet: CHO – 50% CHON – 30% Fats – 20% -Or offer alternative food products or beverage. -Glass of orange juice. Exercise – after meals when blood glucose is rising. Monitor complications of DM Atherosclerosis – HPN, MI, CVA Microangiopathy – small blood vessels Eyes – diabetic retinopathy , premature cataract & blindness Kidneys – recurrent pyelonephritis & Renal Failure (2 common causes of Renal Failure : DM & HPN) Gangrene formation Peripheral neuropathy Diarrhea/ constipation Sexual impotence Shock due to cellular dehydration Foot care mgt Avoid waking barefooted Cut toe nails straight Apply lanolin lotion – prevent skin breakdown Avoid wearing constrictive garments Annual eye & kidney exam Monitor urinalysis for presence of ketones Blood or serum – more accurate Assist in surgical wound debridement Monitor signs or DKA & HONKC Assist surgical procedure BKA or above knee amputation Overview: HEMATOLOGICAL SYSTEMS I Blood II Blood vessels III Blood forming organs Thymus – removed myasthenia gravis Liver – largest gland Lymph nodes Lymphoid organs – payers patch Bone marrow Spleen – destroys RBC Blood vessels Veins –SVC, IVC, Jugular vein – blood towards the heart Artery – carries blood away from the Aorta, carotid Capillaries Blood 45% formed elements – 55% plasma – fluid portion of vlood. Yellow color. Serum Plasma CHON’s (Produced in Liver) 1. Albumin- largest, most abundant plasma Maintains osmotic pressure preventing edema FXN: promotes skin integrity 2. Globulins – alpha – transports steroids Hormones & bilirubin ( - Transports iron & copper Gamma – transport immunoglobulins or antibodies 3. Prothrombin – fibrinogen – clotting factor to prevent bleeding Formed Elements: 1. RBC (erythrocytes) Spleen life span = 120 days (N) 3 – 6 M/mm3 - Anucleated - Biconcave discs - Has molecules of Hgb (red cell pigment) Transports & carries O2 SICKLE CELL ANEMIA –sickle shaped RBC. Should be round. Impaired circulation of RBC. -immature cells=hemolysis of RBC=decreased hgb 3 Nsg priority 1. a/w – avoid deoxygenating activities - High altitude is bad 2. Fluid deficit – promote hydration 3. Pain & comfort Hgb ( hemoglobin) F= 12 – 14 gms % M = 14-16 gms % Hct – 3x hgb 12 x 3 = 36 (hamatocrit) F 36 – 42% 14 x 3 = 42 M 42 – 48% Average 42% - Red cell percentage in whole red Substances needed for maturation of RBC Folic acid Iron Vit C Vit B12 (cyanocobalamin) Vit B6 (Pyridoxine) Intrinsic factor Pregnant: 1st trimester- Folic acid – prevent neural tube deficit 3rd tri – iron Life span of rbc – 80 – 120 days. Destroyed at spleen. WBC – leucocytes 5,000 – 10,000/mm3 GRANULOCYTES 1. Polymorphonuclearneutrophils Most abundant 60-70% WBC - fx – short term phagocytosis For acute inflammation 2. PM Basophils -Involved in Parasitic infection - Release of chem. Mediator for inflammation Serotonin, histamine, prostaglandin, bradykinins 3. PM eosinophils - Allergic reactionsNON-GRANULOCYTES 1. Monocytes (macrophage) - largest WBC - involved in long term phagocytes - For chronic inflammation - Other name macrophage Macrophage in CNS- microglia Macrophage in skin – Histiocytes Macrophage in lungs – alveolar macrophage Macrophage in Kidneys – Kupffer cells 2. Lymphocytes B Cell – L – bone marrow or bursa dependent T cell – dev’t of immunity- target site for HIV NK cell – natural killer cell Have both antiviral & anti-tumor properties 3.Platelets (thrombocytes) N- 150,000 – 450, 000/ mm3 it promotes hemostasis – prevention of blood loss by activating clotting - Consists of immature or baby platelets known as megakaryocytes – target of virus – dengue - Normal lifespan 9 – 12 days Drug of choice for HIV Zidovudine (AZT or Retrovir) Standard precaution for HIV gloves, gown, goggles & mask Malaria – night biting mosquito Dengue – day biting mosquito Signs of platelet dis function: Petecchiae Ecchemosis/ bruises Oozing or blood from venipuncture site ANEMIA Iron deficiency Anemia – chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate absorption of iron leading to hypoxemic injury. Incidence rate: 1. Common – developed country – due to high cereal intake Due to accidents – common on adults 2. Common – tropical countries – blood sucking parasites 3. Women – 15 – 35yo – reproductive yrs 4. Common among the poor – poor nutritional intake Suicide - common in teenager Poisoning – common in children (aspirin) Aspiration – common in infant Accidents – common in adults Choking – common in toddler SIDS – common in infant in US Common in tropical zone – Phil due blood sucks Predisposing factor: Chronic blood loss Trauma Mens GIT bleeding: Hematemesis- Melena – upper GIT – duodenal cancer Hematochezia – lower GIT – large intestine – fresh blood from rectum 2. Inadequate intake of food rich in iron 3. Inadequate absorption of iron – due to : a. Chronic diarrhea b. Malabsorption syndrome –celiac disease-gluten free diet. Food for celiac pts- sardines c. High cereal intake with low animal CHON ingestion d. Subtotal gastrectomy 4. Improper cooking of food S/Sx: Asymptomatic Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells Atropic glossitis, dysphagia, stomatitis Pica – abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic behavior) Brittle hair, spoon shaped nail – atrophy of epidermal cells N = capillary refill time < 2 secs N = shape nails – biconcave shape, 180( Atrophy of cells “Plummer Vinsons Syndrome” due to cerebral hypoxia 1. Atropic glossiti – inflammation of tongue due to atrophy of pharyngeal and tongue cells 2. Stomatitis – mouth sores 3. Dysphagia Dx Proc: RBC Hgb Reticulocyte Hct Iron Ferritin Nsg Mgt Monitor signs of bleeding of all hema test including urine & stool Complete bed rest – don’t overtire pt =weakness and fatigue=activity intolerance Encourage – iron rich food Raisins, legumes, egg yolk Instruct the pt to avoid taking tea - impairs iron absorption Administer meds Oral iron preparation Ferrous SO4 Fe gluconate Fe Fumarate Nsg Mgt oral iron meds: Administer with meals – to lessen GIT irritation If diluting in iron liquid prep –adm with straw Straw Lugol’s Tetracycline Oral iron Macrodantine Give Orange juice – for iron absorption Monitor & inform pts S/E Anorexia n/v Abdominal pain Diarrhea or constipation Melena If pt can’t tolerate oral iron prep – administer parenteral iron prep example: Iron dextran (IV, IM) Sorbitex (IM) Nsg Mgt parenteral iron prep Administer of use Z tract method to prevent discomfort, discoloration leakage to tissues. Don’t massage injection site. Ambulate to facilitate absorption. Monitor S/E: Pain at injury site Localized abscess (“nana”) Lymphadenopathy Fever/ chills Urticaria – itchiness Hypotension – anaphylactic shock Anaphylactic shock – give epinephrine PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to Hypochlorhydria – decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement. Predisposing factor Subtotal gastrectomy – removal stomach Hereditary Infl dse of ileum Autoimmune Strict vegetable diet STOMACH  Parietal or ergentaffen Oxyntic cells  Fxn – produce intrinsic factor Fxn – secrets Hcl acid  For reabsorption of B12 Fx aids in digestion  For maturation of RBC Diet high caloric or CHO to correct wt loss S/Sx: Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor GIT changes Red – beefy tongue – PATHOGNOMONIC – mouth sores Dyspepsia – indigestion Wt loss Jaundice CNS – Most dangerous anemia: pernicious due to neuroglogic involvement. Tingling sensation Paresthesia (+) Romberg’s test Ataxia Psychosis Dx:- Shilling’s test Nsg Mgt – Pernicious anemia Enforce CBR Administer B12 injections at monthly intervals for lifetime as ordered. IM- dorsogluteal or ventrogluteal. Not given oral – due pt might have tolerance to drug Diet – high calorie or CHO. Increase CHON, iron & Vit C Avoid irritating mouthwashes. Use of soft bristled toothbrush is encouraged. Avoid applying electric heating pads – can lead to burns APLASTIC ANEMIA – stem cell disorder due to bone marrow depression leading to pancytopenia – all RBC are decreased  Decrease RBC decrease WBC decrease platelets Anemia leukopenia thrombocytopenia Increase WBC leukocytocys Increase RBC polycythemia vera – complication stroke, CVA, thrombosis Predisposing factors leading to Aplastic Anemia Chemicals – Banzene & its derivatives radiation Immunologic injury Drugs – cause bone marrow depression Broad spectrum antibiotic - Chlorampenicol - Sulfonamides – bactrim Chemo therapeutic agents Methotrexate – alkylating agents Nitrogen mustard – anti metabolic Vincristine – plant alkaloid S/Sx: 1. Anemia: a. Weakness & fatigue b. Headache, dizziness, dyspnea c. cold sensitivity, pallor d. palpitations 2. Leucopenia – increase susceptibility to infection 3. Thrombocytopenia – Peticchiae Oozing ofblood from venipuncture site ecchymosis Dx: CBC – pancytopenia Bone marrow biopsy/ aspiration at post iliac crest – reveals fatty streaks in bone marrow Nsg Mgt: Removal of underlying cause Blood transfusion as ordered Complete bed rest O2 inhalation Reverse isolation due leukopenia Monitor signs of infection Avoid SQ, IM or any venipuncture site = HEPLOCK Use electric razor when shaving to prevent bleeding Administer meds Immunosuppresants Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days – 3 weeks to achieve max therapeutic effect of drug. BLOOD TRANSFUSION: Objectives: To replace circulating blood volume To increase O2 carrying capacity of blood To combat infection if there’s decrease WBC To prevent bleeding if there’s platelet deficiency Nsg Mgt & principles in Blood Transfusion Proper refrigeration Proper typing & crossmatching Type O – universal donor AB – universal recipient 85% of people is RH (+) Asceptically assemble all materials needed: Filter set Isotonic or PNSS or .9NaCl to prevent Hemolysis Hypotonic sol – swell or burst Hypertonic sol – will shrink or crenate Needle gauge 18 - 19 or large bore needle to prevent hemolysis. Instruct another RN to recheck the following . Pts name, blood typing & cross typing expiration date, serial number. e.) Check blood unit for presence of bubbles, cloudiness, dark in color & sediments – indicates bacterial contamination. Don’t dispose. Return to blood bank. f.) Never warm blood products – may destroy vital factors in blood. - Warming is done if with warming device – only in EMERGENCY! For multiple BT. - Within 30 mins room temp only! g.) Blood transfusion should be completed < 4hrs because blood that is exposed at room temp for > 2h causes blood deterioration. h.) Avoid mixing or administering drug at BT line – leads to hemolysis i.) Regulate BT 10 – 15 gtts/min KVO or 100cc/hr to prevent circulatory overload j.) Monitor VS before, during & after BT especially q15 mins(local board) for 1st hour. NCLEX-q5min for 1st 15min. - Majority of BT reaction occurs within 1h. BT reactions S/Sx Hemolytic reaction: H – hemolytic Reaction 1. Headache, dizziness, dyspnea, palpitation, lumbar/ sterna/ flank pain, A – allergic Reaction hypotension, flushed skin , (red) port wine urine. P – pyrogenic Reaction C – circulatory overload A – air embolism T - thrombocytopenia C – citrate intoxication – expired blood =hyperkalemia H – hyperkalemia Nsg Mgt: Hemolytic