So how do you deal with your patient’s pain? What meds do you give? Well, we are here to break it down and teach you the solid foundations to pain management basics!
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Cool. We’re going to give everybody just another minute or so to hop on and then we’ll get started going over some pain management stuff today. I’m also going to give you a few, uh, I am, I’m excited. This is actually cool stuff. Pain management was my, uh, forte actually. Um, when I was in the surgical trauma unit, that’s kind of where I was. So I dealt with a lot of, a lot of patients with different varying degrees of pain and I had dealt with so many different types of pain management. So we’re going to get into that.
So, uh, let’s see. Chris is saying there’s no sound ever. Can you hear me? That’s one. Actually let’s do one thing real quick.
Once I’m actually going to refreshing the different window. I’m going to try something different once that guys, so let’s do something
Henrietta, hang on one sec. Leave the, it’s going to say offline for one second. I want to do one thing for you guys. Alright. Try this. Hopefully maybe the audio video will be a little bit better. So if you guys can hear me, just let me know. Oh yeah, Yup, Yup. Yeah, I know there’s, sometimes it happens. It depends on the browser that we’re using. Uh, sometimes I just, um, I realized it was on the wrong browser, so I just fixed that. So we’re gonna go. All right guys who’s ready to get started on some pain management? So I’m going to share my screen. I want you, uh, let’s see. Let’s see. Bear with me one sec. And
it’s actually on my end, amber, you’re asking which browser it is. Um, so, uh, with, um, with this, uh, it actually helps us a little bit better for whatever you’re using. Um, it, uh, Google chrome is fine. Um, we actually found that casting with our or presenting these tutoring sessions with Mozilla actually gives us a much better quality. And so we’ve continued to use that and we’re so used to using, uh, or I, my personal preference is chrome all the time. And so it just so happens that all them show, I’ll jump into the session and be like, Oh crap, I’m in the wrong one. So here we go. All right, so pain management. What we’re going to do is we’re gonna do some really, really cool stuff too with pain management. So pain management. When we’re talking about painting management, we’re going to talk about several different aspects.
Today we’re going to talk about, um, how we do with pain. We’re going to talk about what medications we use. I’m going to have you asking you guys some questions I want you to interact with and give me your answers. Um, so let’s get started. So the first thing we want to talk about, Mara talking about pain management is we’re gonna look at first about tolerance and dependence. So what we want to remember with our patients is that some patients, um, there’s a difference between tolerance, independence and there’s a misconception, especially among, uh, like baby boomers for instance, and you know, baby boomer patients. So these are patients that, um, they’re going to be in their sixties, seventies, eighties. Now, um, you’re going to see a lot of, um, a lot of them say I don’t want payment occasion, um, because I don’t want to become dependent on it because I don’t want to become addicted.
Um, there’s a lot more that goes into addiction. They looked at several, lots of studies have been done on addiction and unless you have some sort of addictive personality or, um, or there’s, there’s, there’s just a lot more that goes into it. So what you need to do is it’s your responsibility as a nurse to make sure that you’re educating those patients on, look, we need to control your pain because your pain is going to prevent you from leaving the hospital. It’s going to increase. Your length of stay in the hospital is going to increase the chances of you coming back. It’s going to decrease your ability. It’s going to put you at higher risk for things like, because you’re in pain, you don’t want to get out of bed because you don’t want to get out of bed. You don’t want to mobilize, not mobilizer.
You’re not going to be able to, um, decrease your risk for things like pneumonia. So there’s like this cascade that happens. So what we need to do as nurses, we make sure we’re educating those patients and say, look, you are going to, um, you’re not going to become addicted. Um, we can try and minimal amounts of pain, so pain, pain management, and we can try different methods. So we need to do, when we’re talking about this is we need to make sure we’re educating our patients so that we can kind of get rid of that idea that just because they’re getting a narcotic medication, that they’re going to become addicted. And so that the range to be kind of Dr Tolerance. And so some patients, depending on their levels of tolerance, this has a lot to do with, um, but the physiology and the amount of receptors they have and the amount of pain Ahab and some patients are maybe have, uh, some sort of reaction to a drug.
