ARELLANO UNIVERSITY

College of Nursing
2600 Legarda, Sampaloc, Manila
PACUCOA Level III RE-Accredited Status
www.arellano.edu.ph

College of Nursing
HEALTH ASSESSMENT

Name:_______________________________Semester & SY:__________________

Year and Section:______________________Date:_________________________

Focused Assessment – Cardiovascular System

Learning Objectives
At the end of this chapter, the learner will:
1. Obtain health history related to the heart and peripheral vascular systems.
2. Perform physical assessment of the heart and the peripheral vascular system using
correct techniques.
3. Document findings of cardiac and peripheral-vascular assessment.

Overview of the Cardiovascular System

The assessment of the cardiovascular system will include examinations of the peripheral
vascular system by assessing the color, temperature, edema, capillary refills, and peripheral
pulses and examinations of the heart by inspecting, palpating and auscultating the
landmarks of the heart.

Medical Terminology
Angina pectoris chest pain, a result of myocardial ischemia

formation of plaques of fatty material within arterial

Arteriosclerosis (Atherosclerosis)
walls

Bradycardia slow heart rate

a blowing sound heard in auscultation over a
Bruit
peripheral vessel or an organ.

time required for return of color after application of

Capillary Refill Time (CRT)
blanching pressure to a distal capillary bed

Cyanosis bluish-gray discoloration of the skin

period of time within the cardiac cycle in which

Diastole
ventricles are relaxed

discoloration of skin caused by leakage of blood

Ecchymosis
into the subcutaneous tissue

Embolus blood clot or foreign object in the circulatory system

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JOANNE MARIE S. GARCIA, RN, MAN

 a blowing, whooshing, or rasping sound heard
during a heartbeat which is caused byturbulent
Heart murmurs
blood flow through the heart valves or near the
heart.

Hypertension high blood pressure

series of sounds that correspond to changes in

Korotkoff Sounds blood flow through an artery as pressure is
released

Myocardial infarction heart attack

Palpitations sensations of pounding or racing of the heart

an indentation remains after the swollen skin is
Pitting Edema
pressed

Pulse Pressure difference between systolic and diastolic pressure

an elevated systolic blood pressure of 120-139

Prehypertension
mmHg and diastolic 80-89 mmHg

period of time within the cardiac cycle in which

Systole
ventricles contract

Tachycardia rapid heart rate

Thrombus blood clot

Deep Venous Thrombosis (DVT) formation of a blood clot in a deep vein

Step by Step Assessment

 Perform hand hygiene.

 Check room for contact precautions.
 Introduce yourself to patient.
 Confirm patient ID using two patient identifiers (e.g., name and date of birth).
 Explain process to patient.
 Assemble equipment prior to starting exam.
 Be organized and systematic in your assessment.
 Use appropriate listening and questioning skills.
 Listen and attend to patient cues.
 Ensure patient’s privacy and dignity.
 Apply principles of asepsis and safety.
 Check Vital signs.

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JOANNE MARIE S. GARCIA, RN, MAN

 Additional Information
Steps

Ask relevant questions related to chest pain,

1. Conduct a focused interview related to palpitations, shortness of breath (dyspnea),
cardiovascular and peripheral vascular cough, edema, fatigue, cardiac risk factors, leg
disease. pain, skin changes, swelling in limbs, history of
past illnesses, history of diabetes.

Cyanosis is an indication of decreased

perfusion and oxygenation.

To check capillary refill, squeeze nails or pads of

fingers until they blanche; release compression
and observe how many seconds the original
color returns. Normal is 2 seconds or less.

Assess capillary refill on bilateral lower legs.

2. Inspect:

 Face, lips, and ears for cyanosis

 Chest for deformities, scars, visible
pulsations
 Bilateral arms/hands, noting color,
warmth, movement, sensation
(CWMS), edema, color of nail beds,
nail shape, and capillary refill
 Bilateral legs, noting CWMS, hair
distribution, edema to lower legs and
feet, color of nail beds, and capillary
refill, numbness/tingling
 calf size/pain for signs of deep venous Assess capillary refill bilateral lower legs
thrombosis (DVT)
Alterations and bilateral inconsistencies in
CWMS may indicate underlying conditions or
injury.

