Complementary and Alternative Therapies

Complementary and
Alternative Therapy
C. Matthews MSN, RN
Marilee Elias, MSN, RN
Spring 2012
Please make phones silent & visible

Reading
 Required:
– Wilkinson-Ch. 40
– Ignatavicius – Ch. 2
 Suggested Additional reading:
– Lilley – Ch. 8 “Over the counter drugs and
Herbal products”
Some references in this presentation will be
from pages in your textbooks other than
required chapters – highly recommended
reading.
C. Matthews RN, MSN
2/15/2019 M. Elias RN, MSN 2
Course Outcomes
1. Identify the roles of the nurse in a variety of
community settings to maintain optimal level of
wellness.
2. Client - centered teaching.
3. Apply the nursing process to meet the
physiological and psychosocial needs of clients
and their families at the end of life.
4. Standards of safe medication administration.
C. Matthews RN, MSN

2/15/2019 M.Elias RN, MSN SP10 3
UNIT OUTCOMES
1. Integrate complementary therapies into health promotion
activities for the well client.
2. Assess client need for Complementary or Alternative
therapy.
3. Identify use of Complementary or Alternative therapy.
4. Evaluate outcomes of Complementary or Alternative
therapy practices.
5. Provide non-pharmacological measures for pain relief.
6. Identify quackery or unscrupulous practitioners.
C. Matthews RN, MSN

CONTENT FOR ALTERNATIVE THERAPIES
 I. Systems of Health Care

– Traditional Chinese Medicine
– Native American medicine
– Homeopathy
 II. Mind-Body Therapies
– A. Journaling
– B. Imagery
– C. Meditation
 III. Manipulative Therapies
– D. Massage
– E. Tai Chi
C. Matthews RN, MSN

CONTENT FOR ALTERNATIVE THERAPIES
 IV. Biologic Based Therapies

– A. Aromatherapy
– B. Herbal preparations
 V. Energy Therapies
– Healing touch
– Therapeutic touch
– Reiki
C. Matthews RN, MSN

History of Western Medicine
C. Matthews RN, MSN

Ancients -- Myths & Religion –
Basis For Medical Practice
C. Matthews RN, MSN

History of Western Medicine:
Ancient Greece & Rome
 Hippocrates
 Galen
C. Matthews RN, MSN

 Early Christian era

ushers in hospitals
and health care
similar to
established Arab
Medicine
C. Matthews RN, MSN

2/15/2019 M.Elias RN, MSN SP11 10
 Middle Ages
– Midwives
– Witches
– Physicians
C. Matthews RN, MSN

2/15/2019 M.Elias RN, MSN SP11 11
 Renaissance
C. Matthews RN, MSN

2/15/2019 M.Elias RN, MSN SP11 12
– Lister
– Nightingale
C. Matthews RN, MSN

2/15/2019 M. Elias RN, MSN SP11 13
 20th and 21st

Centuries
C. Matthews RN, MSN

2/15/2019 M. Elias RN, MSN SP11 14
Integrative Health Care is
A Concept of Coordinated Health Care that
Includes ALL the Treatments
(Conventional and CAMs) and Health
Practices that Your Patient uses in their
Life.
How do We get our Patients to Tell us about

the CAMs they use?
Course outcome #1 C. Matthews RN, MSN
Unit outcome #1 M. Elias RN, MSN SP11 15
What is Holism?
 Concept focused on Relationships among
all living things.
 Therapeutic Encounters include:
– Enhancing Resistance to Illness
– Reducing aggravating behaviors
– Stress Management
– Goal is Optimal state of Wellness for each
unique person

RNs must be familiar with C. A. M.
“The 2007 National Health Interview

Survey (NHIS), which included a
comprehensive survey of CAM use by
Americans, showed that approximately
38 percent of adults use CAM.” NCCAM
retrieved 3/16/11 from http://nccam.nih.gov/health/whatiscam/

What is CAM?
 Complementary modalities
(therapies): used in conjunction with
conventional medical practice.
(Wilkinson, p. 1019)
 Alternative Modalities(therapies):
used instead of traditional care.
(Wilkinson, p.1019)
C. Matthews RN, MSN