What we need to do is we need to make sure that whenever we’re talking to our patients about pain, we need to figure out that that happy medium of what is the minimum amount of pain management, pain management level that we can get to before we need to increase or add another drug. We’ll talk about synergism later, but that’s kind of where this starts out is hey, we need to understand what the difference between what, what tolerances and then also what the difference between dependencies and a lot of what dependents deals with is being able to educate our patients in a way that’s meaningful to them, but also kind of reduces that. So is there a flow sheet that decipher, decipher, amber asks, is there a flow sheet that helps to decipher and dizzy addictive personalities or risk assessments? So, um, we don’t, we don’t have one that deals with that.
I would actually have to go look into specific studies about, um, addictive personalities. I kind of rabbit hold a little bit. Um, but just know that one of the things that you can do for your patients when they say, Hey, I don’t want to become addictive is let them know. I mean, you can do things like a wall. Have you ever had, um, do you have any previous history of addiction, um, or an addiction? Maybe the wrong word. Um, uh, if you ever had a history of excessive use of that may be another way to, to put it as you have it. Do you have a history of maybe excessively using, um, drugs or over the counter medications or maybe even alcohol and you can, you can kind of also do and you’re doing your comprehensive health assessments. Yeah. So you can use, you could say, hey, how are you?
Instead of, instead of being so on the news with it instead of me like, Hey, do you have an addictive personality? You can say something to the effect of, um, when I am, uh, you know, how many, how many drinks, uh, how many alcoholic drinks do you make a week? If they say, I’m making 15, you may consider, but if they say, I have one to two a week. Okay, cool. What are the, you know, what are the circumstances in which you are having those? And they say, Oh, well, you know, you know, every Wednesday I go out to, we have a poker night at my friend’s house and we all have one drink. Cool. That’s like social drinking, less likely have an alcoholic type of abuse situation. Um, have you ever used her, uh, you know, like pain management, like Advil, those kinds of things.
You gotta kind of feel them out and use that idea of a comprehensive health assessment and you, I know that you guys learn about those. Um, I know for my master’s I had to do an entire, an entire course with a comprehensive health assessment. It was pain, it was awful. Um, but you kind of learned, Hey, I, I start to derive the right questions from it. Um, so there are also ways to also not intimidate the patient to make them feel uncomfortable. The Aussie I’m going to do is like build any sort of variance barrier. So just be like, hey, you know, how many, how many are you a smoker? A smoker may give you some insight. Do you smoke? Oh No, I don’t smoke. Okay. Um, do you use drugs recreationally? Oh No, I don’t. Okay, how many drinks a week do you want it to?
Cool. This person is going to be a less likely, they’re going to have a lower likelihood of having them, um, the dependence for a drug. Therefore, they would actually be, they wouldn’t be the print candidate. It’s like, I don’t want any pain medication because I’ll be, y’all get addicted to it. Look, you don’t have historically, you don’t fit the mold for someone who had, who would have an addictive personality. So you know, now that we’ve kind of reduced that, that, um, that barrier, then you can do more education. And that’s when you can start to talk about, even starts to talk about like, what, uh, what does the drug do? What are the expected side effects? You could talk about, you know, hey, make you a little sleepy. Hey, we want to make sure we’re giving you a bowel regimen. Hey, we’re going to do some other things, but there, there’s a lot of education, a lot of talking, and really help to build up your, your patients, um, confidence and, um, security and when doing that.
So let’s move on to the next thing, which is, or remembering, okay. Agonist, antagonist. So the way I like to think about agonist antagonist, and you need to think about when you’re giving you medications, what an agonist antagonist does. Because if you have, um, like, uh, an offer to add energy, um, antagonist, you have to understand what it does to the soul. So you have, if we look here, so this is the receptor site right here. This guy. So this is, this is a Sobel and this is a cell membrane right here. And so there’s a receptor. So every time this natural substance comes in and, and locks in, um, it creates normal cellular activity, right? So let’s say that this is a pain center. So what we want to do is every time, um, there’s an impulse from pain and actually sends a response to the brand that says there’s pain.
Well, let’s say we’ve got this agonist rate. So, um, what, what happens with this agonist is it’s agonist comes in and binds to the receptor. And so here what we’re gonna do is a lot of these to a lot of pain medications or agonists, blockers. So what they’ll actually do is they’ll come in and they’ll, um, they’ll come into this receptor and so you actually get this inhibition of pain. So Hey, this is the way we decrease pain. Then you have these things called antagonists, antagonists. The way they work is they, they still fit into this thing, but they actually, they block it. And they also don’t allow agonists come in either. So think of it like a key, like a locking key. Um, so you have a key, you want to open the door. Well, the door is locked when you’re going to need that key, which is going to be that agonist, which agonize comes in and turns it and opens a door.
