Chapter 25 – Post-Surgery Timeline And Checklist: 50+ Things To Expect From The Day Of Surgery Through Discharge
Chapter 25 – Post-Surgery Timeline And Checklist: What To Expect From The Day Of Surgery Through Discharge
Hip Replacement Book
I had been looking forward to, and dreading, this day for some time. This is what you can expect on your first day after surgery.
Waking Up Is So Very Hard To Do – I was briefly alert in the operating recovery room, but immediately went back to sleep. Next thing I am aware of I am in my hospital room, but I am not sure how I arrived there. The nurse and orderly are hovering over me and I start to go back to sleep. Next sensation I have is they are raising the bed up a bit. I was a like an unemployed teenager on summer vacation and was ready to go back to sleep. My wife is there and wants to be helpful – which means me staying awake.
How To Keep Track Of Time From Your Hospital Bed – Imagine that the Chicago song, Does Anybody Really Know What Time It Is?
is playing somewhere in the background. There is large wall clock on the wall so, during the time I am awake, I can conveniently assess just how slowly the passage of time can be.
“Free at last, free at last, thank orthopod almighty, free at last.”
Martin Luther King on the day after his hip surgery
Thank Your Orthopod – One of the first sensations you will notice shortly after surgery is that you are missing a sensation… arthritic hip pain. You have post-surgery hip pain, but it is different and you understand it will get better.
Pain Is Just Weakness Leaving The Body – Well, I must have had a lot of weakness. After this major orthopedic procedure, I was prescribed with many pain medications, including narcotics, to treat my postoperative pain. Your physician will prescribe the pain medications best for your situation. You will be advised to treat your pain only as needed. Pain medications causes a variety of side effects that can include lightheadedness, confusion, sedation, urinary retention and constipation. Hmm, so far it sounds like my normal day-to-day status.
Hip Tip – 11 Pain Management Techniques: There are several methods you can use to minimize post-operative pain. Below is a list for you to review:
> Being Prepared For Post-Operative Pain: Not surprisingly, when you have a surgery, there will be pain. By recognizing this you will be better prepared for the entire joint replacement surgery experience. Repeat after me, “Oh, that really hurts… but I knew it would.”
> The ‘Elevator Button’ Pain Control, aka Patient-Controlled Analgesia (PCA): You may receive a continuous dose of medication and be able to give yourself booster shots through your IV when you have pain. If your surgically repaired hip is hurting, you just press a button to receive pain meds. Imagine you have pushed the elevator button, but the elevator hasn’t arrived yet, so you push it again (and again). You do not need to worry about giving yourself too much medicine due to a lockout feature that prevents you from over medicating.
> ‘Automated Pain Control,’ aka Patient-Controlled Epidural (PCE): You can just sit back and enjoy the pain, and hopefully the pain management. This involves an epidural (similar to an IV) which is placed in your back and provides small continuous doses of pain medication. There is also a lockout feature on this system.
> ‘It’s In The Bag’ – IV Medication: If you do not have a patient-controlled system as above your medication can be delivered to you via your IV bag. The nurses will add the necessary dose upon reasonable request.
> ‘Groin Direct’ – Femoral Nerve Block: Hmm, this sounds like a male capturing device known only to females. The femoral nerve block involves a local anesthetic applied to your femoral nerve, which is located in your groin. This anesthetic technique would be applied in the pre-operative period before your surgery takes place.
> ‘As Cool As Ice’ Therapy: Apply ice packs to your incision site can help decrease pain and swelling. Be sure not to freeze your skin.
> ‘Some Like It Hot’ Heat Therapy: Some patients respond better to heat, but generally ice should be tried first.
> ‘Mental Distraction’ Technique: Normally I am pretty good at this, but when you are thinking, “My hip doesn’t hurt. MY HIP DOESN’T HURT,” so much, your hip just hurts. Try concentrating on something you find enjoyable. This can include reading, watching TV or listening to music. For me, it was imaging my mother-in-law moving out.
> ‘Visual Imagery’ Technique: Imagine yourself of a happy time or think of your favorite place. From some of those noises I heard coming from my wife when she thought I was asleep, I think she was imagining attending the ‘Thunder Down Under’ show or at least being at Chippendale’s with a fist full of twenties and an hour to kill.