Reaction: Stop BT Notify Doc Flush with plain NSS Administer isotonic fluid sol – to prevent acute tubular necrosis & conteract shock Send blood unit to blood bank for reexamination Obtain urine & blood samples of pt & send to lab for reexamination Monitor VS & Allergic Rxn Allergic Reaction: S/Sx Fever/ chills Urticaria/ pruritus Dyspnea Laryngospasm/ bronchospasm Bronchial wheezing Nsg Mgt: Stop BT Notify Doc Flush with PNSS Administer antihistamine – diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Child-hyperactive If (+) Hypotension – anaphylactic shock administer – epinephrine Send blood unit to blood bank Obtain urine & blood samples – send to lab Monitor VS & IO Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension – indicates anaphylactic shock administer epinephrine 9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB Pyrogenic Reaction: S/Sx Fever/ chills d. tachycardia Headache e. palpitations Dyspnea f. diaphoresis Nsg Mgt: Stop BT Notify Doc Flush with PNSS Administer antipyretics, antibiotics Send blood unit to blood bank Obtain urine & blood samples – send to lab Monitor VS & IO Tepid sponge bath – offer hypothermic blanket Circulatory Overload: Sx Dyspnea Orthopnea Rales or crackles Exertional discomfort Nsg Mgt: Stop BT Notify Doc. Don’t flush due pt has circulatory overload. Administer diuretics Priority cases: Hemolytic Rxn – 1st due to hypotension – 1st priority – attend to destruction of Hgb – O2 brain damage Allergic 3rd Pyrogenic 4th Circulatory 2nd Hemolytic 2nd Anaphylitic 1st priority DIC – DISSEMINATED INTRAVASCULAR COAGULATION Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a def of clotting factors (Prothrombin & Fibrinogen). Predisposing factor: Rapid BT Massive trauma Massive burns Septicemia Hemolytic reaction Anaphylaxis Neoplasia – growth of new tissue Pregnancy S/Sx Petechiae – widespread & systemic (lungs, lower & upper trunk) Ecchymosis – widespread Oozing of blood from venipunctured site Hemoptysis – cough blood Hemorrhage Oliguria – late sx Dx Proc– CBC – reveals decrease platelets Stool for occult blood (+) Specimen – stool Opthalmoscopic exam – sub retinal hemorrhage ABG analysis – metabolic acidosis pH HCO3 R pH PCO2 respiratory alkalosis O ph PCO2 respiratory acidosis M ph HCO3 metabolic alkalosis E ph HCO3 metabolic acidosis Diarrhea – met acidosis Vomitting – met alk Pyloric stenosis – met alkalosis – vomiting Ileostomy or intestinal tubing – met acidosis Cushing’s – met alk DM met acid Chronic bronchitis – resp acid – with hypoxemia, cyanosis Nsg Mgt DIC Monitor signs of bleeding – hema test + urine, stool, GIT Administer isotonic fluid solution to prevent shock. Administer O2 inhalation Administer meds Vit K aquamephyton Pitressin or vasopressin – to conserve water. NGT – lavage - Use iced saline lavage 6. Monitor NGT output 7. Provide heplock 8. Prevent complication: hypovolemic shock Late signs of hypovolemic shock : anuria Oncologic Nsg: Oncology – study of neoplasia –new growth  Benign (tumor) Malignancy (cancer) Diff - well differentiated poorly or undifferentiated Encapulation – (+) (-) Metastasis – (-) (+) Prognosis – good poor Therapeutic modality surgery 1. Chemotherapy plenty S/E 2. Radiation  3. Surgery most preferred treatment 4. Bone marrow transplant - Leukemia only Predisposing factors: (carcinogenesis) G – genetic factors I – immunologic factors V – viral factors a. Human papiloma virus – causing warts b. Epstein barr virus E – environmental Factors 90% a. Physical – irradiation, UV rays, nuclear explosion, chronic irritation, direct trauma b. Chemical factors – - Food additives (nitrates - Hydrocarbon vesicants, alkalies - Drugs (stillbestrol) - Uraehane - Hormones - Smoking Male 3.) Prostate cancer - common 40 & above (middle age & above) BPH – 50 & above 1.) Lung cancer 2.) Liver cancer Female 1. Breast cancer – 40 yrs old & up – mammography 15 – 20 mins (SBE – 7 days after mens) 2. Cervical cancer – 90% multi sexual partners 5% early pregnancy 3. Ovarian cancer Classes of cancer Tissue typing Carcinoma – arises from surface epithelium & glandular tissues Sarcoma- from connective tissue or bones Multiple myeloma – from bone marrow Pathological fracture of ribs & back pain 4. Lymphoma – from lymph glands 5. Leukemia – from blood Warning / Danger Sx of CA C – change in bowel /bladder habits A – a sore that doesn’t heal U – unusual bleeding/ Discharge T – thickening of lump – breast or elsewhere I – indigestion? Dysphagia O – obvious change in wart/ mole N – nagging cough/ hoarseness U – unexplained anemia A - anemia S – sudden wt loss L – loss of wt Therapeutic Modality: Chemotherapy – use various chemotherapeutic agents that kills cancer cells & kills normal rapidly producing cells – GIT, bone marrow, and hair follicle. Classification: Alkylating agents – Plant alkaloids – vincristine Anti metabolites – nitrogen mustard Hormones – DES Steroids Antineoplastic antibiotics S/E & mgt GIT - -Nausea & vomiting Nsg Mgt: 1. Administer anti emetic 4 – 6h before start of chemo Plasil Withhold food/ fluid before start of chemo Provide bland diet post chemo Non irritating / non spicy - Diarrhea 1. Administer anti diarrheal 4 – 6h before start of chemo 2. Monitor urine, I&O qh - Stomatitis/ mouth sores 1. Oral care – offer ice chips/ popsickles 2. Inform pt – hair loss – temporary alopecia Hair will grow back after 4 – 6 months post chemo. -Bone marrow depression – anemia Enforce CBR O2 inhalation Reverse isolation Monitor signs of bleeding Repro organ – sterility Do sperm banking before start of chemo Renal system – increase uric acid Administer allopurinol/ xyloprin (gout) Inhibits uric acid Acute gout – colchicines Increase secretion of uric acid Neurological changes – peristalsis – paralytic ileus Most feared complication ff any abdominal surgery Vincristine – plant alkaloid causes peripheral neuropathy 2. Radiation therapy – involves use of ionizing radiation that kills cancer cells & inhibit their growth & kill N rapidly producing cells. Types of energy emitted Alpha rays – rarely used – doesn’t penetrate skin tissues Beta rays – internal radiation – more penetration Gamma ray – external radiation – penetrates deeper underlying tissues Methods of delivery External radiation- involves electro magnetic waves Ex. cobalt therapy Internal radiation – injection/ implantation of radioisotopes proximal to CA site for a specific period of time. 2 types: a.) Sealed implant – radioisotope with a container & doesn’t contaminate body fluid. b.) Unsealed implant – radioisotope without a container & contaminates body fluid. Ex. Phosphorus 32 3 Factors affecting exposure: A.) Half life – time period required for half of radioisotopes to decay. - At end of half life – less exposure B.) Distance – the farther the distance – lesser exposure C. ) Time – the shorter the time, the lesser exposure D.) Shielding – rays can be shielded or blocked by using rubber gloves – ( & ( gamma – use thick lead on concrete. S/E & Mgt: Skin errythema, redness, sloughing Assist in battling pt Force fluid – 2,000 – 3,000 ml/day Avoid lotion or talcum powder – skin irritation Apply cornstarch or olive oil b.) GIT –nausea / vomiting - 1. Administer antiemetic 4 – 6h before start of chemo - Plasil 2 Withhold food/ fluid before start of chemo Provide bland diet post chemo Non irritating / non spicy Dysglusia – decrease taste sensitivity -When atrophy papilla (taste buds) – 40 yo Stomatitis c.) Bone marrow depression Enforce CBR O2 inhalation Reverse isolation Monitor signs of bleeding Overview of function & structure of the heart HEART Muscular, pumping organ of the body Left mediastinum Weigh 300 – 400 grams Resembles a closed fist Covered by serous membrane – pericardium Pericardium Parietal layer Pericardial Visceral layer Fluid – prevent Friction rub Layer Epicardium – outermost Myocardium – inner – responsible for pumping action/ most dangerous layer - cardiogenic shock Endocardium – innermost layer Chambers Upper – collecting/ receiving chamber - Atria Lower – pumping/ contracting chamber - Ventricles Valves Atrioventricular valves - Tricuspid & mitral valve Closure of AV valves – gives rise to 1st heart sound or S1 or “lub” Semi lunar valve Pulmonic Aortic Closure of semilunar valve – gives rise to 2nd heart sound or S2 or “dub” Extra heart Sound S3 – ventricular Gallop – CHF S4 – atrial gallop – MI, HPN Heart conduction system Sino atrial node (SA node) (or Keith-Flock node) Loc – junction of SVC & Rt atrium Fx- primary pace maker of heart -Initiates electric impulse of 60 – 100 bpm Atrioventicular node (AV node or Tawara node) Loc – inter atrial septum Delay of electric impulse to allow ventricular filling Bundle of His – location interventricular septum Rt main Bundle Branch Lt main Bundle Branch Purkenjie Fiber Loc- walls of ventricles-- Ventricular contractions SA node     Purkenjie Fibers Bundle of His Complete heart block – insertion of pacemaker at Bundle Branch Metal – Pace Maker – change q3 – 5 yo Prolonged PR – atrial fib T wave inversion – MI ST segment depression – angina widening QRS – arrhythmia ST – elev – MI CAD – coronary artery dse or Ischemic Heart Dse (IHD) Atherosclerosis – Myocrdial injury Angina Pectoris – Myocardial ischemia MI- myocardial necrosis ATHEROSCLEROSISARTEROSCLEROSIS- Hardening or artery due to fat/ lipid deposits at tunica intima.- Narrowing or artery due to calcium & CHON deposits at tunica media. Artery – tunica adventitia – outer Tunica intima – innermost Tunica media – middle ATHEROSCLEROSIS Predisposing Factor Sex – male Black race Hyperlipidemia Smoking HPN DM Oral contraceptive- prolonged use Sedentary lifestyle Obesity Hypothyroidism Signs & Symptoms Chest pain Dyspnea Tachycardia Palpitations Diaphoresis Treatment P – percutaneous T – tansluminar C – coronary A – angioplasty Obj: To revascularize the myocardium To prevent angina 3. Increase survival rate PTCA – done to pt with single occluded vessel . Multiple occluded vessels C – coronary A – arterial B – bypass A –and G – graft surgery Nsg Mgt Before CABAG Deep breathing cough exercises Use of incentive spirometer Leg exercises ANGINA PECTORIS- A clinical syndrome characterized by paroxysmal chest pain usually relieved by REST or NGT nitroglycerin, resulting fr temp myocardial ischemia. Predisposing Factor: sex – male black raise hyperlipidemia smoking HPN DM oral contraceptive prolonged sedentary lifestyle obesity 10.hypothyroidism Precipitating factors 4 E’s Excessive physical exertion Exposure to cold environment - Vasoconstriction Extreme emotional response 4. Excessive intake of food – saturated fats. Signs & Symptoms Initial symptoms – Levine’s sign – hand clutching of chest Chest pain – sharp, stabbing excruciating pain. Location – substernal -radiates back, shoulders, axilla, arms & jaw muscles -relieve by rest or NGT Dyspnea Tachycardia Palpitation 6.diaphoresis Diagnosis 1.History taking & PE 2. ECG – ST segment depression 3. Stress test – treadmill = abnormal ECG 4. Serum cholesterol & uric acid - increase. Nursing Management 1.) Enforce CBR 2.) Administer meds NTG – small doses – venodilator Large dose – vasodilator 1st dose NTG – give 3 – 5 min 2nd dose NTG – 3 – 5 min 3rd & last dose – 3 – 5 min Still painful after 3rd dose – notify doc. MI! 55 yrs old with chest pain: 1st question to ask pt: what did you do before you had chest pain. 2nd question: does pain radiate? If radiate – heart in nature. If not radiate – pulmonary origin Venodilator – veins of lower ext – increase venous pooling lead to decrease venous return. Meds: A. NTG- Nsg Mgt: Keep in a dry place. Avoid moisture & heat, may inactivate the drug. Monitor S/E: orthostatic hypotension – dec bp transient headache dizziness Rise slowly from sitting position 4. Assist in ambulation. 