Ineffective tissue perfusion is a critical nursing diagnosis that indicates a reduction in oxygenated blood flow to the body’s tissues. This compromised blood supply is detrimental to organ function and overall systemic health. When tissues and organs fail to receive adequate perfusion, they become vulnerable to damage, potentially leading to severe complications and even death.
For nurses, a thorough understanding of ineffective tissue perfusion is paramount. This includes recognizing its diverse causes, conducting comprehensive assessments, implementing vigilant monitoring, and initiating timely interventions. Ineffective tissue perfusion can manifest acutely in emergency situations like heart attacks or traumatic injuries, or develop gradually due to chronic conditions. In chronic cases, nurses play a crucial role in educating patients about modifiable risk factors and lifestyle adjustments to enhance circulation.
Causes of Ineffective Tissue Perfusion
Ineffective tissue perfusion can stem from a variety of underlying conditions and factors. Common causes include:
- Fluid Imbalances: Both hypervolemia (excess fluid volume) and hypovolemia (fluid volume deficit/blood loss) can disrupt optimal blood flow and perfusion.
- Reduced Hemoglobin Levels: Low hemoglobin levels impair the blood’s oxygen-carrying capacity, leading to decreased oxygen delivery to tissues.
- Compromised Blood Flow: Conditions that obstruct or impede blood flow, such as blood clots or arterial blockages, directly reduce tissue perfusion.
- Hypoventilation: Inadequate ventilation leads to reduced oxygen intake and carbon dioxide removal, affecting blood oxygenation and tissue perfusion.
- Trauma: Physical injuries can disrupt blood vessels and blood flow, causing localized or systemic ineffective tissue perfusion.
- Infection: Infections can trigger systemic inflammatory responses, leading to sepsis and shock, both of which severely impair tissue perfusion.
- Shock: Shock, regardless of the cause (cardiogenic, hypovolemic, septic, etc.), is characterized by widespread inadequate tissue perfusion.
- Cardiac Disorders: Conditions like heart failure, arrhythmias, and myocardial infarction directly impact the heart’s ability to pump blood effectively, leading to poor perfusion.
- Respiratory Disorders: Chronic obstructive pulmonary disease (COPD), pneumonia, and other respiratory illnesses can impair oxygenation and contribute to ineffective tissue perfusion.
- Vascular Disorders: Peripheral artery disease (PAD), venous insufficiency, and other vascular conditions directly affect blood flow to specific tissues and organs.
Signs and Symptoms of Ineffective Tissue Perfusion
Recognizing the signs and symptoms of ineffective tissue perfusion is essential for prompt nursing intervention. These signs can be broadly categorized by body system and further classified as subjective (patient-reported) or objective (nurse-assessed) data.
Cardiopulmonary Manifestations
Ineffective cardiopulmonary perfusion affects the heart and lungs, leading to critical symptoms:
Subjective Symptoms:
- Chest Pain (Angina): Discomfort or pain in the chest, often described as pressure, tightness, or squeezing, indicating myocardial ischemia.
- Dyspnea: Shortness of breath or difficulty breathing, reflecting inadequate oxygen supply to the lungs and tissues.
- Sense of Impending Doom: A feeling of overwhelming anxiety or fear of death, often associated with acute cardiopulmonary events.
Objective Signs:
- Arrhythmias: Irregular heart rhythms, indicating electrical instability and compromised cardiac output.
- Capillary Refill >3 Seconds: Prolonged capillary refill time suggests poor peripheral circulation and reduced blood flow.
- Altered Respiratory Rate: Respirations may be abnormally fast (tachypnea) or slow (bradypnea), reflecting respiratory distress or compensation.
- Use of Accessory Muscles to Breathe: Visible use of neck and shoulder muscles during breathing indicates increased work of breathing and respiratory compromise.
- Abnormal Arterial Blood Gases (ABGs): Deviations in ABG values, such as low PaO2 or high PaCO2, indicate impaired gas exchange and perfusion.
- Unstable Blood Pressure: Blood pressure may be abnormally high (hypertension) or low (hypotension), reflecting cardiovascular instability.
- Tachycardia or Bradycardia: Heart rate may be excessively fast or slow, indicating cardiac dysfunction or compensatory mechanisms.
