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Older Adults 2 > Chapter 15 > Flashcards

Chapter 15 Flashcards

1
Q

occurs suddenly and often without warning

A

acute illness

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2
Q

examples of acute illness

A
  • stroke
  • MI
  • hip fracture
  • infection
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3
Q
  • managed rather than cured
  • always present but not always visible
  • life long and coping can be influenced by perceived uncertainty
A

chronic illness

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4
Q

chronic illness trajectory

A
  • preventive phase (pre trajectory)
  • definitive phase (trajectory onset)
  • crisis phase
  • acute phase
  • stable phase
  • unstable phase
  • downward phase
  • dying phase
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5
Q

designed to stabilize physiological processes and promote recovery from acute phase

A

acute phase of illness management

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6
Q

most common chronic condition in persons over 65

A

arthritis

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7
Q

common chronic cardiovascular diseases

A
  1. htn
  2. coronary heart disease
  3. heart failure
  4. peripheral vascular disease
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8
Q

leading cause of death and 2nd cause of disability in the US

A

cardiovascular disease

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9
Q

most common chronic vascular disease of elderly

A

htn

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10
Q

2nd most common chronic condition in persons over 65

A

htn

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11
Q

diastolic hypertensive blood presure

A

90 and above

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12
Q

systolic hypertensive blood pressure

A

above 140

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13
Q

for persons older than 50, is sbp or dbp more important as a cvd risk factor?

A

sbp

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14
Q

prehypertensive sbp

A

120-139

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15
Q

initial drug treatment for htn

A

thiazide diuretics

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16
Q

concern for pts on antihypertensive meds, especially if the pt falls

A

orthostatic hypotension

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17
Q

ways to minimize risk for heart disease

A
  • maintain bp of 40

- triglycerides <150

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18
Q
  • s/s
  • develop slowly
  • usually asymptomatic until an acute cardiovascular event or end organ damage has been done
A

htn

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19
Q

what to do about htn

A
  • screenings
  • education
  • prevention
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20
Q

group of conditions that either completely or partially obstruct blood flow to the heart muscle

A

coronary heart disease

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21
Q

racial disparity with coronary heart disease

A

african american

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22
Q

s/s of coronary heart disease

A

chest pain

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23
Q

do older adults always have chest pain with coronary heart disease and ischemic attacks

A

no

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24
Q

direct response to ischemic damage

A

chest pain

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25
Q

chest pain with older adults…

A
  • mild
  • localized to back, abd, shoulders, one or both arms
  • n&v, heartburn may be the only symptoms
  • may mimic heartburn
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26
Q

complications of coronary heart disease

A
  • angina

- cardiac remodeling

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27
Q

increase in intensity, frequency or duration with less and less provacation

A

unstable angina

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28
Q
  • heart enlarges and changes shape
  • decrease in pumping ability
  • leads to heart failure within months to years
A

cardiac remodeling

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29
Q

how to diagnose coronary heart disease

A
  • ekg
  • cardiac cath
  • stress test
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30
Q

non-pharm management of coronary heart disease

A

lifestyle changes and reducing risk factors

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31
Q

pharm management of coronary heart disease

A
  • cholesterol modifying drugs
  • asa
  • beta blockers
  • ace inhibitors
  • calcium channel blockers
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32
Q

angioplasty with or without stent placement

A

cardiac cath

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33
Q

what to beware of coronary heart disease

A

anxiety and depression

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34
Q

waht can cause anxiety and depression with coronary heart disease

A
  • changes in functional ability
  • self image
  • fear of another event
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35
Q

inability of the heart to keep up with the workload

A

heart failure

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36
Q

compensation for heart failure

A
  • enlargement of the ventricles

- develop more muscle mass

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37
Q

compensation for heart failure: enlargement of ventricles

A
  • stretches more and contracts more strongly

- only can do this for a short amount of time

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38
Q

heart failure compensation: develop more muscle mass

A
  • initially pumps harder

- eventually decreases size of ventricles

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39
Q

heart failure compensation: blood vessels

A
  • narrow to keep bp up

- diversion of blood away from non-essential body parts

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40
Q

heart failure progression

A
  • increased peripheral resistances
  • failing heart
  • neurohormonal activations
  • peripheral alterations
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41
Q

left sided heart failure

A
  • hypertension
  • aortic stenosis
  • valvulopathy
  • myopathy
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42
Q