5. If giving NTG via patch: avoid placing it near hairy areas-will dec drug absorption avoid rotating transdermal patches- will dec drug absorption avoid placing near microwave oven or during defibrillation-will burn pt due aluminum foil in patch B. Beta blockers – propanolol C. ACE inhibitors – captopril D. Ca antagonist - nefedipine 3.) Administer O2 inhalation 4.) Semi-fowler 5.) Diet- Decrease Na and saturated fats 6.) Monitor VS, I&O, ECG 7.) HT: Discharge planning: Avoid precipitating factors – 4 E’s Prevent complications – MI Take meds before physical exertion-to achieve maximum therapeutic effect of drug Importance of follow-up care. MI – MYOCARDIAL INFARCTION – hear attack – terminal stage of CAD Characterized by necrosis & scarring due to permanent mal-occlusion Types: Trasmural MI – most dangerous MI – Mal-occlusion of both R&L coronary artery Sub-endocardial MI – mal-occlusion of either R & L coronary artery Most critical period upon dx of MI – 48 to 72h Majority of pt suffers from PVC premature ventricular contraction. Predisposing factorsSigns & symptomsDiagnostic Examsex – male black raise hyperlipidemia smoking HPN DM oral contraceptive prolonged sedentary lifestyle obesity hypothyroidism1. chest pain – excruciating, vice like, visceral pain located substernal or precodial area (rare) - radiates back, arm, shoulders, axilla, jaw & abd muscles. - not usually relived by rest r NTG 2. dyspnea 3. erthermia 4. initial increase in BP 5. mild restlessness & apprehensions 6. occasional findings a.) split S1 & S2 b.) pericardial friction rub c.) rales /crackles d.) S4 (atrial gallop) 1. cardiac enzymes a.) CPK – MB – Creatinine Phosphokinase b.) LDH – lactic acid dehydrogenase c.) SGPT – (ALT) – Serum Glutanic Pyruvate Transaminase- increased d.) SGOT (AST) – Serum Glutamic Oxalo-acetic - increased 2. Troponin test – increase 3. ECG tracing – ST segment increase, widening or QRS complexes – means arrhythmia in MI indicating PVC 4. serum cholesterol & uric acid - increase 5. CBC – increase WBC  Nursing Management 1. Narcotic analgesics – Morphine SO4 – to induce vasodilation & decrease levels of anxiety. 2. Administer O2 inhalation – low inflow (CHF-increase inflow) 3. Enforce CBR without BP a.) Bedside commode 4. Avoid valsalva maneuver 5. Semi fowler 6. General liquid to soft diet – decrease Na, saturated fat, caffeine 7. Monitor VS, I&O & ECG tracings 8. Take 20 – 30 ml/week – wine, brandy/whisky to induce vasodilation. 9. Assist in surgical; CABAG 10. Provide pt HT a.) Avoid modifiable risk factors b.) Prevent complications: 1. Arrhythmias – PVC 2. Shock – cardiogenic shock. Late signs of cardiogenic shock in MI – oliguria 3. thrombophlebitis - deep vein 4. CHF – left sided 5. Dressler’s syndrome – post MI syndrome -Resistant to medications -Administer 150,000 – 450,000 units of streptokinase c.) Strict compliance to meds - Vasodilators 1. NTG 2. Isordil - Antiarrythmic  1. Lydocaine blocks release of norepenephrine 2. Brithylium - Beta-blockers – “lol” 1. Propanolol (inderal) - ACE inhibitors - pril 1. Captopril – (enalapril) - Ca – antagonist 1. Nifedipine - Thrombolitics or fibrinolytics– to dissolve clots/ thrombus S/E allergic reactions/ uticaria 1. Streptokinase 2. Urokinase 3. Tissue plasminogen adjusting factor Monitor for bleeding: - Anticoagulants 1. Heparin 2. Caumadin – delayed reaction 2 – 3 days  PTT PT  If prolonged bleeding prolonged bleeding  Antidote antidote Vit K Protamine sulfate - Anti platelet PASA (aspirin) d.) Resume ADL – sex/ activity – 4 to 6 weeks Post-cardiac rehab 1.)Sex as an appetizer rather then dessert – Before meals not after, due after meals increase metabolism – heart is pumping hard after meals. 2.) Position – non-weight bearing position. When to resume sex/ act: When pt can already use staircase, then he can resume sex. e.) Diet – decrease Na, Saturated fats, and caffeine f.) Follow up care. CHF – CONGESTIVE HEART FAILURE - Inability of heart to pump blood towards systemic circulation. - Backflow 1.) Left sided heart failure: Predisposing factors: 1.) 90% mitral valve stenosis – due RHD, aging RHD affects mitral valve – streptococcal infection Dx: - Aso titer – anti streptolysine O > 300 total units - Steroids - Penicillin - Aspirin Complication: RS-CHF Aging – degeneration / calcification of mitral valve Ischemic heart disease HPN, MI, Aortic stenosis S/Sx Pulmonary congestion/ Edema Dyspnea Orthopnea (Diff of breathing sitting pos – platypnea) Paroxysmal nocturnal dysnea – PNO- nalulunod Productive cough with blood tinged sputum Frothy salivation (from lungs) Cyanosis Rales/ crackles – due to fluid Bronchial wheezing PMI – displaced lateral – due cardiomegaly Pulsus alternons – weak-strong pulse Anorexia & general body malaise S3 – ventricular gallop Dx CXR – cardiomegaly PAP – Pulmonary Arterial Pressure PCWP – Pulmonary CapillaryWedge Pressure PAP – measures pressure of R ventricle. Indicates cardiac status. PCWP – measures end systolic/ diastolic pressure PAP & PCWP: Swan – ganz catheterization – cardiac catheterization is done at bedside at ICU (Trachesostomy – bedside) - Done 5 – 20 mins – scalpel & trachesostomy set CVP – indicates fluid or hydration status Increase CVP – decrease flow rate of IV Decrease CVP – increase flow rate of IV 3. Echocardiography – reveals enlarged heart chamber or cardiomayopathy 4. ABG – PCO2 increase, PO2 decrease = = hypoxemia = resp acidosis 2.) Right sided HF Predisposing factor 90% - tricuspid stenosis COPD Pulmonary embolism Pulmonic stenosis Left sided heart failure S/Sx Venous congestion Neck or jugular vein distension Pitting edema Ascites Wt gain Hepatomegalo/ splenomegaly Jaundice Pruritus Esophageal varies Anorexia, gen body malaise Diagnosis: CXR – cardiomegaly CVP – measures the pressure at R atrium Normal: 4 to 10 cm of water Increase CVP > 10 – hypervolemia Decrease CVP < 4 – hypovolemia Flat on bed – post of pt when giving CVP Position during CVP insertion – Trendelenburg to prevent pulmonary embolism & promote ventricular filling. 3. Echocardiography – enlarged heart chamber / cardiomyopathy 4.Liver enzyme SGPT ( ALT) SGOT AST Nsg mgt: Increase force of myocardial contraction = increase CO 3 – 6L of CO 1. Administer meds: Tx for LSHF: M – morphine SO4 to induce vasodilatation A – aminophylline & decrease anxiety D – digitalis (digoxin) D - diuretics O - oxygen G - gases a.) Cardiac glycosides Increase myocardial = increase CO Digoxin (Lanoxin). Antidote: digivine Digitoxin: metabolizes in liver not in kidneys not given if with kidney failure. b.) Loop diuretics: Lasix – effect with in 10-15 min. Max = 6 hrs c.) Bronchodilators: Aminophillin (Theophyllin). Avoid giving caffeine d.) Narcotic analgesic: Morphine SO4 - induce vasodilaton & decrease anxiety e.) Vasodilators – NTG f.) Anti-arrythmics – Lidocaine 2. Administer O2 inhalation – high! @ 3 -4L/min via nasal cannula 3. High fowlers 4. Restrict Na! 5. Provide meticulous skin care 6. Weigh pt daily. Assess for pitting edema. Measure abdominal girth daily & notify MD 7. Monitor V/S, I&O, breath sounds 8. Institute bloodless phlebotomy. Rotating tourniquet or BP cuff rotated clockwise q 15 mins = to promote decrease venous return 9. Diet – decrease salt, fats & caffeine 10. HT: a) Complications :shock Arrhythmia Thrombophlebitis MI Cor Pulmonale – RT ventricular hypertrophy b.) Dietary modifications c.) Adherence to meds PERIPHERAL MUSCULAR DISEASE  Arterial ulcers venous ulcer 1. Thromboangiitis Obliterans – male/ feet 1. Varicose veins 2. Reynauds – female/ hands 2. Thrombophlebitis 1.) Thromboangiitis obliterates/ BUERGER DISEASE- Acute inflammatory disorder affecting small to medium sized arteries & veins of lower extremities. Male/ feet Predisposing factors: Male Smokers S/Sx 1. Intermittent claudication – leg pain upon walking - Relieved by rest 2. Cold sensitivity & skin color changes  White bluish red  Pallor cyanosis rubor 3. Decrease or diminished peripheral pulses - Post tibial, Dorsalis pedis 4. Tropic changes 5. Ulcerations 6. Gangrene formation Dx: Oscillometry – decrease peripheral pulse volume. Doppler UTZ – decrease blood flow to affected extremities. Angiography – reveals site & extent of mal-occulsion.thrombophlebitis ns shockcuff rotated clockwise q 15 mins = to promote decrease venouse return Nsg Mgt: Encourage a slow progression of physical activity Walk 3 -4 x / day Out of bed 2 – 3 x a / day Meds Analgesic Vasodilator Anticoagulant Foot care mgt like DM – Avoid walking barefoot Cut toe nails straight Apply lanolin lotion – prevent skin breakdown Avoid wearing constrictive garments Avoid smoking & exposure to cold environment Surgery: BKA (Below the knee amputation) 2.)REYNAUD’S PHENOMENON – acute episodes of arterial spasm affecting digits of hands & fingers Predisposing factors: Female, 40 yrs Smoking Collagen dse SLE – pathognomonic sign – butterfly rash on face Chipmunk face – bulimia nervosa Cherry red skin – carbon monoxide poisoning Spider angioma – liver cirrhosis Caput medusae – leg & trunk umbilicus- Liver cirrhosis Lion face – leprosy Rheumatoid arthritis – Direct hand trauma – piano playing, excessive typing, operating chainsaw S/Sx: Intermittent claudication - leg pain upon walking - Relieved by rest Cold sensitivity Nsg Mgt: Analgesics Vasodilators Encourage to wear gloves especially when opening a refrigerator. Avoid smoking & exposure to cold environment VENOUS ULCERS 1. VARICOSITIES / Varicose veins - Abnormal dilation of veins – lower ext & trunk - Due to: a.) Incompetent valves leading to b.) Increase venous pooling & stasis leading to c.) Decrease venous return Predisposing factors: Hereditary Congenital weakness of veins Thrombophlebitis Heart dse Pregnancy Obesity Prolonged immobility - Prolonged standing S/Sx: Pain especially after prolonged standing Dilated tortuous skin veins Warm to touch Heaviness in legs Dx: Venography Trendelenberg’s test – vein distend quickly < 35 secs Nsg Mgt: Elevate legs above heart level – to promote venous return – 1 to 2 pillows Measure circumference of leg muscles to determine if swollen. Wear anti embolic or knee high stockings. Women – panty hose Meds: Analgesics Surgery: vein sweeping & ligation Sclerotherapy – spider web varicosities S/E thrombosis THROMBOPHLEBITIS (deep vein thrombosis) - Inflammation of veins with thrombus formation Predisposing factors: Smoking 2. Obesity Hyperlipedemia 4. Prolonged use of oral contraceptives Chronic anemia DM MI CHF Postop complications Post cannulation – insertion of