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Nur 3010 exams > Upper GI > Flashcards

Upper GI Flashcards

1
Q

functions of the GI tract (4)

A
  • breakdown of food for digestion
  • absorption into the bloodstream of small nutrient molecules produced by digestion
  • immunologic function (recognize pathogens)
  • elimination of undigested unabsorbed foodstuffs and other waste products (bacterial content: normal flora)
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2
Q

3 main categories

A

1) alimentary: mouth to anus
2) accessory: enzymes and acids production breaks down lipids/proteins (salivary glands, pancreas, liver/gallbladder)
3) peritoneum: below diaphragm, serous membrane that lines/encloses the abdominal cavity, similar function as the plural cavity (lines abd., filled w/ fluid, reduces friction then we move around)

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3
Q

digestion

A

begins with the act of chewing, in which food is broken down into small particles that can be swallowed and mixed with digestive enzymes

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4
Q

absorption

A
  • major function of the small intestine
  • vitamins and minerals absorbed are essentially unchanged
  • begins in jejunum and is accomplished by active transport and diffusion across intestinal wall into circulation
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5
Q

elimination

A
  • phase of digestive process that occurs after digestion and absorption when waste products are eliminated from the body
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6
Q

gastric hormones and enzymes

A
  • facilitate breakdown of food and subsequent uptake for nutrition
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7
Q

chyme

A
  • mixture of undigested food and gastric acid (pH of about 1.5, lower than vinegar) that accumulates in stomach and is expelled into duodenum
  • stomach lined with gastric acid to protect lining of stomach
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8
Q

assessment of the GI system (2)

A

1) health history: information about abdominal pain, dyspepsia, gas, nausea and vomiting, diarrhea, constipation, fecal incontinence, jaundice, previous GI disease is obtained
2) pain: character, duration, pattern, frequency, location, distribution of referred abdominal pain, time of pain vary greatly depending on underlying cause

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9
Q

pain may be ____?

A

referred
- may radiate to other parts of the body

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10
Q

assessment: dyspepsia

A

most common sx. of patients with GI dysfunction
- belching, heart burn

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11
Q

assessment: intestinal gas

A

bloating, distention, or feeling “full on gas” with excessive flatulence as a symptom of food intolerance or gallbladder disease

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12
Q

assessment: nausea and vomiting

A

nausea is vague, uncomfortable sensation of sickness or “queasiness” that may or may not be followed by vomiting

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13
Q

assessment: bowel habits

A
  • changes in bowel habits and stool characteristics
  • may signal colonic dysfunction or disease
  • constipation, diarrhea
  • details to r/o other diseases (hemorrhoids)
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14
Q

assessment: past health, family, social history (5)

A
  • oral care and dental visits
  • lesions in mouth
  • discomfort with certain foods (lactic intolerance, avoid spicy, alcohol, vape)
  • use of alcohol and tobacco
  • dentures
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15
Q

physical assessment

A

1) oral cavity (good baseline, surrogate for global health)
- lips, gums, tongue
2) abdominal assessment; four quadrant method
- IAPP
3) rectal inspection
- r/o bleeding, not slope RN

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16
Q

diagnostic tests GI

A

1) GI series X rays
2) endoscopic procedures
3) manometry and electrophysiologic studies

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17
Q

GI series XR

A

r/o worm bodies, free air
- multiple XRAYS of body

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18
Q

endoscopic procedures

A
  • direct visuals with camera (2 types: mouth, anus)
  • EGD (esophagogastroduodenoscopy): esophagus, stomach, first part duodenum
  • colonoscopy: entire colon
  • sigmoidoscopy, anoscopy, pcrotoscopy
  • small bowel enteroscopy
  • endoscopy through an ostomy
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19
Q

manometry and electrophysiologic studies

A
  • assess speed/strength peristalsis
  • outpatient
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20
Q

lab tests of GI assessment

A
  • pancreas
  • liver
  • stool
  • breath
  • misc.
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21
Q

pancreas lab tests

A
  • amylase
  • lipase
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22
Q

liver lab tests

A

ALT, ALP, AST, GGT
- albumin: ammonia (protein) + blood urea nitrogen (excretion via kidney) -> metabolic by liver
- bilirubin: product RBC breakdown, if a lot = jaundice (can’t conjugate)