- Cyanosis: Bluish discoloration of the skin and mucous membranes, signifying severe hypoxemia and inadequate oxygen perfusion.
Gastrointestinal Indicators
Ineffective gastrointestinal perfusion affects the digestive system, presenting with:
Subjective Symptoms:
- Nausea: Feeling of sickness and urge to vomit, potentially due to reduced blood flow to the stomach and intestines.
- Abdominal Pain: Discomfort or pain in the abdominal area, which can be diffuse or localized, signaling gastrointestinal ischemia.
- Bloating: Sensation of fullness or distention in the abdomen, possibly related to impaired digestion and motility.
Objective Signs:
- Hypoactive or Absent Bowel Sounds: Reduced or absent bowel sounds indicate decreased peristalsis and gastrointestinal motility due to poor perfusion.
- Distended Abdomen: Swelling or enlargement of the abdomen, potentially caused by fluid accumulation or bowel obstruction related to poor perfusion.
- Vomiting: Expulsion of stomach contents, which can be a sign of gastrointestinal distress and impaired function.
- Electrolyte Imbalance: Abnormal electrolyte levels, such as sodium, potassium, or calcium, can occur due to gastrointestinal dysfunction and fluid shifts.
Renal Signs
Ineffective renal perfusion impacts kidney function, leading to:
- High or Low Blood Pressure: Kidneys play a role in blood pressure regulation; impaired perfusion can lead to fluctuations in blood pressure.
- Decreased Urine Output: Reduced kidney blood flow leads to decreased urine production (oliguria) as the kidneys struggle to filter waste.
- Elevated BUN/Creatinine: Blood urea nitrogen (BUN) and creatinine are waste products normally filtered by the kidneys; elevated levels indicate impaired kidney function.
Cerebral Manifestations
Ineffective cerebral perfusion affects brain function, resulting in neurological symptoms:
Subjective Symptoms:
- Dizziness: Sensation of lightheadedness or unsteadiness, indicating reduced blood flow to the brain.
- Visual Disturbances: Blurred vision, double vision, or other visual changes, suggesting impaired cerebral perfusion.
- Fatigue or Weakness: Generalized tiredness or lack of strength, potentially due to reduced oxygen supply to the brain and body.
Objective Signs:
- Altered Mental Status: Changes in alertness, orientation, cognition, or consciousness, ranging from confusion to coma, indicating significant cerebral hypoperfusion.
- Restlessness: Increased agitation or inability to stay still, potentially due to cerebral hypoxia and discomfort.
- Changes in Speech: Slurred speech, difficulty finding words (aphasia), or other speech impairments, suggesting neurological dysfunction.
- Difficulty Swallowing (Dysphagia): Problems with swallowing, which can be a sign of neurological impairment affecting motor control.
- Motor Weakness: Weakness or paralysis on one side of the body (hemiparesis/hemiplegia), indicating possible stroke or neurological event.
- Changes in Pupillary Reaction: Pupils may be unequal, sluggish, or non-reactive to light, suggesting neurological damage or pressure.
- Syncope: Fainting or loss of consciousness, often due to temporary reduction in cerebral blood flow.
- Seizure: Abnormal electrical activity in the brain, which can be triggered by cerebral hypoperfusion or hypoxia.
Peripheral Manifestations
Ineffective peripheral perfusion affects blood flow to the extremities, presenting with:
Subjective Symptoms:
- Altered Skin Sensations: Numbness, tingling (paresthesia), or abnormal sensations in the extremities.
- Claudication: Pain in the legs, especially calf muscles, that occurs during exercise and is relieved by rest, indicating peripheral artery disease.
- Peripheral Pain: Pain in the extremities, which may be constant or intermittent, related to ischemia or nerve damage.
- Numbness and Tingling: Loss of sensation or pins-and-needles feeling in the fingers or toes, suggesting nerve involvement and poor circulation.
Objective Signs:
- Weak or Absent Peripheral Pulses: Diminished or absent pulses in the extremities (e.g., pedal, popliteal, radial), indicating reduced arterial blood flow.
- Cool Skin Temperature: Extremities may feel cold to the touch due to decreased blood flow and heat dissipation.
- Thickened Nails: Nail changes, such as thickening or ridging, can be a sign of chronic peripheral ischemia.
- Skin Discoloration: Pallor (paleness) when legs are raised and rubor (redness) when dependent, indicating arterial insufficiency.