When an antagonist does is it’s basically it’s a key blocker. So it’ll, it’ll come in fit but it won’t turn the key. But it also will keep another, keep them from coming in. These are just things you need to understand. So when you see, you just need to know the difference between agonist and antagonist when you’re talking about meds and you’re doing it from college. So let’s go to the next one. So we’re going to talk now about no narcotics. So these are non-narcotic ways. So we’re going to give you another, this is not an influx test taking course or an inkling test taking session. But I do want to give you a couple of hints. Um, I am going to pull up one thing real quick. I’m pulling up something in the background. So when she goes to hang out for me, just for one second, cause I want to give you some accurate information but with, um, when we’re talking about non first let’s talk about non, okay. So you have different ways of giving, um, managing a patient’s pain without specifically giving them, um, pain medication. And what we mean by this is inset. So who, can you give me some examples of an inset?
Sure. So once you guys to give me some, some examples of um, of an INSEAD Motrin. Cool. Ibuprofen is one. Um, aspirin is another. So these are things that reduce pain. And then also the other thing that they do is they reduce inflammation. So the other type of nonnarcotic pain, pain management that you can do with a nerve block. So a DICLOFENAC on a tour all is one. Um, let me see. Uh, uh, so there’s [inaudible], there’s Motrin, um, uh, to and all as well. Tyler with another, uh, non narcotic pain management. Um, so let’s talk about nerve blocks for a second. Who here has dealt with nerve blocks before?
Neural blocks? Epidurals. Um, I’ve had dealt with tons of nerve blocks. Will, you’ll see a lot of, um, so if you get, uh, like a, um, like a hepatectomy hepatectomy is, are tortillas, um, like partial hepatectomy or they’re going like, there’s, there’s liver cancer and they go and take, take out that taken out. What you’ll get is you’ll get, um, I actually have a picture of, um, kind of what the pump looks like here in a few minutes, but it’s a pain pump. And what it is is they’ll have, um, so it’s a pump. It’ll have a cartridge and it’ll have like the little button, right? It’s a little button. And what’ll happen though, there’ll be the things like a continuous rate. So there’s a continuous rate, um, a Bolus, um, and then so they’ll continue to get pain, uh, pain, uh, like infused pain, medication infused.
And then at the same time, what they do is they have breakthrough pain. They can actually give themselves a bolus. And what’s nice about, uh, nerve blocks is you can actually use this with, uh, like, um, additional oral medications. So you can actually start to transition your patients from IB or, um, entered fecal, what they call intrathecal pain management and the choose the nerve block, um, into the oral pain management. And then start giving them some of like the oral, uh, nerve pain medications like Gab. And, and that’ll really help. Um, but with this, what you’re doing is with the nerve block, this is another non narcotic pain management. So I had a patient one time until this real quick with his patient. What happening was they had uh, he think he cut off his finger, cut off his cut off a couple of fingers.
He had some sort of really bad hand injury and he’s like, I could not get his pain under control. We are trying all sort of [inaudible] I think the lauded and I, and I actually wouldn’t suggest, I was like look what’s the possibility we could get him a singular nerve block to the shoulder and it’s called a radial nerve block. And with the radial nerve block, awesome. Cause what ends up happening, um, with a radial nerve block has actually just, it starts, um, let me draw your pictures. So here’s the dude, right? So it says up here, oh my goodness. And he said right. He’s like, Oh this hurts cause I injured my hand. He’s got like two fingers. So what happens is they do this nerve block or welcome stripping, so that do the nerve block like right in here. And it actually innovates the radial nerve, which is up here or it, uh, it goes into the radial nerve.
And so basically it cuts off all of his sensation going this way. Um, the things you got to be mindful of when you do these things, are we going to make sure we’re not paralyzing him? Um, but at the same time we’ve got to make sure that we’re actually controlling his pain. So he would get these little doses of this nerve block and it would, it would basically turn off all the nerve impulse. It’s always pant, like his pain gets so much better. So now there are also ways of nonpharmacologic pain management who can tell him some non-pharmacologic ways of managing your patient’s pain. There are several, lots, tens unit music. What else? So much.
