Universal Student Hospital Orientation

A Collaborative Project of the Nassau Suffolk Coordinating Council of Nursing

Education and Practice and the

Nassau Suffolk Hospital Council Inc.

Effective Fall 2010

Final Copy/Presented to NSHC

7-16-10

Introduction

• This presentation is to be viewed by all student nurses in advance of beginning their clinical rotation annually.

• It in no way replaces the site specific information that will be covered by faculty and or institutional personnel upon arrival in the institution.

• Each school will send a letter to the individual hospitals they are using for student rotation attesting to the fact that the students have completed the program and scored an 80 or better on the post-test.

Topical Outline

• Asepsis/Infection Prevention

• Culture

• Environmental/Fire Safety

• HIPAA/Confidentiality

• National Patient Safety Goals– Medications– Communication– Environment

Cultural Competence

Culture• Shared values, beliefs, customs,

symbols

• Learned and passed on

• Provides meaning for group members existence together

• Road map/blueprint to comprehend unwritten rules for living.

Ethnicity

Affiliation with a group often linked by:

• Race

• Nationality

• Language

• Common cultural heritage

Ethnocentrism• Belief that own cultural group’s belief and

values are:– Superior– Most acceptable

• Stems from lack of exposure or ignorance

Stereotyping

• A fixed and distorted generalization made about all members of a group

• Has negative results

• No attempt to learn about the individual

Prejudice• “An injury or damage resulting from some judgment

or action of another in disregard of one’s rights” Webster’s Ninth Collegiate Dictionary

• Strongly held opinions about some topic or group of people

• Stems from:– Ignorance– Misunderstanding– Past experience– Fear

Discrimination

• Acting on prejudice

• Denying the other person’s fundamental right.

Confidentiality

And

HIPAA

Confidentiality

• HIPAA - Health Information Portability and Accountability Act

• PHI - Protected Health Information

• EVERY patient’s Right

Ethical Issues in Health Care

• Both legal and ethical principles apply in the delivery of health care, sometimes leading to conflicts:

• Government Regulations– PSDA (Patient Self-Determination Act of

1991) – Federal Law– Patient Bill of Rights – NYS– Health Care Proxy Law - NYS

Ethical Issues in Health Care (cont’d)

• Patient’s rights under the law– Access to medical record– Patients with disabilities– Patient Self-Determination Act

• NYS Health Care Proxy Law• Patient’s Bill of Rights• Informed Consent

ANA Code of Ethics for Nurses

• Make explicit the primary goals, values, and obligations of the profession of nursing. The code serves the following purposes:– It states the ethical obligations and duties of every

individual who enters the nursing profession;– It is the profession’s nonnegotiable ethical standard;– It is an expression of nursing’s own understanding of

its commitment to society.

Infection Prevention

and

Asepsis

INFECTION PREVENTION INFECTION PREVENTION TRAINING REQUIREMENTSTRAINING REQUIREMENTS

• CDCCDC• New York State Departments of Health & New York State Departments of Health &

EducationEducation• Suffolk County Department of HealthSuffolk County Department of Health• Joint Commission Joint Commission • OSHA Blood borne Pathogen StandardOSHA Blood borne Pathogen Standard• OSHA Tuberculosis StandardOSHA Tuberculosis Standard• EPAEPA

MODES OF TRANSMISSIONMODES OF TRANSMISSION

• ContactContact– directdirect– indirectindirect

• DropletDroplet• AirborneAirborne• Common vehicleCommon vehicle• Vector borneVector borne

BREAKING THE CHAIN BREAKING THE CHAIN OF INFECTIONOF INFECTION

Infectious Agent

Means ofTransmission

(How InfectiousAgent Travels)

Reservoirs(Host of Infectious Agent)

Portal of Exit(How InfectiousAgent Leaves

Host)

P Portal of Entry

(How InfectiousAgent Enters the

Host)

Susceptible Host(Person Likely ToGet The Disease)