RN must:
1.Be non-judgmental despite personal opinions
2. Build rapport by showing client respect – if
not, he may be afraid to tell about CAM use
3. Understand that C.A.M. can be beneficial,
when used correctly
4. Be aware that C.A.M. can be dangerous if it
interacts or interferes with conventional
treatment

RN must:
5. Be willing to teach the public about the
positive and negative information
regarding C.A.M.
6. Be aware that use of C.A.M. is popular
and increasing and must be included in
the history & physical
7. Know that Herbals, in particular, can
have significant effect on prescription
drugs and body function
Course outcome #1,2 C. Matthews RN, MSN

National Center for Complementary
and Alternative Medicine
 National Institutes of Health established
NCCAM.
 Purposes:
– Fund studies evaluating effectiveness of
C.A.M.
– Advance health professional knowledge re:
C.A.M.
– Serve as a clearinghouse for information
about these therapies
C. Matthews RN, MSN
2/15/2019 M. Elias RN, MSN SP11 21
NCCAM Domains of C.A.M.
Ignatavicius pg 8; Wilkinson p. 1020
 National Center for Complementary and

Alternative Medicine – 5 categories
– Systems of Health Care
– Mind-body therapies
– Manipulative and body-based therapies
– Biologically based therapies
– Energy therapies
C. Matthews RN, MSN

Mind-Body
 Meditation
– Stress relief/ reduce anxiety
– Relaxation
– Reduced levels of lactic acid
– Decreased oxygen consumption
– Slowed heart rate
– Decreased blood pressure
– Improved function of immune system
– Reduce pain
– Relieve symptoms of psoriasis
– Improve health
 (References: Ignativicius; Wilkinson)
C. Matthews RN, MSN

Unit outcomes #1-5 M. Elias RN, MSN SP11 23
Relaxation
 Used post-operatively (Ignatavicius, p. 299)
 Relaxation techniques (Ignatavicius, p. 56-57)
– To reduce anxiety, tension & emotional
tension which can exacerbate pain
 Relaxation (Wilkinson Vol 2, p. 967; Vol 1, pg 806-807)
 Progressive muscle relaxation (PMR)
(Wilkinson p. 807)
 Promoting sleep
 Can be taught in home setting
 Nurses can use for reduction of pain & stress.
C. Matthews RN, MSN

Guided Imagery
– Distraction when confronting pain, discomfort
or fear
– Making decisions and altering behavior
– Caution: not recommended for emotionally
unstable or cognitively impaired client
– Helps reduce pain.
– Reduction of nausea & vomiting.
– Decreasing anxiety
– Promoting comfort during cancer treatment
– Ignatavicius, 6th ed. p. 9
C. Matthews RN, MSN

Mind - Body
 Biofeedback (see Wilkinson text p. 1027)
 Journaling
– Provides a vehicle for expressing feelings
 Hypnosis
– Advanced training is NECESSARY
 Humor
– Biochemical Responses?
– Physiologic Responses?
C. Matthews RN, MSN

Spiritual
 Life force beliefs found in most cultures.
(Wilkinson, p 1020)
 Faith healing (Wilkinson page 260)
C. Matthews RN, MSN

2/15/2019 M. Elias RN, MSN SP11 27
Spiritual
 spiritual beliefs – how they affect health
 Longer life span

 Predictors of health outcomes
 Effects on specific diseases
– Page 249 Wilkinson
C. Matthews RN, MSN

Prayer
 Most Widely Used CAM in U.S.
(NCCAM, 2004)
 C.A.M. interventions (Wilkinson page 257)
 Prayer
– For Self
– For Others
– Healing Prayer Services
– Prayer Groups
C. Matthews RN, MSN

Spiritual
 Intercessory prayer
– An organized and regular form of prayer in
which someone communicates with his or
her higher power on behalf of another who
is in need.
 Healing prayer
– Studies showing evidence of improvement
 Wilkinson, p 259-260
C. Matthews RN, MSN