Okay. Amber, I’m gonna throw a hypothetical out there. Um, this actually happened to me and this is why guided guided imagery, so visualization yet, give them like some sort of way to preoccupy their mind. So let’s go back to massage for a second and we check your critical thinking skills. So I had a patient one time, she was in her seventies. Um, she was there for some abdominal pain she was on, and she was, I was in the, that I knew she didn’t really well. Um, but she came as just a, hey, here’s a little bit, would you mind massaging it? And I’m like, all right, tell me a little bit more about it. So do you think that me should have, do you think I should have asked that question or do you think I should’ve just gone in the sauce? Ah, cool. Yeah. So come to find out, I started looking, there’s a little bit red. Um, but I asked her, I was like, where’s you link hurt? And she was like, Oh, I’ve had this history of this blood clot in my leg. So what do you think of that? I did.
I’m asking you guys, do you tell me what you think, what do you think that I did? And I’ve recorded this position.
anybody else? So basically what I did was I just want to know. So yeah, so I documented a comment. I assessed, I did too. I totally did do that. I didn’t need to report to the position cause if it’s a shiny new, but what I did was I said I kept trying to lay and that’s where I took the opportunity to educate mind my patient. I was like, hey look, you work on your way. If I start massaging, like I could dislodge that clot and he can travel all the way up into your lungs and give you something called o pulmonary embolism and then everybody has a bad day. I’m like, I know it’s uncomfortable. Let’s try to get you some, maybe that’s when I checked her mar to see if she had any other payment medications. I um, you know, we talked about mobilizing, we talked about a couple of different things.
So it was like, let me try to figure out what other ways that I can deal with this. Because my first option should not be to just go ahead and do what she’s asking also because have you pushed it? Loader’s going to be really difficult for me to spend time in their massaging or leg. Um, but at the same time it was, this is what the patient is asking me to do. I want to make sure that I, uh, that I’m not going to cause harm to the patient. So we’re gonna I’m going to jump over to something in collects related real quick. Cause I know you guys always have questions about and cliques, but I’m going to keep it really brief. So inside the influx, uh, there are several different, um, there are several different what we call cat or what are called categories and what they are, are there eight of them inside it? Uh,
you’re given different tasks, right? So you’re, it’ll say, okay, well, hey, you know, when we talk about a pharmacologic pain, um, you’re going to see this in about 15%. So pharmacologic pain, um, in oral therapies is what it’s called as the category. You’re going to see about 15% of your questions, competence. And then there’s non-pharmacologic pain management.
well make sure, okay, here we go. Non-Pharmacologic pain management is actually in a category called basic care and comfort and basic caring comfort is about, let me see, I just want to make sure I pull this number for you real quick. We’ll always have those basic care and comfort is about nine. So anytime you see non-pharmacologic pain management, this is in the basic care and comfort.
That’s that category. And about let’s say roughly 10%, one of every 10 questions that you’ll get may be related to non-pharmacologic pain management. So that’s just a little tip for you guys when it comes to the end. Clark’s, so let’s move on to the next one. So let’s talk about narcotics for a second. And Chronic Susan in narcotics that you’re going to see, you guys see things like morphine and fentanyl and oxy and I had to code, um, coding, uh, tramadol maturity, um, hydromorphone. Hydromorphone is also known as the Loddon. You’re gonna see all of these. But the thing I want you to, if you guys have not seen the sock method on learning medications, I know that in the past sessions you can go watch those and we break down the segment a little bit more. There’s a lesson on it. So basically when we look at narcotics, we also want to think about the sock method, right? So who can tell me what s stands for? We’re going to do something real quick on this. Anybody. SOC stands for side effects. So when we’re talking about narcotics as is side effects. Okay, who can tell me what one of the main side effects that we’re looking at with a narcotic is like, what’s the big one that we always look for with a narcotic when we’re given pain, pain medication.