> ‘Breathe Deep’ Relaxation Breathing: You can take slow, rhythmic breathing to help reduce muscle tension. I tried this, fine in concept, but I must not have been very good at it as my hip still hurt. Deep breathing also helps to prevent serious illness, such as pneumonia.
> The One Technique That Usually Works: Push the nurse call button and plead like crazy for more pain meds.
TED Used To Mean A Great Conference, But Now It Is Unstylish Foot Apparel – I have watched quite a few TED Talks at their site Ted.com and also at YouTube.com. The TED Talks have intelligent people talking about sophisticated ideas, breakthrough products and stimulating concepts. But like many things with dual meanings (Internet Explorer vs. Ford Explorer, Apple music vs. Apple computers) I found that, at this point in my life, TED now means compression socks. And these blood clot reducing socks now were appearing on my feet.
On listening to TED Talks…
To signify to the hospital staff that I was an “at risk for falls” patients, I had bright yellow, anti-skid socks covering the TED stockings.
No skid socks
For additional styling points, the covered-up TED socks offer a convenient opening at the toe end to let your toes breathe, I guess. But those dainty size 14 feet (unfortunately that correlating rumor isn’t true) only allowed a few toes to escape the fashion prison and I couldn’t even bend down anywhere near to my feet to adjust which toes would see the light of day. At least the TED slogan, “Anti-embolism” sounded sophisticated. Plan on wearing these trend setters for at least the first few weeks, or until your spouse hauls them off to the washing machine.
Five In-Hospital Rehab Exercises
The physical therapist instructed me to do various ‘exercises’ while laying in bed. These exercises are discussed earlier, but they are important for your rehab. The following post hip replacement exercises were my assignment:
> Ankle Pumps: To minimize bloods clots you will perform ankle pumps. You move your feet up and down 10 times every hour that you are awake.
> Short Arc Quad: Place a pillow under your knee so your knee is bent. Then straighten your knee by tightening the muscle on top of thigh. Be sure to keep bottom of knee on the pillow. Bend your knee and then return to starting position. Repeat 10 times. Complete at least two sessions per day.
> Isometric Gluteals: Squeeze buttocks muscles as tightly as possible while counting out loud to three. Repeat 10 times. Complete at least two sessions per day.
> Heel Slides: While lying on your back (you won’t be able to position yourself in any other way anyways) slide your heel toward your buttocks. Then extend your heel back to a straight leg position. Repeat 10 times. Complete at least two sessions per day.
> Isometric Quadriceps: Slowly tighten muscles on thigh of straight leg while counting out loud to three. Be sure to do both legs. Repeat 10 times. Complete at least two sessions per day.
“Drugs Win Drug War”
Headline – Onion.com
Symptoms from pain medications can include nausea and, in worst case, addiction, so be careful with your drugs – you don’t want them winning. Some hip replacement patients I spoke with were using an over-the-counter pain medication over three months after their surgery.
Cue To The “Theme from Mission: Impossible”
Written and composed by Lalo Schifrin+
Anesthesia Wears Off, Reality Wears In – I am sore and my first thought is that it is going to be impossible to go from laying on this bed to ambulating around town. I can barely sit up, slide my body or get to the edge of the bed and I wonder how do I get there from here? It was a difficult mission. But I have no choice but to accept the challenge.
Liquid Progress – A few hours after surgery I awoke again and by now I was in the hospital room. I vaguely recalled the catheter from when I initially awoke in the surgical recovery room. There it was, still inserted in my body. The floor nurse came in, examined in near wonderment, smiled, and immediately reached for the urine collected in the clear bag attached to my bed. It was full. “That’s all from me?” I wondered. I hadn’t produced that much urine since a post-finals celebration in college.
Who Is Pushing My Buttons? I spoke with friend who had his hip replaced. He told me I would have a ‘patient controlled analgesia’ button. I knew it as the pain button. If my hip hurt, I pushed the button and get a little dose of Dilaudid or Morphine. Well, that may be true for some hospitals, but in my hospital room the pain button was a nurse who asked me every couple of hours if I was in pain. She would always refer to the pain scale so I could recite a number between one and 10.
Post Surgery Therapy Goals
At hip replacement class they told us that on the first evening after surgery the goal was to sit up on the edge of the bed with a physical therapist. The next day would include two physical therapy visits plus one occupational therapist visit. Sounded easy.