CONTROL OF THE MODES AND CONTROL OF THE MODES AND ROUTES OF TRANSMISSIONROUTES OF TRANSMISSION

Antibiotic resistant organismsAntibiotic resistant organisms

• MRSAMRSA• VREVRE• VISAVISA• VRSAVRSA• ESBLsESBLs

E.coliE.coliKlebsiella pneumoniaeKlebsiella pneumoniae

Organisms with Increasing ResistanceOrganisms with Increasing ResistanceStreptococcal pneumoniaeStreptococcal pneumoniaePseudomonas-Stenotrophomonas maltophiliaPseudomonas-Stenotrophomonas maltophiliaMultiply Drug Resistant TBMultiply Drug Resistant TB

Clostridium difficileClostridium difficile

• Leading cause of hospital acquired Leading cause of hospital acquired diarrheadiarrhea

• Antibiotics major factorAntibiotics major factor

• Spore forming Spore forming

• Difficult to kill – sterilization neededDifficult to kill – sterilization needed

• Lasts in environmentLasts in environment

• Hand washing – alcohol based gel Hand washing – alcohol based gel ineffectiveineffective

HANDWASHINGHANDWASHING• Single most important Single most important

component of an Infection component of an Infection Prevention programPrevention program

• Hands must be washed with Hands must be washed with soap & water when:soap & water when:– Before and after contact with patients,

body fluids, specimens, and contaminated or soiled item.

– Between “clean” and “dirty” procedures on the same patient.

– After removing gloves.– Before and after performing invasive

procedures.– After using the bathroom.– Before eating.– When your hands are visibly soiled.– After coughing and sneezing.

ALCOHOL BASED HAND GELALCOHOL BASED HAND GEL

• The alcohol based hand antiseptic should The alcohol based hand antiseptic should adequately wet hands. Allow to air dry. adequately wet hands. Allow to air dry. Alcohol gel is appropriate for hand antisepsis Alcohol gel is appropriate for hand antisepsis before and after patient care, except when the before and after patient care, except when the hands are visibly soiled. hands are visibly soiled. Do not use if the Do not use if the patient has C.difficile.patient has C.difficile.

Nurses Nail Care

• Artificial nails, tips, wraps banned. • Natural nails ¼ inch long past fingertip• Intact nail polish-all healthcare workers that

have pt. contact.• Neonatal nursery in Oklahoma babies died,

PSAE infection, CDC, State DOH –tested staff –genotype for strain done and found 2 nurses, 1 with artificial nails and the other with long nails had same strain on nails.

Recommended Hand Hygiene TechniqueRecommended Hand Hygiene Technique

HandrubsHandrubs– Apply to palm of one hand, Apply to palm of one hand,

Rub hands together coveringRub hands together coveringall surfaces until dry all surfaces until dry

– Volume: based on manufacturerVolume: based on manufacturer

HandwashingHandwashing – Wet hands with water,Wet hands with water,

apply soap, rub hands apply soap, rub hands together for at least together for at least 15 seconds15 seconds

– Rinse and dry with Rinse and dry with disposable toweldisposable towel

– Use towel to turn off faucetUse towel to turn off faucet

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

OSHA BLOODBORNE OSHA BLOODBORNE PATHOGEN STANDARDPATHOGEN STANDARD

• EXPOSURE CONTROL EXPOSURE CONTROL PLANPLAN– The Occupational The Occupational

Health and Safety Health and Safety Administration requires Administration requires the employer to the employer to protect employees protect employees from exposure and from exposure and contamination from the contamination from the blood and body fluids blood and body fluids of another person. of another person.

– The written Exposure The written Exposure Control Plan is found Control Plan is found in the Infection Control in the Infection Control Manual.Manual.

THE PLAN INCLUDES :THE PLAN INCLUDES :

- Standard PrecautionsStandard Precautions

- Housekeeping procedures to ensure Housekeeping procedures to ensure cleanliness and sanitationcleanliness and sanitation

- Hepatitis B vaccinations for employees at Hepatitis B vaccinations for employees at riskrisk

- Exposure evaluation and follow-up for Exposure evaluation and follow-up for exposure incidentsexposure incidents

- Hazardous material container warnings Hazardous material container warnings such as biohazard labelssuch as biohazard labels

- Confidential, accurate employee medical Confidential, accurate employee medical recordsrecords

- Engineering ControlsEngineering Controls

- Work Practice ControlsWork Practice Controls

- Selection and use of protective clothingSelection and use of protective clothing

PRECAUTIONS FOR ALL BLOOD AND PRECAUTIONS FOR ALL BLOOD AND OTHER POTENTIALLY INFECTIOUS BODY OTHER POTENTIALLY INFECTIOUS BODY

FLUIDSFLUIDS

• Standard PrecautionsStandard Precautions Applies to all patients regardless of diagnosis or Applies to all patients regardless of diagnosis or

presumed infection status.presumed infection status.