So with um, with narcotics and the side effects, the main one we’re gonna look for is that respiratory. Oops,
The main one I’m looking for is respiratory depression. That’s a main one we’re looking for. And we, we’re talking about o o stands for Oregon’s, we’re looking for a, that is going to do a couple of things. So this is a pain medication. We really work on that neurosystem but because we actually get this respiratory depression, we’re also working on the respiratory system. This is how we use assigned method c a, the class, these are all narcotics. So c stands for class and then k is known and must know. So you’re not gonna see any unit you’re on. You’re never going to see all of these medications. You may see a couple of them. I tell you the ones that I saw, I saw morphine, I saw fennel, I fit under this. I give oxycodone. Hydrocodone rarely gave coding, rarely gave terminal, never gave the parody.
But you have a ton of the allotted. So I seen several of these. So let’s keep going. All right, muscle relaxes. These are other types of men. These are nonnarcotic drugs, but these are muscle relaxer, so she can’t spell today. So cyclobenzaprine with the carbon wall. So this one is also known as flex or row. I can remember how to spell it. Uh, methocarbamol is a robaxin and metaxalone is skull oxen. These are all drugs that you’re going to potentially see on a unit. So apply the SOC method to those the same way. So nerve pain, medications we talked about, these are different than nerve blocks. These are not nerve blocks. These are actually nerve pain medication. So Gabapentin also known as Neurontin. You’re going to see a ton of this. I think that’s how you spell it for Gavlin Topamax, a cover map. Carbamazepine, these are all judging in a see.
So what you’re gonna see is if you use these like for patients that maybe have a diabetic neuropathy. So I’ll have that burning sensation you’ll have, you’ll see also in multiple sclerosis patients, cause it’s like a burning sensation that just goes down. So that’s why you use these. So if you have a patient that has made me like, let’s say they have a trauma to their, to their arm, right? So I know that I’ve, we’ve, the nerves have been pissed off from the injury. They’re gonna need some overall pain medication. They may or may not need a muscle relaxer, but a nerve pain medication real will really help them here. So things go. These are the three types that you’re most likely going to see your verbal. So this should actually be, well, let me take this back. Okay. Mild pain is one to three. What are you going to see in the Mar? Typically in your medication administration record, you’re going to see something that says, give the Loddon a 0.2 milligrams ivy. Um, if pain is like eight to 10, and then you’ll have another one that will say, uh, like hydrocodone of like five, three 25, and that’ll be a one tab by mouth. Um, if pain is, let’s say pain is, uh, four, seven, and then the last one will say something like, uh, Ibuprofen
she usually 200 or, sorry, 200 milligrams, two tabs by mouth if pain is one of three. Cool, right? So this is where tomorrow looks like, because I’ve already read that.
So in the Mar, if I, if I ask my patient, okay, from a scale and what you want to do is you want to say, hey, if my patient’s pain is um, my patient’s pain scale, uh, you know, hey Mr. Johnson, I know you’re, you’ve been a little uncomfortable today. Zero is no pain, 10 is like the worst pain of your life. The thing I usually say is 10 as I ripped your arm off and beat you with it. And I usually get a chuckle. But what happens is, is they’ll give you a pain scale. So okay, my pain is about a six. Cool. That I know that I could come over here to the mar and look and see what that pain scale says. The pain scale says four to seven. I’m going to give him hydrocodone and then it’ll say like, the other thing you don’t have is like frequency.
So that’s the other thing you need to keep track of. Now your nonverbal patients are gonna be the patients and be on a ventilator and you’ll use things like agitation, grimace, vital signs, that is your nonverbal. And then you have things like the baker wall. These are going to be your patients, your like your pediatric patients, um, which is basically the face of skin. They don’t use it as often and they’re trying to incorporate a verbal pain scale a lot earlier. However, there are some kids that just don’t get that. So just in this, the idea behind, we’re gonna use multiple types of pain management to control our patients pain. So example, if you have a trauma, let’s say you have, um, let’s say you have, um, an injury to an arm.
Well you know what’s going to be mad, right? So you’ve got muscles that are involved, you’ve got pain receptors that are involved and you could, um, have some nerve pain, right? Plus or minus. So what I’m going to do first is I’m going to, I’m going to focus in on this pain, right? I’m going to say, Hey, I know I need some sort of pain management. Now I can consider something like, um, a muscle relaxant. And then I want to talk to my provider. If they’re still complaining, I’m their pain. Hey are complaining of some sort of other pain. I could say, hey, maybe consider adding Gabapentin and they’ll throw in like a Gabapentin, a hundred milligrams every eight hours, like a low dose just to try and give them just enough. Cause what you want to do is you would get those patients off as pain medications as soon as possible because those are the things that are increased your link mistake or your patients.