- Loss of Hair to Legs: Decreased hair growth on the lower legs and feet, a sign of chronic peripheral artery disease.
- Edema: Swelling in the extremities, especially in the legs and ankles, which can be related to venous insufficiency or fluid retention.
- Delayed Wound Healing: Wounds on the extremities may heal slowly or poorly due to inadequate blood supply and oxygen delivery.
Alt text: Nurse palpating pedal pulse on a patient’s foot to assess peripheral tissue perfusion, a key step in vascular nursing assessment.
Expected Outcomes for Ineffective Tissue Perfusion
Nursing care plans for ineffective tissue perfusion aim to achieve specific, measurable outcomes. Common goals include:
- Maintaining Adequate Peripheral Perfusion: Patient will demonstrate adequate peripheral perfusion, evidenced by strong peripheral pulses, warm skin temperature, intact skin without edema, and appropriate capillary refill.
- Maintaining Cardiopulmonary Perfusion: Patient will maintain adequate cardiopulmonary perfusion, evidenced by normal sinus heart rhythm, heart rate and blood pressure within normal limits, absence of shortness of breath, and normal oxygen saturation (SaO2).
- Adopting Lifestyle Modifications: Patient will demonstrate understanding and implement appropriate lifestyle modifications, such as smoking cessation, dietary changes, and exercise, to support adequate tissue perfusion in the long term.
- Improving Cerebral Perfusion: Patient will exhibit improved cerebral perfusion, evidenced by intact orientation to person, place, and time, stable neurological status, and absence of neurological deficits.
General Nursing Assessment for Ineffective Tissue Perfusion
A thorough nursing assessment is the foundation of effective care. Key components of the general assessment include:
1. Comprehensive Health History: Obtain a detailed patient history, focusing on pre-existing acute and chronic conditions that impact perfusion. This includes history of blood clots, myocardial infarction, congestive heart failure, diabetes, vascular diseases, and organ failure. Recognize that some conditions can affect multiple body systems simultaneously.
2. Infection Awareness: Be vigilant for signs of infection, as sepsis is a critical cause of poor perfusion and organ failure. Monitor for decreased urine output, abrupt changes in mental status, and mottled skin, which are red flags for sepsis.
3. Review of Laboratory and Diagnostic Results: Regularly review relevant lab work and test results, including arterial blood gases (ABGs), complete blood counts (CBC), electrolytes, and imaging studies like CT scans or Doppler ultrasounds. These provide objective data on perfusion status and can be used for trend analysis.
Ineffective Cardiopulmonary Perfusion: Focused Assessment and Interventions
When ineffective cardiopulmonary perfusion is suspected, specific assessments and interventions are crucial:
Nursing Assessment for Cardiopulmonary Perfusion
1. Assess for Sudden Changes: Be alert to sudden onset of chest pain, diaphoresis (excessive sweating), respiratory distress, and hemoptysis (coughing up blood), which may indicate acute events like pulmonary embolism or myocardial infarction.
2. Monitor Vital Signs and EKG: Continuously monitor blood pressure, heart rate, respiratory rate, and cardiac rhythm via EKG. Compare current data to baseline values to identify trends and changes in the patient’s condition.
3. Monitor Hemoglobin Levels: Regularly check hemoglobin levels. Reduced hemoglobin directly decreases the blood’s oxygen-carrying capacity, impacting tissue oxygenation and perfusion.
4. Assess Capillary Refill: Evaluate capillary refill time as an indicator of peripheral perfusion and circulation. Prolonged capillary refill (>3 seconds) may suggest hypovolemia, shock, peripheral artery disease, or heart failure.
Nursing Interventions for Cardiopulmonary Perfusion
1. Administer Medications: Provide prescribed medications to improve blood flow. Vasodilators like nitroglycerin (for chest pain) or hydralazine (for hypertension) may be used to dilate blood vessels and enhance circulation.
2. Oxygen Therapy: Administer supplemental oxygen as needed to support oxygenation and improve gas exchange. Oxygen therapy helps ensure adequate oxygen delivery to tissues.
3. Surgical Interventions: Prepare patients for potential surgical interventions like coronary angioplasty or bypass surgeries to address blockages impeding blood flow. Provide pre- and post-operative education and monitoring for complications.
