virtual scenario pain assessment ati quizletsection 962 election statement template
a Place the probe in the mild to severe and can have a slow or sudden onset. creates helps reduce pain perception. This is the patients systolic blood pressure. For repeated measurements or comparison of measurements over time, be sure to use the same site each time. reliable indicators of body temperature. l. CAM therapy: herbal remedies, therapeutic touch, Help students master more than 180 essential nursing skills from the convenience of an online skills lab. failure, septic shock, or diabetic ketoacidosis. That heat is then converted to a digital reading. Purpose of the tool: The Postpartum Hemorrhage In Situ Simulation tool provides a sample scenario for labor and delivery (L&D) staff to practice teamwork, communication, and technical skills in the unit where they work.Upon completion of a Postpartum Hemorrhage In Situ Simulation, participants should be able to do the following: Demonstrate effective communication with the patient and support . Several different types of thermometers are available for measuring temperature. and anxiety. Count the apical pulse rate while the patient is at rest. When the silver-colored metal sodium reacts with water,it forms a solution of sodium hydroxide and a molecular gas bubbles out of the solution. temperature, time of day, body site, and medications can all influence body temperature. of the spinal canal to create a regional nerve block To determine precise tidal volume, you would need a With the arm at heart level and the palm turned up, palpate for the brachial pulse. breathing followed by apnea. EMERGENCY PEDIATRICS GERONTOLOGY MEDICAL - SURGICAL MATERNAL & CHILD FACULTY RESOURCES LIBRARY MENTAL HEALTH. What one The temporal artery is an excellent location for measuring temperature as it is suitable for all ages and Most tympanic devices produce an easy-to-read digital display quickly. b duty as nurses is to assess and treat the pain that the How often you measure blood pressure varies from patient to patient. Bradypnea: an abnormally slow respiratory rate, usually fever than 12 breaths per minute in an Pulse deficits are often associated with irregular cardiac rhythms and can be a sign of alterations in cardiac output. d. Thermal Therapies: The benefit of applying cold is that it Known as: Tim A Lee, Timothy A Leeper, Timothy L Ee. receptors of organs in the thoracic, pelvic, abdominal b Compare the two rates; the difference between the two is the pulse deficit, which reflects the number of ineffective cardiac contractions in 1 minute. Somatic Pain: (musculoskeletal pain Provide privacy and explain the procedure to the patient. Latest. We will do it Jul 6, 2021 ati virtual challenge timothy lee . Changes in this volume can affect blood pressure, as can age, ethnicity, gender, position changes, exercise, weight, anxiety, medications, time of day, and smoking. It helps t. Wong Baker FACES Scale; pain assessment tool that Learn how to register for the ATI TEAS and get the best score possible on your exam by using prep materials from ATI, the creator of the exam. compelling the person to use a substance, despite knowing The rhythm of a patients respirations is usually regular, but certain conditions and illnesses can on command. is best to count for at least 1 minute to obtain the rate. With improved pain control, your patient can get up sooner and breathe deeper, thus preventing a variety of . allows the patient to select a point on the number line between the two extremities: no pain - severe pain. h Pain: physical distress or discomfort that persists secretion and motility, increased blood sugar, Determining pain is an important component of a physical assessment, and pain is sometimes referred to as the "fifth vital sign.". patients who have heart failure or increased intracranial pressure. Place the diaphragm of your stethoscope over the PMI and auscultate for normal S and S heart sounds. Learn vocabulary, terms, and more with flashcards, games, and other study tools. sure it is clean. Pulse pressure: the difference between the systolic and the diastolic BPs, Radial pulse: beating or throbbing felt over the radial artery, usually palpated over the groove In other cultures, pain is part of ritualistic An electronic thermometer consists of a rechargeable, battery-powered display unit, a thin wire cord, and two temperature probes. Ethnicity Matters in the Assessment and Treatment of Children's Pain PEDIATRICS Vol. abnormalities. Apnea is the absence of breathing and is often temperature on the display. comparison of measurements over time, be sure to use the same site each time. You might observe this pattern in patients who have heart failure or increased intracranial pressure. A normal blood pressure for a healthy adult ranges from 90 to 119 mm Hg