But let’s see, PCA protips about a PCA. P P stands for patient controlled analgesia. So patient controlled LGS. So the nerve block, like an epidural actually looks like this. You’ve got the button, you’ve got this. It’ll usually say something like blue pivot canes. Sometimes they have morphine in them and then you’d have to log them. Uh, but the big thing is is you have a dose, which is how much is delivered in each push. So every time a patient hits the button, they’re going to get x amount of medication. Then you have a lockout lockout. It says how long before they receive their next dose. And so use something like 0.2. Let’s say this patient’s getting 0.2 milligrams of dilaudid. Um, their lockout is 10 minutes and there are four hour limit is the Max dose that can get in four hours to 10 and then 10 milligrams, right?
So you’ll see this thing, it’s like, so though you asked for what’s a PCA and control that, and they’ll say like 0.2 and 10 and 10. What that means is they’re going to, every time they push the button, they’re going to get 0.2 milligrams. They can only get it every 10 minutes. And the maximum amount that they can get in four hours is 10. Cause sometimes you’ll get things like a nurse Bolus, um, like they’ll come in and you can actually override it and you can give them extra dose. So let’s do an example here real quick. So forgetting logging one milligram. So you get something called a loading dose. So you’ll hook it up to the patient and you’ll give him one milligram and then you’ll get, okay, cool. My demand is 0.2 milligrams. And every time they get, um, every time they get it, the most they can get, um, is 0.2, every 10 minutes.
And the most are going to get in that four hour limit is six milligrams. So you’ll see them like that. So you got to pay attention, order, pay attention in concentration. And then so morphine’s a little bit different. So you can get, like here you can get a loading dose of four milligrams because in terms of pain management, the that is, um, is more concentrated and more potent than morphine. So you have to require a larger dose of morphine so they can get four milligrams of morphine at the loading dose every time they push the button, which is what this is, they’re going to get one milligram. They can, it’s got a lockout. They can only get every 30 minutes. Um, and then the two hour limit is 20 milligrams. So they look very different. So you have to pay attention to what the mar says in terms of what drug you’re getting and how it’s set up. So that’s pain management kind of in a nutshell. I want you guys, I’ve got just a few minutes. Um, and then if you can just, uh, if you guys have questions, I’ll be happy to answer them for you. Let me take the screen share off real quick.
Whoops. All right. Do you guys have any questions about payments? Right? And kind of what that looks like for your patients. Anything I’ve gone over today that, that you really need to, um, that you may have questions on.
All right guys, well, if you don’t have any questions, I’m going to check out for today. And then what we’ll wait, amber says, I think an intro of you from for this time. So yeah, so use the sock that, that, well, like I said, we have the SOC. Um, we have the SOC, uh, here’s on minute, call it the video along the manner, which is like the pasturing sessions where I’ve gone over the summer class and there’s several of them in here. There’s also the SAR method in, um, and all the lessons that we kind of break every one of those down so people can learn to farm that way. And just remember, you want to think about your side effects. You were thinking about organs are involved, you remember, um, what class of medications are in, um, which tells you like how they work, what they do pharmacologically and what they do therapeutically.
And then also think about, do I really need to know what the dose is from a parenting if I never give it on the unit? So that’s what, that’s what that case stands for. So, amber, I encourage you to take some time to review kind of the sock method and then take that method and then apply it as you’re learning these different types of drugs and then spend some time for oncology. Everybody struggles with it. Just take some time. Learning the drugs, learning the ones that you’re going to be most common. So as you switch from like one course to another course, Hey, I’m gonna do this one thing and then gonna do this. So the thing in ob, I need to know about, um, music postal, a pitocin butylene that’s where I need to know about that. Those drugs. Yeah. Oh, uh, let’s see.
Miriam is going to be doing an ob farm lesson tomorrow. I think. Just go in. If you please go watch it. She does a great job. She breaks all these down. The ones you’re most likely going to see, oh, it’s on Saturday. Well, hey, you can always go back. They’re always on demand, so you can go back and review them. We’ll push them live. So, all right guys, I’m going to get out of here for today. Thank you for joining me. It’s always been, it’s always a pleasure. So I go out and your best selves today and as always, happy nursing.