While checking for capillary refill, inspect the nail

base angle. The normal angle of the nail base is
160 degrees. Assessing for Clubbing
Fingers However, if the angle of nails become
greater than 160 degrees, they are called
clubbing fingers. Clubbing fingers are related to
chronic hypoxemia.

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JOANNE MARIE S. GARCIA, RN, MAN

 Clubbing fingers

Sudden onset of intense, sharp muscle pain that

increases with dorsiflexion of foot is an indication
of DVT, as is increased warmth, redness,
tenderness, and swelling in the calf.

Assess calf for CWMS (Color, Warmth,

Movement, Sensation)

Note: DVT requires emergency referral because

of the risk of developing a pulmonary embolism.

3. Auscultate: Have the patent breathe normally. Use the

diaphragm side of the stethoscope to hear the
Aortic/Pulmonic/Erb’s point/Tricuspid/Mitral five landmark areas:

Auscultate apical pulse for one minute. Aortic Area – 2nd ICS on the right sternal border.
Note the rate and rhythm.
Pulmonic Area – 2nd left ICS

ERB’s Point – 3rd left ICS

Tricuspid Area – 4th left ICS (for children 4th or

 Heart Sounds (PREVIIOUS 5th left ICS)

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JOANNE MARIE S. GARCIA, RN, MAN

DISCUSSION)
Mitral Area (Apical) – 5th left ICS medial to the
MCL

Auscultate for rate, rhythm, and pitch (the quality

of the sound).

Auscultate apical pulse at the fifth intercostal

space and midclavicular line.

Note the heart rate and rhythm. Identify S1 and

S2 and follow up on any unusual findings.

 The ball of the hand (at the base of the

fingers) is the most sensitive at detecting
thrills. Inspect and palpate for:

 Pulsations- are more visible when patients

4. Palpate:
 Inspect and palpate of the heart
 Bilateral radial, brachial, dorsalis
pedis, and posterior tibialis pulses.
 Skin turgor
 edema
are thin. Pulsations may indicate increased
blood volume orpressure.
 Lift or heaves- these are forceful cardiac
contractions that cause a slight to vigorous
movement of sternum and ribs.
 Thrills- these are the vibrations of loud
cardiac murmurs. Thrills occur with turbulent
blood flow.
 The finger pads are more sensitive in
detecting pulsations. Use the finger pads of index
and middle fingers and apply light pressure on
the pulsation site. If pulses cannot be felt, a
Doppler to amplify the sounds can be used.
While palpating the artery, note the rate (normal
60-100 beats/min), rhythm (normal: regular),
amplitude (normal: easily palpable, 2+), and
contour (normal: smooth and rounded).

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JOANNE MARIE S. GARCIA, RN, MAN

 Pulse Amplitude (strength): 0 = absent; 1+ =
decreased, barely palpable; 2+ = normal; 3+ =
Full volume; 4+ = bounding pulse

Absence of pulse may indicate vessel

constriction, possibly due to surgical procedures,
injury, or obstruction.

 To check skin turgor, use the thumb and

index fingers to pinch an area of the skin and
release it. It should instantly return to place.
 To check edema, press down the skin and
release the pressure, the skin normally will
return to place right away. Assessing
Edema. When the indentation of the thumb
or any fingers remain in the skin, it is pitting
edema. Documenting Pitting Edema

5. Report and document assessment

Accurate and timely documentation and reporting
findings and related health problems
promote patient safety.
according to agency policy.

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JOANNE MARIE S. GARCIA, RN, MAN

 ARELLANO UNIVERSITY
College of Nursing
2600 Legarda, Sampaloc, Manila
PACUCOA Level III RE-Accredited Status
www.arellano.edu.ph

College of Nursing
HEALTH ASSESSMENT

Name:_______________________________Semester & SY:__________________

Year and Section:______________________Date:_________________________

Focused Assessment- Respiratory System

Learning Objectives
At the end of this chapter, the learner will:
1. Conduct a health history pertaining to the respiratory system.
2. Identify anatomic landmarks in identifying underlying structures and the location of
physical findings.
3. Inspect the thorax for pattern of respiration, skin, symmetry, and use of accessory
muscles.
4. Auscultate the anterior and posterior thorax for normal breath sounds and adventitious
sounds.
5. Describe the findings using correct terminology.
6. Document the findings of the respiratory exam.