systolic and from 60 to 79 mm Hg diastolic. If blood volume decreases, the pulse is often weak and difficult to palpate. If the patient has been active, wait at least 5 to 10 hemoglobin level can all increase respiratory rate. The point at which you no longer feel the pulse is Pain Management- Include the pre and posttests. The patient activates the Remove the protective cap and wipe the lens of the scanning device with an alcohol swab to make IX. Two areas on the leg where you can measure blood pressure are the thigh just above the knee, using the popliteal pulse, and the calf just above the ankle, using the posterior tibial pulse. Baby toy or any exchange. This new feature enables different reading modes for our document viewer. : an American History, Quick Books Online Certification Exam Answers Questions, Essentials of Psychiatric Mental Health Nursing 8e Morgan, Townsend, Leadership class , week 3 executive summary, I am doing my essay on the Ted Talk titaled How One Photo Captured a Humanitie Crisis https, School-Plan - School Plan of San Juan Integrated School, SEC-502-RS-Dispositions Self-Assessment Survey T3 (1), Techniques DE Separation ET Analyse EN Biochimi 1, Nurs & Healthcare I: Foundations [Lec] (NURS356). (Remember to use a pain scale to Assessment of other peripheral sites, such as the carotid or femoral pulses, is not usually part of routine vital-sign measurement. For more information about pain management, both pharmacological and non-pharmacological, see the pain-management skills module. nondominant hand to palpate the brachial pulse. During a normal cardiac cycle, blood pressure reaches a high point and a low point. Factors that influence an axillary temperature are the time of day the temperature is measured and the patient's level of activity prior to temperature measurement. addicted. Pain management Personal hygiene Specimen collection Surgical asepsis Urinary elimination Vital signs Wound care Preparing students and building confidence for lab and clinicals with practice in topics such as: Skills Modules covers Virtual Scenarios CLINICAL PREP + Pain assessment + HIPAA + Vital signs + Nutrition + Blood transfusion Baby toy or any exchange. Components may include: Chief complaint Present health status Past health history Current lifestyle Psychosocial status Ati Study Quizlet Pediatric Case Asthma Video [EUWJA4] Mendeley Data Repository is free-to-use and open access. Burn Pain: most severe type of pain, burns that use of the substance is likely to have negative Slowly release the valve on the bulb and allow the manometer needle to drop at a rate of 2 to 3 mm Hg per second. Continue to deflate the blood-pressure cuff slowly, noting the number at which the sound disappears. This condition may iii. j. Epidural anesthesia : medication injected through a chelation, reflexology, magnetic therapy, homeopathy, and For patients whose cognitive abilities are impaired or for those who cannot respond verbally, it is essential to assess nonverbal cues such as facial expressions, behavior, vocal sounds (moaning), and unusual movements. patient's axilla. Develop clinical decision-making skills, competence, and confidence in nursing students through vSim for Nursing | Pharmacology, co-developed by Laerdal Medical and Wolters Kluwer. afraid of taking opioids because they dont want to become left midclavicular line and the PMI. . space. Virtual-ATI A master's prepared Nurse Educator will serve as your personal tutor to guide you through online NCLEX preparation. It involves Nurses can support patients recovering from surgery and identify complications. dishonor to the individual and to the family, thus a person . increase the systolic blood pressure. Focused Gastrointestinal Assessment. iv. A pulse rate slower than 60 beats per minute is called bradycardia. a = SUBJECTIVE , unpleasant sensation that exists when Patient movement, hypothermia, medications that cause vasoconstriction, peripheral edema, hypotension, and an abnormal hemoglobin level can also affect pulse-oximetry readings. Virtual-ATI. Many patients experiencing acute pain are Purpose of the tool: The Preeclampsia/Seizure In Situ Simulation tool provides a sample scenario for labor and delivery (L&D) staff to practice teamwork, communication, and technical skills in the unit where they work.Upon completion of the Preeclampsia/Seizure In Situ Simulation, participants will be able to do the following:. For a student, they require practice, time and remediation. Because each patient experiences pain differently, it is important to manage it on an individual basis. Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Give Me Liberty! Others have 5, with multiple answers being correct. tissues that are adjacent to the source worst pain Distraction Be careful not to apply too much pressure, as this can impair blood flow. The Concept of Pain Virtual-ATI A master's prepared Nurse Educator will serve as your personal tutor to guide you through online NCLEX preparation. pumping or contracting; the maximum pressure exerted against the arterial walls If the apical pulse is regular, count for 30 seconds, then multiply that number by 2. Dry the axilla, if needed. Radiating Pain: pain perceived at the source and in e. Massage inflammatory response makes the pain intense. Position the patient either in a supine or a sitting position and expose the patient's sternum and the ATI Skills Modules 3.0 Virtual Scenario: Vital Signs Lesson Plan Virtual Clinical Materials Computer Internet connection Reference books Expert chart - Alfred Cascio Active Learning Templates Skills Module 3.0 Learning Modules: Vital Signs Skills Module 3.0 Virtual Scenarios: Vital Signs Objectives After completion of the Virtual Scenario, the student will be able to: Implement phases of the . NA PULMONARY (i. Some arterial-scan thermometers recommend sliding the device from the forehead to just below the ear lobe. Move your fingers down the left side of the sternum to the fifth intercostal space and laterally to the left midclavicular line and the PMI. Designed to simulate real nursing scenarios, vSim allows students to interact with patients in a safe, realistic environment, available anytime . The scan across the forehead is gentle, comfortable, and acceptable. indicate a lack of peripheral perfusion for some of the heart contractions. The client should hold the cane on the stronger side of the body: in this scenario. To provide the most effective pain relief when using pharmacological agents, the medication should be prescribed and administered on a regular schedule rather than on an as-needed basis. cavities and felt as a generalized aching or cramping Electronic probe thermometers can also be used for Nonpharmacologic Approaches Confirm name and date of birth. The temporal artery is an excellent location for measuring temperature as it is suitable for all ages and poses no risk of injury for the patient or for the clinician. Likes: 572. what makes it better or worse? Is it normal, weak or thready, full or bounding, or absent? (5) On Dec 5, 2018, while accessing my checking account I noticed there was a direct deposit made into my account labeled - OPM1 TREAS 310 XXCIV. Neuropathic Pain: pain that arises from abnormal despite therapeutic doses of analgesics number at which the pulse reappears. endorphins) become too depleted to be effective. Virtual Scenario: Pain assessment Virtual Scenario: HIPAA discouraged, depressed, and withdrawn. If you use one that does not have this feature, convert degrees F to degrees C by subtracting 32 and then multiplying by 5/9; convert degrees C to degrees F by multiplying by 9/5 and then adding 32. one measurement scale to the other. You might observe this pattern in disappears. Inspiration is an active process that involves the diaphragm moving down, the external intercostal muscles contracting, and the chest cavity expanding to allow air to move into the lungs. Remind the patient not to bite down on the temperature probe. i. Efficacy : ability of drug to achieve its desired effect Cross), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), The Methodology of the Social Sciences (Max Weber), Biological Science (Freeman Scott; Quillin Kim; Allison Lizabeth). Inspect:-hair-teeth and mouth-gag reflex . Factors that Influence Pain amounts of same drug do not increase the analgesic effect Palpate a patient's pulse to determine circulation distal to the pulse site and for rhythm, quality, and causes vasoconstriction and reduces swelling. If you use a patients finger, make sure nail polish and artificial nails are removed because they can interfere with obtaining an accurate reading. Among the trends in nursing education, providing more experiential learning . It is usually slightly faster in women and more rapid in infants and children. DismissTry Ask an Expert Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions . Pain assessment. Pulse strength is usually described as absent, weak, diminished, strong, or bounding. Recognize the technique for performing pupillary light reflex assessment. above the patients estimated systolic pressure. the lower level of pressure (usually occurring in patients who have hypertension) VIII. The cone-shaped tip of the tympanic thermometer uses infrared technology to measure body temperature Numerical Rating Scale 0= no pain 1-3= mild pain 4-6= moderate pain 7-10= severe pain a visual analog scale allows the patient to select a point on the number line between the two extremities: no pain - severe pain Wong-Baker FACES scale that includes images of facial expressions. An interactive, personalized simulation experience for every student. Age, exercise, hormones, stress, environmental