-main: concern about liver function

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23
Q

stool lab tests

A
  • occult blood, parasites/bacteria (C.Diff) -> rectal exam
  • cancer screening via stool card (stool smear)
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24
Q

breath lab tests

A
  • urea breath test for helicobacter pylori (rare, usually measure in blood) -> serum antibodies
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25
Q

misc. lab tests

A
  • CBC/CMP
  • PT/INR
  • PTT
  • lipid levels
  • lactic acid: arterial clot, tissue not getting perfused (decreased O2) -> anaerobic metabolism -> increase lactic acid
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26
Q

upper GI disorders (10)

A
  • peridodontal disease
  • jaw disorders
  • salivary gland disorders
  • oral cancer (radial neck dissections)
  • dysphagia
  • GERD (hiatal hernias, barret’s esophagus)
  • gastritis
  • PUD (peptic ulcer disease): gastric, duodenal
  • GI bleeding
  • gastric cancer
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27
Q

periodontal disease (most common cause, at risk, connected to)

A

1) most common cause of tooth loss in adults
- gingivitis: inflammation of the gums
- periodontitis: involves soft tissue and bone supporting the teeth
2) individuals at risk: older adult, current smokers, low income, less educated
3) connected to systemic disease: CV, DM, rheumatoid arthritis

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28
Q

periodontal disease - dental hygiene (dental plaque, treatment, prevention (5))

A

1) dental plaque: causes dental decay, caries
2) treatment for dental caries: treatment fillings, dental implants, extraction
3) prevention: routine dental care
- fluoride varnish/gel and fluroide toothpaste
- routine dental care and applying dental sealants
- community water fluoridation (goal for teeth)
- refrain from smoking and alcohol use
- less sugar and starch in diet, healthy snacks, brushing after meals

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29
Q

periodontal disease - dental abscess (what, s/sx, clinical manifestations)

A

1) abscessed tooth: cavity unchecked
2) presence of pus in the apical dental periosteum and tissue surrounding the apex
3) clinical manifestations: pain, cellulitis, facial edema (impair ability to breathe), fever, malaise

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30
Q

medical and nursing management

A

1) needle aspiration: drill opening to relieve pressure, pain, and promote drainage, extraction
2) assess for bleeding: instruct to use warm saline/water rinse, take antibiotic and analgesic

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31
Q

jaw disorders(6)

A
  • temporomandibular disorders: jaw is joint, may become arthritic
  • myofascial pain
  • internal derangement of joint
  • degenerative joint disease
  • fracture (of bone)
  • mandibular structural abnormalities
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32
Q

salivary gland disorders

A
  • parotitis: inflammation of parotid gland
  • sialadenitis: inflammation of the salivary glands
  • sialolithiasis: salivary stones
  • neoplasms: cancer
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33
Q

oral cancer (RF, increased in, location)

A

1) RF (risk factors)
- tobacco use, including smokeless tobacco (vape)
- alcohol
- infection with human papilloma virus prevention
- history of head and neck cancer
2) increased incidence in men twice as often as women
3) may occur in any area, but lips, lateral tongue, and floor of the mouth are most frequently affected
- spreads quickly d/t vascular
- not many sx. early on

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34
Q

oral cancer - manifestations (early (3), late (4)

A

1) early stage
- few or no symptoms in early stage
- painless sore or mass that does not heal; indurated ulcer with raised edges
- may bleed easily and present with red or white patch
2) later manifestations include:
- complaints of tenderness (no oral)
- difficulty in chewing, swallowing, or speaking
- coughing up blood tinged sputum
- enlarged cervical lymph nodes

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35
Q

oral cancer - assessment (2) and mgmt (3)

A

1) assessment
- health history: include symptoms related to oral problems, oral hygiene, and dental care, use of tobacco, alcohol, and eating and nutrition
- inspect and palpate the structures of the mouth and neck (always palpate laterally, one at a time)
2) medical management
- surgical resection: radical neck dissection
- radiation therapy: clean margins, cancer eradicated
- chemotherapy

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36
Q

oral cancer - radial neck dissection (what, nursing interventions)

A

1) removes of all cervical lymph nodes from the mandible to the clavicle and removal of the sternocleidomastoid muscle, internal jugular vein, and spinal accessory muscle on one side of the neck
2) nursing interventions post post neck dissection:
- maintaining airway clearance
- manage pain
- wound care
- managing enteral nutrition (peg tube, quality of life decisions, palliative care)