Just What Is Occupational Therapy? Occupational therapy helps patients recover in their ability to perform the tasks of daily living. An occupational therapist (OT) will teach you how to use a dressing stick to pull on underwear or slacks without bending from the waist, how to use a sock aid to position and draw a sock or stocking onto the operated leg and how to use a shoe horn to put on your shoes without tormenting your hip. They will also give you tips such as sliding heavy objects along the counter rather than lifting them, carrying hot liquids in covered containers (nobody wants to sue their spouse for a hot coffee spill), sitting on a high stool when working at a counter and how to use a reacher to pick up objects from the floor and using a basket or bag attached to your walker to free your hands as you slowly move throughout your home. Occupational therapists teach you how recover while in your home.
Just What Is Physical Therapy? Physical therapy helps patients learn how to prevent, manage or recover from their medical condition so they will achieve long-term health benefits. Physical therapists (PT) use treatment techniques to promote the ability to move, reduce pain, restore function and prevent disability. In the hospital, your PT will work with the occupational therapist to teach you how to use your walker, how to get into your car and show you exercises to help with your hip recovery. Physical therapists teach you how to help your body recover.
1984 Apple Super Bowl Commercial
Assembly Line Medicine – A brief comment about both the physical and occupational therapists exclusive to the rehab floor that treated me – while to a certain degree I was simply the next Model T on the assembly line, the therapists viewed me more than attaching a door, installing a seat and tightening the bolts on the tires. I had expected a drone-like process delivered much like the people all dressed in gray to introduce the Macintosh computer to the world. Even though the therapists were constantly were treating patients with knee and hip surgeries, and those treatments rarely exceeded three days, I received a highly personalized experience. Hopefully you will too.
Recovery Day One – I got out of surgery late so I missed my first physical therapy session. The next morning finally came and a person walked into my room and on the whiteboard wrote my appointments for the day – two physical therapy appointments and one occupational therapy visit. My dance card was full.
Walker On Water – Imagine Michael Jackson’s Bad playing in the background.
I was confident that I would be showing my therapists I could ‘walker on water’ when they came to treat me. The physical therapist came at 10 am gave me an overview of what to expect for my first appointment. She then took my blood pressure while laying down (I will understand why she did in less than five minutes). Next she had me to slide to the edge of the bed and slid a walker over. After my two months of prehab efforts, I was really confident about standing up all by myself, attaching the bicycle streamers I brought and then spiking the walker to the ground, followed by doing the Michael Jackson moonwalk
and finally triumphantly shouting, “Who’s bad?” Well, it didn’t quite go that way.
“Down Goes Frazier! Down Goes Frazier!
Down Goes Frazier!”
Ali – Frazier Fight – Howard Cosell
He’s Up… He’s Down – It took two long minutes to traverse the 20” from the center of the bed to the edge and sit up. When I sat up, I felt light-headed but said nothing. This was my Punxsutawney Phil moment – if I could stand and see my shadow all would work out well. The PT instructed me to extend my operated leg out, support myself with my good leg and then use the walker to push myself up. I placed one hand on the bed and one on the walker and stood. Then I wobbled as if I had been knocked senseless by George Foreman. I immediately got sweaty and clammy, and reluctantly said, “I am feeling dizzy,” while trying to stay up. My wife promptly barked at me to sit down – of course, after years of browbeating and training (her mother was a great role model), I quickly complied. I thought I was Spartacus, now I was just a ‘cus. My wife tucked the bicycle streamers back into my suitcase as I wouldn’t be needing them. She probably considered taping a sign to my back, “Slow Down – Slow Adult.” The therapist said she would be back tomorrow. So much for a moonwalk, maybe tomorrow I could at least do the Ickey Shuffle.
NASCAR Geriatric Racing – True to her word the physical therapist returned to teach me how to use the walker. I already felt appreciably better and still ready to show off all the prehab work I had completed. I stood, waited to make sure I wasn’t woozy and pronounced myself fit and raring to go. We exited my little fiefdom and merged into the circular hallway of patient rooms with nursing stations in the center. I took a step, then another, then the therapist said I was doing great, followed by a cautious, “How are you feeling?”