right sided heart failure

A
  • ischemia
  • infarction
  • myopathy
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43
Q

s/s of heart failure

A
  • shortness of breath
  • coughing or wheezing
  • edema
  • tiredness/fatigue
  • lack of appetite
  • confusion/impaired thinking
  • tachycardia
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44
Q

blood backing up in the pulmonary veins leads to

A

SOB

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45
Q

fluid build up in lungs leads to

A

coughing or wheezing

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46
Q

fluid build up in the body leads to

A

edema

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47
Q

not pumping enough blood to meet the body’s need leads to

A

tiredness/fatigue

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48
Q

decrease in blood flow to the digestive system leads to

A

lack of appetite

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49
Q

changing levels of electrolytes leads to

A

confusion/impaired thinking

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50
Q

make up for the loss of pumping ability leads to

A

tachycardia

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51
Q

heart failure treatment

A
  • early diagnosis
  • treat underlying cause
  • stop it from getting worse
  • lifestyle changes
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52
Q

lifestyle changes for heart failure

A
  • low sodium diet
  • low fat diet
  • high potassium intake
  • weight loss
  • physical activity
  • quit smoking
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53
Q

unmodified risk factors for CV events

A
  • age
  • gender
  • heredity
  • ethnicity
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54
Q

modifiable risk factors for CV events

A
  • smoking
  • stress
  • obesity/diet
  • physical inactivity
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55
Q

treatable risk factors for CV events

A
  • diabetes mellitus
  • htn
  • hyperlipidemia
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56
Q
  • build endurance, self reliance, and facilitate self care and quality of life
  • begin with light activity and increase in intensity
  • must be done with the supervision of a nurse of physical therapist
A

cardiac rehab

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57
Q

granulomatous inflammation of aorta and its brances and cranial arteries

  • affects people over 50
  • more common in women
A

giant cell (temporal) arteritis

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58
Q

s/s of giant cell (temporal) arteritis

A

-bruits
-fever
headache
-tenderness of scalp
-jaw pain
-tongue pain
-blurred vision/vision loss
-tinnitus
-elevated esr and crp

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59
Q

how to diagnosis giant cell (temporal) arteritis

A
  • biopsy
  • US
  • MRI
  • CT
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60
Q

treatment of giant cell (temporal) arteritis

A

corticosteroids

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61
Q

pain and stiffness in shoulder and pelvic girdle; muscles of neck, shoulders, lower back and thighs

A

polymyalgia rheumatica

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62
Q

when is pain greatest with polymyalgia rheumatica?

A

at night and early morning

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63
Q

ischemic events

A
  • arterial disease

- cardioempolism

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64
Q

build up of plaque in the arteries

A

arterial disease

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65
Q

where is arterial disease usually seen

A

arteries of leg

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66
Q

arterial disease can cause lack of blood flow to the:

A
  • head
  • arms
  • kidneys
  • stomach
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67
Q

arterial disease increases risk for:

A
  • cad
  • mi
  • cva
  • tia
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68
Q

late s/s of hypothyroidism

A
  • goiter

- slow speech and hoarse breaking voice

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69
Q

where is arterial disease usually seen

A

arteries of the leg

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70
Q

treatment for polymyalgia rheumatica

A

steroids

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71
Q

what meds are not effective on polymyalgia rheumatica

A

NSAIDs

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72
Q

pharmacological treatment for arterial disease

A
  • cholesterol lowering meds
  • htn meds
  • dvt prophylaxis
  • symptom relief meds
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73
Q

non-pharmalogical treatment of arterial disease

A
  • angioplasty
  • bypass surgery
  • exercise
  • diet
  • prevention
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74
Q

changes to the leg with cad

A
  • pale
  • absence of leg hair
  • thin skin
  • shiny skin
  • weak-absent pulses
  • cool to touch
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75
Q

where is an embolic cva commonly formed

A

left side of heart

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76
Q

pain with pad

A
  • with exertion

- better with rest

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77
Q

pain with pvd

A
  • with rest

- better with movement

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78
Q

changes to leg with pvd

A
  • deep dark color
  • leg hair
  • thicker skin
  • pulses present
  • warm to touch
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79
Q

how to diagnose cardioembolism

A
  • neuro exam
  • ct/mri
  • symptoms
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80
Q

how to treat cardioembolism

A
  • underlying cause
  • symptom management
  • thrombolysis
  • rehabilitation
  • prevention
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81
Q

symptoms of tia or stroke

A
  • sudden weakness or numbness on one side of the body
  • dimness or loss of vision in one eye
  • slurred speech, loss of speech, difficulty comprehending speech
  • dizziness, difficulty walking, loss of coordination, loss of balance, falls
  • sudden severe headache
  • difficulty swallowing
  • sudden confusion
  • N&V
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82
Q

main difference between cva and tia

A

tia symptoms begin to resolve in minutes and are totally resolved within 24 hours