4. Patient Education on Heart Attack Signs: Educate patients on recognizing heart attack symptoms, emphasizing that symptoms can differ between males and females. Women may experience atypical symptoms like nausea, jaw pain, back pain, or arm pain, rather than classic chest pain.
Alt text: Example of a normal sinus rhythm electrocardiogram (EKG) strip, indicating healthy cardiac electrical activity and effective cardiopulmonary perfusion.
Ineffective Gastrointestinal Perfusion: Focused Assessment and Interventions
For patients with suspected ineffective gastrointestinal perfusion, specific nursing actions are required:
Nursing Assessment for Gastrointestinal Perfusion
1. Identify Underlying Causes: Determine if the cause of reduced gastrointestinal perfusion is systemic or specific to the GI system. The underlying cause guides treatment strategies.
2. Assess Bowel Sounds: Auscultate bowel sounds to assess peristalsis and intestinal motility. Hypoactive or absent bowel sounds are indicative of decreased perfusion.
3. Characterize Abdominal Pain: Evaluate the location, onset, characteristics, and severity of abdominal pain. Sudden, severe abdominal pain can signal serious conditions like aortic aneurysm rupture. Consider conditions like gallstones, pancreatitis, appendicitis, or bowel obstruction based on pain location and presentation.
4. Monitor Stool Changes: Observe for changes in stool frequency, consistency, and color. Constipation can result from slowed digestion. Blood in the stool (bright red or black, tarry stools) may indicate ischemic colitis or gastrointestinal bleeding.
Nursing Interventions for Gastrointestinal Perfusion
1. Manage Nausea and Vomiting: Administer antiemetics to control nausea and vomiting. Address potential dehydration by replacing fluids and electrolytes, possibly with intravenous (IV) fluids.
2. Encourage Small, Easily Digested Meals: For patients recovering from bowel surgeries or illnesses, start with clear liquids and progress to bland, easily digestible diets to avoid overwhelming the digestive system.
3. Nasogastric (NG) Tube Insertion: Prepare for NG tube insertion as needed for bowel rest or decompression. Monitor gastric output (color, volume, consistency) to assess bowel function.
Ineffective Renal Perfusion: Focused Assessment and Interventions
Addressing ineffective renal perfusion requires careful monitoring and specific interventions:
Nursing Assessment for Renal Perfusion
1. Evaluate Urine Output: Monitor urine output amount and characteristics. Decreased urine output (<30 ml/hour) or dark, concentrated urine suggests inadequate renal perfusion.
2. Review BUN and Creatinine Ratio: Analyze BUN and creatinine levels and their ratio. Elevated BUN and creatinine indicate impaired kidney function. A high BUN-to-creatinine ratio specifically suggests poor blood flow to the kidneys. Assess electrolyte levels as well.
3. Observe for Edema: Assess for edema, particularly in the extremities. Fluid retention and swelling can result from impaired kidney filtration.
Nursing Interventions for Renal Perfusion
1. Intake and Output Monitoring: Accurately measure and document fluid intake (oral, IV) and output (urine, emesis) to monitor fluid balance.
2. Daily Weight Monitoring: Weigh patients daily to detect fluid retention. Sudden weight gain can indicate worsening fluid overload due to renal dysfunction.
3. Dietary Education: Educate patients about dietary recommendations, which may include fluid and sodium restrictions to manage fluid retention. Reduced animal protein intake may be advised to minimize kidney stress.
4. Supportive Therapies: Administer therapies to support kidney function based on the underlying cause of hypoperfusion. These may include blood pressure medications, diuretics, fluid resuscitation, or dialysis.
Ineffective Cerebral Perfusion: Focused Assessment and Interventions
Managing ineffective cerebral perfusion is critical due to the brain’s sensitivity to oxygen deprivation:
Nursing Assessment for Cerebral Perfusion
1. Assess Level of Consciousness (LOC) and Mentation: Regularly assess LOC and mental status using tools like the Glasgow Coma Scale. Monitor for confusion, speech changes, motor control issues, vision changes, sensory alterations, and loss of consciousness. Assess pupillary response and for numbness or tingling.
2. Assess for Stroke Signs: Be vigilant for signs of stroke, including facial drooping, slurred speech, and/or unilateral muscle weakness.