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37
Q

nursing mgmt. for disorders of the oral cavity (6)

A
  • promote oral care (good hygiene - reduce pneumonia)
  • facilitate adequate nutrition
  • minimize pain (avoid hot, spicy, hard foods, oral care, vicious lidocaine or other pain medications)
  • prevent infections (assess for signs and symptoms of infections, appropriate wound and skin care)
  • patient education (how to manage dressings)
  • support positive self image
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38
Q

dysphagia (what, results (2), diagnosis)

A
  • difficulty swallowing
  • results from: (1)structural abnormalities (tumors, strictures, edema), (2)functional abnormalities (affecting nerves or muscles - CVA, ALS, Parkinson’s, Alzheimer’s)
  • diagnosis requires evaluation by “speech language pathologist” (recognized by RN officially)
39
Q

symptoms of dysphagia (triggers SLP order)

A
  • choking on food or drink
  • coughing during or after swallowing
  • coughing or vomiting up food
  • having a weak, soft voice
  • aspirating (getting food or liquid into your lungs)
  • excessive salvia or drooling
  • difficulty chewing
  • trouble moving food to the back of your mouth
  • food sticking in your throat (back of throat)
40
Q

dysphagia treatment (6)

A
  • follow recommendations placed by a SLP (speech language pathologist) -> dietary modifications (thickened liquids - nectar/honey thick)
  • maintain bed at 90 degrees during and after meals
  • encourage patient to tuck chin while eating
  • 1:1 feeding/supervision (important for safety)
  • may require enteral feeding tube (determine care of life, hospice/palliative, disease progression won’t necessarily improve)
  • helps direct food to esophagus rather than trachea
41
Q

dysphagia complications (what, results, s/sx, tx)

A

1) aspiration pneumonia (esophagus to trachea)
- bacteria and gastric contents are aspirated into the lungs
2) results in pneumonitis from stomach and
3) s/sx: SOB, fever, tachypnea, etc.
4) treatment: involves broad spectrum abx. and possible mechanical ventilation (requires some modification to swallow)

42
Q

GERD - gastroesophageal reflux disease (what, excessive reflux d/t (4))

A

1) back flow of gastric/duodenal contents into the esophagus that causes troublesome symptoms and/or mucosal injury to the esophagus (back flow acid -> esophagus damages)
2) excessive reflux may occur because of:
- incompetent lower esophageal sphincter (LES): doesn’t fully close, causing contents to come back through opening
- pyloric stenosis: not appropriate emptying
- hiatal hernia: stomach increase to diaphragm causing issues to sphincter
- motility disorders: peristalsis not moving like they should

43
Q

risk factors GERD (6)

A
  • irritable bowel syndrome
  • obstructive airway disorders (asthma, COPD, cystic fibrosis)
  • tobacco use
  • coffee drinking
  • alcohol consumption
  • gastric infection with helicobacter pylori (disrupts mucus goblet cells)
44
Q

GERD signs/symptoms (8)

A
  • “heart burn”, burning sensation in throat
  • regurgitation
  • salty/sour taste in mouth
  • worse pain at night/morning (laying flat supine)
  • difficulty swallowing
  • sensation of a lump in the throat
  • sore throat/hoarseness
  • chronic cough: unusual -> acid stimulates cough, related to GERD
45
Q

GERD mgmt (5)

A
  • low fat diet
  • avoid caffeine, tobacco, beer, milk, foods containing peppermint or spearmint, carbonated beverages/citrus, spicy foods: anything that makes worse = acid
  • avoid tight clothing: affects peristalsis of GI contents
  • elevated the HOB at least 30 degrees (blocks at home)
  • drugs: H2 antagonists, antacids, proton pump inhibitors (protonix)
46
Q

barret’s esophagus (results from, RF, considered)

A
  • results from long term exposure acid/chyme
  • risk factors: bulimia, GERD, chronic N/V
  • considers a precursor to esophageal cancer -> adenocarcinoma and squamous cell carcinoma
47
Q

esophageal cancer (further asks, sx, tx)

A
  • further asks include alcohol and tobacco use
  • dysphagia, sensation of mass in throat, regurgitation
  • treatment: based on staging including surgery, radiation, chemotherapy, and palliative
48
Q