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83
Q

risk factors for tia or stroke

A
  • heart disease
  • htn
  • arrhythmia
  • hypercholesterolemia
  • diabetes
  • smoking
  • coagulopathies
  • brain tumor
  • family hx
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84
Q

progressive disease of basal ganglia and involves he dopaminergic nigrostriatal pathway

A

Parkinson’s disease

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85
Q

is parkinsons more common in men or women

A

men

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86
Q

onset of parkinsons

A

60 years

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87
Q

possible causes of parkinsons

A
  • genetic
  • viral
  • toxic
88
Q

complication in late stages of parkinsons that can be fatal

A
  • pressure ulcers
  • pneumonia
  • aspiration
  • falls
89
Q

presents the greatest risk for injury with parkinsons

A

falls

90
Q

clinical signs of parkinsons disease

A
  • tremor at rest
  • muscle rigidity
  • akinesia
  • postural abnormalities
  • sleep/wake reversal
  • visual disturbances
  • hypotension
  • depression
  • psychosis
91
Q

parkinson med

A

carbidopa-levodopa

92
Q

surgical procedures of parkinsons

A
  • abalation
  • deep brain stimulation
  • transplantation
93
Q

disorder of glucose metabiolism

A

diabetes mellitus

94
Q

absolute deficiency of insulin production due to autoimmune destruction of pancreatic cells

A

type 1 dm

95
Q

combination of relative insulin deficiency and insulin resistance

A

type 2 dm

96
Q

these influence development of diabetes

A
  • genetics
  • lifestyle
  • aging
97
Q

risk factors for dm

A
  • ethnicity
  • increasing age
  • blood pressure 140/90
  • 1st degree relative with dm
  • hx of impaired glucose tolerance or impaired fasting plasma glucose
  • obesity
  • previous gestational dm
  • undesirable lipid levels
98
Q

undesirable lipid levels

A

HDL- 35

triglycerides-250

99
Q

at risk ethnicities for dm

A
  • african americans
  • mexican americans
  • american indians
  • native hawiians
  • asian americans
100
Q

risk identification for people with diabetes

A
  • diabetes for 10+ years
  • male
  • poor glucose control
  • cv, retinal, or renal complications
  • increased risk for amputation
101
Q

risk factors for amputation with diabetes

A
  • peripheral neuropathy with loss of sensation
  • evidence of increased pressure
  • peripheral vascular disease
  • hx of ulcers
  • hx of amputation
  • severe nail pathology
102
Q

what may make diagnosis of dm in older adults tricky

A

classic s/s may not be present in the older adult

103
Q

how often should hemoglobin a1c be checked

A

quarterly

104
Q

most frequent cause of chronic autoimmune thyroiditis; also radioiodine tx, surgery, meds, pituitary/ hypothalamic abnormality

A

hypothyroidism

105
Q

lab findings for hypothyroidism

A

tsh >6

t3 <4.5

106
Q

med management of hypothyroidism

A

synthroid

107
Q

hypothyroidism emergency

A

myxedema coma

108
Q

patho of hypothyroidism

A
  • hyposecretion of parathyroid
  • hyposecretion of thyroid hormones
  • decreased body metabolism
109
Q
  • thyroid gland