3. Medication Review: Review the patient’s medication list for potential interactions or medications (narcotics, sedatives, antiseizure drugs, antihypertensives) that may mask neurological symptoms or contribute to altered perfusion.
Nursing Interventions for Cerebral Perfusion
1. Frequent Neurological Exams: Perform neurological assessments at prescribed intervals to monitor for changes in neurological status. Use the NIH Stroke Scale for stroke patients.
2. Prepare for Imaging Studies: Prepare patients for brain imaging (CT or MRI scans) to identify the underlying cause of neurological changes.
3. Head of Bed Elevation: Elevate the head of the bed to 30 degrees and maintain a neutral neck position to promote venous return and reduce intracranial pressure (ICP), if elevated.
4. Administer Medications: Administer prescribed medications, which may include sedatives to limit agitation, osmotic diuretics to reduce ICP, corticosteroids to reduce inflammation and edema, or thrombolytics to dissolve clots in ischemic stroke.
Ineffective Peripheral Perfusion: Focused Assessment and Interventions
Addressing ineffective peripheral perfusion is crucial for maintaining limb viability and patient comfort:
Nursing Assessment for Peripheral Perfusion
1. Thorough Skin Assessment: Conduct a comprehensive skin assessment of the extremities, noting edema, wounds, ulcerations, skin color, temperature, hair loss, and nail changes.
2. Peripheral Pulse Assessment: Palpate peripheral pulses in all extremities. Document and report weak or absent pulses.
3. Pain and Sensation Assessment: Assess for pain, numbness, tingling, or other altered sensations in the extremities, particularly in patients with diabetes or peripheral vascular disease (PVD).
Nursing Interventions for Peripheral Perfusion
1. Doppler Ultrasound: Use a Doppler ultrasound device to assess blood flow if peripheral pulses are difficult to palpate.
2. Anti-embolism Stockings: Apply anti-embolism stockings or compression stockings to improve venous return and reduce edema in the lower legs, as prescribed.
3. Avoid Prolonged Sitting/Ankle Crossing: Discourage prolonged sitting or crossing legs/ankles, as these positions impede blood flow.
4. Lifestyle Modifications: Educate patients on lifestyle changes to improve blood flow, including smoking cessation, diabetes management through diet control, and regular exercise.
5. Cold Exposure Prevention: Advise patients to avoid cold exposure, especially those with Raynaud’s disease, which causes vasoconstriction in response to cold. Recommend staying indoors during cold weather and wearing gloves or mittens.
Alt text: Nurse applying compression stockings to a patient’s legs, a common intervention to improve venous return and address peripheral tissue perfusion issues.
Nursing Care Plans for Ineffective Tissue Perfusion: Examples
Nursing care plans provide a structured approach to prioritizing assessments and interventions for patients with ineffective tissue perfusion. Here are examples of care plans for different scenarios:
Care Plan #1: Ineffective Tissue Perfusion related to Hypervolemia
Diagnostic Statement: Ineffective tissue perfusion related to hypervolemia secondary to renal failure, as evidenced by elevated BUN/creatinine and edema.
Expected Outcomes:
- Patient will demonstrate effective tissue perfusion, evidenced by balanced fluid intake and output, stable vital signs within normal limits (BP: 90/60-130/90 mmHg, RR: 12-20 breaths/min, HR: 60-100 bpm, Temp: 97.8-99.1°F), and absence of edema.
- Patient will demonstrate optimal renal function, evidenced by urine output >30 cc/hr, BUN within 6-24 mg/dL, and Creatinine within normal ranges (0.74-1.35 mg/dL for men, 0.59-1.04 mg/dL for women).
Assessments:
- Monitor intake and output: Note urine output, especially for oliguria or anuria in early renal failure. Fluid replacement is based on fluid losses.
- Monitor blood and urine lab tests:
- BUN, creatinine: Elevated in renal failure.
- Hemoglobin/hematocrit: Assess for anemia due to reduced erythropoietin production and decreased red blood cell lifespan.
- Sodium/Potassium: Monitor for hyponatremia (dilutional hypervolemia) and hyperkalemia (altered filtration/excretion).
- Monitor daily weights: Use the same scale, time, and clothing. Sudden weight gain indicates fluid retention.