GI MEDS: histamine 2 receptor antagonist (drug, function, treats, patho, ADR)

A
  • Pepcid (famotidine) -> most common
  • function: oppose histamine
  • treats: GERD, PUD/Ulcers, Zollinger-ellison syndrome (overproduction of gastric acid) -> no real consequences, more at risk GERD
  • blocks H2 receptors in the gut to reduce acid sectriont: prevents more acid production
  • ADRs: headache, GI upset, not as strong as PPI
49
Q

GI MEDS: proton pump inhibitors (drug, treats, function, length, ADR)

A
  • Prilosec (omeprazole), protonic (pantoprazole)
  • treat: GERD, ulcers, Zollinger Ellison syndrome
  • inhibits an enzyme required for gastric acid secretion (same as H2 blockers, teach: won’t see affects for a while, need to take month or two)
  • takes about 8 weeks to fully take effect
  • ADR: GI upset, C. Diff, long term use results in osteoporosis (affects absorption calcium)
50
Q

GI MEDS: mucosal protectants (drug, function, treats, ADR, dosing, teaching)

A
  • carafate (sucralfate)
  • creates a coating that adheres to the GI mucosa (and ulcers) to protect from acids (raises pt. a little bit)
  • treat: GERD, ulcers
  • ADRs: constipation
  • dosing: 1 hour before meals and at bedtime (4 times daily)
  • teaching: increase fiber and fluids (reduce risk constipation)
51
Q

GI MEDS: antacids (what, function, treats, ADR, dosing, teaching)

A
  • tums, aluminum hydroxide
  • neutralizes stomach acids (raise pH)
  • treats: GERD, ulcers
  • ADRs: constipation
  • dosing: after meals (as acid production increases after we eat) and at bedtime -> issues with calcium absorption, unless takes with tums
  • teaching: give them 1-2 hours apart from other drugs as they will affect the absorption of other drugs
52
Q

GI MEDS: prostaglandins (drug, prevents, decreases, ADR)

A
  • misoprostol
  • prevents ulcers in patients taking NSAIDS, also induces labor via cervical ripening
  • decreases stomach acid secretion, increases protective mucus production and bicarbonate
  • ADRs: dysmenorrhea (uterine bleed/contraction), GI upset, uterine contractions), black box warning for pregnant women (we need an HCG if we give to women of childbearing age)
53
Q

gastritis

A
  • inflammation of the gastric mucosa - disease process
  • disruption of the mucosal barrier that normally protects the stomach tissue from digestive juices
54
Q

acute gastritis (causes)

A
  • rapid onset of symptoms usually caused by dietary changes (within a day)
  • medications (steroids, metformin, vitamin): decrease GI mucosal protection, give PPI to prevent
  • alcohol
  • bile reflux: too much tums, too much acid
  • radiation
  • acid/alkali intake (too many tums, too much pH strong foods)
55
Q

chronic gastritis (what, causes) (4)

A
  • prolonged inflammation, atrophy of gastric tissue
  • neoplasms: cancers
  • helicobacter pylori
  • autoimmune disease
  • alcohol, smoking
56
Q

gastritis manifestations acute (6)

A
  • epigastric pain
  • dyspepsia/indigestion (burping, upset stomach after eating White Castle)
  • anorexia
  • hiccups
  • nausea/vomiting
  • hematemesis: vomiting blood -> coffee ground appearance) -> blood and acid turns brown, looks like coffee grounds
57
Q

gastritis manifestations chronic (8)

A
  • melena: blood in stool
  • fatigue
  • heartburn
  • sour/salty taste
  • anorexia
  • N/V
  • pernicious anemia: malabsorption of B12
  • ulcer formation: GIB and blood loss anemia
58
Q

gastritis manifestations (tests) (3)

A
  • chronic gastritis mostly
  • diagnosis via endoscopy and histologic examination: direct visualization
  • FOB test: fecal occult blood (stool smear)
  • H. pylori breath test: breathe into device to tell H.pylori in blood
59
Q

gastritis management acute (3)

A
  • refrain from food until symptoms subside
  • re-introduce with a bland diet: BRAT DIET
  • supportive therapy: IV, NGT, Pharmacologic agents
60
Q

gastritis management chronic

A
  • modify diet
  • promote rest
  • reduce stress
  • avoid ETOH
61
Q

peptic ulcer disease (PUD) (what, RF)