- radioiodine treatment for hyperthyroidism

A

primary hypothyroidism

110
Q

early s/s of myxedema coma

A
  • fatigue
  • apathy
  • mental sluggishness
111
Q

symptoms of tia or stroke

A
  • sudden weakness or numbness on one side of the body
  • dimness or loss of vision in one eye
  • slurred speech, loss of vision in one eye
112
Q

early s/s of hypothyroidism

A
  • cold intolerance
  • constipation
  • wt gain
  • bradycardia
  • fatigue
  • decreased sweating
  • muscle cramps
  • dry itchy skin
  • thin, brittle fingernails
  • rapid thoughts
  • depression
  • poor muscle tone
  • female infertility
  • hyperprolactinemia and galactorrhea
113
Q

late s/s of hypothyroidism

A
  • goiter
  • slow and hoarse voice
  • dry, puffy skin
  • thinning of outer 3rd eyebrows
  • abnormal menstrual cycles
  • low temp
  • infertility in women
  • acute fatigue syndrome
  • stress
  • lowered libido
  • hypotension
  • carpal tunnel
  • thyroid related depression
114
Q
  • main case
  • thyroid gland
  • radioiodine treatment of hyperthyroidism
A

primary hypothyroidism

115
Q
  • pituitary gland
  • not secreting enough tsh
  • tumor, radiation, surgery
  • 5-10% of cases
A

secondary hypothyroidism

116
Q

early s/s of myxedema coma

A
  • fatigue
  • apathy
  • mental sluggishness
117
Q

treatment of myxedema coma

A
  • mechanical ventilation
  • iv high doses of thyroid hormones
  • iv levothyroxine
  • corticosteroids
118
Q

most common form of hyperthyroidism in older adults

A

graves disease

119
Q

other causes of hyperthyroidism

A
  • toxic goiter
  • iodine ingestion
  • contrast agents
  • meds
120
Q

lab findings of hyperthyroidism

A
  • decreased tsh

- elevated t3 and t4

121
Q

what do beta blockers do for hyperthyroid treatment

A

symptom management

122
Q

food and diet changes for hyperthyroidism

A

low iodine

123
Q

surgical management for hyperthyroidism

A

damaging or removing the thyroid

124
Q

radioiodine treatment for hyperthyroidism

A

radioactive iodine damages the thyroid

125
Q
  • medical emergency
  • elevated in body temp (104)
  • tachycardia
  • arrhythmia
  • vomiting
  • diarrhea, dehydration
  • coma and death
A

thyroid storm

126
Q

treatment for thyroid storm

A
  • high doses of methinazole

- need to reduce circulating levels and production of thyroid hormones

127
Q

small herniations or saclike outpouchings of mucosa

A

diverticular disease

128
Q

movement of gastric contents, especially gastric acid, into the esophagus

A

GERD

129
Q

goal of gi disorder therapy

A

prevent exacerbation symptoms

130
Q
  • airway and lung injury caused by inhalation of toxins and pollutants earlier in life, especially by tobacco smoke
  • progressively debilitating condition characterized by exacerbations and remission of symptoms
A

COPD

131
Q
  • increased goblet cell number and activity (increased mucous production)
  • increased mucous=decreased airway diameter
A

chronic bronchitis

132
Q

lung damage and inflammation of the alveoli

A

emphysema

133
Q

destruction of the alveoli walls=

A

decreased surface area

134
Q

s/s of copd

A
  • wheezing
  • cough
  • dyspnea on exertion
  • increased phlegm production
135
Q

how is copd diagnosed

A

pulmonary function tests

136
Q

biggest barrier to copd treatment

A

acceptance and willingness to make lifestyle changes

137
Q

later copd symptoms

A
  • pursed lip breathing
  • barrel chest
  • air tapping
  • hyperresonance
  • fingernail clubbing
  • pale/cyanotic nail beds
  • use of accessory breathing muscles
138
Q

complications of copd

A
  • pneumonia
  • frequent hospitalization
  • impaired functional status
  • home o2 therapy/bronchodilators
  • non invasive respiratory support
  • endotracheal intubation
139
Q

inflammatory airway disease linked to allergenic mechanisms

  • narrowing of airways
  • expiratory wheezing
A

asthma

140
Q

goal of asthma therapy

A
  • reduce triggers

- maintain quality of life

141
Q

what is asthma influenced by?