Spiritual
 Nurses should expect to work in
collaboration with others, particularly
ministers, pastors and chaplains, to meet
the complex spiritual needs of all patients.
 Potential problem: the nurse and patient

have different views of spirituality
– Respect patient’s wishes
– If patient asks for spiritual intervention that is
inconsistent with the nurse’s beliefs, seek
assistance from another nurse or chaplain.
C. Matthews RN, MSN
Manipulative and body-based methods
 Movement & exercise
– Strengthens circulatory & respiratory
function
– Endorphins
– Helps regulate metabolism
– Enhances Immune system
C. Matthews RN, MSN

Manipulative and Body-based Therapies
 Yoga
– “life forces in correct balance and flow
– Concentration, strength, flexibility, symbolic
movements
– Breathing, movement & posture
 Tai Chi
– Promotes the flow of qi or energy throughout the
body
– Ignatavicius, p. 11
– Reduces sx. of fibromyalgia
– Used in cardiac rehab programs, can lower BP
C. Matthews RN, MSN

Other Movement Therapies
 Dance Therapy
C. Matthews RN, MSN

Chiropractic and Osteopathy
 Chiropractic
– Relationship between Body Structure and
Function
– Subluxation & Adjustment
 Osteopaths D.O. vs. M.D.
– Includes Osteopathic Manipulation
C. Matthews RN, MSN

Massage
– Muscles & Soft Tissues
– Benefits of Massage
– Contraindications for Massage
– Can we (nurses) do Massage?
C. Matthews RN, MSN

Unit outcomes #1-5 M.Elias RN, MSN SP10 36
Energy – Based Therapies
 “A group of techniques
that work with the
body’s energy field by
the use of the hands to
direct or redirect the
energy to enhance
balance within the field.”
(see Wilkinson page 1033-34)
alternativecancer.us/aura.jpg
C. Matthews RN, MSN

 Energy fields www.windsofchange.eu.com/chakra.
http://images.google.com/images?hl=en&q=layers+of+body+energy+field&btnG=Se
html
arch+Images&gbv=2
– Layers
– Chakras
– Reflexology ‘zones’
http://images.google.com/images?gbv=2&hl=en&q=reflexology+zones&btnG=S
earch+Images
– Traditional Chinese Medicine – 12 Meridians

(Ignatavicius, 6th ed., page 9)
– Acupressure ‘meridians’ (Wilkinson figure 40-3 page 1024)
– Acupuncture chi/blockages
CC. Matthews RN, MSN

 Therapeutic massage
– Precaution – Wilkinson p. 1033
 Therapeutic touch
– Caution for touch – Ignatavicius 6th ed., page 13
 Healing touch
 Reiki
 Acupressure
 Reflexology
C. Matthews RN, MSN
 TT (Therapeutic Touch)
– Integral to assessment
– Bonding
– Communication
– Soothing, calming, comfort
– orientation
 Contraindications
– When NOT to touch – Ignatavicius pg. 13
C. Matthews RN, MSN

Reiki
 Create Energy Balance
 Patient draws Energy
 Reiki Masters & Training
“Reiki is a Japanese technique for stress

reduction and relaxation that also
promotes healing. It is administered by
"laying on hands" and is based on the idea
that an unseen "life force energy" flows
through us and is what causes us to be
alive.”
http://www.centurylink.net/search/index.php?q=google&context=www.centurylink.net
C. Matthews RN, MSN

Reflexology/Acupressure
 Reflexology
– Ancient Egypt
– Energy Zones Top to Bottom
– Pressure Points
– What conditions benefit from it?
 Acupressure
– Meridians & Pressure Points
C. Matthews RN, MSN

Acupuncture
 Derived from traditional Chinese medicine
and other countries and alternative
systems
 Qi (chi) Energy travels through 72
Meridians in the body
 Needles are applied to Acupoints on the
Meridians to restore the flow of qi
C. Matthews RN, MSN

Acupuncture – uses for
Migraine headache – Ignatavicius, p. 953
Pain and Anesthesia – Ignatavicius p. 57
C. Matthews RN, MSN