Early Pit Stop – I was feeling good until I hit the first left hand turn and could see other patients with their therapists and walkers. The competitive side of me quickly compared my pace to others and, sadly, I said to my therapist, “This feels like a NASCAR race and I am going slower than that spry, elderly woman (walker number 87, sponsored by Metamucil). She will lap me before to long, and if she does, I am going to have to get a new pit boss.” The therapist replied that the speeding woman had been there five days and was ready for discharge and it was only my first session. Even more fortunately my pre-prescribed regimen was only a half-a-lap so I cut through the nursing station infield back to my room, saving me from utter humiliation and defeat.
“The Journey Of A Thousand Miles Begins With A Single Walker Slide.”
Ancient Hip Replacement Saying
“A-One, An-A-Two” There are no shortcuts, you just have to do it. Rehab involves your body naturally healing and you healing your body via rehab and exercise. Your body will proceed at the pace your body can perform. You can assist your recovery via your exercise regimen. If it will take you walking 30 miles to improve your muscular response, then it takes 30 miles. If you do those 30 miles over four weeks or eight weeks, it takes 30 miles. There are no shortcuts, you have to do the work. The sooner you start the sooner you finish. You just start your walker therapy at the beginning and continue to improve every day. Of course your spouse will be there echoing the wisdom of your orthopod, “Don’t overdo it!”
“You put your right foot in,
You put your right foot out;
You put your right foot in,
And you shake it all about.
You do the Hokey-Pokey,
And you turn yourself around.
That’s what it’s all about!”
Hokey Pokey Song
Hip Tip – How To Use Your Walker In Nine Steps: You will need to master your walker to be discharged. It is sorta’ like learning how to do the Hokey Pokey. Here is how you use a walker:
This is an instructional video on the concept.
> Move the walker forward first.
> Then, move the operated leg side forward.
> Place your weight on your hands when you step forward with your non-operated leg.
> Be sure not to pivot on your operated leg.
> When turning, pick up your feet and turn using small steps.
> Always land on your heel and push off on your toes when walking.
> Lean your back against the wall for support if you become tired.
> Frequent, short walks are recommended.
> Practice, practice and more practice.
Walking Papers – Once you prove that you can master the walker the physical therapist will issue ‘walking papers,’ meaning you are now almost ready to go home.
And a medical video on using a cane, and at the 32 second mark, information on using a walker.
One Tug Of War You Don’t Want To Win
“On Three, Cough” Even though I recalled from hip joint replacement class that a catheter was going to stay inside of me for at least a couple of days, I asked the nurse to take out the catheter. I knew full well I wasn’t ready to stand, let alone hobble over to the bathroom. She also knew I wasn’t ready and said that tomorrow might be better. The next day, after my physical therapy walker lesson, I felt I could get up and make a slow dash to the bathroom and finally convinced the day nurse to pull the catheter. She came over and asked permission to lift the blanket, I consented even though post surgery pain had surely shrunk what little of my manhood remained. The nurse then outlined the game plan; first she would grab the plastic tubing, second she will gently (damn) touch my penis, third she will pull the entire catheter out with a steady, but quick, pull. I thought, “OK, this sounds easy, and she is doing all the work.” Then, after a pause, she added the kicker, “I am going to count to three and on three, cough.” I nodded, then, as if it was a never-ending story. She added, “I had one patient who on three said the word ‘cough.’ Don’t do that, I want you to cough.” I felt confident that I could perform, even in my somewhat diminutive state. And, I had already mastered the medical cough during one of my many, “Turn your head and cough young man,” doctor exams.
The Countdown – “One,” she said, then it seemed a while before she got to, “Two,” and then with even a longer gap she said, a bit louder, “Three!” As I coughed in a manner that would surely earn me an Emmy award for best voice-over, I felt this funny sensation deep inside my urethra. It was reminiscent of when you are in an earthquake and you get the first sound and low rumbling of the earth moving and you wonder what is going on. Before the timing would allow for a, “Four,” I felt the slip fault sensation of the urethra erupting from where it was all the way to exit point.
She Looked Like Such A Nice, Friendly, Kind Nurse – For a half-a-second I thought to myself, “Well, that wasn’t too bad. I did OK. That was easy. She is a great nurse.” I soon was thinking she performed the catheter removal like a well-rehearsed slight-of-hand magician. Bravo!