perceptions. Many thermometers can convert a temperature reading from one measurement scale to the other. Antipyretic: a substance or procedure that reduces fever k pain: pain usually a burning or tingling and i. on a pain scale, reported sore and stated that it does not hurt unless . Auscultatory gap: temporary disappearance of sounds usually heard over the brachial artery, "My pain feels like I'm being stabbed by a knife." Students also viewed Acid-Controlling Drugs 15 terms Gemini03297 Sleep and Rest 16 terms Recent flashcard sets Family sentences A normal adult pulse rate ranges from 60 to 100 beats per minute. . Place the bell or the diaphragm of your stethoscope over the pulse. Hand hygein. Then slowly deflate the cuff at a rate of 2 to 3 mm Hg per second. VITAL SIGNS ATI MODULE NOTES Vocabulary Words: Antipyretic: a substance or procedure that reduces fever Apnea: temporary or transient cessation of breathing Auscultatory gap: temporary disappearance of sounds usually heard over the brachial artery, occurring when the cuff pressure is high and gradually reduced, with the sounds again heard at the lower level of pressure (usually occurring in . Pain assessment is an ongoing process rather than a single event (see Figure 2.1). Start studying ATI: Virtual scenario Nutrition. pressure exerted against the arterial walls at all times Each Cheyne-Stokes respirations are breathing cycles that increase in rate and depth An increasing number of nursing schools are offering nursing simulation scenarios to students to better train tomorrow's nurses, today, and as a direct response to the increased scrutiny of nurses and other health care professionals to provide safe, effective care. (5) On Dec 5, 2018, while accessing my checking account I noticed there was a direct deposit made into my account labeled - OPM1 TREAS 310 XXCIV. Ethnicity Matters in the Assessment and Treatment of Children's Pain PEDIATRICS Vol. patient's inner wrist. Biots respirations involve a period of slow and deep or rapid and shallow breathing followed by apnea. Apply light pressure with the pads of the fingers in the groove along the radial or thumb side of the patient's inner wrist. resulting from direct stimulation of nerve tissue of the VI. One person assesses the peripheral pulse rate while the other person assesses the apical pulse rate. A patient's report is clearly the best indicator of pain. Sensorium Normal acuityAcute Pain True med surg final exam quizlet med surg ati test questions ati med surg test answers med surg ati quizlet. intermittent but persists 3 months or more, but Inflate the blood-pressure cuff with your dominant hand while you use the fingertips of your nondominant hand to palpate the brachial pulse. To check the radial pulse with the patient supine, position the patient's arm along the side of the Cross), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Civilization and its Discontents (Sigmund Freud), Educational Research: Competencies for Analysis and Applications (Gay L. R.; Mills Geoffrey E.; Airasian Peter W.), Brunner and Suddarth's Textbook of Medical-Surgical Nursing (Janice L. Hinkle; Kerry H. Cheever), Campbell Biology (Jane B. Reece; Lisa A. Urry; Michael L. Cain; Steven A. Wasserman; Peter V. Minorsky), Forecasting, Time Series, and Regression (Richard T. O'Connell; Anne B. Koehler), Give Me Liberty! are affected as well; examples are reduced gastric practices, thus individuals are taught that being stoic and g pain : flaring of moderate to severe pain Heat causes uses a computerized pump with a button the patient can Eupnea: normal respiration -mouth pain-weak hand grip-fatigue when eating. The width of the cuff should be 40% of the circumference of the midpoint of the limb on which you position the cuff, and the length of the bladder should be twice its width. You can score a Level 2 or 3! How well do they The cell Anatomy and division. Patient denies difficulty hearing. Gently push the disposable plastic cover over the tip of the electronic thermometer until the cover locks into place. Wrap the cuff evenly and snugly around the patients upper arm. Under normal circumstances, blood volume remains constant at 5,000 mL. X. Pharmacologic Pain Management The FACES pain scale or the OUCHER pain scale is commonly used with pediatric patients. We have done our best to simplify pharmacology by creating a thorough, easy-to-use and understand . Assuming that the resistivity and density of the material are unaffected by the stretching, find the ratio of the new length to. If the pulse is irregular, count for 1 full minute. left side of the chest. Wrap the cuff evenly and snugly around the leg about 1 inch, or 2.5 centimeters, above the popliteal artery, with the bladder over the posterior aspect of the mid-thigh. Slide your fingers down each side of the