various cardiac catheters S/Sx: Pain at affected extremities Cyanosis (+) Homan’s sign - Pain at leg muscles upon dorsiflexion of foot. Dx: Angiography Doppler UTZ Nsg Mgt: Elevate legs above heart level. Apply warm, moist packs to decrease lymphatic congestion. Measure circumference of leg muscles to detect if swollen. Use anti embolic stockings. Meds: Analgesics. Anticoagulant: Heparin Complication: Pulmonary Embolism: - Sudden sharp chest pain - Dyspnea - Tachycardia - Palpitation - Diaphoresis - Mild restlessness OVERVIEW OF RESPIRATORY SYSTEM: I. Upper respiratory tract: Fx: Filtering of air Warming & moistening Humidification Nose – cartilage - Parts: Rt nostril separated by septum Lt nostril Consists of anastomosis of capillaries – Kessel – Bach Plexus – site of epistaxis b. Pharynx (throat) – muscular passageway for air& food Branches: Oropharynx Nasopharynx Layngopharynx c. Larynx – voice box Fx: For phonation Cough reflex Glottis – opening Opens to allow passage of air Closes to allow passage of food II. Lower Rt – Fx for gas exchange Trachea – windpipe - has cartillagenous rings - site for permanent/ artificial a/w – tracheostomy b. Bronchus – R & L main bronchus c. Lungs – R – 3 lobes = 10 segments L – 2 lobes – 8 segments Post pneumonectomy - position affected side to promote expansion of lungs Post segmental lobectomy – position unaffected side to promote drainage Lungs – covered by pleural cavity, parietal lobe & visceral lobe Alveoli – acinar cells site of gas exchange (O2 & CO2) diffusion: Daltons law of partial pressure of gases Ventilation – movement of air in & out of lungs Respiration – movement of air into cells Type II cells of alveoli – secrets surfactant Surfactant - decrease surface tension of alveoli Lecithin & spinogometer L/S ratio 2:1 – indicator of lung maturity If 1:2 – adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness. I. PNEUMONIA – inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled with exudates. Etiologic agents: Streptococcus pneumoniae (pnemococcal pneumonia) Hemophilus pneumoniae(Bronchopneumonia) Escherichia coli Klebsiella P. Diplococcus P. High risk elderly & children below 5 yo Predisposing factors: Smoking Air pollution Immuno-compromised AIDS – PLP Bronchogenic CA - Non-productive to productive cough 4. Prolonged immobility – CVA- hypostatic pneumonia 5. Aspiration of food 6. Over fatigue S/Sx: Productive cough – pathognomonic: greenish to rusty sputum Dyspnea with prolonged respiratory grunt Fever, chills, anorexia, gen body malaise Wt loss Pleuritic friction rub Rales/ crackles Cyanosis Abdominal distension leading to paralytic ileus Sputum exam – could confirm presence of TB & pneumonia Dx: Sputum GSCS- gram staining & culture sensitivity - Reveals (+) cultured microorganism. CXR – pulmo consolidation CBC – increase WBC Erythrocyte sedimentation rate ABG – PO2 decrease Nsg Mgt: Enforce CBR Strict respiratory isolation Meds: Broad spectrum antibiotics Penicillin or tetracycline Macrolides – ex azythromycin (zythromax) Anti pyretics Mucolytics or expectorants Force fluids – 2 to 3 L/day Institute pulmonary toilet- Deep breathing exercise Coughing exercise Chest physiotherapy – cupping Turning & reposition - Promote expectoration of secretions 6. Semi-fowler 7. Nebulize & suction 8. Comfy & humid environment 9. Diet: increase CHO or calories, CHON & vit C 10. Postural drainage - To drain secretions using gravity Mgt for postural drainage: Best done before meals or 2 – 4 hrs after meals to prevent Gastroesophageal Reflux Monitor VS & breath sounds Normal breath sound – bronchovesicular c.) Deep breathing exercises d.) Adm bronchodilators 15 – 30 min before procedure e.) Stop if pt can’t tolerate procedure f.) Provide oral care – it may alter taste sensation g.) C/I – pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma) Normal IOP – 12 – 21 mmHg 11. HT: a.) Avoidance of precipitating factors b.) Complication: Atelectacies & meningitis c.) Compliance to meds PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of mycobacterium TB or tubercle bacilli or acid fast bacilli – gram (+) aerobic, motile & easily destroyed by heat or sunlight. Predisposing factors: 1. Malnutrition 2. Overcrowding 3. Alcoholism 4. Ingestion of infected cattle (mycobacterium BOVIS) 5. Virulence Over fatigue S/Sx: Productive cough – yellowish Low fever Night sweats Dyspnea Anorexia, general body malaise, wt loss Chest/ back pain Hempotysis Diagnosis: Skin test – mantoux test – infection of Purified CHON Derivative PPD DOH – 8-10 mm induration WHO – 10-14 mm induration Result within 48 – 72h (+) Mantoux test – previous exposure to tubercle bacilli Mode of transmission – droplet infection Sputum AFB – (+) to cultured microorganism CXR – pulmonary infiltrate caseosis necrosis CBC – increase WBC Nursing Mgt: CBR Strict resp isolation O2 inhalation Semi fowler Force fluid to liquefy secretions DBCE Nebulize & suction Comfy & humid environment Diet – increase CHO & calories, CHON, Vit, minerals Short course chemotherapy Intensive phase INH – isoniazide - give before meals for absorption Rifampicin - given within 4 months, given simultaneously to prevent resistance -S/E: peripheral neutitis – vit B6 Rifampicin -All body secretions turn to red orange color urine, stool, saliva, sweat & tears. PZA – Pyrazinamide – given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity Standard regimen Injection of streptomycin – aminoglycoside Ex. Kanamycin, gentamycin, neomycin S/E: Ototoxicity – damage CN # 8 – tinnitus – hearing loss Nephrotoxicicity – monitor BUN & Crea HT: Avoid pred factors Complications: Atelectasis Miliary TB – spread of Tb to other system Compliance to meds - Religiously take meds HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with histoplasma capsulatum transmitted to birds manure. S/Sx: Same as pneumonia & PTB – like Productive cough Dyspnea Chest & joint pains Cyanosis Anorexia, gen body malaise, wt loss Hemoptysis Dx: Histoplasmin skin test = (+) ABG – pO2 decrease Nsg Mgt: CBR Meds: Anti fungal agents Amphotericin B (Fungizone) S/E : Nephrotoxcicity check BUN Hypokalemia b.)Corticosteroids c.) Mucolytic/ or expectorants 3. O2 – force fluids 4. Nebulize, suction 5. Complications: a.) Atelectasis b.) Bronchiectasis COPD 6. Prevent spread of histoplasmosis: a.) Spray breading places or kill the bird. COPD – Chronic Obstructive Pulmonary Disease Chronic bronchitis Bronchial asthma Bronchiectasis Pulmonary emphysema – terminal stage CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or hyperplasia of goblet mucus producing cells leading to narrowing of smaller airways. Predisposing factors: Smoking – all COPD types Air pollution S/Sx: Prod cough Dyspnea on exertion Prolonged expiratory grunt Scattered rales/ rhonchi Cyanosis Pulmo HPN – a.)Leading to peripheral edema b.) Cor pulmonary – respiratory in origin 7. Anorexia, gen body malaise Dx: ABG PO2 PCO2 Resp acidosis  Hypoxemia – causing cyanosis Nsg Mgt: (Same as emphysema) 2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity leading to narrowing of smaller airway. Predisposing factor: Extrinsic Asthma – called Atropic/ allergic asthma Pallor Dust Gases Smoke Dander Lints Intrinsic Asthma- Cause: Herediatary Drugs – aspirin, penicillin, ( blockers Food additives – nitrites Foods – seafood, chicken, eggs, chocolates, milk Physical/ emotional stress Sudden change of temp, humidity &air pressure mixed type: combi of both ext & intr. Asthma 90% cause of asthma S/Sx: C – cough – non productive to productive D – dyspnea W – wheezing on expiration Cyanosis Mild apprehension & restlessness Tachycardia & palpitation Diaphoresis Dx: Pulmo function test – decrease lung capacity ABG – PO2 decrease Nsg Mgt: CBR – all COPD Meds- Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroids Corticosteroids – due inflammatory. Given 10 min after adm bronchodilator c.) Mucolytic/ expectorant d.) Mucomist – at bedside put suction machine. e.) Antihistamine Force fluid O2 – all COPD low inflow to prevent resp distress Nebulize & suction Semifowler – all COPD except emphysema due late stage HT Avoid pred factors Complications: Status astmaticus- give epinephrine & bronchodilators Emphysema Adherence to med BRONCHIECTASIS – abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic tissues of alveoli. Predisposing factors: Recurrent upper & lower RI Congenital anomalies Tumors Trauma S/Sx: Productive cough Dyspnea Anorexia, gen body malaise- all energy are used to increase respiration. Cyanosis Hemoptisis Dx: ABG – PO2 decrease Bronchoscopy – direct visualization of bronchus using fiberscope. Nsg Mgt: before bronchoscopy Consent, explain procedure – MD/ lab explain RN NPO Monitor VS Nsg Mgt after bronchoscopy Feeding after return of gag reflex Instruct client to avoid talking, smoking or coughing Monitor signs of frank or gross bleeding Monitor of laryngeal spasm DOB Prepare at bedside tracheostomy set Mgt: same as emphysema except Surgery Pneumonectomy – removal of affected lung Segmental lobectomy – position of pt – unaffected side PULMONARY EMPHYSEMA – irreversible terminal stage of COPD Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of gases. Body will compensate over distension of thoracic cavity Barrel chest Predisposing factor: Smoking Allergy Air pollution High risk – elderly Hereditary - ( 1 anti trypsin to release elastase for recoil of alveoli. S/Sx: Productive cough Dyspnea at rest – due terminal Anorexia & gen body malaise Rales/ rhonchi Bronchial wheezing Decrease tactile fremitus (should have vibration)– palpation – “99”. Decreased - with air or fluid Resonance to hyperresonance – percussion Decreased or diminished breath sounds Pathognomonic: barrel chest – increase post/ anterior diameter of chest Purse lip breathing – to eliminated PCO2 Flaring of alai nares Diagnosis: 1. Pulmonary function test – decrease vital lung capacity 2. ABG – Panlobular / centrolobular emphysema pCO2 increase pO2 decrease – hypoxema resp acidosis Blue bloaters Panacinar/ Centracinar pCO2 decrease pO2 increase – hyperaxemia resp alkalosis Pink puffers Nursing Mgt: CBR Meds – Bronchodilators Corticosteroids Antimicrobial agents Mucolytics/ expectorants O2 – Low inflow Force fluids High fowlers Neb & suction Institute P – posture E – end E – expiratory to prevent collapse of alveoli P – pressure HT Avoid smoking Prevent complications Cor pulmonary – R ventricular hypertrophy CO2 narcosis – lead to coma Atelectasis Pneumothorax – air in pleural space Adherence to meds RESTRICTIVE LUNG DISORDER PNEUMOTHORAX – partial / or complete collapse of lungs due to entry or air in pleural space. Types: Spontaneous pneumothorax – entry of air in pleural space without obvious cause. Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions Eg. open pneumothorax – air enters pleural space through an opening in chest wall -Stab/ gun shot wound Tension Pneumothorax – air enters plural space with @ inspiration & can’t escape leading to over distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side. Eg. flail chest – “paradoxical breathing” Predisposing factors: 1.Chest trauma 2.Inflammatory lung conditions 3.Tumor S/Sx: Sudden sharp chest pain Dyspnea Cyanosis Diminished breath sound of affected lung Cool moist skin Mild restlessness/ apprehension Resonance to hyper resonance Diagnosis: ABG – pO2 decrease – CXR – confirms pneumothorax Nursing Mgt: Endotracheal intubation Thoracenthesis Meds – Morphine SO4 Anti microbial agents Assist in test tube thoracotomy Nursing Mgt if pt is on CPT attached to H2O drainage Maintain strict aseptic technique DBE At bedside Petroleum gauze pad if dislodged Hemostan If with air leakage – clamp Extra bottle Meds – Morphine SO4 Antimicrobial Monitor & assess for oscillation fluctuations or bubbling If (+) to intermittent bubbling means normal or intact - H2O rises upon inspiration - H2o goes down upon expiration b.) If (+) to continuous, remittent bubbling 1. Check for air leakage 2. Clamp towards chest tube 3. Notify MD c.) If (-) to bubbling 1. Check for loop, clots, and kink 2. Milk towards H2O seal 3. Indicates re-expansion of lungs When will MD remove chest tube: If (-) fluctuations (+) Breath sounds CXR – full expansion of lungs Nursing Mgt of removal of chest tube DBE Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space. Apply vaselinated air occlusive dressing Maintain dressing dry & intact GIT I. Upper alimentary canal - function for digestion Mouth Pharynx (throat) Esophagus Stomach 1st half of duodenum II. Middle Alimentary canal – Function: for absorption - Complete absorption – large intestine 2nd half of duodenum Jejunum Ileum 1st half of ascending colon III. Lower Alimentary Canal – Function: elimination 2nd half of ascending colon Transverse Descending colon Sigmoid Rectum IV. Accessory Organ Salivary gland Verniform appendix Liver Pancreas – auto digestion Gallbladder – storage of bile I. Salivary Glands 1. Parotid – below & front of ear 2. Sublingual 3. Submaxillary Produces saliva – for mechanical digestion 1200 -1500 ml/day - saliva produced PAROTITIS – “mumps” – inflammation of parotid gland -Paramyxo virus S/Sx: Fever, chills anorexia, gen body malaise Swelling of parotid gland Dysphagia Ear ache – otalgia Mode of transmission: Direct transmission & droplet nuclei Incubation period: 14 – 21 days Period of communicability – 1 week before swelling & immediately when swelling begins. Nursing Mgt: CBR Strict isolation Meds: analgesic Antipyretic Antibiotics – to prevent 2( complications Alternate warm & cold compress at affected part Gen liquid to soft diet Complications Women – cervicitis, vaginitis, oophoritis Both sexes – meningitis & encephalitis/ reason why antibiotics is needed Men – orchitis might lead to sterility if it occur during / after puberty. VERNIFORM APPENDIX – Rt iliac or Rt inguinal area Function – lymphatic organ – produces WBC during fetal life - ceases to function upon birth of baby APENDICITIS – inflamation of verniform appendix Predisposing factor: Microbial infection Feacalith – undigested food particles – tomato seeds, guava seeds Intestinal obstruction S/Sx: Pathognomonic sign: (+) rebound tenderness Low grade fever, anorexia, n/v Diarrhea / & or constipation Pain at Rt iliac region Late sign due pain – tachycardia Diagnosis: CBC – mild leukocytosis – increase WBC PE – (+) rebound tenderness (flex Rt leg, palpate Rt iliac area – rebound) Urinalysis Treatment: - appendectomy 24 – 45( Nursing Mgt: Consent Routinary nursing measures: Skin prep NPO Avoid enema – lead to rupture of appendix Meds: Antipyretic Antibiotics *Don’t give analgesic – will mask pain - Presence of pain means appendix has not ruptured. 4. Avoid heat application – will rupture appendix. 5. Monitor VS, I&O bowel sound Nursing Mgt: post op If (+) to Pendrose drain – indicates rupture of appendix Position- affected side to drain Meds: analgesic due post op pain Antibiotics, Antipyretics PRN Monitor VS, I&O, bowel sound Maintain patent IV line Complications- peritonitis, septicemia Liver – largest gland Occupies most of right hypochondriac region Color: scarlet red Covered by a fibrous capsule – Glisson’s capsule Functional unit – liver lobules Function: Produces bile Bile – emulsifies fats - Composed of H2O & bile salts -Gives color to urine – urobilin Stool – stircobilin Detoxifies drugs Promotes synthesis of vit A, D, E, K - fat soluble vitamins Hypevitaminosis – vit D & K Vit A – retinol Def Vit A – night blindness Vit D – cholecalciferon Helps calcium Rickets, osteoarthritis 4. It destroys excess estrogen hormone 5. For metabolism A. CHO – 1. Glycogenesis – synthesis of glycogens 2. Glycogenolysis – breakdown of glycogen 3. Gluconeogenesis – formation of glucose from CHO sources B. CHON- 1. Promotes synthesis of albumin & globulin Cirrhosis – decrease albumin Albumin – maintains osmotic pressure, prevents edema 2. Promotes synthesis of prothrombin & fibrinogen 3. Promotes conversion of ammonia to urea. Ammonia like breath – fetor hepaticus C. FATS – promotes synthesis of cholesterol to neutral fats – called triglycerides LIVER CIRRHOSIS - lost of architectural design of liver leading to fat necrosis & scarring Early sign – hepatic encephalopathy Asterixis – flapping hand tremors Late signs – headache, restlessness, disorientation, decrease LOC – hepatic coma. Nursing priority – assist in mechanical ventilation Predisposing factor: Decrease Laennac’s cirrhosis – caused by alcoholism Chronic alcoholism Malnutrition – decreaseVit B, thiamin - main cause Virus – Toxicity- eg. Carbon tetrachloride Use of hepatotoxic agents S/Sx: Early signs: Weakness, fatigue Anorexia, n/v Stomatitis Urine – tea color Stool – clay color Amenorrhea Decrease sexual urge Loss of pubic, axilla hair Hepatomegaly Jaundice Pruritus or urticaria 2. Late signs a.) Hematological changes – all blood cells decrease Leukopenia- decrease Thrombocytopenia- decrease Anemia- decrease b.) Endocrine changes Spider angiomas, Gynecomastia Caput medusate, Palmar errythema c.) GIT changes Ascitis, bleeding esophageal varices – due to portal HPN d.) Neurological changes: Hepatic encephalopathy - ammonia (cerebral toxin) Late signs: Early signs: Headache asterexis Fetor hepaticus (flapping hand tremors) Confusion Restlessness Decrease LOC  Hepatic coma Diagnosis: Liver enzymes- increase  SGPT (ALT) SGOT (AST) Serum cholesterol & ammonia increase Indirect bilirubin increase CBC - pancytopenia PTT – prolonged Hepatic ultrasonogram – fat necrosis of liver lobules Nursing Mgt CBR Restrict Na! Monitor VS, I&O With pt daily & assess pitting edema Measure abdominal girth daily – notify MD Meticulous skin care Diet – increase CHO, vit & minerals. Moderate fats. Decrease CHON Well balanced diet Complications: Ascites – fluid in peritoneal cavity Nursing Mgt: Meds: Loop diuretics – 10 – 15 min effect Assist in abdominal paracentesis - aspiration of fluid - Void before paracentesis to prevent accidental puncture of bladder as trochar is inserted Bleeding esophageal varices - Dilation of esophageal veins 1. Meds: Vit K Pitrisin or Vasopresin (IM) 2. NGT decompression- lavage - Give before lavage – ice or cold saline solution - Monitor NGT output 3. Assist in mechanical decompression - Insertion of sengstaken-blackemore tube - 3 lumen typed catheter - Scissors at bedside to deflate balloon. Hepatic encephalopathy – Assist in mechanical ventilation – due coma Monitor VS, neuro check Siderails – due restless Meds – Laxatives – to excrete ammonia HEPATITIS- jaundice (icteric sclera)  Bilirubin   Kernicterus/ hyperbilirubinia Irreversible brain damage Pancreas – mixed gland (exocrine & endocrine gland) PANCREATITIS – acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto digestion. Bleeding of pancreas - Cullen’s sign at umbilicus Predisposing factors: Chronic alcoholism Hepatobilary disease Obesity Hyperlipidemia Hyperparathyroidism Drugs – Thiazide diuretics, pills Pentamidine HCL (Pentam) Diet – increase saturated fats S/Sx: Severe Lt epigastric pain – radiates from back &flank area Aggravated by eating, with DOB N/V Tachycardia Palpitation due to pain Dyspepsia – indigestion Decrease bowel sounds (+) Cullen’s sign - ecchymosis of umbilicus hemorrhage (+) Grey Turner’s spots – ecchymosis of flank area Hypocalcemia Diagnosis: Serum amylase & lipase – increase Urine lipase – increase Serum Ca – decrease Nursing Mgt: 1. Meds a.) Narcotic analgesic - Meperidine Hcl (Demerol) Don’t give Morphine SO4 –will cause spasm of sphincter. b.) Smooth muscle relaxant/ anti cholinergic - Ex. Papavarine Hcl Prophantheline Bromide (Profanthene) c.) Vasodilator – NTG d.) Antacid – Maalox e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation f.) Ca – gluconate 2. Withold food & fluid – aggravates pain 3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation Complications of TPN Infection Embolism Hyperglycemia 4. Institute stress mgt tech a.) DBE b.) Biofeedback 5. Comfy position - Knee chest or fetal like position 6. If pt can tolerate food, give increase CHO, decrease fats, and increase CHON 7. Complications: Chronic hemorrhagic pancreatitis GALLBLADDER – storage of bile – made up of cholesterol. CHOLECYSTITIS/ CHOLELITHIASIS – inflammation of gallbladder with gallstone formation. Predisposing factor: High risk – women 40 years old Post menopausal women – undergoing estrogen therapy Obesity Sedentary lifestyle Hyperlipidemia Neoplasm S/Sx: Severe Right abdominal pain (after eating fatty food). Occurring especially at night Fatty intolerance Anorexia, n/v Jaundice Pruritus Easy bruising Tea colored urine Steatorrhea Diagnosis: Oral cholecystogram (or gallbladder series)- confirms presence of stones Nursing Mgt: Meds – a.) Narcotic analgesic - Meperdipine Hcl – Demerol b.) Anti cholinergic - Atropine SO4 c.) Anti emetic Phenergan – Phenothiazide with anti emetic properties Diet – increase CHO, moderate CHON, decrease fats Meticulous skin care Surgery: Cholecystectomy Nursing Mgt post cholecystectomy -Maintain patency of T-tube intact & prevent infection Stomach – widest section of alimentary canal J shaped structures Anthrum Pylorus Fundus Valves 1.cardiac sphincter Pyloric sphincter Cells Chief/ Zymogenic cells – secrets Gastric amylase - digest CHO Gastric lipase – digest fats Pepsin – CHON Rennin – digests milk products Parietal / Argentaffin / oxyntic cells Function: Produces intrinsic factor – promotes reabsorption of vit B12 cyanocobalamin – promotes maturation of RBC Secrets Hcl acid – aids in digestion Endocrine cells - Secrets gastrin – increase Hcl acid secretion Function of the stomach 1.Mechanical 2.Chem. Digestion 3.Storage of food -CHO, CHON- stored 1 -2 hrs. Fats – stored 2 – 3 hrs PEPTIC ULCER DISEASE – (PUD) – excoriation / erosion of submucosa & mucosal lining due to: Hypercecretion of acid – pepsin Decrease resistance to mucosal barrier Incidence Rate: Men – 40 – 55 yrs old Aggressive persons Predisposing factors: Hereditary Emotional Smoking – vasoconstriction – GIT ischemia Alcoholism – stimulates release of histamine = Parietal cell release Hcl acid = ulceration Caffeine – tea, soda, chocolate Irregular diet Rapid eating Ulcerogenic drugs – NSAIDS, aspirin, steroids, indomethacin, ibuprofen Indomethacin - S/E corneal cloudiness. Needs annual eye check up. Gastrin