Apply to:Apply to:- blood- blood

- all body fluids, secretions, and excretions except sweat regardless - all body fluids, secretions, and excretions except sweat regardless of whether or not they contain visible blood.of whether or not they contain visible blood.

- non-intact skin, non-intact skin, - mucous membranesmucous membranes

• Assumes that each person is potentially infectious and Assumes that each person is potentially infectious and contagious.contagious.

To protect yourself from exposure, you must To protect yourself from exposure, you must

wearwear Personal Protective Equipment Personal Protective Equipment (PPE)(PPE)

• Gloves (vinyl & latex)Gloves (vinyl & latex)• gowns(fluid proof, fluid gowns(fluid proof, fluid

resistant)resistant) • protective eyewearprotective eyewear• mask(surgical, non-surgical, mask(surgical, non-surgical,

respirator)respirator)

• All PPE should be removedAll PPE should be removed IMMEDIATELYIMMEDIATELY and and disposed of according to disposed of according to Hospital policy.Hospital policy.

Prior to entering the patient’s Prior to entering the patient’s room:room:

1.1.      Put on protective garments before Put on protective garments before entering the patient's room entering the patient's room

2.2.      Put on maskPut on mask3.3.      Put on protective eyewear (if necessary)Put on protective eyewear (if necessary)

4.4.      Put on gown, tie at neck and backPut on gown, tie at neck and back5.5.      Don disposable gloves Don disposable gloves 

Leaving the patient’s room:Leaving the patient’s room:1.1.      Remove protective garments before Remove protective garments before

leaving the patient's room. leaving the patient's room.2.2.      Take off gloves, turning them inside out Take off gloves, turning them inside out

when removing. when removing. 3.3.      Take off gown, turning back into front Take off gown, turning back into front

so that inside of gown is on the outside. so that inside of gown is on the outside.4.4.      Take off mask or respirator and eye Take off mask or respirator and eye

protection. protection.5.5.      Discard in clear waste receptacleDiscard in clear waste receptacle..

6.6.      Wash hands.Wash hands.

SEQUENCE OF SEQUENCE OF PUTTING ON PUTTING ON AND TAKING AND TAKING OFF PPEsOFF PPEs

EXPOSURE TO BLOOD AND/OR BODY FLUIDEXPOSURE TO BLOOD AND/OR BODY FLUID

• Needle stick or sharp object injury:Needle stick or sharp object injury:• Wash the area thoroughly with soap and waterWash the area thoroughly with soap and water• If blood spills or splashes on your hands:If blood spills or splashes on your hands:• Wash hands thoroughly with soap and waterWash hands thoroughly with soap and water• If blood spills or splashes in your eyes:If blood spills or splashes in your eyes:• Be aware of location of eye wash station Be aware of location of eye wash station Flush eyes with large amounts of waterFlush eyes with large amounts of water Notify your SupervisorNotify your Supervisor Complete an incident reportComplete an incident report Go to the Emergency Department within 30 minutes Go to the Emergency Department within 30 minutes

of the incidentof the incident

Reference Source: www.joint commission . org

National Patient Safety Goals

National Patient Safety Goals

• The purpose of the National Patient Safety Goals is to improve patient safety. The Goals focus on problems in health care, safety and how to solve them.

Why Performance Improvement?

• The purpose of the Performance Improvement Program is to do the right thing at the right time, and for the right reasons, for our patients.

• The Interdisciplinary Performance Improvement Program supports hospital departments and staff in achieving standards of “Excellence” and Patient Safety

Dimensions of Performance

Doing the Right Thing• Efficacy – Are we

producing the desired effect?

• Appropriateness – Are we doing the proper thing?

Dimensions of Performance

Doing the Right Thing WellAre we doing the right things

• Timely• Effectively• Safely• Efficiently• With Respect

and Caring

Patient Safety Facts

• Institute of Medicine reported that 44,000 to 98,000 people die in the US hospitals each year as a result of medical errors.