Burn, Baby, Burn – That jubilant conclusion was short lived and replaced by a sensation that something like a slightly rough-hewed thermometer had been pulled out from the entire length of my urethra and that it was, all at once, itchy, uncomfortable and a slightly burning sensation as I felt that diameter of the urethra had been uncomfortably expanded by 20%. I winced and waited for the unusual feeling to dissipate. It wasn’t quite the yell of the Yeti but I remember thinking that maybe this is how gonorrhea must feel. Thankfully I was still in a mild post-surgical groggy state and couldn’t focus on the time duration of discomfort… but it seemed like about 30 minutes.
Dentist: I have to pull the aching tooth, but don’t worry it will take just a few minutes.
Patient: And how much will it cost?
Dentist: It’s $100.00.
Patient: $100.00 for just a few minutes work? That is a lot of money for such a short period of time.
Dentist: I can extract it very slowly if you like.
The Slow Pull – As a side note, when the evening nurse came in to check on me she noticed I no longer had my catheter. Feeling spry, I told her that the day nurse used the new technique on me. The evening nurse looked confused and asked, “What new technique? We only do it one way.” I told her that the day nurse said since I had been such a wonderful, compliant and trouble-free patient that she would remove the catheter according to the latest study. She stated she should position herself at the foot of the bed to allow natural gravity to work, and the removal technique should now be a slow and steady pull on the tube, lasting at least 60 seconds. I told the evening nurse I had commented on how irritating and painful that was but that the day nurse assured me that pain was much worse with a fast tug for removal. I told her that the day nurse said only their special patients get the slow and steady treatment. The evening nurse looked like she wanted to say something, but didn’t comment as she left.
Hip Tip – Lose The Catheter, Gain A (Male) Urine Bottle: I found out that I didn’t have to stand to urinate (why start now?). The orderly gave me a clear plastic jug that looked like it could be a collegiately fashionable beer mug. I was asked if I could manage peeing into the plastic device. Confident of my aim, especially at such a short distance, of course I said yes. Over the rest of my stay there, I would pee in the container, fill it about half full, ring for the nurse, then they would take the contents to the bathroom, hold up to the light and inspect like a jeweler does a diamond, and finally flush. They next recorded the volume of pee. I would repeat this process about every hour or two. The Noah’s Ark flood had nothing on me.
Incision Drain Tube – Besides the catheter you will have a piece of bonus tubing placed inside your body – the incision drain tube. This allows the fluid from your surgery to more easily drain out. The hospital staff will remove it prior to discharge. To an outsider, it will look like a splinter being taken out, but it felt as if King Arthur was slowly removing a rusty Excalibur.
Just Like Woodstock: “Three Days Of Peace, Music And Understanding…” The most amazing fact about hip replacement surgery is that supervised rehab is only three days long. You will normally see an OT and PT on each day of your hospital stay. Once you complete those sessions you become eligible for discharge. Most healthy patients will be discharged after three days while other patients may need to be transferred to a rehabilitation hospital for additional therapy. Your age, the availability of family or friends to assist with daily activities, the quality of your home environment, safety considerations and your ability to use assistive devices will all influence whether you go home or to an intermediary facility.
Just like Woodstock, my hospital stay was only three days…
A Stitch In Time – Some orthopods will use staples, some stitches and some will use surgical glue and Steri-Strip tape (sounds like how I repair most things around the house). The advantage of the surgical glue and Steri-Strip tape is it makes for a clean surgical scar and you don’t go back to have stitches removed. I had steri-strips and not staples, so I didn’t need to go back to the doctor’s office for removal. I was advised that my steri-strips should stay in place until they fall off on their own. If the strips have not fallen off by three weeks, it is time for the strips to come off.
Maybe Vanilla Ice Was Right – Imaging Van Winkle’s Ice – Ice Baby playing in the background. You will find quite a few perspectives on whether to apply heat or ice to your hip after surgery. While one theory is heat allows the blood to flow faster and heals your wound faster and that it reduces swelling. I found greater relief by applying ice… a lot of ice to my hip and incision area. Consult with your health care team to see if they are Vanilla Ice devotees (baby).
Freeze Dried – A floor nurse came into my hospital room the first night and asked if I would like any ice. My rear end felt like I had a rusty gallon can cut through my skin and it was really sore. I placed a two-pound bag of ice, wrapped in a pillow case, on my rear end, then my hip. I felt relief. About 30 minutes later I touched the skin where the ice had been applied and it was cold to the touch, but there was no moisture; it was dry to the touch. It was funny that my hip, or rear, couldn’t feel how cold it was, but my fingers could.