angle of Louis to the second intercostal space. k severe is the pain? Module Report Simulation: Skills Modules 3.0 Module: Virtual Scenario: Pain assessment Individual Name: Alena Yukich Institution: Hibbing CC Program Type: ADN Simulation Scenario In this virtual simulation, you cared for Amy Jenkins who was admitted to an acute care facility to receive treatment for left flank pain. The low point is referred to as diastole and occurs when the ventricles relax and minimal pressure is exerted against the vessel wall. Agency policy usually specifies whether to document a temperature reading in degrees i. Transduction:Sensory neurons detect tissue Pain Assessment Perform hand hygiene before and after patient care and document your findings on the appropriate flow ii. emotional consequences Questions: 10 | Attempts: 1029 | Last updated: Mar 21, 2022. Exercise, anxiety, fever, and a low hemoglobin level can all increase respiratory rate. For repeated measurements or reacts to pain and how much pain that person is willing to Inflate the cuff until the gauge reads at about 180 mmHg. over drug use, compulsive use, continued use despite harm Continue to deflate the blood-pressure cuff slowly, noting the number at which the sound disappears. l. How does the pain affect your life? The pulse oximeter works by reading the light reflected from hemoglobin molecules. Determining an apical pulse involves locating the point of maximal impulse (PMI), placing the bell or experience and individuals are taught to keep pain to Ati virtual challenge timothy lee quizlet. Core temperature: the amount of heat in the deep tissues and structures of the body, such as To calculate the pulse deficit, subtract the radial pulse rate from the apical pulse rate. Discard the disposable cover and document the results. Question: Part 2: Pain Management Complete the following ATI Skills Modules 3.0. work? s. Visual analog scale: pain rating scale using a straight 3 On the other hand, when debriefing is conducted poorly, the result is often poor clinical judgment. A numeric rating scale is the most common pain assessment tool used for teens and adults. where they previously had a limb that has been Perform hand hygiene before and after patient care and document your findings on the appropriate flow sheet or record. It generally resolves with healing. over a long period time an doesnt always have a cause The sphygmomanometer consists of a pressure manometer, a cloth or vinyl cuff that covers an inflatable rubber bladder, and a pressure bulb. virtual scenario pain assessment ati quizlet Posted 2022610by Our simulations are designed for your program goals and course objectives - select your program level below to learn more. the painful stimuli. Swift River Med Surg. The depth of a patients breathing, also called tidal volume, is the amount of air that moves in Objective data is also assessed. Oximetry: determination of the oxygen saturation of arterial pressuring using a photoelectric p Pain: well-localized pain that results from Provide privacy, explain the procedure, and perform hand hygiene. If the pulse is irregular, count for 1 full minute. Korotkoff sounds: a series of 5 sounds (4 sounds followed by an absence of sounds) heard roxanna_s__galluccio. the artery because of the proximally placed pneumatic cuff The goal was to perform a pain assessment and intervene based on the client . During a pain assessment, a nurse asks questions about the quality of an adult client's pain. ATI pain assessment - Ati virtual assignment - Identify relevant subjective and objective assessment - Studocu On Studocu you find all the lecture notes, summaries and study guides you need to pass your exams with better grades. - Cuff Width = 20% greater than the diameter of the limb at its midpoint or 40% numbing sensation felt in the extremities and associated The two stages are then separated by a small explosive charge placed between them. also affects how individual patients perceive pain and its Start with an evaluation and a personalized study plan will be developed just for you. asks patients to select one of several faces indicating 222 terms. body or across the upper abdomen with the patient's wrist relaxed. Most tympanic devices produce an easy-to-read digital display quickly. Which of the following actions should the nurse take? learn more Live NCLEX Review Our in-person, nurse educator-led NCLEX Review will guarantee you pass the NCLEX. Vital signs generally stabilize during the early pathways that modulate the transmission of pain Tool selection is based on the patients age and cognitive abilities. Diastolic pressure: the force exerted when the heart is at rest between each beat; the lowest S2: the second heart sound, heard when the semilunar (aortic and pulmonic) valves close rises and falls. h. Guided Imagery i. Hypnosis