Medical Error

• Medical Errors happen when something that was planned as part of medical care doesn’t work out, or when the wrong plan was used in the first place

• They can happen during even the most routine tasks

• Most errors result from problems created by today’s complex healthcare system; but errors also happen when we don’t communicate well

The Good News

• Most medical errors are preventable

Nurses – The Patient Safety “Ace”

A – Advocate

C – Caregiver

E - Educator

Nurses the Patient Safety “ACE”

Advocate

Assure that our policies and procedures are executed as intended

Report unsafe practices

Speak Up for our patients

Coordinate Care

Communicators

Nurses the Patient Safety “ACE”

Care Giver

Practice within our scope of practice

Assess and communicate effectively

Create effective plans of care

Execute our plans of care

Create safe environments

Nurses the Patient Safety “ACE”

EducatorTeach patients & families to participate in their

careInform them about their illnessInfection control practicesMedicationsTreatmentsSafety PrecautionsAfter Hospital Care

NPSG - Improve the Accuracy of Patient Identification

• Use two patient identifiers when providing care, treatment or services (administering medications, handling specimens, during surgery, blood transfusions, procedures and other treatments).

• It is necessary to know what the institution you are in is using as their two identifiers. Additionally you must know how the institution handles those who are hearing impaired or non-verbal. – Ask patient to state name and date of birth– Check information against a source document– Utilize the Surgical & Invasive Procedure Protocol

Perioperative Check List and Verification, Surgical Site Marking, Time-out

– Specimen Containers are labeled in the presence of the patient– Two persons verify blood transfusions

Never use the patients room number or physical location as an identifier!

NPSG – Improve the Effectiveness of Communication Among Caregivers

• Telephone Orders and Test Results are written down and verified with a “Read-back” – get confirmation!

• Do Not Abbreviate: Morphine, Magnesium, Daily, Every Other Day, Heparin, Coumadin, Unit, International Units, Both Eyes, and

• Always Use Leading Zeros, Never Use Trailing Zeros• Measure and Improve the timeliness of reporting and

receipt by the caregiver of Critical Test Results & Critical Values.

• Standardize approach to “hand off” communication & includes opportunity to ask and respond to questions; verifying information was understood

NPSG - Improve the Safety of Using Medications

• ‘Look-alike/Sound-alike’ drugs used in the organization are identified & actions taken to prevent errors involving the interchange of these drugs.

• Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field. Discard unused liquids.

NPSG - Improve the Safety of Using Medications

• Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.– Defined anticoagulation management program– Use oral unit-dose or pre-mixed infusions– Establish monitoring practices – Use approved protocols– Utilize INR for monitoring– Utilize a food/drug interaction program– Assess baseline and ongoing laboratory testing– Staff, patients and families are educated to anticoagulation

therapy– Anticoagulation Safety Practices undergo evaluation

Reduce the Risk of Healthcare Acquired Infections

• Comply with current Centers for Disease Control and Prevention (CDC) Hand Hygiene guidelines.

• Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare acquired infection.

• Implement evidence-based practices to prevent – health care-associated infections due to multi-drug

resistant organisms in acute care hospitals.– central line associated infections.– surgical site infections

NPSG- Accurately and Completely Reconcile Medication Across the Continuum

of Care

• Obtain and document patient’s current medications upon admission/entry

• Compare the list to those ordered and resolve discrepancies

• Communicate a complete list of the patient’s medications to the next provider of service when transferred to another setting, service, practitioner or level of care within or outside the organization. The next provider checks the medication reconciliation list again to make sure it is accurate and in concert with any new medication to be ordered/prescribed.

• The complete list of medications is provided to the patient on discharged from the organization.

NPSG – Reduce the Potential of Patient Harm Resulting from Falls

• Implement a fall reduction program that includes

• An evaluation as appropriate to the patient, the setting and services provided;

• patient, family and staff education;

• and program effectiveness

NPSG – Encourage patients’ active involvement in their own care as a patient

safety strategy

• Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

• Provide patients and families with information regarding infection control practices

• Describe to patients the methods used to prevent adverse events in surgery (Universal Protocol)

• Encourage patients to report concerns

NPSG – The organization identifies safety risks inherent in its patient population

• The organization identifies patients at risk for suicide and addressed the patient’s immediate safety needs and most appropriate setting for treatment

• The organization provides information such as a crisis hotline to individuals and their family members for crisis situations.