producing tumor or gastrinoma – Zollinger Ellisons sign Microbial invasion – helicobacter pylori. Metromidazole (Flagyl) Types of ulcers Ascending to severity Acute – affects submucosal lining Chronic – affects underlying tissue – heals & forms a scar According to location Stress ulcer Gastric ulcer Duodenal ulcer – most common Stress ulcers – common among eritically ill clients 2 types 1.Curing’s ulcer – cause: trauma & birth   hypovolemia GIT schemia   Decrease resistance of mucosal barriers to Hcl acid Ulcerations 2.Cushing’s ulcer – cause – stroke/CVA/ head injury  Increase vagal stimulation  Hyperacidity  Ulcerations GASTRIC ULCER DUODENAL ULCER SITEIntrum or lesser curvatureDuodenal bulbPAIN-30 min – 1 hr after eating - epigastrium - gaseous & burning - not usually relieved by food & antacid-2-3 hrs after eating - mid epigastrium - cramping & burning - usually relieved by food & antacid - 12 MN – 3am pain HYPERSECRETIONNormal gastric acid secretion Increased gastric acid secretionVOMITINGcommonNot commonHEMORRHAGEhematemeisMelenaWTWt lossWt gainCOMPLICATIONSa. stomach cause b. hemorrhagea. perforationHIGH RISK60 years old20 years oldDiagnosis: Endoscopic exam Stool from occult blood Gastric analysis – N – gastric Increase – duodenal GI series – confirms presence of ulceration Nursing Mgt: Diet – bland, non irritating, non spicy Avoid caffeine & milk/ milk products Increase gastric acid secretion Administer meds Antacids AAC Aluminum containing antacids Magnesium containing antacids Ex. aluminum OH gel ex. milk of magnesia (Ampho-gel) S/E diarrhea S/E constipation  Maalox (fever S/E) H2 receptor antagonist Ex Ranitidine (Zantac) Cimetidine (Tagamet) Tamotidine (Pepcid) Avoid smoking – decrease effectiveness of drug Nursing Mgt: Administer antacid & H2 receptor antagonist – 1hr apart -Cemetidine decrease antacid absorption & vise versa Cytoprotective agents Ex 1. Sucralfate (Carafate) - Provides a paste like subs that coats mucosal lining of stomach 2. Cytotec d.) Sedatives/ Tranquilizers - Valium, lithium e.)Anticholinergics Atropine SO4 Prophantheline Bromide (Profanthene) (Pt has history of hpn crisis With peptic ulcer disease. Rn should not administer alka seltzer- has large amount of Na. 4. Surgery: subtotal gastrectomy - Partial removal of stomach Billroth I (Gastroduodenostomy) -Removal of ½ of stomach & anastomoses of gastric stump to the duodenum.Billroth II (Gastrojejunostomy) - removal of ½ -3/4 of stomach & duodenal bulb & anastomostoses of gastric stump to jejunum. Before surgery for BI or BII - Do vagotomy (severing of vagus nerve) & pyloroplasty (drainage) first. Nursing Mgt: Monitor NGT output Immediately post op should be bright red Within 36- 42h – output is yellow green After 42h – output is dark red Administer meds: Analgesic Antibiotic Antiemetics Maintain patent IV line VS, I&O & bowel sounds Complications: Hemorrhage – hypovolemic shock Late signs – anuria Peritonitis Paralytic ileus – most feared Hypokalemia Thromobphlebitis Pernicious anemia 7.)Dumping syndrome – common complication – rapid gastric emptying of hypertonic food solutions – CHYME leading to hypovolemia. Sx of Dumping syndrome: Dizziness Diaphoresis Diarrhea Palpitations Nursing mgt: Avoid fluids in chilled solutions Small frequent feeding s-6 equally divided feedings Diet – decrease CHO, moderate fats & CHON Flat on bed 15 -30 minutes after q feeding BURNS – direct tissue injury caused by thermal, electric, chemical & smoke inhaled (TECS) Nursing Priority – infection (all kinds of burns) Head burn-priority- a/w 2nd priority for 1st & 2nd ( - pain 2nd priority for 3rd ( - F&E Thermal- direct contact – flames, hot grease, sunburn. Electric, – wires Chem. – direct contact – corrosive materials acids Smoke – gas / fume inhalation Stages: Emergent phase – Removal of pt from cause of burn. Determine source or loc or burn Shock phase – 48 - 72(. Characterized by shifting of fluids from intravascular to interstitial space =Hypovolemia S/Sx: BP decrease Urine output HR increase Hct increase Serum Na decrease Serum K increase Met acidosis 3. Diuretic/ Fluid remobilization phase - 3 to 5 days. Return of fluid from interstitial to intravascular space 4. Recovery/ convalescent phase – complete diuresis. Wound healing starts immediately after tissue injury. Class: I. Partial Burn 1. 1st degree – superficial burns - Affects epidermis - Cause: thermal burn - Painful - Redness (erythema) & blanching upon pressure with no fluid filled vesicles 2. 2nd degree – deep burns - Affects epidermis & dermis - Cause –chem. burns - very painful - Erythema & fluid filled vesicles (blisters) II Full thickness Burns 1. Third & 4th degrees burn - Affects all layers of skin, muscles, bones - Cause – electrical - Less painful - Dry, thick, leathery wound surface – known as ESCHAR – devitalized or necrotic tissue. Assessment findings Rule of nines Head & neck = 9% Ant chest = 18% Post chest = 18% @ Arm 9+9 = 18% @ leg 18+18 = 18% Genitalia/ perineum= 1% Total 100% Nursing Mgt 1. Meds a.) Tetanus toxoid- burn surface area is source of anaerobic growth – Claustridium tetany Tetany  Tetanolysin tetanospasmin Hemolysis muscle spasm b.) Morphine SO4 c.) Systemic antibiotics 1. Ampicillin 2. Cephalosporin 3. Tetracyclin 4. Topical antibiotic : 1. Silver Sulfadiazene (silvadene) 2. Sulfamylon 3. Silver nitrate 4. Povidone iodine (betadine) 2. Administer isotonic fluid sol & CHON replacements 3. Strict aseptic technique 4. Diet – increase CHO, increase CHON, increase Vit C, and increase K- orange 5. If (+) to burns on head, neck, face - Assist in intubation 6. Assist in hydrotherapy 7. Assist in surgical wound debridement. Administer analgesic 15 – 30 minutes before debridement 8. Complications: a.) Infection b.) Shock c.) Paralytic ileus - due to hypovolemia & hypokalemia d.) Curling’s ulcer – H2 receptor antagonist e.) Septicemia blood poisoning f.) Surgery: skin grafting GUT – genito-urinary tract Function: Promote excretion of nitrogenous waste products Maintain F&E & acid base balance 1. Kidneys – pair of bean shaped organ Retro peritonially (back of peritoneum) on either side of vertebral column. Encased in Bowmans’s capsule. Parts: Renal pelvis – pyenophritis – infl Cortex Medulla Nephrones – basic living unit Glomerulus – filters blood going to kidneys Function of kidneys: Urine formation Regulation of BP Urine formation – 25% of total CO (Cardiac Output) is received by kidneys Filtration Tubular Reabsorption Tubular Secretion Filtration – Normal GFR/ min is 125 ml of blood Tubular reabsorption – 124ml of ultra infiltrates (H2O & electrolytes is for reabsorption) Tubular secretion – 1 ml is excreted in urine Regulation of BP: Predisposing factor: Ex CS – hypovolemia – decrease BP going to kidneys Activation of RAAS Release of Renin (hydrolytic enzyme) at juxtaglomerular apparatus  Angiotensin I mild vasoconstrictor  Angiotensin II vasoconstrictor  Adrenal cortex increase CO increase PR  Aldosterone  Increase BP Increase Na & H2O reabsorption Hypervolemia Ureters – 25 – 35 cm long, passageway of urine to bladder Bladder – loc behind symphisis pubis. Muscular & elastic tissue that is distensible - Function – reservoir or urine 1200 – 1800 ml – Normal adult can hold 200 – 500 ml – needed to initiate micturition reflex Color – amber Odor – aromatic Consistency – clear or slightly turbid pH – 4.5 – 8 Specific gravity – 1.015 – 1.030 WBC/ RBC – (-) Albumin – (-) E coli – (-) Mucus thread – few Amorphous urate (-) Urethra – extends to external surface of body. Passage of urine, seminal & vaginal fluids. Women 3 – 5 cm or 1 to 1 ½ “ Male – 20cm or 8” UTI CYSTITIS – inflammation of bladder Predisposing factors: Microbial invasion – E. coli High risk – women Obstruction Urinary retention Increase estrogen levels Sexual intercourse S/Sx: Pain – flank area Urinary frequency & urgency Burning upon urination Dysuria & hematuria Fever, chills, anorexia, gen body malaise Diagnosis: Urine culture & sensitivity - (+) to E. coli Nursing Mgt: Force fluid – 2000 ml Warm sitz bath – to promote comfort Monitor & assess for gross hematuria Acid ash diet – cranberry, vit C -OJ to acidify urine & prevent bacterial multiplication Meds: systemic antibiotics Ampicillin Cephalosporin Sulfonamides – cotrimaxazole (Bactrim) - Gantrism (ganthanol) Urinary antiseptics – Mitropurantoin (Macrodantin) Urinary analgesic- Pyridum 6. Ht a.) Importance of Hydration b.) Void after sex c.) Female – avoids cleaning back & front Bubble bath, Tissue paper, Powder, perfume d.) Complications: Pyelonephritis PYELONEPHRITIS – acute/ chronic infl of 1 or 2 renal pelvis of kidneys leading to tubular destruction, interstitial abscess formation. Lead to Renal Failure Predisposing factor: Microbial invasion E. Coli Streptococcus Urinary retention /obstruction Pregnancy DM Exposure to renal toxins S/Sx: Acute pyelonephritis Costovertibral angle pain, tenderness Fever, anorexia, gen body malaise Urinary frequency, urgency Nocturia, dsyuria, hematuria Burning on urination Chronic Pyelonephritis Fatigue, wt loss Polyuuria, polydypsia HPN Diagnosis: Urine culture & sensitivity – (+) E. coli & streptococcus Urinalysis Increase WBC, CHON & pus cells Cystoscopic exam – urinary obstruction Nursing Mgt: Provide CBR – acute phase Force fluid Acid ash diet Meds: Urinary antiseptic – nitrofurantoin (macrodantin) SE: peripheral neuropathy GI irritation Hemolytic anemia Staining of teeth Urinary analgesic – Peridium Complication- Renal Failure NEPHROLITHIASIS/ UROLITHIASIS- formation of stones at urinary tract - calcium , oxalate, uric acid  milk cabbage anchovies cranberries organ meat nuts tea nuts chocolates sardines Predisposing factors: Diet – increase Ca & oxalate Hereditary – gout Obesity Sedentary lifestyle Hyperparathyroidism S/Sx: Renal colic Cool moist skin (shock) Burning upon urination Hematuria Anorexia, n/v Diagnosis: IVP – intravenous pyelography. Reveals location of stone KUB – reveals location of stone Cytoscopic exam- urinary obstruction Stone analysis – composition & type of stone Urinalysis – increase EBC, increase CHON Nursing Mgt: 1.Force fluid 2.Strain urine using gauze pad 3.Warm sitz bath – for comfort 4.Alternate warm compress at flank area 5. a.) Narcotic analgesic- Morphine SO4 b.) Allopurinol (Zyeoprim) c.) Patent IV line d.) Diet – if + Ca stones – acid ash diet If + oxalate stone – alkaline ash diet - (Ex milk/ milk products) If + uric acid stones – decrease organ meat / anchovies sardines Surgery Nephectomy – removal of affected kidney Litholapoxy – removal of 1/3 of stones- Stones will recur. Not advised for pt with big stones Extracorporeal shock wave lithotripsy - Non - invasive - Dissolve stones by shock wave Complications: Renal Failure BENIGN PROSTATIC HYPERTROPHY - enlarged prostate gland leading to Hydro ureters – dilation of ureters Hydronephrosis – dilation of renal pelvis Kidney stones Renal failure Predisposing factor: High risk – 50 years old & above 60 – 70 – (3 to 4 x at risk) Influence of male hormone S/Sx: 1.Decrease force of urinary stream 2.Dysuria 3.Hematuria 4.Burning upon urination 5.Terminal bubbling 6.Backache 7.Sciatica