Overview of the Respiratory System

The assessment of the respiratory system includes assessing the thorax, lungs, ventilatory
function and oxygenation of the body. Focused assessment techniques will be applied
intensively in this system: inspect level of consciousness, agitation, skin color, clubbing
fingers, shortness of breath, use of accessory muscles, position and alignment of the spine;
auscultate breathing sounds; palpate position of the trachea, subcutaneous emphysema;
percuss to assess the underlying structure of the chest.

Medical Terminology

Important terms to know and understand:

Adventitious sounds abnormal breath sounds

Apnea involuntary cessation of breathing

Atelectasis incomplete expansion or collapse of a part of the lungs

Bradypnea slow rate of breathing

Cheyne-Stokes gradual increase and then gradual decrease in depth of

Respirations respiration followed a period of apnea

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JOANNE MARIE S. GARCIA, RN, MAN

 crackling sounds made as air moves through wet secretions
Crackles
in the lungs

a grating sound or sensation under the skin around the

Crepitus
lungs, or in the joints

Cyanosis bluish coloring of the skin

Dyspnea difficult or labored breathing

Hemoptysis sputum containing blood

condition in which there is more than the normal amount of
Hyperventilation
air entering and leaving lungs

Hypoventilation decreased rate or depth of air movement into the lungs

Hypoxia inadequate amount of oxygen available to the cells

nostrils widen while breathing indicates difficulty in
Nasal Flaring
breathing

shortness of breath when lying flat and relieved by sitting or

Orthopnea
standing

Pneumothorax air in the pleural space

harsh, high-pitched sound usually heard on inspiration when

Stridor
upper airway become narrowed

Tachypnea rapid rate of breathing

a person sits or stands leaning forward and supports the

Tripod position or
upper body with hands on knees or other surface, often
orthopneic position
adopted by people experiencing respiratory distress

Wheezes high-pitched, musical noise that sounds like a squeak

Step by Step Assessment

Safety considerations:

1. Perform hand hygiene.

2. Check room for contact precautions.
3. Introduce yourself to patient.
4. Confirm patient ID using two patient identifiers (e.g., name and date of birth).
5. Explain process to patient.
6. Be organized and systematic in your assessment.
7. Use appropriate listening and questioning skills.
8. Listen and attend to patient cues.
9. Ensure patient’s privacy and dignity.

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JOANNE MARIE S. GARCIA, RN, MAN

10. Apply principles of asepsis and safety.
11. Check vital signs.

Steps Additional Information

Ask relevant questions related to

1. Conduct a focused interview related to history of
dyspnea, cough/sputum, fever, chills,
respiratory disease, smoking, and environmental
chest pain with breathing, previous
exposures.
history, treatment, medications, etc.

Patients in respiratory distress may have

an anxious expression, pursed lips,
and/or nasal flaring.
2. Inspect:
The anteroposterior (AP) diameter of the
 Use of accessory muscles and work of thorax should be approximately 1/2 of
breathing the lateral diameter.

 Use of accessory breathing muscles while at

rest is a sign of respiratory distress. Accessory
muscles include scalenes,
sternocleidomastoid muscle, and intercostal
muscles. Lifting the sides of the nostrils could
indicate excessive breathing effort.

 Shape and symmetry of the chest,

anteroposterior to lateral diameter

 Respirations for rate (1 minute), depth, rhythm

pattern
 Skin color of lips, face, hands (clubbing fingers)
 O2 saturation with a pulse oximeter
Ratio of AP to Lateral diameter

Asymmetrical chest expansion may

Note: Click the hyperlink to access more
details. Copyrighted materials used with
permission of the author, A. Chandrasekhar,
Loyola University Medical Education Network.
indicate conditions such as
pneumothorax, rib fracture, severe
pneumonia, or atelectasis.
With hypoxemia, cyanosis of the
extremities or around the mouth may be
noted.

3. Auscultate lungs for breath sounds and
adventitious sounds.
 Instruct the patient to take deep breaths
through the mouth during auscultation.
 Place the diaphragm side of the stethoscope
against the skin to listen to breath sounds.
 Use a systematic pattern to auscultate
Fine crackles (rales) may indicate
asthma and chronic obstructive
pulmonary disease (COPD).
Coarse crackles may indicate pulmonary
edema.