NPSG – Improve recognition and response

to changes in a patient’s condition

• The organization selects a suitable method that enables healthcare staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.

• The organization empowers staff, patients, and/or families to request additional assistance when they have a concern about the patient’s condition.

• Hospitals developed the Rapid Response Team (RRT) to attend to patients with a change in condition.

Universal Protocol to Prevent Wrong Site, Wrong Procedure, Wrong Person Surgery

• Pre-operative verification – active patient identification with 2 identifiers and source document

• Utilize the pre-operative checklist• The person performing the procedure should mark the

operative site for procedures involving right/left distinction, multiple structures (fingers/toes/lesions), or multiple levels (spinal surgery)

• Conduct a ‘Time Out’ immediately before starting the procedure – active communication among all team members to verify patient, procedure, implant and site.

Safety

FIRE Safety

Everyone’s Responsibility

Environment of Care

• The environment of care refers to key elements and issues that are significant in how the hospital operates related to patients, families, visitors and employees.

• Hospitals have a Safety Management Plan that addresses all Joint Commission, OSHA and NYS Department of Health requirements.

• The objective is to free of hazards and work performed in a safe manner with the have a physical environment reduced risk of injuries and hazards. This is accomplished through the EOC Committee whose purpose is to identify and reduce safety risks at each hospital.

Seven Areas of Environment of Care

Safety Management Security Management Hazardous Material and Waste Management Emergency Management Fire Prevention Management Medical Equipment Management Utilities Management

Safety

• Preventing Injuries is the focus of all Hospital Safety plans.

• If you are injured while in clinical , you should: • Notify both your faculty member and manager of unit.

Report to Employee Health Services (EHS) if the injury is not serious and it is during the week.

• If the injury is serious, report to the Emergency Department after informing your faculty member.

• You must complete an Incident Report form and any additional paperwork required by your school and return it to EHS.

• If the injury or accident involves a patient or visitor:• You must document the incident on a incident report and

the patient’s Medical Doctor should be notified.

Environmental Security

• The Security Program addresses security issues related to staff, patients and visitors on the grounds of the specific hospital. As students you are visitors to the facility and must adhere to all rules and regulations.

• To minimize security risks: • All students and faculty are required to wear ID Badges

at all times and the ID badge must be visible. • Please bring minimal personal belongings to the units

and leave valuables at home or locked in your car. • The Hospital Security staff is visible on the grounds and

conduct routine patrols.

Emergency Codes• Each hospital has different Emergency Codes• Your faculty member will review the following:• Medical Emergency• Fire Drill• REAL Fire • Bomb Threat • Abduction of a child • Decon Hazmat Team (Bioterrorism)• SECURITY EMERGENCIES• Internal/External Disasters

Class of Fires

• Class of Fires: A- B-C

• Class A: Fires are ordinary combustibles (wood, paper, plastic and rubber)

• Class B: Fires are flammable liquids/chemicals (grease, oil and petroleum)

• Class C: Fires are electrical fires (TV, VCR, computers, etc.)

Types of Extinguishers

-Types of Extinguishers

A pressurized water

BC dry chemical or C02

ABCmultipurpose dry chemical

Fire Bells

Your response when you hear the fire bells: • Listen • Count bells• Determine location by checking the alarm chart

located above every alarm box• Listen to the overhead page• If the fire is in your location, follow the RACE

plan. • If your area is above, below or adjacent to the

point of origin, close all doors, remove items from the corridors, have patients return to their rooms and listen for overhead pages of status of situation.