2/15/2019 M.Elias RN, MSN SP10 44
 The dreaded nausea and vomiting which commonly
occurs in some patients undergoing chemotherapy
and inevitably, with the use of certain classes of
agents, can often be worse than the disease itself.
Most oncologists have experienced the patients
who start vomiting at the thought of their next clinic
visit. At the University of Los Angeles (UCLA)
School of Medicine, a well-controlled study
completed over two Years ago, the authors of the
published paper reported significant reduction of
nausea and vomiting when pre-treated with. It is
now routinely administered before, after and in
between chemotherapy treatment sessions for
control or nausea and emesis. Such treatments are
relatively simple and easily executed in an
outpatient setting. Its effectiveness helps in
minimizing the use of standard, expensive multi-
drug anti-nausea regimens with their attendant side
effects, given along with the chemotherapeutic
agents.
 Acupuncture in Cancer Treatment by Eugene Mak, MD@
http://www.medicalacupuncture.org/acu_info/articles/cancertreatment.html
C. Matthews RN, MSN
2/15/2019 M.Elias RN, MSN SP10 45
Biologically Based Therapies
 Dietary Therapies
 Herbs
 Vitamins
 Aromatherapy
Course outcome #2, 3 & 4 C. Matthews RN, MSN

Dietary Therapies
 Nutraceuticals and phytonutrients
 Protective or healing agents found in plant
and animal foods.
 Free radicals: unstable molecules that alter
genetic codes and trigger the development of
cancer growth in cells.
 Antioxidants: react with free radicals,
preventing their damaging effects
– Sources of antioxidants: vitamin C, beta-
carotene, vitamin E

Dietary Therapies
 Macrobiotic Diets
– Yin/ yang of foods
– Balanced foods
– Foods to avoid: processed and treated foods,
red meat, sugar, dairy products, eggs,
caffeine
– Caution: children and pregnant women may
have deficiency in Vitamins D and B12

Aromatherapy –
Wilkinson page 1030
 Essences from oils extracted from plants &

flowers.
 Conditions responsive to aromatherapy:
– Stress and anxiety
– Muscular and rheumatic pains
– Digestive disorders
– Skin conditions

Aromatherapy
 Can be used for sense of smell, but also
as compresses, baths or topical
C. Matthews RN, MSN

2/15/2019 M. Elias RN, MSN SP11 50
Aromatherapy
(Ignativicius, p.12)
 Lavender – promotes relaxation & sleep

 Peppermint – stimulation, concentration
 Sandalwood – ease depression
 Tea tree – treating MRSA?
 Chamomile – relaxation
 Lemon – promotes sleep/ tx for insomnia
and/or digestive disorders

Herbals
Cherokee story
 “…humans were without diseases until the
animals created them in retribution for the
lack of respect humans had shown them.
The plants, however, felt that the animals
were much too harsh and volunteered
themselves to provide a cure for every
disease the animals had created.”
 Cavendar, p. 55
Course outcome # 3 & 4 C. Matthews RN, MSN

HERBALS – what RN needs to know
 Major drawback: May delay important diagnosis
and treatment.
 Nursing Intervention: Make certain MD or ARNP
is aware of client’s use of herbals.
 Nursing action: What to assess & instruct pre-
op client regarding herbal therapy.

HERBALS – what RN needs to know
 FDA categorized herbals as food and nutritional
supplements not as drugs
 The Dietary Supplement Health & Education Act

(DSHEA) of 1994 allowed herbs to be sold as
dietary supplements as long as there are no
health claims written on labels
 DSHEA requires no proof of safety or efficacy

and sets no standards for products labeled as
supplements, i.e. no guarantee the herb is
properly prepared
Commonly used Herbals
Ignatavicius page 12 – table 2-3
 Know intended uses for each

 Know Caution & adverse effects of each
– Gingko bilboa
– Garlic
– Echinacea
– Ginseng
– St. John’s Wort

Ginko Biloba
 Reduce Memory Problems, Dementia,
Peripheral Vascular Disease
 Antioxidant & Vasodilatory Properties
 BUT can cause BLEEDING when used
with Anticoagulants
 Avoid before surgery
 Also cause Headache, GI Upset