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JOANNE MARIE S. GARCIA, RN, MAN

 anterior, lateral, and posterior chest walls (see
illustration below). Wheezing may indicate asthma,
 Listen to at least one full breath (inspiration bronchitis, or emphysema.
and expiration) at each spot.

Low-pitched wheezing (rhonchi) may

indicate pneumonia.

Pleural friction rub (creaking) may

indicate pleurisy.

Interventions should be provided if

decrease or absence of breath sounds is
Com noted. It may indicate severe respiratory
pare one side with the other problems such as airway obstruction,
pneumonia, pneumothorax, pleural
 Normal breath sounds include tracheal, effusion, or atelectasis (Reyes et al.,
bronchial, bronchovesicular, and vesicular. 2020).
Vesicular breath sounds are heard over most
of the peripheral lung fields; bronchovesicular
sounds are heard over main bronchi; tracheal
and bronchial sounds are heard over trachea.

4. Report and document assessment findings and

Accurate and timely documentation and
related health problems according to agency
reporting promote patient safety.
policy.

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JOANNE MARIE S. GARCIA, RN, MAN

 ARELLANO UNIVERSITY
College of Nursing
2600 Legarda, Sampaloc, Manila
PACUCOA Level III RE-Accredited Status
www.arellano.edu.ph

College of Nursing
HEALTH ASSESSMENT

Name:_______________________________Semester & SY:__________________

Year and Section:______________________Date:_________________________

Focused Assessment- Gastrointestinal and Genitourinary

Learning Objectives
At the end of this chapter, the learner will:
1. Provide safety and privacy during gastrointestinal and genitourinary assessments.
2. Identify the location of the organs contained in the abdominal cavity.
3. Obtain health history relevant to the gastrointestinal and genitourinary assessments.
4. Describe two methods (4 quadrants and 9 regions) of anatomic mapping used to describe
findings related to the abdominal assessment.
5. Perform gastrointestinal and genitourinary assessments using the correct exam order and
techniques.
6. Document findings of the gastrointestinal and genitourinary systems using correct medical
terminology.

I. Overview of the gastrointestinal (GI) and Genitourinary (GU) Systems:

The gastrointestinal (GI) system is responsible for the ingestion of food, the absorption of
nutrients, and eliminating waste as stool. The genitourinary (GU) system, also called the
renal or urinary system is responsible for electrolytes and pH balance, blood volume and
pressure, and eliminates waste as urine.

Medical Terminology
Ascites accumulation of fluid in the peritoneal cavity

Anuria no urine; 24-hour urine output is less than 100 mL

high levels of nitrogen-containing compounds (body

Azotemia
waste) in the blood

Blood urea nitrogen

a blood test to check the amount of urea nitrogen
(BUN)

Creatinine a waste generated from muscle metabolism

Diuresis increase in urine excretion

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JOANNE MARIE S. GARCIA, RN, MAN

Frequency increase number of urinations
Gastroesophageal
Stomach acid flows up from the stomach into the
Reflux Disease
esophagus causing heartburn
(GERD)

Hematemesis vomiting blood

Hesitancy Inability to start or maintain a urine stream

Hematuria Blood in urine

the protrusion of the stomach through the esophageal
Hiatal Hernia
opening in the diaphragm

Hypervolemia too much fluid in the blood

Hypovolemia a decreased volume of circulating blood in the body.

Incontinence loss of bladder control leading to involuntary urination

Melena dark tarry sticky feces containing blood

inadequate production or secretion of urine; 24-hour

Oliguria
urine output less than 400 mL

the involuntary constriction and relaxation of the

Peristalsis
muscles of the intestine

the serous membrane lining the cavity of the abdomen

Peritoneum
and covering the abdominal organs

Polyuria the excessive output of urine (diuresis)

pain felt when pressure as to the abdomen is suddenly

Rebound Tenderness
removed

a nitrogen-containing substance normally cleared from

Urea
the blood by the kidney into the urine

Urinary Retention inability to empty the bladder completely

Urine flow has been impaired and is used

Urinary Stasis
interchangeably with urinary retention.

Urinary Tract Infection

an infection in the urinary system
(UTI)

Assessment of the gastrointestinal system includes obtaining relevant subjective and

objective data and is focused on the mouth and abdomen. The genitourinary system
assessment also needs subjective and objective data and focuses on the examination of the
body’s ability to get rid of urine, the genitalia, and the urine itself.