Fire SafetyFire Safety

Remove Patients from danger

Announce - Activate Alarm

Confine Close Doors

Extinguish With Proper Fire Extinguisher

Fire Safety

Pull Pin

Aim @ fire

Squeeze Handle

Swish side to side

Extinguishing a Fire• How do you extinguish a fire?• The fire extinguisher is your primary means of extinguishing a small fire, but first you

have to identify the type of fire. •  • Identify type of fire: A, B or C and Identify the size. Extinguish only the small fires. • Select appropriate type of extinguisher. Be sure it is MRI compatible. • Know how to use the extinguisher• P Pull the pin• The small metal pin located near the top of the extinguisher.• A Aim nozzle at the base of the fire• Aim the extinguisher at the base of the fire• S Squeeze the handle• Holding the extinguisher tightly, squeeze the handle of the extinguisher• S Sweep side to side at the base of the fire• Using a sweeping motion, move the extinguisher from side to side. Stand 6 to 8 feet

from the fire when you start spraying.

Customer Service

General Guidelines:• Introduce yourself and your role• Make eye contact• Greet the patient by their surname• Explain all procedures and actions• Ask if any further assistance is needed

before leaving the room• Smile

Define Our Image•Professional respect begins with having self-respect and respecting our own profession•Value Nursing and project that image daily•Take ourselves seriously and dress the part•Recognize and promote the value of what we do•Believe in ourselves and our colleagues

Professional ImageHow is Image Defined?

•Description•Portrayal•Attitude•Popular Conception

–Usually projected through the Mass Media

The Essence of Nursing

• Nightingale in her Notes on Nursing, wrote, “nursing’s most important work is caring” (1859).

• Reading Nightingale one is struck by the simplicity of her message and its continued applicability to the health care system of today.

• Enjoy your clinical experience this semester and your future careers as nurses

Complete the following Post-TestComplete the 20 question post-test found on

the following Slides 72-76.

Fill in your answers on the separate answer sheet found on Slide 77.

Print out your completed answer sheet and submit to your clinical instructor.

Nassau Suffolk Coordinating Council of Nursing Education and PracticeUniversal Student Hospital Orientation

Name: ______________________School: ____________________Date: _______________________

Matching: Cultural Competence Please Use Separate Answer Sheet

1. Culture A. Belief that one’s own cultural group belief is superior.

2. Ethnicity B. Acting on prejudice and/or denying the other person’s rights.

3. Ethnocentrism C. Injury or damage from some judgment or action of another in

disregard of one’s rights. 4. Stereotyping D. Fixed and distorted generalization made about all members of

a group.

5. Prejudice E. Affiliation with a group linked by race, nationality, language,

or common cultural heritage

6. Discrimination F. Shared values, beliefs, customs and symbols that are learned

and passed on from generation to generation.

True/False

7. Ethical issues in healthcare include legal principles and governmental regulations, but do not include the ANA Code of Ethics, which are optional in the acute care settings. (True/False)

8. Infection prevention strategies include hand washing and personal protective equipment. (True/False)

9. Alcohol based hand gel is appropriate for al situations. (True/False)

True/False10. Standard Precautions apply to all patients,

regardless of diagnosis or presumed infection status. (True/False)

11. You should always contact your instructor immediately if you sustain a needle stick. (True/False)

12. National Patient Safety Goals focus on problems in healthcare, safety and how to solve them. (True/False)

13. The National Patient Safety Goals improve communication among caregivers via a standardized approach to hand off communication. (True/False)

True/False

14. According to the National Patient Safety Goals, all medications should be labeled. (True/False)

15. Fire Safety is everyone’s responsibility and response to a fire within the health care system is facilitated by the RACE acronym. (True/False)

16. Patient confidentiality is every patient’s right and legislature protecting these rights include HIPPA (Health Information Portability and Accountability Act) and PHI (Protected Health Information).

(True/False)

True/False

17. ACE stands for Advocate, Caregiver and Educator. (True/False)

18. Preventing injuries is the focus of all Hospital Safety plans.

(True/False)

19. The nursing professional image is enhanced when nurses value nursing and project that image daily and promote the value of the nursing profession. (True/False)

20. Customer service includes greeting patients by their first names and referring the patients to support staff for toileting needs.

(True/False)

Suffolk Coordinating Council of Nursing Education and PracticeUniversal Student Hospital Orientation

Post-Test

Name: ______________________ School: Suffolk County Community College

Date: ___________

ANSWER SHEET

1.____ 6.____

2.____ 7.____

3.____ 8.____

4.____ 9.____

5.____ 10.____

11.____ 16.___

12.____ 17.___

13.____ 18.___

14.____ 19.___

15.____ 20.___