Garlic
 Lowers Cholesterol, Lowers BP, Natural
Antibiotic,
 Natural Anti-platelet Agent
 BUT Causes BLEEDING with other Anti-
platelet Drugs
 Potentiates Anti-diabetic Drugs
 Avoid before Surgery

Echinacea
 Builds Immunity, Helps Wound Healing
 Use > 8 Weeks & Possible Immune
Function Suppression
 NOT Recommended for People with
Immune Diseases

Ginseng
 Asian Ginseng- Diabetes, Erectile
Dysfunction, “Unclear” Thinking
 American Ginseng- Diabetes,
Prevention of Colds & Flu
 Siberian Ginseng- Prevent Colds & Flu,
reduce Severity of Herpes Simplex type 2
Infections
 BUT, BUT, BUT, BUT…

Ginseng and the Big Buts
C. Matthews RN, MSN

2/15/2019 M. Elias RN, MSN SP11 60
Ginseng & The BIG BUTS
 Insomnia, Headache, Agitation, GI Upset,
Unusual Menstrual Bleeding, Breast Pain,
Dizziness, Increase or Decrease BP,
Hypoglycemia,
Fast/Pounding/Irregular Heartbeat;
Severe Allergic Reaction
 Not with Immune System Disorders,
Schizophrenia, Endometriosis, Fibroids
 NOT FOR Long-term Use
Course outcome # 2, 3 & 4 C. Matthews RN, MSN

St. John’s Wort
 Ease Mild to Moderate Depression
 BUT causes Photosensitivity
 DO NOT use in Major Depression
 DO NOT use with Other Antidepressants

Herbals
 Alert: “Natural” does not always mean
harmless.
 Plants used improperly can be poisonous.
 Chemicals within herbs can strengthen the
immune system, alter blood chemistry, or
protect specific organs against disease
 Caution: some individuals may have
allergies

Herbals
 Special precaution with pregnant or
lactating women and children – should not
use without physician’s knowledge
Rationale:
Unpredictable biologic effects
Possible allergies
Side effects
Herbs have chemical composition
Little or no regulation of production/ quality
Possible herb/drug or herb/herb interaction
Possible delay of treatment is dangerous
Herbals & the RN
 Teach about signs of allergic
reactions
 Teach that herbs can be dangerous

even if they are not Rx and are
“natural”

Herbals & the RN
 Always ask about use of herbals when
getting medication history
 “What is the story of why the patient is

using the plant medicine or therapy?”
– Libster, p. 809
 Teach clients to look for products labeled

‘standardized’ – these more likely to have
accurate amounts of herb and less likely
to have contamination
Frankincense and Myrrh* medicinal use
 Have had spiritual significance since ancient

times and they also were adopted as medicines
for physical ailments.
 In modern Chinese Materia Medica, these two

resins are classified as herbs for vitalizing
circulation of blood and are utilized for treating
traumatic injury, painful swellings, masses, and
other disorders related to stasis syndromes.
– MYRRH AND FRANKINCENSE by Subhuti Dharmananda, Ph.D., May 2003 @
http://www.itmonline.org/arts/myrrh.htm

Unit outcomes #1-5 M. Elias RN, MSN SP11 *Will not be on the test! 67
 Pain in the epigastrum, abdomen, hypochondria, and/or
heart due to qi and blood stasis, and stagnation in the
viscera and bowels or the channels (jing) and network
vessels (luo).
 Amenorrhea, dysmenorrhea, or postpartum abdominal

pain due to blood stasis.
 Rheumatic complaints due to wind damp causing qi and
blood stagnation and stasis in the network vessels.
 Wounds, scars, and skin inflammation with blood stasis
and necrotic tissue.
 Traumatic injuries with pain, swelling, and redness due

to qi stagnation and blood stasis.
– MYRRH AND FRANKINCENSE by Subhuti Dharmananda, Ph.D., May 2003 @
http://www.itmonline.org/arts/myrrh.htm
C. Matthews RN, MSN

2/15/2019 M. Elias RN, MSN SP11 68
Folk Medicine
(Ignatavicius, 6th ed., page 32-33)
 Learned from experience