A
  • genetics
  • environmental
  • lifestyle
142
Q

if a client has asthma, they are at a higher risk for…

A

lower respiratory infections

143
Q
  • med
  • activates beta2 receptors in bronchial smooth muscle (vasodilation)
  • bronchospasm is relieved
  • histamine release inhibited
  • ciliary motility increased
A

albuterol

144
Q

use of albuterol

A
  • prevention of asthma episode
  • treats bronchospasm
  • long term control
145
Q

beta2-adrenergic agonists for asthma

A
  • albuterol
  • formoterol (foradil aerolizer)
  • terbutaline (brethine)
146
Q

beta2 adrenergic agonist-inhaled, long acting

A

formoterol (foradil aerolizer)

147
Q

beta2 adrenergic agonists- oral, long acting

A

terbutaline (brethine)

148
Q

beta2 adverse effect when alpha1 receptors are activated in the heart

A

tachycardia

149
Q

activation of beta2 receptors in muscle causes:

A

tremors

150
Q

beta blockers and beta2=

A

cancelled out

151
Q

meds mixed with beta2 adrenergic that cause an increased risk of tachycardia and cp

A

MAOI’s and triciycline antidepressant

152
Q

methylxanthines

A

theohyline

153
Q

causes relaxation of bronchial smooth muscle, resulting in bronchodilation

A

theohyline

154
Q

normal level of theohyline

A

5-15

155
Q

adverse effects of theohyline

A
  • gi distress
  • restlessness
  • dysrhythmias
  • seizures
156
Q

increases adverse effects of theophyline

A

caffiene

157
Q

decrease levels of theophyline

A

phenobarbital and phenytoin

158
Q

increases levels of theophyline

A

cimitedine and cipro

159
Q

inhaled anticholinergics

A
  • ipratropium (atrovent)

- tiotropium (spiriva)

160
Q

these meds block muscanaric receptors in bronchi

  • bronchodilation
  • relief of bronchospasms, allergen and exercises induced asthma
A

inhaled anticholinergics

161
Q

inhaled anticholinergics are contraindicated with…

A

peanut allergies

162
Q

use inhaled anticholinergics cautiously with..

A

BPH and narrow angle glaucoma

163
Q

glucocorticoids - inhaled

A
  • beclomethasone (qvar)
  • budesonide and formoterol (symbicort)
  • budesonide (pulmicort flexhaler)
  • fluticasone (flovent)
  • monetasone furoate and formoterol fumarate dihydrate (dulera)
164
Q

oral glucorticoid

A

prednisone

165
Q

these meds prevent inflammation, suppress airway mucous production and promote responsiveness of beta2 receptors in the bronchial tree

A

glucocorticoids

166
Q

adverse effects of glucocorticoids

A
  • hoarseness and candidiasis
  • suppression of adrenal gland function
  • bone loss
  • hyperglycemia and glucosria
  • pud
  • infection
  • fluid and electrolyte imbalance
167
Q

med interactions with glucocorticoids

A
  • k+ depleting diuretics
  • nsaids
  • hypoglycemic
168
Q

leukotriene modifiers

A
  • montelukast (singulair)
  • zileuton (zyflo)
  • zafirlukast (accolate)
169
Q

can cause liver injury and can inhibit the metabolism of warfarin ad theophyline

A
  • zileuton (zyflo)

- zafirlukast (accolate)

170
Q
  • prevents effects of leukotriens

- suppresses inflammation, bronchoconstriction, airway edema, mucous production

A

leukotriene modifiers

171
Q

who is more likely to get tb

A

residents and group living and long term care

172
Q

infection may lie dormant and appear when person is immunocompromised

A

tb

173
Q

bacterium that cause tb

A
  • mycobacterium bovis
  • africanum
  • tuberculosis
174
Q

states that cause activation of tb

A
  • age related changes to immune system
  • chemo
  • hiv
  • cancer
  • renal failure
  • diabetes
  • long term steroid treatment
  • poor nutritional status
175
Q
  • infects macrophages in lungs
  • causes inflammation and tissue destruction
  • granulomas form
  • bacteria in granulomas may become dormant
A

tb

176
Q

how to confirm tb

A
  • skin test
  • chest x ray
  • sputum cultures
177
Q

antimycobacterial treatment for tb

A
  • zileuton (zyflo)
  • zafirlukast (accolate)
  • pyrazinamide (pza)
  • ethambutol (myambutol)
  • rifapentine (prifitin)
178
Q

isoniazid only: 6-9 months, or isoniazid with rifapentine once weekly for 3 months

A

latent therapy for tb

179
Q

several antimycobacterial meds must be used to treat a client who is active
-multiple meds

A

active tb treatment

180
Q

adverse effects of tb meds

A
  • peripheral neuropathy
  • hepatotoxicityy
  • hyperglycemia
  • isoniazid
181
Q

tb meds that inhibits metabolism of phenytoin

A

isoniazid

182
Q

most common musculoskeletal disorders

A
  • osteoporosis
  • osteoarthritis
  • rheumatoid arthritis
  • gout
  • polymyalgia rheumatica
183
Q

for women, fastest overall loss of bone mineral density is when?