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JOANNE MARIE S. GARCIA, RN, MAN

 Pain is the most common complaint related to abdominal problems and can be attributed to
multiple underlying etiologies. Because of the potential variability of contributing factors, a
careful and thorough assessment of this chief complaint should occur.

Nausea, vomiting, diarrhea, and constipation are common issues experienced by

hospitalized patients due to adverse effects of medications or medical procedures. It is
important to ask a hospitalized patient daily about the date of their last bowel movement and
flatus so that a bowel management program can be initiated if necessary. If a patient is
experiencing diarrhea, it is important to assess and monitor for signs of dehydration or
electrolyte imbalances. Dehydration can be indicated by dry skin, dry mucous membranes,
or sunken eyes. These symptoms may require contacting the health care provider for further
treatment.

Additional specialized assessments of GI system function can include examination of the

oropharynx and esophagus. For example, patients who have experienced a cerebrovascular
accident (CVA), also called a “stroke,” may experience difficulty swallowing (dysphagia). The
nurse is often the first to notice these difficulties when swallowing pills, liquid, or food and
can advocate for treatment to prevent complications, such as unintended weight loss or
aspiration pneumonia.[4]

The nursing assessment of the genitourinary system generally focuses on bladder

function. Ask about urinary symptoms, including, urinary frequency, or urinary urgency.
Dysuria is any discomfort associated with urination and often signifies a urinary tract
infection. Patients with dysuria commonly experience burning, stinging, or itching sensations.
In elderly patients, changes in mental status may be the presenting symptom of a urinary
tract infection. In women with dysuria, asking whether the discomfort is internal or external is
important because vaginal inflammation can also cause dysuria as the urine passes by the
inflamed labia.

Abnormally frequent urination (e.g., every hour or two) is termed urinary frequency. In older
adults, urinary frequency often occurs at night and is termed nocturia. The frequency of
normal urination varies considerably from individual to individual depending on personality
traits, bladder capacity, or drinking habits. It can also be a symptom of a urinary tract
infection, pregnancy in females, or prostate enlargement in males.

Urinary urgency is an abrupt, strong, and often overwhelming need to urinate. Urgency often
causes, a leakage of urine. When patients experience urinary urgency, the desire to urinate
may be constant with only a few milliliters of urine eliminated with each voiding.[5

Step by Step Assessment

1. Perform hand hygiene.

2. Check room for contact precautions.
3. Introduce yourself to the patient.
4. Confirm patient ID using two patient identifiers (e.g., name and date of birth).
5. Explain the process to the patient.
6. Assemble equipment prior to starting the exam.
7. Be organized and systematic in your assessment.
8. Use appropriate listening and questioning skills.
9. Listen and attend to patient cues.
10. Ensure patient’s privacy and dignity.
11. Apply principles of asepsis and safety.

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JOANNE MARIE S. GARCIA, RN, MAN

12. Check vital signs.

Steps Additional Information

Ask relevant questions to obtain

subjective data relevant to:

 is there any history of

gastrointestinal disease in the
family? (Eshogeal, stomach, colon
or rectal cancer)
 is there any difficulty chewing
and/or swallowing? ( overlap from
the HEENT system)
 is there any problem with teeth or
does the patient wear dentures?
(overlap from the HEENT system)
 what type of diet does the patient
follow? Has there been a recent
change in food tolerance?
 What medication is the patient
taking including laxatives or
enemas?
 has there been an unexplained
1. Conduct a focused interview
weight loss or weight gain in the
related to the Gastrointestinal system.
last six weeks?
 is heartburn a problem and if it is
when and how often is it
experienced?
 is the patient experiencing more
flatus than normal?
 is the patient experiencing nausea,
vomiting, diarrhea, or constipation?
 Are there any bloody stools
including hematochezia; melena;
bloating (abdominal distention), or
hematemesis?
 When was the last bowel
movement and what did it look
like?
 is there any pain or tenderness to
the abdomen and if so point to the
area? Utilize OLD CART to obtain
symptoms.

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JOANNE MARIE S. GARCIA, RN, MAN

  Abdominal distension may indicate
ascites associated with conditions
such as heart failure, cirrhosis, and
pancreatitis.