 Passed from generation to generation
 Preservation of heritage/ culture
 Some have been scientifically proven (ex.
Garlic)
 Plants/herbs
 Hot/cold
 “Evil Eye” (Mal de Ojo)
C. Matthews RN, MSN
2/15/2019 M. Elias RN, MSN SP11 70
Folk Medicine
 Own terminology: (Feel free to ask the meaning)
– “high blood” “low blood” “thin blood”
– “Thick blood” conjure water
– “fall out” gimpy dropsy
– risin’ sugar cut pain
– Weeded breasts
– “snuffing the mother”
– “the itch”
– Cavendar, 2003

What is Quackery?
 A pretender
 Questionable products & services
 Overpromotion vs fraud
 Misinformation
 Useful for some purposes, not others

How to spot Quackery
 Tell only part of the story
 Overpromotes nutritional insurance
 Play on fears about chemicals
 ‘Everyone needs supplements’
 Promise quick, dramatic, miraculous results
 Anecdotes & testimonials
 Questionable credentials
 Claim persecution
 Promote distrust
 Take claims directly to the media, not peers
 Resist peer review

Nurses Educate the Public
 Teach signals of fraudulent practice
 Avoid ‘healers’ who:
– Promise immediate relief or success
– State that their way is the only sure therapy
– Refuse to work with other health care
providers
– Claim to have all the answers
– Use testimonials that claim amazing results

One Minute Paper
Now is the time to write short answers
to:
1. What is something you heard today that
is new to you?
2. How do you plan to approach your
clients about CAM?
3. List one thing that surprised you.
4. List one thing that reinforced something
you already believed.
C. Matthews RN, MSN

2/15/2019 M. Elias RN, MSN SP11 76
References
 Cavender, A.(2003) Folk Medicine in Southern
Appalachia. The University of North Carolina Press,
Chapel Hill, N.C.
 Ignatavicius, D.D. & Workman, M.L. (2010) Medical-
Surgical Nursing. 6th ed. Elsevier Saunders, St. Louis,
Missouri.
 Libster, M.L. (2002) Delmar’s Integrative Herb Guide for
Nurses. Delmar Thomson Learning. United States.
 Wilkinson, J.M. & Treas, L.S. (2011) Fundamentals of
nursing, 2nd ed. FA Davis Company, Philadelphia, PA.
C. Matthews RN, MSN

2/15/2019 M. Elias RN, MSN SP11 77

Complementary and Alternative Therapies

Diunggah oleh

Informasi Dokumen

Deskripsi Asli:

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Complementary and Alternative Therapies

Diunggah oleh

Hak Cipta:

Format Tersedia

Complementary and

Please make phones silent & visible

C. Matthews RN, MSN

C. Matthews RN, MSN

 I. Systems of Health Care

C. Matthews RN, MSN

 IV. Biologic Based Therapies

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

 Early Christian era

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

 20th and 21st

C. Matthews RN, MSN

How do We get our Patients to Tell us about

Course outcome #1 C. Matthews RN, MSN

“The 2007 National Health Interview

retrieved 3/16/11 from http://nccam.nih.gov/health/whatiscam/

Course outcome #1 C. Matthews RN, MSN

C. Matthews RN, MSN

Course outcome #1 C. Matthews RN, MSN

Course outcome #1,2 C. Matthews RN, MSN

 National Center for Complementary and

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

 Faith healing (Wilkinson page 260)

C. Matthews RN, MSN

 Longer life span

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

 Potential problem: the nurse and patient

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

– Traditional Chinese Medicine – 12 Meridians

CC. Matthews RN, MSN

C. Matthews RN, MSN

“Reiki is a Japanese technique for stress

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

C. Matthews RN, MSN

Course outcome #2, 3 & 4 C. Matthews RN, MSN

Course outcome #2, 3 & 4 C. Matthews RN, MSN

Course outcome #2, 3 & 4 C. Matthews RN, MSN

 Essences from oils extracted from plants &

Course outcome #2, 3 & 4 C. Matthews RN, MSN

C. Matthews RN, MSN

 Lavender – promotes relaxation & sleep

Course outcome #2, 3 & 4 C. Matthews RN, MSN

Course outcome # 3 & 4 C. Matthews RN, MSN