A

5 years after menopause

184
Q

nonmodifiable risk factors for osteoporosis

A
  • female
  • caucasian
  • Northern European ancestry
  • advanced age
  • family hx
185
Q

modifiable risk factors for osteoporosis

A
  • low body weight
  • low calcium intakee
  • estrogen deficiency
  • low testosterone
  • inadequate exercise or activity
  • use of steroids or anticonvulsants
  • excess coffee or alcohol
  • current cigarette smokingg
186
Q

promotion of bone health begins…

A

teen years

187
Q
  • normal soft and resilient cartilaginous lining in joint becomes thin and damaged
  • joint space narrows and bones of joint rub together, causing joint destruction
A

osteoarthritis

188
Q

most common symptoms of osteoarthritis

A
  • stiffness with activity

- pain with activity relieved by rest

189
Q

non pharmacological therapy for osteoarthritis

A
  • exercise

- physical therapy

190
Q

pharmacological therapy for osteoarthritis

A
  • tylenol

- nsaids

191
Q

other osteoarthritis therapies

A
  • acupuncture

- surgical intervention

192
Q
  • chronic systemic inflammatory joint disorder

- autoimmune disease where inflammation of joint lining destroys surrounding cartilage and eventually bone as well

A

rheumatoid arthritis

193
Q

focus of RA research

A
  • genetic factors
  • environmental triggers
  • hormonal triggerss
194
Q

pharmacological therapy for RA

A
  • pain management
  • dmard’s
  • biological response modifier
195
Q

acute and/or chronic inflammatory disease caused by accumulation of uric acid in blood and synovial fluid

A

gout

196
Q

gout is associated with which diet

A

high purine diet

197
Q

most common gout site

A

great toe joint

198
Q

treatment of gout

A
  • pain management

- low purine diet

199
Q

purine foods

A
  • meat, poultry, fish
  • fat
  • alcohol
  • caffeine
  • high fructose corn syrup
200
Q

BPH at risk population

A
  • african americans

- hispanics with a family hx

201
Q

symptoms of BPH

A
  • frequency
  • urgency
  • nocturia
  • weak stream
  • incomplete emptying
202
Q

symptom management of bph

A
  • avoidance of caffeine
  • meds
  • surgical treatment
203
Q

bph meds

-5-alpha reductase inhibitors

A
  • finasteride (proscar)

- dutasterride (avodart)

204
Q

med that decreases usable testosterone, and causes reduction in prostate size
-also increases hair growth

A

5-alpha reductase inhibitors

205
Q

adverse and contraindications with 5-alpha reductase inhibitors

A
  • pregnancy category x
  • liver disease
  • decreased libido and ejaculate volume
  • gynecomastia
  • orthostatic hypotension
206
Q

alpha 1 adrenergic antagonists

A
  • tamsulosin (flowmax)
  • alfuzosin (uroxatral)
  • terazosin
  • doxazosin (cardura)
207
Q

relaxes smooth muscle of bladder neck and prostate

-also lowers bp

A

alpha 1 adrenergic antagonists

208
Q

adverse effects of alpha 1 adrenergic antagonists

A
  • hypotension
  • failure to ejaculate
  • decreased volume of ejaculate
209
Q

use cautiously in clients with renal impairment

A

silodosin

210
Q

med/food interactions with alpha 1 adrenergic antagonistss

A
  • cimetidine
  • antihypertension, nitroglycerine
  • erythromycin and hiv meds
211
Q

tamulosin timing

A

30 mins after meal

212
Q

silodosin timing

A

with same meal each day

213
Q

alfuzosin timing

A

right after meal

214
Q

doxazosin timing

A

same time each day

215
Q

coping with chronic health problem factors

A
  • gender
  • sexuality
  • fatigue
  • grieving
  • family
  • locating care
  • prevention of iatrogenic complications
216
Q

most common chronic condition in persons over 65

A

HTN

217
Q

this could be a symptom of a chronic illness, a side effect of a med, a symptom of depression, or all of these

A

fatigue

Older Adults 2 (7 decks)

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