- Monitor vital signs and jugular veins: Assess HR, BP, RR, and jugular vein distention for signs of fluid volume excess (increased BP, tachycardia, tachypnea, jugular vein distention).
Interventions:
- Administer fluids as prescribed: Fluid restriction may be needed in the oliguric phase. Fluid replacement is required during the diuretic phase, with close monitoring of electrolytes.
- Administer diuretics as prescribed: Diuretics manage fluid volume excess but require careful monitoring to avoid hypovolemia, which can worsen renal perfusion.
- Gentle handling and repositioning: Handle edematous patients gently and reposition frequently to prevent skin breakdown.
- Prepare for renal replacement therapy: Hemodialysis may be necessary to remove excess fluid and correct electrolyte imbalances in renal failure.
Care Plan #2: Ineffective Tissue Perfusion related to Arteriosclerosis
Diagnostic Statement: Ineffective tissue perfusion related to compromised blood flow secondary to arteriosclerosis, as evidenced by claudication and skin temperature changes.
Expected Outcomes:
- Patient will exhibit optimal peripheral tissue perfusion in the affected extremity, evidenced by strong, palpable pulses, reduced or absent claudication, adequate capillary refill, and warm, dry extremities.
- Patient will not experience leg ulceration.
Assessments:
- Pain and sensation assessment: Assess for pain, numbness, and tingling, noting causative factors, onset, quality, severity, and relieving factors. Intermittent claudication is common in peripheral artery disease (PAD). Pain at rest indicates severe disease.
- Segmental limb pressure measurements: Assess ankle-brachial index (ABI). Normal ABI >0.9. ABI <0.9 indicates PAD; <0.4 indicates severe disease.
- Monitor diagnostic results: Review pulse volume recordings, vascular stress testing, MRA, arteriography, Doppler ultrasound to determine location and severity of arterial disease.
Interventions:
- Educate on disease progression prevention:
- Smoking cessation
- Dietary modification (low fat, low cholesterol)
- Hypertension management
- Diabetes management
Address risk factors for atherosclerosis to slow disease progression in coronary, cerebral, and renal vessels.
- Provide information on daily exercise program:
- Walk on a flat surface to relieve calf pain.
- Walk until claudication occurs, then rest.
- Stop and rest until discomfort subsides.
- Repeat 2-3 times daily for 30 minutes.
Exercise promotes collateral circulation and lactic acid removal.
- Instruct in complication prevention:
- Keep extremities warm (stockings, warm house).
- Avoid direct heat (hot water bottles, heating pads).
- Avoid cold applications and cold temperatures (vasoconstriction).
- Regular foot inspection for injury or infection.
Warmth promotes vasodilation; cold causes vasoconstriction.
- Administer medications as ordered: Antiplatelets (aspirin, clopidogrel), Cilostazol, lipid-lowering agents to reduce atherosclerosis progression and provide symptom relief.
Care Plan #3: Ineffective Tissue Perfusion related to Venous Pooling
Diagnostic Statement: Ineffective tissue perfusion related to dependent venous pooling, as evidenced by varicose veins and thick nails.
Expected Outcomes:
- Patient will demonstrate palpable peripheral pulses and warm, dry skin.
- Patient will demonstrate strategies to prevent venous pooling.
Assessments:
- Skin color and temperature: Note reddish-blue discoloration with dependency (dilated vessels), brownish discoloration on anterior tibia (chronic venous insufficiency).
- Pain assessment: Assess extremity pain, noting severity, quality, timing, exacerbating/alleviating factors. Venous insufficiency pain lessens with leg elevation and exercise.
- Skin texture and integrity: Assess skin texture, ulcerations, hair distribution, ulcers, or gangrene on legs/feet. Ulcerations on the side of the leg are associated with venous insufficiency.
Interventions:
- Elevate edematous legs: Elevate legs as ordered, avoiding pressure under knees and heels to prevent pressure ulcers, especially in bedbound patients. Elevation increases venous return.
- Apply graduated compression stockings: Ensure proper fit. Compression stockings improve circulation and prevent blood pooling.
- Encourage walking with compression stockings and leg exercises: Toe-up and point-flex exercises increase venous return and strengthen calf muscles.
- Discuss lifestyle modifications: Counsel on avoiding prolonged standing/sitting, wearing compression socks at work, increasing activity, and avoiding tight clothing and high heels.
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