Diagnosis: Digital rectal exam – enlarged prostate gland KUB – urinary obstruction Cystoscopic exam – obstruction Urinalysis – increase WBC, CHON Nursing Mgt: Prostatic message – promotes evacuation of prostatic fluid Limit fluid intake Provide catheterization Meds: Terazozine (hytrin) - Relaxes bladder sphincter Fenasteride (Proscar) - Atrophy of Prostate Gland 5. Surgery: Prostatectomy – TURP- Transurethral resection of Prostate- No incision -Assist in cystoclysis or continuous bladder irrigation. Nursing mgt: Monitor symptoms of infection Monitor symptoms gross/ flank bleeding. Normal bleeding within 24h. 3. Maintain irrigation or tube patent to flush out clots - to prevent bladder spasm & distention ACUTE RENAL FAILURE – sudden immobility of kidneys to excrete nitrogenous waste products & maintain F&E balance due to a decrease in GFR. (N 125 ml/min) Predisposing factor: Pre renal cause- decrease blood flow Causes: Septic shock Hypovolemia Hypotension decrease flow to kidneys CHF Hemorrhage Dehydration Intra-renal cause – involves renal pathology= kidney problem Acute tubular necrosis- Pyelonephritis HPN Acute GN Post renal cause – involves mechanical obstruction Stricture Urolithiasis BPH CHRONIC RF – irreversible loss of kidney function Predisposing factors: DM HPN Recurrent UTI/ nephritis Exposure to renal toxins Stages of CRF Diminished Reserve Volume – asymptomatic Normal BUN & Crea, GFR < 10 – 30% 2. Renal Insufficiency 3. End Stage Renal disease S/Sx: 1.) Urinary System a.) polyuria b.) nocturia c.) hematuria d.) Dysuria e.) oliguria2.) Metabolic disturbances a.) azotemia (increase BUN & Crea) b.) hyperglycemia c.) hyperinulinemia3.) CNS a.) headache b.) lethargy c.) disorientation d.) restlessness e.) memory impairment4.) GIT a.) n/v b.) stomatitis c.) uremic breath d.) diarrhea/ constipation5.) Respiratory a.) Kassmaul’s resp b.) decrease cough reflex6.) hematological a.) Normocytic anemia bleeding tendencies 7.) Fluid & Electrolytes a.) hyperkalemia b.) hypernatermia c.) hypermagnesemia d.) hyperposphatemia e.) hypocalcemia f.) met acidosis8.) Integumentary a.) itchiness/ pruritus b.) uremic frostNursing Mgt: Enforce CBR Monitor VS, I&O Meticulous skin care. Uremic frost – assist in bathing pt 4. Meds: a.) Na HCO3 – due Hyperkalemia b.) Kagexelate enema c.) Anti HPN – hydralazine d.) Vit & minerals e.) Phosphate binder (Amphogel) Al OH gel - S/E constipation f.) Decrease Ca – Ca gluconate 5. Assist in hemodialysis Consent/ explain procedure Obtain baseline data & monitor VS, I&O, wt, blood exam Strict aseptic technique Monitor for signs of complications: B – bleeding E – embolism D – disequilibrium syndrome S – septicemia S – shock – decrease in tissue perfusion Disequilibrium syndrome – from rapid removal of urea & nitrogenous waste prod leading to: n/v HPN Leg cramps Disorientation Paresthesia Avoid BP taking, blood extraction, IV, at side of shunt or fistula. Can lead to compression of fistula. Maintain patency of shunt by: Palpate for thrills & auscultate for bruits if (+) patent shunt! Bedside- bulldog clip - If with accidental removal of fistula to prevent embolism. - Infersole (diastole) – common dialisate used 7. Complication - Peritonitis - Shock 8. Assist in surgery: Renal transplantation : Complication – rejection. Reverse isolation EYES External parts Orbital cavity – made up of connective tissue protects eye form trauma. EOM – extrinsic ocular muscles – involuntary muscles of eye needed for gazing movement. Eyelashes/ eyebrows – esthetic purposes Eyelids – palpebral fissure – opening upper & lower lid. Protects eye from direct sunlight Meibomean gland – secrets a lubricating fluid inside eyelid Stye/ sty or Hordeolum- inflamed Meibomean gland Conjunctiva Lacrimal apparatus – tears Process of grieving Denial Anger Bargaining Depression Acceptance Intrinsic coat I. sclerotic coat – outer most a.) Sclera – white. Occupies ¾ post of eye. Refracts light rays b.) Canal of schlera – site of aqueous humor drainage c.) Cornea – transparent structure of eye II/ Uveal tract – nutritive care Uveitis – infl of uveal tract Consist of: a.) Iris – colored muscular ring of eye 2 muscles of iris: 1. Circular smooth muscle fiber - Constricts the pupil 2.radial smooth muscle fiber - Dilates the pupil 2 chambers of the eye 1. Anterior a.) Vitereous Humor – maintains spherical shape of the eye b.) Aqueous Humor – maintains intrinsic ocular pressure Normal IOP= 12-21 mmHg II. Retina (innermost layer) Optic discs or blind spot – nerve fibers only No auto receptors  cones (daylight/ colored vision) rods – night twilight vision phototopic vision “scotopic vision” = vit A deficiency – rods insufficient Maculla lutea – yellow spot center of retina Fovea centralis – area with highest visual acuity oracute vision Physiology of vision 4 Physiological processes for vision to occur: 1. Refraction of light rays – bending of light rays 2. Accommodation of lens 3. Constriction & dilation of pupils 4. Convergence of eyes Unit of measurements of refraction – diopters Normal eye refraction – emmetropia ERROR of refraction Myopia – near sightedness – Treatment: biconcave lens Hyperopia/ or farsightedness – Treatment: biconvex lens Astigmatisim – distorted vision – Treatment: cylindrical Prebyopia – “old slight” – inelasticity of lens due to aging – Treatment: bifocal lens or double vista Accommodation of lenses – based on thelmholtz theory of accommodation Near vision = far vision= Ciliary muscle contracts= ciliary muscle dilates / relaxes= Lens bulges lens is flat Convergence of the eye: Error: Exotropia – 1 eye normal Esophoria – corrected by corrective eye surgery Strabismus- squint eye Amblyopia – prolong squinting GLAUCOMA – increase IOP – if untreated, atrophy of optic nerve disc – blindness Predisposing factors: High risk group – 40 & above HPN DM Hereditary Obesity Recent eye trauma, infl, surgery Type: Chronic – (open angle G.) – most common type Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema Acute (close angle G.) – Most dangerous type Forward displacement of iris to cornea leading to blindness. Chronic (closed – angle) - Precipitated by acute attack S/Sx: 1. Loss of peripheral vision – tunnel vision 2. Halos around lights 3. Headache 4. n/v 5. Steamy cornea 6. Eye discomfort 7. If untreated – gradual loss of central vision – blindness Diagnosis: 1. Tonometry – increase IOP >12- 21 mmHg 2. Perimetry – decrease peripheral vision 3. Gonioscopy – abstruction in anterior chamber Nursing mgt: Enforce CBR Maintain siderails Administer meds Miotics – lifetime - contracts ciliary muscles & constricts pupil. Ex Pilocarpine Na (Carbachol) Epinephrine eye drops – decrease secretion of aqueous humor Carbonic anhydrase inhibitors. Ex. acetapolamide (Diamox) - Promotes increase out flow of aquaeous humor d.) Temoptics (Timolol maleate)- Increase outflow of aquaous humor Surgery: Invasive: Trabeculectomy – eyetrephining – removal of trabelar meshwork of canal or schlera to drain aqueous humor Peripheral Iridectomy – portion of iris is excised to drain aqueous humor Non-invasive: Trabeculoctomy (eye laser surgery) Nursing Mgt pre op- all types surgery Apply eye patch on unaffected eye to force weaker eye to become stronger. Nursing Mgt post op – all types of surgery Position unaffected/ unoperated side - to prevent tension on suture line. Avoid valsalva maneuver Monitor symptoms of IOP Headache n/v Eye discomfort Tachycardia Eye patch – both eyes - post op CATARACT – partial/ complete opacity of lens Predisposing factor: 90-95% - aging (degenerative/ senile cataract) Congenital Prolonged exposure to UV rays DM- S/Sx: Loss of central vision - “Hazy or blurring of vision” Painless Milky white appearance at center of pupil Decrease perception of colors Diagnosis: Opthalmoscopic exam – (+) opacity of lens Nsg Mgt: Reorient pt to environment – due opacity Siderails Meds – a.) Mydriatics – dilate pupil – not lifetime Ex. Mydriacyl Cyslopegics – paralyzes ciliary muscle. Ex. Cyclogye Surgery E – extra C - capsular C – cataract partial removal of lens L - lens E – extraction  I - intra C - capsular C – cataract total removal of lens & surrounding capsules L - lens E – extraction Nursing Mgt: 1.Position unaffected/ unoperated side - to prevent tension on suture line. 2.Avoid valsalva maneuver 3.Monitor symptoms of IOP Headache n/v Eye discomfort Tachycardia 4.Eye patch – both eyes - post op RETINAL DETACHMENT- separation of 2 layers of retina Predisposing factors: Severe myopia – nearsightedness Diabetic Retinopathy Trauma Following lens extraction HPN S/Sx: “Curtain –veil” like vision Flashes of lights Floaters Gradual decrease in central vision Headache Diagnosis- opthaloscopic exam Nursing Mgt: Siderails (all visual disease) Surgery: Cryosurgery Scleral buckling EAR – Hearing Balance (Kinesthesia or position sense) Parts: Outer- Pinna/ auricle – protects ear from direct trauma Ext. auditory meatus – has ceruminous gland. Cerumen Tympanic membrane – transmits sound waves to middle ear Disorders of outer ear Entry of insects – put flashlight to give route of exit Foreign objects – beans (bring to MD) H2O - drain 2. Middle ear a.) Ear osssicle  1. Hammer -malleus 2. Anvil -Incus for bone conduction disorder conductive hearing loss 3. Stirrups -stapes b. Eustachian tube - Opens to allow equalization of pressure on both ears - Yawn, chew, and swallow Children – straight, wide, short Otitis media Adult – long, narrow & slanted c. Muscles 1. Stapedius 2. Tensor tympani 3. Inner ear a. Bony labyrinth – for balance, vestibule Utricle & succule Otolithe or ear stone – has Ca carbonate Movement of head = Righting reflex = Kinesthesia b. Membranous Labyrinth Cochlea – ( function for hearing) has organ of corti Endolymph & perilymph – for static equilibrium Mastoid air cells – air filled spaces in temporal bone in skull Complications of Mastoditis – meningitis Types of hearing loss: Conductive hearing loss – transmission hearing loss Causes: Impacted cerumen – tinnitus & conduction hearing loss- assist in ear irrigaton Immobility of stapes – OTOSCLEROSIS Middle ear disease char by formation of spongy bone in the inner ear causing fixation or immobility of stapes Stapes can’t transmit sound waves Surgery Stapedectomy – removal of stapes, spongy bone & implantation of graft/ ear prosthesis Predisposing factor: Familiar tendency Ear trauma & surgery S/Sx: Tinnitus Conductive hearing loss Diagnosis: Audiometry – various sound stimulates (+) conductive hearing loss Weber’s test – Normal AC> BC result BC > AC Stapedectomy Nursing Mgt post op Position pt unaffected side DBE No coughing & blowing of nose - Night lead to removal of graft Meds: Analgesic Antiemetic Antimotion sickness agent. 