A
  • erosion of the gastric mucosa resulting ulcer formation in the stomach, esophagus, or duodenum
  • Risk factors: NSAID (chronic ibuprofen), steroids, stress (chronic, decreased BF gut d/t overstimulation SNS), helicobacter pylori infection
62
Q

peptic ulcer disease (PUD) manifestations (5 + pain referred)

A
  • epigastric pain
  • nausea/vomiting
  • bloating
  • hematemesis/coffee ground emesis
  • melena: tarry black stool
  • PAIN: significant to location (gastric: 15-30 minutes after meals, worse during day, worse with eating) (duodenal: 2-3 hours after meals, worse at night, better during eating)
63
Q

peptic ulcer disease (PUD) diagnosis (r/o, 2 types)

A
  • r/o H. pylori
  • EGD: direct visualization
  • urea breath test for H. pylori
64
Q

peptic ulcer disease (PUD) treatment

A
  • meds: PPI, H2 antagonists
  • avoid food triggers
65
Q

peptic ulcer disease teaching

A

avoid caffeine, smoking/nicotine, alcohol

66
Q

peptic ulcer disease (PUD) complications (3)

A
  • GI bleeding (eroded wall can erode tissue)
  • hypovolemic shock: tachycardia, low BP, requires fluid resuscitation/blood products
  • perforation: through stomach lining, full thickness erosion of the stomach/small intestine, allows for translocation of bacteria (usually sterile), severe pain, fever, rigid “board” like abdomen (suggestive of peritonitis), requires surgery to treat via peritoneal washout/lavage with saline
67
Q

GI bleed (location, occur with (5))

A
  • can occur anywhere between the mouth and rectum
  • can occur with PUD, gastric cancer, inflammatory bowel disease (Crohn’s, UC) diverticulitis, esophageal varicose (fissures)
68
Q

GI bleeding terms (4)

A
  • melena: black tarry stool
  • hemtochezia: bright red blood in the stool (low in system)
  • hematemesis: vomiting blood/coffee ground in appearance
  • other manifestations: tachycardia, SOB, syncope, abdominal pain, chest pain, fatigue
69
Q

GIB diagnosis (7)

A
  • stool test: FOB
  • CBC: hgb, iron levels
  • NG lavage: not common
  • CT scan: perforation
  • endoscopy: EGD, colonoscopy (esophagus, duodenum, large intestine)
  • capsule endoscopy: small capsule that can visualize the GI tract (not common)
  • angiography: contrast into arteries (GI compartments)
70
Q

GIB treatment

A
  • PPI
  • H2 blockers
  • antacids
  • Strict NPO

supportive therapy: endoscopic cauterization (via electricity), arterial embolization (vasculature), ligation/clipping or lower GI polyps (metal bands)

71
Q

gastric cancer

A
  • incidence: more common among older adults; males
  • overall poor prognosis d/t so much movement in GI, hard to identify
72
Q

gastric cancer risk factors (11)

A
  • diet
  • chronic inflammation of the stomach
  • H.pylori
  • infection
  • pernicious anemia
  • smoking
  • achlorhydria (decreased chloride reduces mucous production)
  • gastric ulcers
  • previous subtotal gastrectomy
  • genetics
  • diets rich in acids
73
Q

gastric cancer manifestations (9)

A

later onset
- pain
- dyspepsia
- early satiety
- weight loss
- abdominal pain
- loss or decrease in appetite
- bloating after meals
- nausea/vomiting
- may be asymptomatic until metastasis

74
Q

gastric cancer management (4)

A
  • chemotherapy
  • radiation
  • surgical removal
  • palliative care

tip: important to screen colonoscopy

75
Q

gastrointestinal intubation (6)

A
  • decompress the stomach
  • lavage the stomach (OD -> sterile water + suck out)
  • diagnose GI disorders
  • administer medications and feeding
  • to compress a bleeding site
  • to aspirate gastric contents for analysis
76
Q

feeding tubes types

A
  • Nasogastric tubes (NGT)
  • donhoff/cotrak tubes
  • PEG/PEJ tubes

parenteral nutrition

77
Q

gastrointestinal tubes/ enteral feeding tube: nasogastric tubes (what, indication, tip_