2. Inspect:

 the mouth, teeth, and the ability

to swallow
 the skin and oral mucosa for
signs of dehydration
 the sclera, nails bed, and
palm/soles for signs of jaundice
and anemia
 the abdomen for color, shape,
contour, symmetry, scars, striae,
distention, or any visible masses.
 the umbilicus for shape,
positioning, herniation, or
discharge.  Ascites
 Observe for any abdominal
movements associated with
Markedly visible peristalsis with
respiration, or any pulsations or
abdominal distension may indicate
peristaltic waves
intestinal obstruction.
 Inspect the suprapubic area (from
umbilicus to pelvis) for distention.
 While observing the abdominal 
wall, ask the patient to cough. No
bulging from anywhere on the
abdominal wall should be noted
as bulging could be a sign of a
hernia.
 Abdominal distension may
indicate ascites associated with
conditions such as heart failure,
cirrhosis, and pancreatitis.


Striae

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JOANNE MARIE S. GARCIA, RN, MAN

 Bladder Distention


Umbilical Hernia

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JOANNE MARIE S. GARCIA, RN, MAN

  Please focus on the auscultation
4. Auscultate the abdomen in all four portion of the video.
quadrants

 Auscultation is performed prior

to palpation to prevent altering
 For bruits at the Aortic, Renal, and
the regularity of bowel sounds.
Illiac arteries. Most of the time
nurses do not auscultate for
abdominal bruits at main blood
 Abdominal examination (text)
vessels.
 When bowel sounds are not
present, a minimum of 5 minutes
should be auscultated before
determining the bowel sounds
are absent.  Nurses do not assess the
Hepatic and Splenic arteries.

4. Palpate the abdomen

 Begins farthest away from pain

 press abdomen lightly (1-2 cm) in
all four quadrants.
 Assess for rigidity, discomfort, or In the MC nursing program, percussion
masses. is considered an advanced practice
 Gently palpate the suprapubic skill and is not an expectation for
area. It should be felt soft, non- students. Therefore, the next step of
tender, and non-distended. A the abdominal assessment will be
distended bladder is palpated as palpation.
suprapubic fullness which
indicates urinary retention. The Nurses complete light palpation
patient may experience pain in only. All four quadrants need to be
the bladder, abdomen, and or palpated.
lower back.
 Documentation of normal
findings: Abdomen is soft, non-
distended, non-tender with
positive bowel sounds to all four
quadrants.

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JOANNE MARIE S. GARCIA, RN, MAN

5. Report and document assessment
Accurate and timely documentation and
findings and related health problems
reporting promote patient safety.
according to agency policy.
Steps
1. Conduct a focused interview related to the
Genitourinary system.
Inspect
 The face, upper and lower extremities for
edema.
 Inspect the suprapubic area and abdomen for
distention indicating bladder distention.
Please click on the link below and scroll down
to inspect a patient with a distended bladder:
HEALTH
18 ASSESSMENT
Additional Information
Ask relevant questions to obtain subjective data
relevant to:
 is there a history of diabetes, heart disease,
renal disease, prostate disease, urinary tract
infections, kidney stones, pelvic inflammatory
disease, incontinence, nocturia, sexually
transmitted infections, or trauma to the
genitourinary system required catheterization?
 is there any difficulty urinating?
 how often does the patient urinate and
approximately how much?
 what is the color of the urine? Is there any
Hemituria,
 has the odor or appearance of the urine
changed recently?
 is the patient experiencing itching, burning,
irritation, hesitancy, frequency, urgency, or
incomplete emptying with urination?
 has the patient noticed a change in energy
and eating habits?
 Inspect the neck, scapula, chest, arms, and
femoral areas for Hemodialysis access sites
or abdomen for the peritoneal access site.
 If the patient has a Foley catheter, inspect the
bag for urine amount, color, and clarity.
Inspect skin at the insertion site (meatus) for
redness/breakdown.
1
JOANNE MARIE S. GARCIA, RN, MAN
 A patient with visible bladder distention

 Closed Urinary Drainage catheter system

 Inspect the color, odor, and volume of urine

and send a sample for tests as ordered.
 Inspect weight and assess for unexpected
weight gain or weight loss. Unexpected
weight loss can occur with renal disease from
a lack of appetite and fatigue. Unexpected
weight gain can occur with fluid retention as
kidneys cannot get rid of waste and fluid.

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JOANNE MARIE S. GARCIA, RN, MAN