Identify relevant subjective and objective assessment findings. dressing changes Interactive scenarios challenge students to apply the skills they've learned as they care for authentic virtual clients in both hospital and clinic-based settings. Pulse pressure: the difference between the systolic and the diastolic BPs, Radial pulse: beating or throbbing felt over the radial artery, usually palpated over the groove along the thumb side of the inner wrist, S1: the first heart sound, heard when the atrioventricular (mitral and tricuspid) valves close S2: the second heart sound, heard when the semilunar (aortic and pulmonic) valves close, Sims position: a side-lying position with the lowermost arm behind the body and the uppermost leg flexed, Stroke Volume: the amount of blood entering the aorta with each ventricular contraction Systolic pressure: the amount of force exerted within the arteries while the heart is actively pumping or contracting; the maximum pressure exerted against the arterial walls, Tachycardia: an abnormally fast pulse, usually above 100 beats per minute in an adult, Tachypnea: an abnormally fast respiratory rate, usually more than 20 breaths per minute in an adult, Tympanic: pertaining to the ear canal or eardrum (tympanic membrane), Vital signs: measurements of physiological functioning, specifically temperature, pulse, respirations, and blood pressure, but may also include pain and pulse oximetry. Provide privacy, explain the procedure, and perform hand hygiene. 12 Test Bank PhysioEx Exercise 9 Activity 3 Final Exam Study Guide PhysioEx Exercise 8 Activity 3 BANA 2082 - Chapter 2.1 Nociceptors What helps to ease the pain? Introduce yourself. When the apical pulse is irregular, it worse? A two-stage rocket moves in space at a constant velocity of 4900 m/s. Copyright 2023 StudeerSnel B.V., Keizersgracht 424, 1016 GC Amsterdam, KVK: 56829787, BTW: NL852321363B01, Antipyretic: a substance or procedure that reduces fever Apnea: temporary or transient cessation of breathing, Auscultatory gap: temporary disappearance of sounds usually heard over the brachial artery, occurring when the cuff pressure is high and gradually reduced, with the sounds again heard at the lower level of pressure (usually occurring in patients who have hypertension), Bradycardia: an abnormally slow pulse rate, usually fewer than 60 beats per minute in an adult Bradypnea: an abnormally slow respiratory rate, usually fever than 12 breaths per minute in an adult, Cardiac output: the amount of blood pumped into the arteries by the heart during one minute; the product of the heart rate and stroke volume, Celsius: relating to the international thermometric scale on which 0 degrees is the freezing point and 100 degrees is the boiling point; centigrade. A nursing scenario is given and you apply the knowledge from that chapter in that scenario NCLEX Connections at the beginning of each unit - pointing out areas of the detailed test plan that relate to the content in that unit QSEN Competencies. Pulse oximetry is a quick and noninvasive way to measure a patients oxygen saturation. The temperature is is chronic, such as with cancer or arthritis. feet flat on the floor without crossing legs. It can also be a sign that death Applying the knowledge gained from learning modules, students step into the nurse's role to engage virtual clients in authentic dialogue and assess all major body systems of diverse, life-like virtual clients, all while practicing EHR documentation. The second sound is a whooshing sound, the third is a knocking sound, and the fourth is a softer blowing sound that fades. Measurement of body temp. When determining an apical pulse, it is important to use anatomical landmarks for correct placement of d Virtual scenario pain assessment ati quizlet. The goal was to complete a head-to-toe health assessment. After exercise or other physical exertion, respiration tends to deepen. You have demonstrated a thorough understanding of evidence-based practice related to client pain. This number is usually between 30 and 50 mm Hg and provides information about a patients cardiac function and blood volume. i. Idiopathic Pain: chronic pain that persists in the an oral temperature of 98 F (37 C) the norm. iv. learn more. such as opiates, can slow the respiratory rate. Expose the patient's sternum and the left side of the chest. Chronic Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. If you find a pulse deficit, assess the patient for other signs and symptoms of decreased cardiac output, such as dyspnea, fatigue, chest pain, and palpitations. Pulse oximetry is rarely part of a general examination. The difference between the systolic and diastolic values is called the pulse pressure. Assist the patient to a sitting position and move the bed linens, gown, or other clothing to expose the patient's axilla.