A
  • advanced into the stomach, placement confirmed with XR
  • indications: feeding/meds, gastric decompression with low intermittent suction, allow us to check “residuals” (ideal to be <250 mL) Q4hours
  • stiff, rigid
    TIP: if coil, dip in ice water to stiffen
78
Q

gastrointestinal tubes/ enteral feeding tube: dobhoff/cortrak tubes

A
  • advanced into duodenum, lower risk of aspiration
  • placement confirmed with ultrasound (not XR)
  • indications: feedings, meds ONLY
79
Q

measuring NGT

A

nose -> earlobe -> xiphoid process

80
Q

enteral feeding tube advantages (5)

A
  • safe, cost effective
  • preserve GI integrity
  • preserve the normal sequence of intestinal and hepatic metabolism
  • maintain fat metabolism, lipoprotein synthesis
  • maintain normal insulin and glucagon ratios (if done correctly, not usually in hospitals)
81
Q

enteral feeing tube disadvantages

A
  • uncomfortable
  • nasal mucosal injuries
  • risk of aspiration (with NG tubes) - maintain HOB 30-45 degrees, check residuals per institutional policy (usually Q4 hours)
82
Q

semi-permanent gastrointestinal tubes

A
  • PEG: percutaneous endoscopic gastronomy tube (stomach)
  • PEJ: percutaneous endoscopic jejunostomy tube (jejunum)
  • tip: no need to check residuals
83
Q

PEG/PEJ tubes advantages

A
  • fewer long term complications (dislodgment d/t confusion)
  • less concern with aspiration
  • relatively comfortable (surgical procedure, tube obstruction/clogging)
84
Q

PEG/PEJ tube complications (4)

A
  • infection/cellulitis, leakage
  • GI bleeding
  • premature dislodgment of tube (common with confused patients)
  • tube obstruction/clogging
85
Q

enteral nutrition (indication, methods (4))

A

indication: meet nutritional needs of the body when the patient is otherwise unable to
methods:
- intermittent bolus feedings
- intermittent gravity drip (hospital base continuous)
- continuous infusion
- cyclic feeding

86
Q

parenteral nutrition (what, required, filter, BS?)

A
  • nutrition administered through the central veins (osmotically rich, hurts veins)
  • requires central line (subclavian, internal jugular), pick or mediport (usually not)
  • tubing filter: nutrients can precipitate and form crystals
  • Q6 blood sugars: d/t glucose disregulation (regardless diabetes)
87
Q

parenteral nutrition reason for having

A
  • intake is insufficient to maintain anabolic state
  • ability to ingest food orally or by tube is impaired
  • the underlying medical condition precludes oral or tube feeding
  • preoperative and postoperative nutritional needs are prolonged
88
Q

parenteral nutrition - complications (8)

A
  • infection/sepsis
  • liver insufficiency with high lipid content
  • pneumothorax, air embolism
  • clotted or displaced catheter
  • sepsis
  • hyperglycemia
  • rebound hypoglycemia
  • fluid overload (HF)
89
Q

parenteral nutrition - prevention of infection (6)

A
  • appropriate catheter and IV site care
  • strict sterile technique for dressing changes
  • wear mask when changing the dressing
  • assess insertion site
  • assess for indications of infection
  • proper IV and tube care
90
Q

nausea

A
  • describes a feeling of sickness coupled with vomiting
91
Q

nausea causes (6)

A
  • irritation of the nerves of the stomach and duodenum/gastric stasis
  • chemoreceptor trigger zones (activation)
  • disturbance in the semicircular canals in the inner ear
  • hypoglycemia (downward spiral makes worse)
  • shock/pain/increased intracranial pressure (brain jury -> vomiting -> issues!)
  • idiopathic
92
Q

nausea non pharm interventions (5)

A
  • gastric decompression (when causes by bowel obstruction)
  • BRAT diet: bananas, rice, applesauce, toast
  • ginger
  • peppermint
  • alcohol swabs: open and smell (allegedly as effective as zofran)
93
Q

nausea pharmacologic treatment (5)

A
  • 5-HT3 antagonists (ondansetron - zofran)
  • steroids (dexamethasone)
  • antihistamine (cyclizing, promethazine)
  • phenothiazines (phenergan - prochlorperazine)
  • dopamine antagonist (reglan - metoclopramide)

tip: give zofran post op always as it helps with nausea

Nur 3010 exams (13 decks)

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