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Use shower cap SENSORY NEURAL HEARING LOSS/ NERVE DEAFNESS Cause: Tumor on cocheal Loud noises (gun shot) Presbycusis – bilateral progressive hearing loss especially at high frequencies – elderly Face elderly to promote lip reading Meniere’s disease – endolymphatic hydrops Inner ear disease char by dilation of endo – lympathic system leading to increase volume of endolin Predisposing factor of MENIERE’S DISEASE Smoking Hyperlipidemia 30 years old Obesity – (+) chosesteatoma Allergy Ear trauma & infection S/Sx: TRIAD symptoms of Meniere’s disease Tinnitus Vertigo Sensory neural hearing loss Nystagmus n/v Mild apprehension, anxiety Tachycardia Palpitations Diaphoresis Diagnosis: Audiometry – (+) sensory hearing loss Nursing mgt: Comfy & darkened environment Siderails Emetic basin Meds: Diuretics –to remove endolymph Vasodilator Antihistamine Antiemetic Antimotion sickness agent Sedatives/ tranquilizers Restrict Na Limit fluid intake Avoid smoking Surgery – endolymphatic sac decompression- Shunt     PAGE  PAGE 89 AV [”l”¢¢|¢ ¢“£Ą£k¤l¤m¤o¤p¤r¤s¤u¤v¤x¤y¤¤€¤¤ƒ¤„¤Š¤‹¤¤Ž¤¤‘¤’¤ ¤óėßėÓėÓėĻĒĆĒĆĒĆĒĆ¹³¹³Ļ¹³¹Ø¹³ĻĆĻh€:0JmHnHu hHVŅ0JjhHVŅ0JUhéūjhéūUhHVŅhHVŅB*CJaJph’hHVŅ5>*CJ\aJhHVŅCJaJhHVŅB*CJaJph’†”ź”ė”ģ”¢¢-¢:¢V¢^¢u¢v¢|¢ ¢©¢±¢Ķ¢×¢Ū¢ö¢££££÷õõõļļļļļļõéŻŃŃŃŻŻŻŻŻŻĖ„ ^„  & F<„p^„pgdéū & F<„ ^„ gdéū„Š^„Š„¼^„¼ & F;gdéū£'£M£N£[£x£‚££•£“£Ą£Ī£Ł£ó£ ¤ ¤¤,¤:¤k¤l¤n¤o¤q¤łķēēŪŪŪŪĻĻĻĻĻĻēŪŪŪŪÉĒĒĒ ĘąĄ! & F<„p^„pgdéū & F>„ ^„ gdéū„ ^„  & F=„ ^„ gdéū„Š^„Šq¤r¤t¤u¤w¤x¤¤‚¤ƒ¤¤¤‘¤’¤œ¤¤ž¤Ÿ¤ ¤żżżżżōīżōīżżżżżżč ĘąĄ!„h]„h„ų’„&`#$,1h°Š/ °ą=!°Š"°Š#Š$Š%°°Š°Š Šˆ$$If–!vh5Ö5Öƒ #v#vƒ :V –l tąÖ0’’’’’’ö6ö5Öˆ$$If–!vh5Ö5Öƒ #v#vƒ :V –l tąÖ0’’’’’’ö6ö5Öˆ$$If–!vh5Ö†5Ö‚#v†#v‚:V –l tąÖ0’’’’’’ö6ö5Ö‘$$If–!vh5Ö5Öł#v#vł:V –l tąÖ0’’’’’’ö65Ö/Ö ’‘$$If–!vh5Ö5Öł#v#vł:V –l tąÖ0’’’’’’ö65Ö/Ö ’Ÿ$$If–!vh5Öœ 5Öw5Öõ#vœ #vw#võ:V –l tąÖ0’’’’’’ö65Ö/Ö ’Ÿ$$If–!vh5Öœ 5Öw5Öõ#vœ #vw#võ:V –l tąÖ0’’’’’’ö65Ö/Ö ’Ÿ$$If–!vh5Ö“5ÖR 5Ö #v“#vR #v :V –l tąÖ0’’’’’’ö65Ö/Ö ’Ÿ$$If–!vh5Ö“5ÖR 5Ö #v“#vR #v :V –l tąÖ0’’’’’’ö65Ö/Ö ’Ÿ$$If–!vh5Ö“5ÖR 5Ö #v“#vR #v :V –l tąÖ0’’’’’’ö65Ö/Ö ’Ÿ$$If–!vh5Ö“5ÖR 5Ö #v“#vR #v :V –l tąÖ0’’’’’’ö65Ö/Ö ’Ÿ$$If–!vh5Ö“5ÖR 5Ö #v“#vR #v :V –l tąÖ0’’’’’’ö65Ö/Ö ’Ÿ$$If–!vh5Ö“5ÖR 5Ö #v“#vR #v :V –l tąÖ0’’’’’’ö65Ö/Ö ’Ÿ$$If–!vh5Ö“5ÖR 5Ö #v“#vR #v :V –l tąÖ0’’’’’’ö65Ö/Ö ’Ÿ$$If–!vh5Ö“5ÖR 5Ö #v“#vR #v :V –l tąÖ0’’’’’’ö65Ö/Ö ’‘$$If–!vh5Ö¢5Öf#v¢#vf:V –l tąÖ0’’’’’’ö65Ö/Ö ’‘$$If–!vh5Ö²5ÖA #v²#vA :V –l tąÖ0’’’’’’ö65Ö/Ö ’‘$$If–!vh5Ö²5ÖA #v²#vA :V –l tąÖ0’’’’’’ö65Ö/Ö ’‘$$If–!vh5Ö²5ÖA #v²#vA :V –l tąÖ0’’’’’’ö65Ö/Ö ’‘$$If–!vh5Ö²5ÖA #v²#vA :V –l tąÖ0’’’’’’ö65Ö/Ö ’^ ˜˜˜˜˜˜˜˜ž666666666vvvvvvvvv666666>666666666666666666666666666Ø6666666666ø666666666666hH66666666666666666666666666666666666666666666666666666666666666666°62ĄŠąš 0@P`p€ĄŠąš2(Ųč 0@P`p€ĄŠąš 0@P`p€ĄŠąš 0@P`p€ĄŠąš 0@P`p€ĄŠąš 0@P`p€ĄŠąš 0@P`p€8XųV~_HmH nH sH tH @`ń’@ NormalCJ_HaJmH sH tH N@N  Heading 1$ Ę T€€@&5CJ\aJ@@@  Heading 2$@& >*B*ph>@>  Heading 3$@& 5>*aJF@F  Heading 4$„h@&`„h 5>*\B@B  Heading 5$@&5>*CJaJF@F  Heading 6$@&5>*CJ\aJ:@:  Heading 7$@&5>*T@T  Heading 8$„Š@&`„Š5B*CJ\aJph’DA`ņ’”D Default Paragraph FontVi@ó’³V  Table Normal :V ö4Ö4Ö laö (k`ō’Į(No List .)@¢ń. 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„ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.)‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„ „˜žĘ ^„ `„˜žo(.€ „p„˜žĘp^„p`„˜ž‡hˆH.‚ „@ „L’Ę@ ^„@ `„L’‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.€ „ą„˜žĘą^„ą`„˜ž‡hˆH.‚ „°„L’Ę°^„°`„L’‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.€ „P„˜žĘP^„P`„˜ž‡hˆH.‚ „ „L’Ę ^„ `„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.)‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„8„0żĘ8^„8`„0żo(.„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„8„˜žĘ8^„8`„˜žo(.)€ „„˜žĘ^„`„˜ž‡hˆH.‚ „Ų „L’ĘŲ ^„Ų `„L’‡hˆH.€ „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH.€ „x„˜žĘx^„x`„˜ž‡hˆH.‚ „H„L’ĘH^„H`„L’‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.€ „č„˜žĘč^„č`„˜ž‡hˆH.‚ „ø„L’Ęø^„ø`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„8„˜žĘ8^„8`„˜žo(.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „Ų „L’ĘŲ ^„Ų `„L’‡hˆH.€ „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH.€ „x„˜žĘx^„x`„˜ž‡hˆH.‚ „H„L’ĘH^„H`„L’‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.€ „č„˜žĘč^„č`„˜ž‡hˆH.‚ „ø„L’Ęø^„ø`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.)„$ „˜žĘ$ ^„$ `„˜žo()„@ „˜žĘ@ ^„@ `„˜žo(. „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„8„˜žĘ8^„8`„˜žo(.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „Ų „L’ĘŲ ^„Ų `„L’‡hˆH.€ „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH.€ „x„˜žĘx^„x`„˜ž‡hˆH.‚ „H„L’ĘH^„H`„L’‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.€ „č„˜žĘč^„č`„˜ž‡hˆH.‚ „ø„L’Ęø^„ø`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„8„˜žĘ8^„8`„˜žo(.„„˜žĘ^„`„˜žo(.„Œ „˜žĘŒ ^„Œ `„˜žo(.)€ „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH.€ „x„˜žĘx^„x`„˜ž‡hˆH.‚ „H„L’ĘH^„H`„L’‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.€ „č„˜žĘč^„č`„˜ž‡hˆH.‚ „ø„L’Ęø^„ø`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(. „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜žCJaJo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.)‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„„˜žĘ^„`„˜žo(.€ „Ų „˜žĘŲ ^„Ų `„˜ž‡hˆH.‚ „Ø „L’ĘØ ^„Ø `„L’‡hˆH.€ „x„˜žĘx^„x`„˜ž‡hˆH.€ „H„˜žĘH^„H`„˜ž‡hˆH.‚ „„L’Ę^„`„L’‡hˆH.€ „č„˜žĘč^„č`„˜ž‡hˆH.€ „ø„˜žĘø^„ø`„˜ž‡hˆH.‚ „ˆ„L’Ęˆ^„ˆ`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „8„˜žĘ8^„8`„˜ž‡hˆH.) „„˜žĘ^„`„˜ž‡hˆH. „Ų „˜žĘŲ ^„Ų `„˜ž‡hˆH. „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH. „x„˜žĘx^„x`„˜ž‡hˆH. „H„˜žĘH^„H`„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „č„˜žĘč^„č`„˜ž‡hˆH. „ø„˜žĘø^„ø`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.)‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „Ų „˜žĘŲ ^„Ų `„˜ž‡hˆH. „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH. „x„˜žĘx^„x`„˜ž‡hˆH. „H„˜žĘH^„H`„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „č„˜žĘč^„č`„˜ž‡hˆH. „ø„˜žĘø^„ø`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.) „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„„˜žĘ^„`„˜žo(.€ „ģ„˜žĘģ^„ģ`„˜ž‡hˆH.‚ „¼„L’Ę¼^„¼`„L’‡hˆH.€ „Œ „˜žĘŒ ^„Œ `„˜ž‡hˆH.€ „\ „˜žĘ\ ^„\ `„˜ž‡hˆH.‚ „,„L’Ę,^„,`„L’‡hˆH.€ „ü„˜žĘü^„ü`„˜ž‡hˆH.€ „Ģ„˜žĘĢ^„Ģ`„˜ž‡hˆH.‚ „œ„L’Ęœ^„œ`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„L’Ęp^„p`„L’‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€„ „˜žĘ ^„ `„˜ž.‚„p„L’Ęp^„p`„L’.€„@ „˜žĘ@ ^„@ `„˜ž.€„„˜žĘ^„`„˜ž.‚„ą„L’Ęą^„ą`„L’.€„°„˜žĘ°^„°`„˜ž.€„€„˜žĘ€^„€`„˜ž.‚„P„L’ĘP^„P`„L’.„Š„˜žĘŠ^„Š`„˜žo(.)„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)„ „˜žĘ ^„ `„˜žo(. „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „„0żĘ^„`„0ż‡hˆH. „$ „˜žĘ$ ^„$ `„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „8„˜žĘ8^„8`„˜ž‡hˆH.) „„˜žĘ^„`„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€„ „˜žĘ ^„ `„˜ž.‚„p„L’Ęp^„p`„L’.€„@ „˜žĘ@ ^„@ `„˜ž.€„„˜žĘ^„`„˜ž.‚„ą„L’Ęą^„ą`„L’.€„°„˜žĘ°^„°`„˜ž.€„€„˜žĘ€^„€`„˜ž.‚„P„L’ĘP^„P`„L’. „Š„˜žĘŠ^„Š`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „8„˜žĘ8^„8`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „8„˜žĘ8^„8`„˜ž‡hˆH.) „„˜žĘ^„`„˜ž‡hˆH. „Ų „˜žĘŲ ^„Ų `„˜ž‡hˆH. „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH. „x„˜žĘx^„x`„˜ž‡hˆH. „H„˜žĘH^„H`„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „č„˜žĘč^„č`„˜ž‡hˆH. „ø„˜žĘø^„ø`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„ „˜žĘ ^„ `„˜žo(.€ „p„˜žĘp^„p`„˜ž‡hˆH.‚ „@ „L’Ę@ ^„@ `„L’‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.€ „ą„˜žĘą^„ą`„˜ž‡hˆH.‚ „°„L’Ę°^„°`„L’‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.€ „P„˜žĘP^„P`„˜ž‡hˆH.‚ „ „L’Ę ^„ `„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.„$ „˜žĘ$ ^„$ `„˜žo(.)€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Į„˜žĘĮ^„Į`„˜žo(.€ „‘„˜žĘ‘^„‘`„˜ž‡hˆH.‚ „a„L’Ęa^„a`„L’‡hˆH.€ „1 „˜žĘ1 ^„1 `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „Ń„L’ĘŃ^„Ń`„L’‡hˆH.€ „”„˜žĘ”^„”`„˜ž‡hˆH.€ „q„˜žĘq^„q`„˜ž‡hˆH.‚ „A„L’ĘA^„A`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)„ „˜žĘ ^„ `„˜žo(.„$ „˜žĘ$ ^„$ `„˜žo()€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo()‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„8„˜žĘ8^„8`„˜žo(.„„˜žĘ^„`„˜žOJPJQJ^Jo( ‚ „Ų „L’ĘŲ ^„Ų `„L’‡hˆH.€ „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH.€ „x„˜žĘx^„x`„˜ž‡hˆH.‚ „H„L’ĘH^„H`„L’‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.€ „č„˜žĘč^„č`„˜ž‡hˆH.‚ „ø„L’Ęø^„ø`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žOJPJQJ^Jo(‡hˆH- „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH.)„@ „˜žĘ@ ^„@ `„˜žOJQJo(‡hˆH·š„„˜žĘ^„`„˜žOJQJ^Jo(‡hˆHo„ą„˜žĘą^„ą`„˜žOJQJo(‡hˆH§š„°„˜žĘ°^„°`„˜žOJQJo(‡hˆH·š „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)„ „˜žĘ ^„ `„˜žo(. „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(. „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„8„˜žĘ8^„8`„˜žo(.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „Ų „L’ĘŲ ^„Ų `„L’‡hˆH.€ „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH.€ „x„˜žĘx^„x`„˜ž‡hˆH.‚ „H„L’ĘH^„H`„L’‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.€ „č„˜žĘč^„č`„˜ž‡hˆH.‚ „ø„L’Ęø^„ø`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„8„˜žĘ8^„8`„˜žo(.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „Ų „L’ĘŲ ^„Ų `„L’‡hˆH.€ „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH.€ „x„˜žĘx^„x`„˜ž‡hˆH.‚ „H„L’ĘH^„H`„L’‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.€ „č„˜žĘč^„č`„˜ž‡hˆH.‚ „ø„L’Ęø^„ø`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜žCJaJo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„L’Ęp^„p`„L’‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žOJPJQJ^Jo(-„ „˜žĘ ^„ `„˜žOJQJ^Jo(‡hˆHo„p„˜žĘp^„p`„˜žOJQJo(‡hˆH§š„@ „˜žĘ@ ^„@ `„˜žOJQJo(‡hˆH·š„„˜žĘ^„`„˜žOJQJ^Jo(‡hˆHo€„ą„˜žĘą^„ą`„˜žOJQJo(‡hˆH§š€„°„˜žĘ°^„°`„˜žOJQJo(‡hˆH·š€„€„˜žĘ€^„€`„˜žOJQJ^Jo(‡hˆHo€„P„˜žĘP^„P`„˜žOJQJo(‡hˆH§š„Š„˜žĘŠ^„Š`„˜žo(.)€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.)„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„8„˜žĘ8^„8`„˜žo(.„„˜žĘ^„`„˜žo(.)‚ „Ų „L’ĘŲ ^„Ų `„L’‡hˆH.€ „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH.€ „x„˜žĘx^„x`„˜ž‡hˆH.‚ „H„L’ĘH^„H`„L’‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.€ „č„˜žĘč^„č`„˜ž‡hˆH.‚ „ø„L’Ęø^„ø`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH.) „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„@ „˜žĘ@ ^„@ `„˜žo(.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.€ „ „˜žĘ ^„ `„˜ž‡hˆH.€ „š„˜žĘš^„š`„˜ž‡hˆH.‚ „Ą!„L’ĘĄ!^„Ą!`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(. „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.„ „˜žĘ ^„ `„˜žo(.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„Š„˜žĘŠ^„Š`„˜žo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „8„˜žĘ8^„8`„˜ž‡hˆH.) „„˜žĘ^„`„˜ž‡hˆH. „Ų „˜žĘŲ ^„Ų `„˜ž‡hˆH. „Ø „˜žĘØ ^„Ø `„˜ž‡hˆH. „x„˜žĘx^„x`„˜ž‡hˆH. „H„˜žĘH^„H`„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „č„˜žĘč^„č`„˜ž‡hˆH. „ø„˜žĘø^„ø`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH.) „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH. „Š„˜žĘŠ^„Š`„˜žCJaJo(.€ „ „˜žĘ ^„ `„˜ž‡hˆH.‚ „p„L’Ęp^„p`„L’‡hˆH.€ „@ „˜žĘ@ ^„@ `„˜ž‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.‚ „ą„L’Ęą^„ą`„L’‡hˆH.€ „°„˜žĘ°^„°`„˜ž‡hˆH.€ „€„˜žĘ€^„€`„˜ž‡hˆH.‚ „P„L’ĘP^„P`„L’‡hˆH. „Š„˜žĘŠ^„Š`„˜ž‡hˆH. „ „˜žĘ ^„ `„˜ž‡hˆH. „p„˜žĘp^„p`„˜ž‡hˆH. „@ „˜žĘ@ ^„@ `„˜ž‡hˆH. „„˜žĘ^„`„˜ž‡hˆH. „ą„˜žĘą^„ą`„˜ž‡hˆH. „°„˜žĘ°^„°`„˜ž‡hˆH. „€„˜žĘ€^„€`„˜ž‡hˆH. „P„˜žĘP^„P`„˜ž‡hˆH.„ „˜žĘ ^„ `„˜žo(.€ „p„˜žĘp^„p`„˜ž‡hˆH.‚ „@ „L’Ę@ ^„@ `„L’‡hˆH.€ „„˜žĘ^„`„˜ž‡hˆH.€ „ą„˜žĘą^„ą`„˜ž‡hˆH.‚ „°„L’Ę°^„°`„L’‡hˆH.€ 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