Hip Tip – Don’t Apply Ice Directly To Your Skin: Your skin can be irritated and possibly damaged by prolonged, direct exposure to ice. Think Robert Falcon Scott and the ill-fated result from his Antarctic exploration or the frostbite you see on a National Geographic special.
Post Game Review – Just How Bad Was My Hip?
Thrashed And Trashed – I saw my orthopedic surgeon and asked how the surgery went. He said, “In surgical terms, your hip was thrashed and trashed.” He indicated I had arthritis, bone cysts, ridges and about everything else that could be wrong with a hip. I asked where my hip condition rated compared with other surgeries he had performed and he said, “It was in the bottom five percent.” I never told my mother-in-law that as it would be one more thing to prove her right.
Almost Bo Derek – My doctor told me I had a lot of muscle mass and also it was the largest bone he ever had to cut through. He said that the largest hip prosthetic they make is a size 10 and I was a size nine. The cup that receives the new hip was a 65 mm.
Joe Namath Wore Panty Hose, Why, Oh Why, Can’t I? As the bed rises I can see my feet which are now adorned with bright yellow socks. I came to learn this is hospital code for signifying that I am at risk to fall and can’t be left unattended. I also see I am wearing hosiery, much like my mother, and Joe Namath, wore, except, like my mother, I didn’t shave my legs.
The support stockings are to be worn 24 hours a day. The purpose of the support stocking is help control blood clots. Most patients wear the support stocking for up to four to six weeks after surgery.
Well, That Isn’t Swell – Swelling (edema) is common after surgery. The most common areas for swelling are the foot, ankle, knee and the thigh. Some patients may have ankle swelling for up to three months. If you are experiencing swelling just lie down and elevate your leg so your foot and ankle are higher than your heart, the swelling should go away. Of all the post operative directions, this was the easiest to complete. If swelling does not decrease and becomes a concern call your doctor. Keep your compression stockings on during the day for six weeks. You may remove them at night.
Blood Clot Symptoms – While you will have quite a few medical professionals around you, you still must take an active role in your recovery. One thing to know are the symptoms which may indicate the formation of a blood clot. If you notice any of these symptoms, please notify your nurse or call your doctor immediately:
> Your calf is painful and feels warm to the touch.
> If you have constant swelling of your foot, ankle, or calf, not resolved by elevating your leg.
> If you are experiencing chest pain or shortness of breath.
Visiting Hours Are… Never – Everyone is different about visitors, but when my father asked about which hospital I would be at and wanted to come visit, I told him to stay home. I would be little fun and unable to really enjoy a visit. I suggested he should visit me at home in a week or three when I will be better and he could have a better experience, especially if he brought chocolate. Plus it would save him a two hour, each way, drive.
Hip Tip: I Told You I Was In Pain – Of course by allowing visitors, you may find gain some amount of pity-points from friends and family members who doubted that you were really in that much pain.
“I’ll Have The Steak, Well-Done, Baked Potato With Everything, A Side of Corn, A Slice Of Pie And…” After surgery, mentally you will be hungry, but physically you won’t feel like eating. The nurse will offer you ice chips and/or water. For dinner you may be given a clear liquid diet such as Jell-O, juice or soup. The next morning you will probably be ready to eat.
Who Thought Sleeping Could Be Complicated?
10,000 Hours Makes You An Expert – Malcolm Gladwell has stated that if you do something for 10,000 hours…
you have done enough repetitions to become an expert, whether golf, basketball, cooking or piano. Grabbing my handy calculator and dividing 10,000 hours by eight hours of sleep a night, I determine that in a mere 1,250 days I became an expert at sleeping with my new hip.
Sunny Side Up – My physician now indicated the rules that apply to my post surgery sleeping needs. His rule was simple, sleep only on your back for the first six weeks. For many, sleeping on your back isn’t a problem, but I was a stomach sleeper. I would fall asleep on my stomach, sleep like a dead man, and wake up in exactly the same position. I found sleeping on my back difficult, especially when accompanied by post surgery hip pain. I went online and found many post-surgical patients having problems sleeping.
Alrighty… that concludes Chapter 25.